Eastern Mediterranean Health Journal | All issues | Volume 31 2025 | Volume 31, issue 7 | Mitigating the increasing threat of cholera in Yemen and other conflict-affected countries in the Eastern Mediterranean Region

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Mitigating the increasing threat of cholera in Yemen and other conflict-affected countries in the Eastern Mediterranean Region

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Editorial

Hanan H Balkhy1

1Regional Director, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt.

Keywords: cholera, conflict, health emergency, Yemen, Eastern Mediterranean

Citation: Balkhy HH. Mitigating the increasing threat of cholera in Yemen and other conflict-affected countries in the Eastern Mediterranean Region. East Mediterr Health J. 2025;31(7):423-425. https://doi.org/10.26719/2025.31.7.423.

Copyright © Authors 2025; Licensee: World Health Organization. EMHJ is an open access journal. All papers published in EMHJ are available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Cholera, an age-old disease driven by poverty, poor sanitation and insufficient access to clean water, remains a major public health concern in the WHO Eastern Mediterranean Region (EMR). In January 2023, WHO declared cholera a Grade 3 global public health emergency, requiring organization-wide support and response (4). In 2024, 8 EMR countries reported 597 026 cholera cases and 2403 deaths, including acute watery diarrhoea (AWD) cases reported in Afghanistan, contributing to almost 74% of the global cholera burden (5).

Armed conflict occurring in several countries across the EMR is exacerbating the resurgence of devastating cholera outbreaks (1). Syria and Lebanon reported cholera outbreaks in late 2022 after nearly 30 years of its absence in the 2 countries (2,3). These are clear examples of conflict-triggered cholera outbreaks in the EMR. Population displacement, resource constraints, fragile health systems, collapsed water and sanitation infrastructure, extreme weather events, and environmental shock are additional drivers of cholera outbreaks in conflict-affected areas (6–9).

The World Bank has listed Afghanistan, Iraq, Lebanon, Libya, Somalia, Sudan, Syria, West Bank and Gaza, and Yemen as fragile and conflict-affected countries in the EMR (10), and this classification, not surprisingly, overlaps with the regional cholera burden. Between 2016 and 2022, Yemen reported over 2.5 million suspected cholera cases along with 4000 deaths (11). Cholera outbreak has now become endemic in the country, with 282 495 suspected cases and 909 deaths reported between 2023 and epidemiologic week 17 of 2025. In the past 2 years, up until epidemiologic week 19 of 2025, Sudan had reported 70 225 suspected cases and 1719 deaths (CFR 2.4%). Somalia reported 43 514 suspected cases and 202 associated deaths (CFR 0.5%) between 2023 and epidemiologic week 17 of 2025. Syrian Arab Republic reported 186 920 suspected cases and 12 deaths (CFR 0.006%) in 2023–2024. And in 2024 Pakistan reported 77 483 cases, Iraq 596, Lebanon 14 142, and Afghanistan 175 463 cases and 84 deaths due to acute watery diarrhoea with dehydration (11).

WHO and partners have contributed to cholera outbreak response across the region, with remarkable progress in preparedness and response. With WHO support, EMR countries have developed and implemented national strategic action plans that are tailored to their needs and priorities. Focus has been on enhancing coordination; strengthening surveillance; improving laboratory capacities; establishing case management facilities; advancing water, sanitation and hygiene (WASH) measures; fostering effective community engagement; and ensuring the availability of essential cholera supplies (3,14). In 2023 alone, more than 29 million doses of oral cholera vaccine (OCV) were distributed across the region (15), and in 2025, WHO supported Somalia, Sudan and Syria in identifying priority areas for multisectoral interventions on cholera.

WHO has leveraged its networks with partners such as UNICEF, Gavi, Global Outbreak Alert and Response Network (GOARN), Standby Partnership, and others to enhance coordination and information sharing, mobilization of financial and human resources, strengthening of capacities across the different response pillars, and improvement of outbreak planning and response. During a sub-regional meeting facilitated by WHO in Lebanon in 2023 (12), stakeholders reaffirmed their commitment to a multisectoral approach to cholera prevention and control. Partners emphasized the importance of sustained funding, cross-border coordination and national ownership in preventing future outbreaks and strengthening health system resilience. The Cholera Preparedness and Response Strategy for the WHO Eastern Mediterranean Region 2025–2028 now provides a structured framework for coordinated planning and action in the region (13).

Some challenges, however, persist. WASH infra­structure remains inadequate in many cholera-endemic and at-risk settings, global OCV supplies are limited and logistics barriers hinder timely distribution. Surveillance systems often lack the capability for early detection and timely response to outbreaks, and cholera control efforts are frequently reactive rather than preventive (16). Although emergency response is critical, it cannot replace long-term investments in resilient health systems and sustainable WASH infrastructure (17).

To build resilient health systems and end cholera as a public health threat, EMR countries should:

  1. Enhance overall multisectoral coordination on cholera control by strengthening coordination mechanisms and developing multisectoral roadmaps, including expanding partnerships and ensuring that financing mechanisms are predictable, flexible and sustainable. This requires the development of evidence-based national cholera action plans with priority interventions and targets. The Cholera Preparedness and Response Strategy for the WHO Eastern Mediterranean Region 2025–2028 (13) and the Global Roadmap to End Cholera by 2030 (18) provide alignment frameworks with clear implementation milestones and measurable indicators.
  2. Enhance early detection of cholera outbreaks and rapid response by strengthening disease surveillance systems and building capacities for timely response. Investment in digital health data tools, laboratory capacities, strategic use of rapid diagnostic tests, and community-based surveillance systems will help strengthen cholera control efforts. The deployment of oral cholera vaccines in responsive and preventive situations should be part of comprehensive national cholera control plans.
  3. Increase access to quality case management services at cholera treatment facilities and in the community, to improve treatment outcomes and reduce cholera-associated mortality. Timely establishment of community-based case management systems with clear referral pathways to treatment centres, implementing standard case treatment protocols, and ensuring availability of essential supplies are imperative.
  4. Improve WASH services by constantly monitoring water quality and ensuring adequate WASH and infection prevention and control standards and supplies at health facilities. This will require strengthening WASH and infection prevention and control protocols and standards in health facilities (19) and establishing water quality surveillance and monitoring systems in communities and households.

