© UNICEF Ethiopi/2023/NahomTesfaye

CHOLERA OUTBREAK IN EASTERN

AND SOUTHERN AFRICA
Over 28 million people in need across 11 countries

March 2023
 OVERVIEW

Today, eleven countries in eastern and southern

Africa are grappling with one of the worst cholera
outbreaks to hit the region in decades.

By the third week of March 2023, a 28.4 million

total of 93,681 cases and 2,023
Number of people in need in
deaths have been registered in eastern and southern Africa due
Malawi, Somalia, Mozambique, to the cholera epidemic and its
Kenya, Ethiopia, Zambia, South effect on water supplies (which
Sudan, Burundi, Tanzania, Zimbabwe, are contaminated in many areas),
food insecurity, and the provision of
and South Africa.1 lifesaving services.

Most cholera deaths are entirely

preventable. When people with cholera
receive early quality care, fatality rates 14.2 million
typically remain below 1 per cent.2 When Approximate number of children in need
rates creep above 1 per cent, it usually in eastern and southern Africa due to
signals problems with the quality, access, the cholera epidemic and its effect on
and speed of treatment. Unfortunately, water supplies (which are contaminated
in many areas), food insecurity, acute
the average case fatality rate across the 11 malnutrition, and the provision of
affected countries in eastern and southern lifesaving services for children.
Africa is currently 2.2 per cent--more than
double the accepted benchmark of 1 per
cent.. In some affected areas, such as
Malawi’s capital of Lilongwe, case fatality
rates reached as high as 5.9 per cent in 93,681
mid-February 2023. Mortality figures this
large are an indication of inadequate care. Cumulative number of cholera
cases in eastern and southern
In other words, large numbers of people are Africa as of the third week of
1 Countries are listed in
dying across the region from a disease that March 2023.
order from those with is easily treatable and curable if quality care
the greatest recorded
cumulative number of is provided in a timely manner.
cases to those with
the least. Most of the
current outbreaks in the Cholera and children
ESA region began in
2022.

2 WHO (30 March 2022). Because of the quickly evolving nature 5.9%
Cholera Key Facts. Avail-
able at Cholera (who. of the epidemic, updated disaggregated Case fatality rate in Lilongwe,
int). data by gender and age are not available Malawi’s capital city, which is one of
3 Age-disaggregated data in every affected country. However, age- the country’s cholera epicenters (as
reflects the number of February 2023). When people with
of cases in children disaggregated data are available from cholera receive early quality care,
under the age of 19 in
Malawi as of 6 February Malawi and Mozambique, and show that case fatality rates typically remain
2023, and the number
children comprise an estimated 40 per cent below 1 per cent. The high fatality
of cases in children
rate in Lilongwe (and Malawi as a
under the age of 18 in of cholera cases in Malawi and 30 per cent whole) is a function of inadequate
Mozambique as of the
first week of February of cholera cases in Mozambique.3 care.
2023 (week 5).

1
 In response to the cholera outbreak, UNICEF has supported the Malawi Government with establishing new safe water sources and delivered
over $470,000 USD worth of lifesaving health and water, sanitation and hygiene supplies. © UNICEF/UN0789454/

Extreme weather and climate change

In several cholera-affected countries, the

Approximately 27 devastating effects of floods, droughts,
per cent of cholera
and other extreme weather events have 4 As of 6 February 2023, 32
deaths in Malawi have
occurred in children exacerbated the spread of disease well per cent of cholera deaths
had occurred in people over
under 19 (as of mid- beyond traditional hotspots. Within the 50, compared with 27 per
cent of deaths occurring in
February 2023). Horn of Africa, the compounding effects people under the age of 19.
of a multi-year drought have caused 5 Charnley G, Kelman I,
and Murray K. (2022).
widespread food insecurity, malnutrition, “Drought-related cholera
population displacement, and poor access outbreaks in Africa and the
implications for climate
to drought-related cholera,5 especially in change: a narrative review.”
Pathogens and Global
These frequencies suggest that, at least in Somalia, Kenya, and Ethiopia, which have Health 116 (1). Available
certain areas, children are being diagnosed borne the brunt of the Horn of Africa’s at: https://www.ncbi.
nlm.nih.gov/pmc/articles/
with and succumbing to cholera at rates drought crisis. PMC8812730/#

