Cholera in Nigeria: a five-decade review of outbreak dynamics and health system responses

Abstract

Background

Cholera remains a significant public health concern in Nigeria, with recurrent outbreaks over the past five decades. Despite advancements in healthcare, the country continues to record high case fatality rates, largely due to inadequate water, sanitation, and hygiene (WASH) infrastructure, poor health systems, climate variability, and conflict-induced displacement.

Objective

This review aimed to examine the historical trends of cholera in Nigeria, identify key drivers of outbreaks, evaluate government and international responses, and recommend strategic measures for prevention and control.

Methods

A comprehensive analysis was conducted using historical outbreak data, peer-reviewed literature, and reports from national and international health agencies. The study focuses on outbreaks from 1970 to 2024, highlighting epidemiological trends, response strategies, and systemic challenges.

Results

Cholera has persisted as an endemic disease in Nigeria, with major outbreaks recorded in 1991, 2010, and 2021. Case fatality rates often exceeded the World Health Organization’s (WHO) recommended threshold of < 1%, indicating systemic deficiencies in outbreak response and healthcare delivery. Contributing factors include poor sanitation, limited access to clean water, underfunded healthcare infrastructure, and weak surveillance systems. Climate change and population displacement due to conflict have further exacerbated the risk of transmission.

Conclusion

Nigeria’s approach to cholera control remains reactive, with limited progress in sustainable prevention. Multi-sectoral strategies including improved WASH infrastructure, enhanced surveillance, local vaccine production, and community-based interventions are essential to achieving the WHO 2030 cholera elimination goals.

Introduction

Cholera is still a major worldwide health concern and a sign of an impoverished society. Gram-negative Bacillus Vibrio cholerae of serogroups 01 and 0139, is the cause of this severe diarrheal illness, which has a significant morbidity and fatality rate [1–4]. Since the disease first emerged in Nigeria in 1970, cholera has been frequent nationwide. The 1991 outbreak was the worst, with 59,478 cases and 7,654 deaths, with a case fatality rate of 12.9% [5]. Less than 1% is the baseline case fatality rate recommended by the World Health Organization (WHO); in Nigeria, this percentage primarily varied between 1% and roughly 4% [5]. The high prevalence in 1991 was caused by extremely inadequate sanitation and hygiene practices, followed by little to no surveillance, little community involvement, and no education about the disease’s risks [5].

The Northern region of Nigeria experienced the start of a large epidemic in 2010 that was noted for its high incidence of confirmed cases (3,000) and fatalities (781). A little over ten years later, Nigeria reported the largest number of suspected cases of cholera in recent memory, about 100,000 [6, 7]. As a result, between January and July 2021, the Nigerian Center for Disease Control (NCDC) recorded 111,062 cases of cholera and 3,604 deaths in the nation. These amounts were higher than those stated in 2020. More recently, outbreaks of cholera were reported in several Nigerian locations [6, 7]. According to the NCDC report, since January, the nation has reported 4809 suspected cases and 156 suspected deaths (CFR = 3.2%) throughout 35 states as of July 21, 2024 [8].

However, Nigeria remains highly vulnerable to recurring cholera outbreaks due to factors such as lack of access to clean water, flooding, poverty, illiteracy, inadequate healthcare, poor sanitation infrastructure, and displacement caused by conflict; all of which are worsened by weak disease surveillance following outbreaks [5]. Past epidemics have often occurred during natural disasters or armed conflict, where humanitarian crises limit access to food, water, and healthcare, promoting the spread of cholera [7, 9].

Despite these obstacles, much progress has been made in reducing cholera outbreaks through targeted interventions, such as WASH interventions, the introduction of a cholera vaccine, the use of polymerase chain reaction tests for cholera confirmation, the political involvement of important nations, and the resuscitation of the Global Task Force on Cholera Control (GTFCC), which aims to reduce cholera deaths by 90% by 2030 [10–14]. Therefore, the current outbreak is unfolding amid severe economic and social challenges, bringing it close to crisis levels. In times of hardship, people become more susceptible to disease, particularly the poorest, who struggle with hunger, malnutrition, and limited access to healthcare. These conditions have significantly contributed to the spread of cholera in Nigeria [15]. This study aims to examine the trends of cholera outbreaks in Nigeria from 1970 to 2024 and to identify public health measures necessary to prevent future occurrences.

Methods

The data for this study were gathered from Google Scholar, Pubmed, and African health journals. Grey literature from WHO, NCDC, and other public health related organizations was utilized. The search criteria include Cholera, epidemiology, associated risk factor, public health challenges and efforts, and Nigeria. All articles relevant to this study were reviewed and used to write this quality paper.

Historical overview of cholera outbreaks in Nigeria (1970–2010)

Cholera has been endemic in Nigeria since the 1970s, with outbreaks occurring frequently, especially during the rainy season [16, 17]. However, data from 1970 to 2010 remain incomplete due to under-reporting, limited diagnostic capacity, and weak surveillance systems, particularly in rural areas with poor health infrastructure [2, 18]. Inconsistencies in reported cases are also caused by the lack of standardized case definitions, inadequate laboratory confirmation, and the absence of a centralized data reporting system. Additionally, smaller or sporadic outbreaks often go unrecorded until they escalate into larger epidemics [16, 18].

