What is cholera?

How is cholera passed on? 

Most of the time, an epidemic starts with one person with a disease, which then spreads quickly to other people, who can potentially infect other people. Vibrio cholerae bacteria are mainly found in excrement and vomit. Not everyone who comes into contact with the bacteria becomes ill. Nonetheless, asymptomatic people infected with the disease can pass it on to others almost as quickly as people with symptoms. Even people who have died from cholera are still highly infectious, which makes funeral practices particularly delicate.  Animals, meanwhile, cannot catch cholera or pass on the disease: cholera only affects humans.  

The incubation period (during which the patient is not contagious) can vary from a few hours to five days, followed by an asymptomatic contagious phase for up to ten days, then a symptomatic contagious stage. It is worth noting that only 20% of people infected actually develop cholera, and only 4% develop a severe form of it. 

The disease is generally transmitted through food and water contaminated with excrement, perhaps because it has been prepared with dirty hands, or the food has been in contact with contaminated water. It is rarer for the disease to be passed on through direct contact with someone with cholera. 

In areas where sanitation and access to water are inadequate or non-existent, wastewater (excrement, blackwater, greywater) contaminated with Vibrio cholerae can infect water supply points for drinking water, cooking or personal hygiene. 

What kinds of contexts cause cholera to develop? 

Bacteria of the Vibrio genus can survive five to ten days out in the open and are naturally present in freshwater (except groundwater), brackish water and salt water. They proliferate when the water temperature is high. 

Cholera spreads most easily in populations with precarious living conditions, sometimes linked to forced displacement or a severe climate event and exacerbated by conflict. Such a situation can put a whole population in danger. 

In particular, poor personal and environmental hygiene standards, insufficient access to drinking water, poor sanitation systems and critical areas deprived of water and health infrastructures cause the pathogen to spread. 

How can the spread of cholera be contained? 

The first strategy to be promoted is universal access to basic water, sanitation and hygiene services, as well as good health care coverage. 

Clean water, an effective sanitation system and strict, consistently applied hygiene measures – especially proper hand washing and thorough hygiene while breastfeeding and feeding babies and young children – are effective ways of preventing epidemics like cholera and stopping them from spreading. 

A decent health system is also essential, especially in order to raise populations’ awareness of cholera and treat cases adequately. 

Good coordination between health services and water and sanitation services is also fundamental in order to pre-empt and respond to an epidemic. Alert systems and national measures to prevent and control epidemics are crucial. 

Why are malnutrition and cholera so inextricably linked?  

People suffering from malnutrition are much more at risk of being seriously affected by the disease. The reason for this is that poor absorption of nutrients modifies the gastrointestinal tract; the ‘good’ bacteria in the intestines cannot function properly, so the intestinal walls cannot absorb nutrients as well. 

Malnutrition also weakens the immune system. People suffering from malnutrition are therefore more prone to infections and particularly waterborne diseases such as cholera. 

Like other waterborne diseases, cholera can do permanent damage to the immune system, lead to serious loss of water and nutrients, and reduce appetite. This is a vicious circle that makes recovery difficult.  

How is cholera treated? 

People suffering with cholera must be treated as quickly as possible with oral hydration therapy (ORT), consisting of a solution with sugars and salts, administered orally or intravenously in the most severe cases. The treatment is based on rehydration, and cholera is very treatable with this solution. In the most serious cases, antibiotics are also given. 

In addition, oral vaccines offer protection against the infection for a period ranging from six months for children to two years for adults, according to the latest available evidence. 

Access to these medications or vaccines remains a vital issue for many populations (isolated areas, conflict zones, discriminated populations, etc.). 

Where do cholera epidemics occur today?  

 
 
Generally, an epidemic is when a disease occurs widely but in a specific place at a particular time. When an epidemic goes beyond national borders, it becomes a pandemic. The last major pandemic was Covid-19. 

Cholera epidemics happen regularly, especially in regions in crisis. Though the disease is easy to treat in theory, many people still die from it. 

In 2024, several epidemics took place in 33 countries in Africa, Asia, the Middle East and Central America. According to the World Health Organisation, from 1 January 2024 to 29 September 2024, there were 439,724 cases of cholera and 3,432 deaths from the disease. 

How does Action contre la Faim take action in the case of a cholera epidemic?  

Our teams are trained to respond to cholera epidemics, and their intervention procedures were updated in 2023. These procedures, based on international protocols backed by the World Health Organisation, ensure that teams are aware of and follow the standards and rules in effect. 

In health care establishments supported or managed by Action contre la Faim, patients are treated according to current national or international protocols. In particular, we protect children from any deterioration by treating them for malnutrition at the same time. 

Another of our priorities is community health: in at-risk areas, Action contre la Faim secures access to drinking water, builds sanitation infrastructures, establishes wastewater drainage systems to prevent epidemics, and systematically trains the population in personal and environmental hygiene measures. 

Beyond its response to epidemics in the field, Action contre la Faim also contributes towards a more global approach to cholera management by actively participating in the Global Taskforce on Cholera Control, led by the World Health Organisation. The Taskforce’s aim is to eliminate the disease through different strategic angles, including by producing operational guides (Operational Cholera Toolkit 2023) and providing training. 

Another central component in the eradication of this disease is advocacy for better access to the oral vaccine and for universal access to water and basic sanitation in communities exposed to the risk of cholera and in the associated health centres. 

In particular, this advocacy calls for more funding for the water sector (especially in a humanitarian context) and for the humanitarian coordination of the water and health sectors, as well as states’ implementation of the right to water and sanitation. 

Written by Jean Lapegue, Water Sanitation and Hygiene Service (WASH) Manager at ACF-France and member of the Global Taskforce on Cholera Control led by the World Health Organization.