below their share of the population. In

Malawi, for instance, more deaths have
occurred in people over the age of 50.4
However, the data we have on children
is limited in many countries, and children
remain at elevated risk for wasting and
severe acute malnutrition—two deadly
effects of cholera epidemics, especially
in areas with widespread food insecurity,
which is the case in much of the ESA
region. Because of this, UNICEF has
continued to prioritize the management
of nutrition and cholera comorbidities in
cholera treatment units, while underscoring
the importance of early treatment and
rehydration in the community, especially for
A young boy collects what little water he can from a dried up river due to severe
children under five. drought. Dollow, Somalia. © UNICEF/UN0607653

2
A father attending to his child who is being treated for cholera at Area 18 Health Centre, Lilongwe, Malawi. © UNICEF Malawi/UN0792851

Meanwhile, in southern Africa, Cyclone catastrophic flooding and an explosion of

Freddy — which is currently under review cholera.7
by the World Meteorological Organization
6 World Meteorological Or- as one of the longest-lasting and most Given that Cyclone Freddy is currently
ganization (10 March 2023).
“Tropical cyclone Freddy powerful tropical cyclones on record6— active as of mid-March and that cholera
may set new record.”
Available at: https://public.
has caused devastating flooding and is expected to rapidly spread in its wake,
wmo.int/en/media/news/ displacement in Mozambique and Malawi, this call-to-action also includes the
tropical-cyclone-freddy-
may-set-new-record along with destructive winds and heavy requirements needed to respond to the
7 World Meteorologi- rainfall in parts of Zimbabwe and Zambia. ongoing flooding in Mozambique and
cal Organization (26
April 2019). “Another
Over the past few years, cyclones appear to Malawi, the two countries worst hit by the
unprecedented tropical be hitting southern Africa with a frequency cyclone, while prioritizing funding for other
cyclone and flooding hits
Mozambique.” Available at: and intensity that the WMO has referred flood-affected countries. (The situation in
https://public.wmo.int/en/
media/news/another-un-
to as “unprecedented,” particularly after neighboring Zambia and Zimbabwe is being
precedented-tropical-cy- two cyclones struck Mozambique and closely monitored as of mid-March.)
clone-and-flooding-hits-mo-
zambique neighboring countries in 2019, leading to

3
 Priority countries
Because the ongoing flooding brought on
by Cyclone Freddy is a new emergency,
UNICEF is prioritizing four cholera-affected
countries that are either experiencing
flooding, or at risk of flooding, for resource
mobilization: Malawi, Mozambique,
Zimbabwe, and South Sudan. Malawi
currently has the largest cholera outbreak
in the region and, along with Mozambique,
has been hammered by flooding.
Zimbabwe has a history of large cholera
epidemics and is currently dealing with a
nationwide outbreak that is expected to
be adversely affected by Cyclone Freddy.
South Sudan, while not affected by the
cyclone in southern Africa, is nevertheless
struggling with multiple years of extreme
flooding,8 which makes its current outbreak
at risk of quickly worsening (especially
given its weak healthcare system).
8 World Meteorological
Organization (8 September
2022). “State of climate
in Africa highlights water
stress and hazards.” Avail-
able at: https://public.wmo.
int/en/media/press-release/
state-of-climate-africa-high-
lights-water-stress-and-haz-
ards
9 500,000 currently rep-
resents UNICEF’s target.

Cholera Outbreaks in Eastern and Southern Africa (as of 22 March 2023)

Affected Cumulative Cumulative Cumulative Persons in Need Country Priorities

Countries Cases Deaths Cases in 2023

Malawi 54,841 1,684 36,301 4,900,000 Priority

Mozambique 10,841 75 6,483 500,000 Priority

Zimbabwe 159 1 159 2,132,172 Priority

South Sudan 385 1 385 527,000 Priority

Kenya 7,310 114 3,810 4,900,000 --

Somalia 17,498 92 1,845 500,0009 --

Ethiopia 2,095 44 1,203 5,400,000 --

Burundi 193 1 168 46,800 --

Zambia 268 5 228 2,000,000 --

Tanzania 72 3 72 7,007,109 --

South Africa 6 1 6 To come --

TOTAL 93,681 2,023 50,700 28,413,081

© UNICEF Malawi/UN0803549
4
 FUNDING REQUIREMENTS

UNICEF is developing individualized cholera Affected Countries Requirements Funding