Over the decades, Nigeria has experienced varying magnitudes of outbreaks, with major epidemics documented in 1970–1971, 1991, 1995–1996, 1999, and 2010. Over this period, the case fatality ratio (CFR) showed a gradual decline, indicating some progress in health response efforts [16, 18]. The earliest significant cholera outbreak recorded during 1970–1971 resulted in 22,931 cases and an estimated CFR of 12.8% [18]. The most severe outbreak in terms of fatalities occurred in 1991, with 59,478 cases and 7,654 deaths, translating to a CFR of 12.9%, the highest in the four-decade period under review [16, 18]. In 1999, another serious outbreak began in Kano State, spreading to Adamawa and Edo states, resulting in 26,358 cases and 2,085 deaths (CFR: 7.9%) [16, 18]. Several other outbreaks, while smaller in scale, were also significant. For instance, between December 1995 and May 1996, Kano State reported 5,600 cases and 340 deaths, with an overall CFR of 6.1% [18, 19]. In 2001, 2,050 cases and 80 deaths were documented (CFR: 3.9%) [18]. From 2008 to 2009, there were 18,831 cases and 678 deaths (CFR: 3.6%) (Table 1) [18].

Table 1.

Summary of data on the significant reported cases, mortality, and case fatality rate of cholera in Nigeria by reporting year, 1970–2010 [2, 16, 18, 19]

Period	Reported Cases	Reported Deaths	CFR (%)
1970–1971	22,931	2,935	12.8
1991	59,478	7,654	12.9
1995–1996	5,600	340	6.1
1999	26,358	2,085	7.9
2001	2,050	80	3.9
2008–2009	18,831	678	3.6
2010	41,787	1,716	4.1

Note: Death counts for 1970–1971, 2001, and 2008–2009 were derived from the reported CFR using the formula:

The 2010 outbreak marked the most extensive cholera epidemic in Nigeria since 1991, affecting 18 states. It resulted in 41,787 cases and 1,716 deaths, yielding a CFR of 4.1% [2, 16]. This figure exceeded both the average CFR of 2.4% reported across Africa between 2000 and 2005 and the WHO’s recommended maximum CFR of 1% [2]. The outbreak highlighted persistent deficiencies in disease surveillance and response, particularly in low-income communities where children were most affected [2, 16]. Although the number of cholera cases varied from year to year, the CFR showed a downward trend from the peak of 12.9% in the early 1990s to approximately 4.1% by 2010 [16]. The 1991 outbreak remains the deadliest, while the 2010 epidemic was the most widespread regarding geographic coverage [16]. This decline suggests some progress in public health responses and case management. However, data quality issues, ongoing under-reporting, and limited diagnostic capacity continue to hinder reliable assessment and timely interventions [16, 18].

Cholera outbreak in Nigeria (2010–2024): a detailed examination

Despite cholera being endemic in Nigeria, data from 2010 to 2024 remain incomplete with some year data reports missing due to under-reporting, limited diagnostic capacity, weak surveillance systems and inconsistent case definitions. These challenges, particularly in rural areas, result in inaccurate records, with smaller outbreaks often going unreported until they escalate into epidemics [2, 16, 18]. Between 2010 and 2024, Nigeria experienced multiple cholera outbreaks, marked by significant morbidity and mortality. In 2010, 41,787 cases and 1,716 deaths were reported, resulting in a CFR of 4.1% [16]. The 2014 outbreak involved 35,996 suspected cases and 755 deaths (CFR 2%) across 19 states and the Federal Capital Territory (FCT), with Kano State being notably affected [20]. In 2015, there were 5,290 cases and 186 deaths (CFR 3.5%), with Ebonyi State recording a particularly high CFR of 8.6% [20, 21]. The 2016 outbreak saw 768 cases and 32 deaths, with a CFR of 4.17% [18], while the 2017 outbreak involved 1,198 cases and 32 deaths (CFR 2.67%) [18]. In 2018, one of the most severe outbreaks of the decade occurred, with 42,466 cases and 849 deaths, resulting in a CFR of 2%. Kano remained a major hotspot during this period [21]. In 2019, 1,583 cases and 22 deaths were recorded (CFR 1.38%) [16], and in 2021, the country experienced its largest outbreak to date, with 111,062 suspected cases and 3,604 deaths (CFR 3.2%) across 33 states and the FCT. Kano, Bauchi, and Zamfara states were the most affected [7]. The 2022 outbreak accounted for 23,763 cases and 592 deaths (CFR 2.5%). By December 24 of that year, Yobe, Borno, and Jigawa states alone had reported 7,700 cases and 324 deaths [7, 16]. In 2023, 3,683 cases and 128 deaths were reported, resulting in a CFR of 3.5% [16]. By mid-2024, 1,579 cases and 54 deaths (CFR 3.4%) had been reported across 32 states. This figure rose to 4,809 cases and 156 deaths (CFR 3.2%) by July 21, across 35 states (Table 2) [16]. However, as of December, 2024 Nigeria recorded 19,452 suspected cases, 711 death with a case fatality rate of 3.7% [22]. Despite an overall reduction in CFRs from 12.9% in the 1990s to 3.7% in 2024 owing to an improvement in cholera management over the years, Nigeria’s cholera fatality rates still remain above WHO’s recommended threshold of less than 1%, underscoring persistent gaps in case management [2, 20, 23].