Cholera still presents a unique challenge to public health in the EMR. Its continued transmission indicates the urgent need to strengthen systems innovatively for better response (20). WHO, regional partners and national authorities have shown leadership and willingness to address the challenge, and with stronger political commitment, more investment and stronger coordination, cholera can be controlled and ultimately eliminated as a public health threat in the EMR. WHO calls on Member States to prioritize cholera control in their national health agendas, allocate and mobilize more resources as necessary, and invest in long-term health system resilience and development.

References

  1. UNICEF. Cholera: A global call to action. New York: UNICEF, 2023. https://www.unicef.org/reports/cholera-global-call-action.
  2. Bayram Z, Bizri A, Musharrafieh U. Resurgence of cholera in Lebanon. East Mediterr Health J. 2023;29(11):837–838. https://doi.org/10.26719/emhj.23.111.
  3. Al Mandhari A, Hajjeh R, Abubakar A, Buliva E, Brennan R. Mitigating the resurgence of cholera in the Eastern Mediterranean Region. East Mediterr Health J. 2023;29(1):3–5. https://doi.org/10.26719/2023.29.1.3.
  4. World Health Organization. Multi-country outbreak of cholera. External Situation Report #12, 14 March 2024. https://www.who.int/publications/m/item/multi-country-outbreak-of-cholera--external-situation-report--12---14-march-2024.
  5. World Health Organization. Multi-country cholera outbreak. External Situation Report #22, 24 January 2025. https://www.who.int/publications/m/item/multi-country-cholera-outbreak--external-situation-report--22---24-january-2025.
  6. World Health Organization. Cholera. Geneva: World Health Organization, n.d. https://www.who.int/news-room/fact-sheets/detail/cholera.
  7. Deen J, Mengel MA, Clemens JD. Epidemiology of cholera. Vaccine 2020;38:A31–40. DOI: 10.1016/j.vaccine.2019.07.078.
  8. Federspiel F, Ali M. The cholera outbreak in Yemen: lessons learned and way forward. BMC Public Health 2018;18(1):1338. https://doi.org/10.1186/s12889-018-6227-6.
  9. Ali Y, Siddig EE, Ahmed A. Resurgence of cholera amidst ongoing war in Sudan. The Lancet. 2024 Nov;404(10464):1724–5. doi: 10.1016/S0140-6736(24)02290-6.
  10. The World Bank. FY24 List of Fragile and Conflict-affected Situations. Washington DC: World Bank, 2025. https://thedocs.worldbank.org/en/doc/608a53dd83f21ef6712b5dfef050b00b-0090082023/fy24-list-of-fragile-and-conflict-affected-situations.
  11. World Health Organization. Cholera by WHO Region 2000-2023. Geneva: World Health Organization, n.d. https://worldhealthorg.shinyapps.io/page4cholera_WHO_regions/.
  12. World Health Organization. Sub-regional meeting on enhancing cholera/acute watery diarrhea preparedness and response Beirut, Lebanon on 15th – 16th August 2023. Cairo: WHO Regional Office for the Eastern Mediterranean. https://www.emro.who.int/fr/pandemic-epidemic-diseases/news/sub-regional-meeting-on-enhancing-choleraacute-watery-diarrhea-preparedness-and-response-beirut-lebanon-on-15th-16th-august-2023.html.
  13. World Health Organization. WHO launches Cholera Preparedness and Response Strategy for Eastern Mediterranean Region. News, 4 June 2025.
  14. World Health Organization. Global strategic preparedness, readiness and response plan for cholera. Geneva: World Health Organization, 2023. https://www.who.int/publications/m/item/global-strategic-preparedness--readiness-and-response-plan-for-cholera.
  15. Global Taskforce on Cholera Control. OCV dashboard. Geneva: Global Taskforce on Cholera Control, n.d. https://apps.epicentre-msf.org/public/app/gtfcc.
  16. Spiegel P, Ratnayake R, Hellman N, Ververs M, Ngwa M, Wise PH, et al. Responding to epidemics in large-scale humanitarian crises: a case study of the cholera response in Yemen, 2016–2018. BMJ Glob Health 2019;4(4):e001709. https://gh.bmj.com/content/4/4/e001709.
  17. Bogale B, Scambler S, Mohd Khairuddin AN, Gallagher JE. Health system strengthening in fragile and conflict-affected states: A review of systematic reviews. PLOS One 2024;19(6):e0305234. doi: 10.1371/journal.pone.0305234.
  18. Global Taskforce on Cholera Control. Ending cholera: A global roadmap to 2030. Geneva: Global Task Force on Cholera Control, n.d. https://www.gtfcc.org/wp-content/uploads/2025/02/gtfcc-ending-cholera-a-global-roadmap-to-2030.pdf.
  19. World Health Organization. Water and sanitation for health facility improvement tool (WASH FIT): a practical guide for improving quality of care through water, sanitation and hygiene in health care facilities, second edition. Geneva: World Health Organization, 2022. https://iris.who.int/bitstream/handle/10665/353411/9789240043237-eng.pdf?sequence=1.
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