Gap
response plans based on the unique conditions
within each affected country. In total, UNICEF Malawi $56,506,159 88%
is appealing for US$ 170,830,332 to provide Mozambique $50,000,000 93%
lifesaving WASH, health, risk communication,
nutrition, child protection, and education services Zimbabwe $8,047,500 100%
to women and children affected by the outbreak. South Sudan $10,338,904 100%
The budgets for both Malawi and Mozambique
Kenya $13,348,197 87%
include requirements to address each country’s
recent cyclone-related flooding, given that flooding Somalia $8,249,617 71%
is a priority compounding risk to the spread Ethiopia $16,630,539 88%
of cholera. UNICEF is currently frontloading
Burundi $2,474,880 85%
its internal core resources to respond to the
emergency on a no-regrets basis. This includes Zambia $1,978,636 100%
new loan and grant financing and repurposed core Tanzania $2,955,900 100%
resources to fast-track procurement needs and
enhanced community outreach. South Africa $300,000 100%

TOTAL US$ 170,830,332 89%

Generous partners have already contributed

US$ 18.3 million to support the cholera
response across eastern and southern
Africa. With those funds, UNICEF has
been able to scale-up the supply of
chlorine for water purification, medicine for
infection prevention and control, and risk
communication messages that emphasize
the importance of early care and treatment
for cholera infections. Unfortunately,
UNICEF has a regional funding gap of 89
per cent, which is limiting UNICEF’s ability
to meet the full requirements of children
and women affected by the crisis. For
UNICEF and its partners to respond quickly
and equitably based on need, especially in
underfunded sectors, flexible resources will
play a critical role.
Emergency water treatment kit in Oromia, Ethiopia to help purify water and make
it suitable for drinking. © UNICEF/UN0800029