Table 2.

Trends of cholera outbreaks from the years 2010–2024

Year	Total reported cases	Total reported deaths	CFR(%)	Reference
2010	41,787	1,716	4.1	16
2014	35,996	755	2.0	20
2015	5290	180	3.5	20,21
2016	768	32	4.17	18
2017	1,198	32	2.67	18
2018	42,466	849	2.0	21
2019	1583	22	1.38	16
2021	111,062	3604	3.2	7
2022	23,763	592	2.5	7,16
2023	3683	128	3.5	16
2024	19,452	711	3.7	22

Note: Death counts for 2016, 2017 and 2018 were derived from the reported CFR using the formula:

Comparative perspective: Nigeria’s cholera burden in the African context

Since the cholera outbreak began in 1970, Nigeria has fought hard to contain it. Despite persistent challenges, Nigeria’s reported cholera case fatality rate has significantly declined by 2024. Compared to other African nations, these notable responses and case management to cholera outbreak especially in high-risk states in Nigeria are significantly having a greater impact.

For instance, similar to Nigeria, central Africa (Democratic Republic of the Congo (DRC) and neighboring countries), eastern Africa (Mozambique), and west Africa (Chad, Cameroon, Niger) had the most reported cholera cases between 2000 and 2023. Central and West Africa were found to have the highest CFRs. Between 2000 and 2023, the DRC, Nigeria, Mozambique, Zimbabwe, South Africa, Ethiopia, Angola, and Malawi had the largest cholera burden (Fig. 1). More than 20 cholera outbreaks occurred in Uganda, Nigeria, Zimbabwe, DRC, Kenya, Burundi, and Mozambique. Nigeria has reported a high number of outbreaks (29) but had a lower mortality rate than the DRC (4.8 vs. 13.6), which would suggest a potentially better case management system between 2000 and 2023 [24]. The DRC reported the most cases (588,996; 24%) and deaths (13,877; 22%) during the period. It is also one of the countries that reported the most cholera outbreaks (24) with relatively high incidence and mortality rate, but with moderate lethality. Despite being among the top five countries with the highest number of cases, South Africa has one of the lowest documented fatality rates (0.35) and mortality rates per 100,000 people (0.9), which may indicate improved cholera case management [24].

Fig. 1.

Comparative chart of the burden of cholera across eight most affected countries in Africa between 2000–2023 [24]

Other African countries’ WASH systems varied, which was connected to the cholera outbreak, likewise Nigeria’s inadequate sanitation infrastructure and scarce water supply were major factors in the country’s cholera outbreak [25]. Algeria, Botswana, Mauritius, Cape Verde, Seychelles, and South Africa are among the nations with better access to water and sanitation (high scores for the fundamental variables of access to water and sanitation and low scores for the unimproved and limited WASH variables, low open defecation, and low drinking surface water use). Cameroon, Congo, Gambia, Ghana marked by insufficient access to WASH facilities. The countries with the greatest percentages of open defecation and surface water use and low access to WASH services include Burundi, Central African Republic, Chad, DRC, Eritrea, Ethiopia, Madagascar, Niger, South Sudan, and the United Republic of Tanzania [24].

Nigeria and thirty-two of the forty-seven nations in the WHO African region had included cholera in their IDSR reporting as of 2002. Several nations (Cameroon, Central African Republic, Congo, Eritrea, Gambia, Guinea Bissau, Kenya, Lesotho, Malawi, Mauritania, Niger, Rwanda) have experienced cholera epidemics at some point, despite not having cholera integrated into their surveillance system. Compared to a total of 16 nations that reported cholera suspected using IDSR inconsistently, Nigeria reported consistently with the Integrated Disease Surveillance and Response (IDSR) between 2019 and 2023 [24]. This reveals Nigeria is making significant effort but this effort needs not to be a short term but a long-term commitment in complete eradication of the outbreak and will be more significant with regional collaboration and learning from previous outbreaks.

Contributing factors to cholera outbreaks in Nigeria

Sanitation and clean water: analysis of current access to clean water and sanitation facilities

Cholera outbreaks in Nigeria are linked to inadequate access to safe water and poor sanitation. Despite abundant water resources, regional disparities in water availability and management contribute to recurrent outbreaks [25]. The Nigerian government, with support from United Nations Children’s Fund (UNICEF) and the Global Task Force on Cholera Control (GTFCC), prioritizes WASHas a key prevention strategy [16]. However, these efforts face persistent challenges.

