Navigating the Cholera Elimination Roadmap in Zambia - a Scoping Review (2013-2023)

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Abstract Background Cholera outbreaks are increasing in frequency and severity, particularly in Sub-Saharan Africa. Zambia, committed to ending cholera by 2025, is coming off its most significant outbreak in 2024. This review examines the perceived regression in elimination efforts by addressing two questions: (1) what is known about cholera in Zambia; and (2) what are the main suggested mechanisms and strategies to further elimination efforts in the region? Methodology/Principal Findings A scoping literature search was conducted in PUBMED to identify relevant studies published between January 2013 and June 2024 using the search terms ‘cholera’ and ‘Zambia’. We identified 45 relevant publications. With the increasing influence of climate change, population growth, and rural-urban migration, further increases in outbreak frequency and magnitude are expected. Major risk factors for recurrent outbreaks include poor access to water, sanitation, and hygiene services in urban unplanned settlements and rural fishing villages. Interventions are best planned at a decentralized, community-centric approach to prevent elimination and reintroduction at the district level. Pre-emptive vaccination campaigns before the rainy season and climate-resilient WASH infrastructure are also recommended. Conclusions/Significance The goal to eliminate cholera by 2025 was unrealistic as evidence points to the disease becoming endemic. Our findings confirm the need to align health and WASH investments with the Global Roadmap to Cholera Elimination by 2030 through a climate-focused lens. Recommendations for cholera elimination, including improved access to safe drinking water and sanitation, remain elusive in many low-income settings like Zambia. Patient-level information on survival and transmissibility is lacking. New research tailored to country-level solutions is urgently required. Insights from this review will be integrated into the next iteration of the National Cholera Control Plan and could be applicable to other countries with similar settings. Article Summary Despite known evidence of the risks from insufficient safe water supplies, sanitation and hygiene (WASH), the protective effects of oral cholera vaccines, and a Roadmap from the Global Task Force on Cholera Control, there is a continuous increase in cholera outbreaks on the continent. Now endemic in many parts of Zambia, it is postulated that the true burden of cholera in the country is underreported due to inadequate completeness of data, particularly during outbreaks. With an increasing frequency related to climatic conditions and unplanned urbanization, it will be important to adopt a decentralised approach to cholera control in Zambia. There is a continued need to advocate strongly for multisectoral interventions aligning health and WASH investments. The findings expose gaps in the local literature, such as how to improve climate-resilient WASH infrastructure, strategies to boost vaccine availability, and also the host and environmental factors that may be protective at personal and household levels from being asymptomatic or dying of cholera. This work provides evidence-based recommendations for the next iteration of the National Cholera Control Plan for Zambia and for neighbouring countries that may be in the process of developing their own plans.

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