5
 ANNEX: UNICEF’s LIFESAVING RESPONSE
UNICEF will continue to approach cholera in the ESA
region with an agility that priorities UNICEF’s core
accountabilities, including WASH, risk communication
and community engagement, health and case
management, child protection, education, nutrition,
and the prevention of sexual exploitation and abuse.
When responding to a public health emergency like
this one, UNICEF often tries to prioritize areas with high
child case fatality rates. However, given the limited
availability of disaggregated data by age, UNICEF is
pursuing an approach that is broad in scope. In order
to manage the compounding impacts of various risks
WASH: Stopping these cholera outbreaks will
depend on improving access to safe drinking
water, sanitation services, and soap for hand
hygiene. In the long-term, improvements
will need to be made to water and sanitation
infrastructure. In Malawi, which has the largest
outbreak, a recent water quality assessment in
the capital city found that 95 per cent of shallow
wells and 70 per cent of boreholes tested positive
for fecal contamination. UNICEF’s lifesaving
WASH response in all affected countries focuses
on breaking the chains of transmission through
the provision of water treatment chemicals to
ensure that 100 per cent of drinking water is
chlorinated, along with soap for handwashing, oral
rehydration solution, and key hygienic messages.
In terms of supplying safe water, UNICEF is
prioritizing health facilities and cholera treatment
units and centers, along with drought-affected
communities that lack water sources.
95 per cent of
shallow wells and 70
per cent of boreholes
tested positive for
fecal contamination
during a recent water
quality assessment in
Malawi’s capital city.
6
and crises, including the potential for cross-border
cholera transmission, UNICEF will continue to support
host governments and partner agencies in monitoring
population movements, especially in areas badly
affected by flooding. UNICEF’s cross-sectoral approach
will focus on lifesaving interventions, and will be fully
integrated in the work of cluster partners. And given the
recurring and accelerating spread of cholera across the
region, UNICEF will be adding a resilience and systems
strengthening component to this document in the
coming months as we monitor and meet the immediate
needs of people today.
Health: Across the ESA region, cholera mortality
is associated with delays in seeking and receiving
quality care. (Field data from Malawi suggests that
as many as 80 per cent of mortalities at cholera
treatment units can be attributed to treatment
delays and barriers related to access.) With this
in mind, UNICEF is supporting the establishment
of community-based oral rehydration points to
manage mild-to-moderate cholera cases, along
with the provision of cholera kits and other
medical commodities. UNICEF is providing high-
performance tents to increase cholera treatment
centres to better manage severe cases, and
supporting the training of healthcare workers to
provide quality case management and infection
prevention and control. UNICEF is also providing
additional support to maintain the continuity
of essential health services during this period,
given the epidemic’s potential to disrupt routine
maternal, newborn, infant, child, and adolescent
care that is the cornerstone of long-term child
survival and wellbeing.
© UNICEF Malawi/UN0789455
 Nutrition: Acute malnutrition and child
wasting are common co-morbidities in countries
experiencing both cholera outbreaks and food
insecurity, as is the case in cholera-affected
countries across eastern and southern Africa.
Because of this, UNICEF is prioritizing lifesaving
nutrition interventions, including nutrition
screenings in all cholera treatment units, referrals
for appropriate services when needed, and the
provision of acute watery diarrhea (AWD) kits, while
emphasizing the importance of infant-and-young-
child-feeding-practices during cholera trainings for
health workers.
Risk Communication and Community
Engagement: To ensure that affected
populations understand the risks of infection
and the importance of early care-seeking,
UNICEF is developing and broadcasting lifesaving
cholera messages and undertaking community
engagement activities in partnership with existing
community structures.10 UNICEF is also integrating
community feedback mechanisms to ensure that
community concerns are properly understood and
rapidly addressed.
Education: UNICEF is distributing water
treatment chemicals and soap for handwashing to
schools in cholera-affected communities, with the
goal of protecting learners and keeping schools
open during the outbreak. In Malawi, UNICEF is
also providing technical support to rehabilitate
boreholes near schools to keep learners safe.
10 The rollout of Tithetse Kolera m’Malawi campaign in Malawi is being integrated into the country’s ongoing COVID-19 Vaccinate My Village campaign, with the goal of lever-
aging already-existing resources allocated to the health sector.
Child Protection and Gender: Public health
emergencies and food insecurity can coincide
with an increase in violence against children and
gender-based violence. Children are often left
out of interpersonal and community engagement
activities, and can be vulnerable to negative
coping practices, including trading sex for food,
teenage pregnancy, contracting HIV, or dropping
out of school, especially in cases where parents or
guardians have fallen ill or died.
To mitigate these risks, UNICEF will continue to
invest in community-based mental health and
psychosocial support, gender-based violence
prevention and response mechanisms, safe and
accessible channels to report sexual exploitation
and abuse by personnel who provide assistance to
affected populations, and appropriate alternative
care arrangements for children without parental or
family care.
In cholera epidemics and similar public health
emergencies, women and girls often contract
infection due to gender roles such as fetching and
treating water, and caring for sick family members.
Men, on the other hand, may be more affected in
certain settings due to work-related exposure and
may suffer more severe illness and death due to
delays in seeking treatment, which we know to
be common based on behavioral studies. While
gender-disaggregated data is not systematically
available across the various countries experiencing
cholera outbreaks in eastern and southern Africa,
UNICEF will remain cognizant of how gender
and age differences can affect exposure, disease
progression, and the division of labor within
families, with the goal of strengthening surveillance
and treatment, and improving prevention and
control efforts. A gendered response is not only an
issue of gender equality, but also critical to ensuring
effective and sustainable interventions.
7
For every child

Whoever she is.

Wherever he lives.
Every child deserves a childhood.
A future.
A fair chance.
That’s why UNICEF is there.
For each and every child.
Working day in and day out.
In 190 countries and territories.
Reaching the hardest to reach.
The furthest from help.
The most left behind.
The most excluded.
It’s why we stay to the end.
And never give up.

For further information,

please contact:

Jelena Jovanovic
Senior Advisor for Regional Partnerships
jjovanovic@unicef.org

UNICEF Eastern and Southern Africa

Regional Office
P.O. Box 44145
Nairobi
Kenya 00100

© United Nations Children’s Fund (UNICEF)

March 2023