Access to clean water

Nigeria has substantial water resources, including an estimated 215 billion cubic meters of surface water and 87 billion cubic meters of groundwater, sourced mainly from four hydrological basins (the North Central Plateau, Western Highlands, Eastern Highlands, and Uri Plateau) and major rivers such as the Niger and Benue [26]. Despite this, the country faces economic water scarcity due to inadequate investment and weak management, resulting in unmet demand projected to rise from 5.93 billion cubic meters in 2021 to 16.58 billion cubic meters by 2030 [26, 27].

To address these challenges, government initiatives like the Expanded WASH Strategy (2016–2030) and the National WASH Sector Revitalization Action Plan (2018–2022) have been introduced, alongside a Presidential State of Emergency declaration for the WASH sector [28]. However, funding gaps persist, with only 17% of health sector ($14 million of $83 million) and 1% of WASH sector funding ($612,000 of $92.7 million) met as of August 2021 [7].

Also, frequent power outages limit pipe-borne water supply, forcing reliance on poorly constructed wells that are often contaminated, especially where pit latrines are close to water sources [29]. During droughts, dependence on shared, unsafe water sources increases cholera risk, while rising sea levels exacerbate water quality through saltwater intrusion [30].

Sanitation and hygiene

Sanitation remains a significant challenge in Nigeria, where only 33% of the nearly 200 million population have access to adequate facilities [31]. The World Bank estimates that inadequate sanitation results in an annual economic loss of about N455 billion, equivalent to 1.3% of GDP [31]. Poor environmental sanitation has been a major contributor to waterborne diseases, including cholera [31]. Studies in Southern Nigeria’s urban areas reveal widespread reliance on open defecation due to lack of infrastructure [31]. In 2018, over 60 million Nigerians lacked basic drinking water access, and poor water and sanitation conditions contributed to more than 70,000 deaths annually among children under five [31]. The 2019 National Outcome Routine Mapping of WASH Services (WASHNORM) reported that only 44% of Nigerians had proper sanitation access, with just 16% having safe hygiene facilities [31].

Historical cholera outbreaks have been linked to poor sanitation and contaminated water. For example, in 1982, a water shortage in Katsina forced residents to use contaminated abandoned wells [29], while the 1995–1996 Kano outbreak was traced to unsafe water sold by street vendors, underscoring the need for improved water safety measures [19]. Point-of-use water treatment interventions such as chlorination and safe water storage could have lessened outbreak severity [19].

However, efforts to address sanitation challenges have been initiated, including the USAID-funded WASH program in Kebbi, Sokoto, and Zamfara, with a budget of $9.98 million in the year 2021 [31]. The World Bank has committed $700 million to the Nigeria Sustainable Urban and Rural Water Supply, Sanitation, and Hygiene Program (SURWASH) in 2020 to provide 6 million people with basic drinking water and 1.4 million with improved sanitation services [3124]. The World Bank, in collaboration with its partners, has backed the National Urban Water Sector Reform Program (NUWSRP) to expand access to safe drinking water by establishing more than 2,300 water points and 6,546 sanitation units throughout Nigeria [31]. Despite these efforts, reports show that most Nigerians still do not have access to clean drinking water and proper sanitation services, necessitating continued investments and policy reforms [31]. A complicated humanitarian catastrophe has also been brought about by the ongoing conflict in Northeast Nigeria, which has limited the implementation of WASH initiatives and caused the Lake Chad basin, the region’s main water source, to diminish, making it more difficult to reach some towns [32]. Therefore, it is crucial to close the gap caused by the lack of potable water as well as basic facilities and services for the safe disposal of human wastes like urine and feces if Nigeria is to win the fight against infectious illnesses like cholera [31].

Impact of climate change and extreme weather events on cholera outbreaks

Climate change is a major factor driving cholera outbreaks in Nigeria, as extreme weather events like floods and droughts disrupt water and sanitation systems, facilitating disease transmission [16]. Studies in Katsina’s Funtua area have shown a link between rising temperatures, increased rainfall, and cholera incidence, with outbreaks peaking in August [33]. Research in Kano and Ebonyi States similarly indicates higher case numbers during the rainy season [20, 21]. A wider analysis across Sub-Saharan Africa confirms that cholera outbreaks often peak with heavy rainfall and flooding [34]. However, regional variations exist within Nigeria; in northern areas such as Kano, outbreaks typically coincide with the rainy season, while in southern Calabar, cholera is more common during the dry season and declines when rains begin [1, 18]. These patterns suggest that although seasonality affects cholera transmission, outbreaks can occur throughout the year, making their timing in Nigeria less predictable [1, 35].

Impact of flooding

Flooding has played a significant role in cholera outbreaks in Nigeria. In 2010, severe floods in northern Nigeria displaced approximately 258,000 people, heightening cholera risk due to contaminated water and inadequate sanitation [2]. The floods in Anambra, Kogi, and Niger States in 2018 were also linked to increased cholera transmission and higher case fatality rates [23]. Likewise, the 2022 outbreak in northern Nigeria was primarily attributed to widespread flooding [25]. In 2024, Nigeria saw more rainfall than usual, with extended and heavy downpours that caused extensive flooding in a number of states, notably Adamawa, Borno, and Yobe. A favorable environment for the spread of cholera is created when flooding overwhelms water systems and contaminates drinking water sources with Vibrio cholerae from sewage and other waste materials [30]. Furthermore, the bacterium thrives in stagnant floodwaters, which increases its spread during months with the highest rainfall [36].

Role of rainfall and temperature variability

Statistical analyses indicate that increased rainfall and rising temperatures create favorable conditions for Vibrio cholerae proliferation [33]. In Katsina State’s Funtua area, cholera cases peaked during July to September, coinciding with the heaviest rainfall [33]. Similar patterns were observed in Kano and Ebonyi States, where higher temperatures and rainfall correlated with increased cases [16]. Intense rainfall causes flooding, damages pit latrines, and contaminates water sources, thereby facilitating cholera transmission [33]. Historical data show relatively low cholera incidence from 1985 to 1993, followed by a rise from 1994, peaking in 2013 [33]. Notably, cases were lowest during the severe droughts of the 1980s, underscoring the link between rainfall and outbreaks [33]. The 1996 outbreak deviated from typical seasonality, with peaks in early and late rainfall periods, highlighting the role of seasonal transitions in cholera dynamics [37]. Climate variability and rising temperatures also increase air pollution and extreme weather events, promoting cholera spread through contaminated water and food [33]. Unchecked climate change may expand cholera to new regions, disproportionately impacting vulnerable populations with low immunity [33].

According to data from the Nigeria Meteorological Agency (NiMet), rainfall levels in northern Nigeria rose by 18% during the 2022 rainy season when compared to the 10-year average. In Kano and Jigawa states, which together recorded more than 5000 cholera cases during the same time period, this precipitation rise led to catastrophic flooding [38]. These outbreaks, which made up about 40% of the total nationwide, showed a direct correlation between the frequency of cholera and extreme rainfall. According to a retrospective analysis of cholera outbreaks from 2015 to 2020, months with average temperatures above 30 °C saw a 22% increase in cholera cases. Particularly in semiarid areas like Borno and Yobe, which frequently record high cholera rates during peak hot seasons, this temperature range improves Vibrio cholerae’s survival and multiplication in water sources [36]. States that experienced floods, such as Lagos, Bayelsa, and Adamawa, had cholera case fatality rates (CFR) of up to 4.5%, while the national average was 3.2% [39].

Conflict and displacement: impact of regional conflicts and population displacement on cholera spread

Conflict-induced displacement has played a major role in exacerbating cholera outbreaks in Nigeria, particularly in the northeastern and northwestern regions [7]. Poor cleanliness, frequent travel, and congestion exacerbate the spread of disease in places going through internal crises like social displacement and conflict. These difficulties are made worse by inappropriate waste management and limited access to necessities like sanitary restrooms, potable water, and wholesome food, which increases instability and health hazards [40].

Case studies of cholera outbreaks in conflict zones

Maiduguri, Borno State (2015): A cholera outbreak in IDP camps resulted in 385 cases and 13 deaths (CFR: 3.4%) due to poor sanitation and movement between the camps and surrounding communities [25].

Borno State (2017): The outbreak predominantly affected IDP camps, with 5,889 cases reported across five local government areas (LGAs), leading to an overall attack rate of 395.3 per 100,000 population [25]. The CFR was 0.87%, with the highest mortality rate among individuals aged 60 years and above [25]. The destruction of critical infrastructure, including health facilities, sanitation systems, and water supplies, exacerbated the crisis [25]. Muna Garage IDP camp was the outbreak’s initial focal point, from where it spread to other LGAs [25].

Adamawa State (2022): Six LGAs, including Yola, reported 135 cases and seven fatalities, with temporary population displacement contributing to water contamination [7]. Yobe State recorded 1,300 suspected cholera cases across 12 LGAs, but no official outbreak declaration was made [7].

Northern Nigeria (2022): Cholera outbreaks were driven by flooding and ongoing conflicts [25]. Over 10,000 probable cases were reported between June and September, with Borno State accounting for 70.13% of the 7,700 cases and 324 deaths across Borno, Adamawa, and Yobe states [25]. Conflict-induced displacement led to limited access to clean water, increased hospitalizations, and a high mortality rate [25].

Northwestern Nigeria (2022): Armed conflicts displaced 455,000 individuals across Katsina, Zamfara, and Sokoto states, with Zamfara and Katsina hosting the highest numbers of IDPs [7]. Kaduna State recorded 196 cholera-related deaths in 2022, highlighting the direct link between insecurity and cholera outbreaks [7].

Risk factors and public health response

Key risk factors associated with cholera outbreaks in conflict zones include the destruction of WASH infrastructure, overcrowding in IDP camps, limited access to healthcare, and poor surveillance [7]. The Nigerian government and international partners, including the NCDC, WHO, and Médecins Sans Frontières (MSF), have implemented Emergency Operations Centers (EOCs) which was a key invention in the 2017 Borno outbreak to coordinate response efforts and implement oral cholera vaccine campaigns, significantly reducing transmission [25]. Case-Area Targeted Interventions (CATIs) have been effective in reducing cholera clustering by providing targeted interventions to affected households and their neighbors [25]. During the 2010 cholera outbreak, the Nigerian Institute of Medical Research Emergency Response Team (NIMRERT) provided laboratory support to improve disease detection and containment efforts [7]. However, several factors have limited the effectiveness of the public health response.

Health infrastructure: evaluation of the healthcare system’s capacity to manage cholera

Healthcare providers in Nigeria face numerous challenges in managing cholera, primarily due to constrained resources and fragile healthcare infrastructure [40]. A significant obstacle is the inadequate availability of medical equipment and essential supplies, such as oral rehydration solutions (ORS) and rapid diagnostic test kits, which undermines effective treatment and discourages care-seeking behavior [40]. Laboratory diagnostics are further hindered by a persistent shortage of supplies, as vendors avoid stockpiling due to the sporadic nature of outbreaks and associated financial risks, often resulting in expired inventory [40].

Another key challenge to effective cholera surveillance in Nigeria is poor internet connectivity, which delays timely reporting under the IDSR system, despite the availability of tablets and data collection tools [40]. This issue is more severe in rural areas, where internet access is limited and urban surveillance is generally more efficient [40]. Health workers have emphasized the need for surveillance guidelines in local languages to strengthen community-level response [40]. Additionally, inadequate training and low staff commitment undermine intervention efforts and discourage healthcare-seeking, thereby weakening case reporting [40]. Insecurity, cultural beliefs, and low public awareness further contribute to delays in seeking medical care [40].

Challenges in cholera management

Structural weaknesses in Nigeria’s health system hinder effective cholera response. The concentration of treatment services in urban-based specialist and federal hospitals limits access for rural communities, often resulting in delays and increased reliance on self-medication [40]. Frequent referrals to distant, profit-driven private facilities have further eroded public trust in the health system [40]. Coordination challenges also persist, with fragmented communication among government ministries, departments, agencies (MDAs), and development partners. Competing interests often disrupt activities within emergency operations centers [40]. The national cholera coordination platform is largely inactive outside outbreak periods due to inadequate funding and irregular meetings, leading to poor preparedness. Furthermore, weak communication between MDAs has caused overlapping programs, inefficient resource use, and delays in requesting Oral Cholera Vaccines (OCV) from Gavi via the Global Task Force on Cholera Control (GTFCC) [40].

Government response and the impact of COVID-19

In 2018, Nigeria introduced a five-year National Strategic Plan of Action for Cholera Control, aiming to reduce cases and deaths by 67% by 2023 and eliminate the disease by 2030 [41]. OCV were deployed in high-risk states such as Borno, Bauchi, Yobe, and Adamawa [41]. Following a surge in cases in April 2021, the National Cholera EOC was activated in June 22, 2021, and rapid response teams were deployed [41]. WHO and Gavi supplied over 1.5 million vaccine doses to Bauchi, with 710,212 people vaccinated by July 28, 2021 [41]. While vaccination efforts helped contain outbreaks, sustainable cholera control relies on improved WASH infrastructure [41].

By December 19, 2021, Nigeria had reported 109,189 suspected cholera cases and 3,604 deaths across 32 states and the Federal Capital Territory, with children aged 5–14 being the most affected group. The CFR stood at 3.3%, nearly double that of COVID-19 [41]. In addition, the pandemic disrupted cholera control efforts, including humanitarian programs and surveillance activities [29]. Nigeria faces a severe shortage of healthcare workers, with only four doctors and 16.1 nurses or midwives available per 10,000 people which is far below the WHO’s recommended level of one doctor per 600 patients and 23 healthcare workers per 10,000 people [41]. This shortage significantly hampers healthcare delivery, particularly in underserved and remote areas [41].

Health spending in Nigeria was only 3.03% of GDP in 2023, the country’s lowest since 2002 and among the lowest in Africa [42]. Without long-term investment in healthcare and WASH systems, cholera outbreaks are likely to persist, requiring repeated emergency responses [42]. Despite some improvements, untreated waste and poor sanitation continue to challenge cholera elimination efforts [37]. While health worker training programs have been introduced, significant investment is still needed to strengthen surveillance and response capacity [37].

Multi-sectoral response to cholera outbreak in Nigeria following 2024 outbreak

The WHO, UNICEF, the Federal Ministries of Environment and Water Resources, the National Primary Health Care Development Agency (NPHCDA), and other partners have continued to support affected states through the multi-sectoral National Cholera Technical Working Group, coordinated by the NCDC. This support includes WASH interventions, laboratory services, case management, risk communication, active case finding, and the dissemination of cholera awareness messages in both English and local languages [43].

Case management & health system support

To strengthen case management coordination, the WHO supported the Nigerian government at federal, state, and local levels, providing on-site mentorship to healthcare workers at Cholera Treatment Centers and Units to enhance treatment quality and adherence to protocols. Over 75 medical personnel in high-priority areas received guidance on case management procedures [44]. Additionally, through WHO’s advocacy, UNICEF supplied 500 acute watery diarrhea (AWD) community kits, 100 periphery kits, 500 WASH and dignity kits, antibiotics, and ORS to bolster the health system. Coordination efforts with other local and international partners have also been strengthened to support a unified national response [44].

The EOC in Lagos has coordinated daily cholera response sefforts since June 11, with participation from international partners and relevant ministries [45]. On June 12, the state government deployed Rapid Response Teams composed of health, WASH, and risk communication personnel to local government areas [45]. Federal authorities supported the response by distributing Aquatabs, medical supplies, and hygiene kits to affected communities and health facilities [45]. To reduce mortality associated with delayed treatment, the state launched an information campaign encouraging individuals with diarrhea to seek prompt care, emphasizing that public healthcare services are free [45]. UNICEF provided technical assistance in coordination and information management and supported the training and deployment of 100 health workers across all 20 local government areas in Lagos State for cholera case management and infection prevention and control [45].

Following cholera outbreaks in Adamawa and Yobe States and the flood emergency declared on September 10 in Borno, EOC in all three states became operational and have held regular meetings led by the State Ministries of Health, with participation from NGOs, UN agencies, and government ministries [46]. The government ensured security and appointed camp coordinators in IDP camps [46]. In Borno, UNICEF supported the establishment of a cholera treatment unit (CTU) by the International Rescue Committee (IRC) and facilitated the deployment of ten physicians to the Gubio camp [46]. The number of CTUs in Borno increased to six following the rehabilitation of facilities in Jimtilo and Bama [46]. Additional supplies, including 50 cholera beds, 4 isolation tents, and antibiotics, were delivered to treat 500 cases, and the flood-damaged cold store was refurbished [46]. In Adamawa, UNICEF supported the state’s only CTU with medical supplies, 40 cholera beds, and incentives for 54 ad hoc personnel, while 2 CTUs in Yobe received similar assistance [46].

Oral cholera vaccine (OCV) campaign

With support from UNICEF and WHO, the International Coordinating Group (ICG) provided Nigeria with 4.4 million OCV doses to aid the response to the cholera outbreak in the BAY (Borno, Adamawa and Yobe) states [46]. In Borno State, 992,000 doses were delivered to at-risk populations, resulting in the vaccination of 787,164 individuals, including frontline health workers, children, and caregivers in IDP camps and affected communities [46]. In Adamawa, 469,374 doses were distributed to 200,000 individuals in Yola North and Yola South local government areas [46]. In Yobe State, 412,255 doses were administered across 14 local government areas, reaching 136,095 individuals [46].

Water, sanitation, and hygiene (WASH) interventions

On June 27, UNICEF trained thirty government staff in Lagos on the chlorination of community water sources. Subsequently, water points in five high-risk areas were chlorinated based on a list provided by health authorities [45]. UNICEF’s response has been multi-sectoral, prioritizing WASH interventions. Flexible funding and an additional $2.1 million, including private sector contributions for borehole construction from IHS Towers, have supported flood and cholera response activities in the BAY states. An additional $1.5 million in flexible funding is required to meet growing cholera-related needs [46].

To contain the outbreak, UNICEF implemented the CATI strategy. 42 trained CATI teams composed of multi-sectoral Rapid Response Teams (RRTs) and local NGOs were deployed to affected areas with coordination and technical support provided to WASH authorities. 18 teams were sent to Borno, 16 to Adamawa, and 8 to Yobe [46]. These teams focused on hygiene promotion, disinfection of homes and toilets, testing and chlorinating 396 water sources, and distributing cholera kits to affected and neighboring communities. Hygiene messages reached approximately 35,527 individuals, with 19,151 in Borno, 7,773 in Adamawa, and 8,603 in Yobe [46]. WASH authorities and district-level units received chlorine, aqua tablets, personal protective equipment, and 4,400 WASH and cholera kits. The WASH sector pipeline, which held 8,955 cholera kits by mid-October, supplied materials to NGO partners [46]. To reduce open defecation, 250 emergency latrines were constructed in flood-affected IDP camps. Environmental sanitation activities were also conducted, including the cleaning of 1,036 toilets in IDP camps, with 305 in Borno, 656 in Adamawa, and 75 in Yobe [46].

Risk communication & community engagement (RCCE)

From the onset of the cholera outbreak, UNICEF has primarily supported government-led efforts through technical assistance, with a focus on strengthening community engagement and risk communication strategies [45]. In collaboration with the Lagos State government, UNICEF facilitated the training of 1,194 community mobilizers, including 66 Nigerian Red Cross volunteers, to ensure consistent messaging on cholera prevention, response, and hygiene practices [43]. Approximately 5 million people were reached through 420 radio jingles aired in English, Pidgin, and Yoruba across six radio stations and social media platforms [45].

UNICEF developed and distributed information, education, and communication (IEC) materials such as posters and banners placed in strategic public spaces across 7,520 communities, reaching an estimated 820,000 individuals daily [45]. Additionally, through the ward development committee structure in 376 wards, UNICEF supported the establishment of community feedback mechanisms that facilitated daily interactions with roughly 22,560 people. Most of the 752 comments collected highlighted a need for clearer hygiene guidance and better access to clean water and WASH services [45].

In collaboration with Unilever, UNICEF integrated cholera awareness into short sessions held on university campuses in Lagos and Ogun States, reaching 4,700 young people who committed to promoting preventive measures within their communities [45].

In Borno State, over 1,000 trained volunteer community mobilizers (VCM), with support from UNICEF, conducted door-to-door hygiene promotion, reaching 142,408 individuals [46]. Three community feedback mechanisms (CFM) in IDP camps in Bakassi, Teachers Village, and Gubio received 2,570 responses, ranging from expressions of gratitude to concerns about food distribution. Feedback was shared with relevant stakeholders [46]. A survey involving 298 participants in the BAY states, conducted through the U-Report platform, found that 76% of respondents did not personally know anyone affected by cholera [46].

Future direction

To eliminate cholera by 2030, Nigeria must adopt the strategies outlined in the World Health Organization’s cholera roadmap [47]. This global framework aims to reduce cholera mortality by 90% and eliminate disease transmission in as many countries as possible by focusing on three core areas: timely detection and rapid response to outbreaks, a targeted multi-sectoral prevention approach, and effective coordination for technical assistance, advocacy, resource mobilization, and partnerships at both local and international levels [47]. Central to the cholera epidemic response is the reduction of mortality and transmission. The NCDC has prioritized treatment, care, infection prevention and control, and enhanced surveillance to achieve these goals [48].

Improving surveillance system in Nigeria

Given the endemic nature of cholera in Nigeria, the surveillance system holds significant potential for facilitating early outbreak detection and initiating a coordinated response [49]. Strengthening this surveillance infrastructure remains a central strategy for controlling the disease, particularly due to the multifactorial nature of cholera outbreaks, which are driven by poor hygiene, inadequate environmental sanitation, and the effects of climate change. Enhancing the diagnostic capacity of federal, state, and local health facilities is critical for timely laboratory confirmation of cases. Achieving this objective requires sustained investment in both financial and human resources. Ayenigbara et al. [12] highlighted the importance of robust community engagement, reinforced early warning systems, laboratory capacity, health system preparedness, and the availability of rapid response teams, even in fragile settings like Nigeria. Although collaborative efforts between government and non-governmental actors have been established, further action is needed to prevent future outbreaks. Real-time surveillance, improved reporting mechanisms, and prompt notification remain vital for generating early alerts and enabling rapid intervention, particularly during seasonal surges [47].

Vaccine development and deployment

Vaccination is widely regarded as the most effective method for preventing and controlling infectious disease outbreaks, including cholera. Its timely deployment can significantly reduce the spread and impact of epidemics by facilitating swift containment measures [50]. In Nigeria, insights from social listening conducted by Nigeria Health Watch reveal public concerns about the availability and affordability of cholera vaccines. This underscores the urgent need for accessible, accurate information on immunization, as well as proactive strategies to counter misinformation and disinformation as they emerge [48].

Beyond the immediate benefits of outbreak control, vaccination contributes to long-term disease prevention. The Public-Private Partnership Vaccination Program (PVac) is currently being implemented to improve both the manufacturing and distribution of cholera vaccines, ensuring prompt and efficient responses during public health emergencies [48]. While Gavi is expected to continue supplying a substantial proportion of Africa’s vaccine needs in the near term, its role is projected to decline by 2040 as countries gradually transition toward self-financing of vaccine procurement. This anticipated shift highlights the critical importance of building local capacity.

To maintain adequate vaccine coverage and reduce dependency on external support, Nigeria must invest in domestic vaccine manufacturing. Supporting local producers and promoting sustainable, low-cost manufacturing models will not only secure national supply chains but also enhance regional health security in the long term [51].

Addressing climatic and environmental factors

Effectively addressing the recurrent cholera epidemics in Nigeria requires strengthening public infrastructure, improving climate resilience to prevent flooding, and fostering meaningful community engagement [48]. As climate change continues to alter environmental conditions, proactive and adaptable interventions are increasingly important for protecting public health and preventing future outbreaks [48]. The persistent cholera outbreaks in Nigeria serve as a reminder of the critical relationship between health and climate, highlighting the need for sustained investments in environmentally friendly solutions and cross-sector collaboration [52].

Since inadequate hygiene remains the primary driver of cholera transmission, state health authorities have a significant responsibility in preventing fatalities from this preventable disease. Implementing a multisectoral response based on the One Health approach is essential for reducing the frequency of cholera epidemics. This approach involves providing access to safe water, promoting community involvement, and ensuring continuous health education [48]. Additionally, long-term interventions must address the root causes of the disease, particularly inadequate sanitation and the presence of contaminated water supplies [49].

Prevention is widely recognized as the most effective method for controlling cholera outbreaks. Practical measures such as boiling water for drinking and cooking, disinfecting contaminated surfaces and materials, properly disposing of infected waste including clothing and bedding, treating wastewater from cholera patients, and sterilizing utensils using boiling water or chlorine bleach can significantly reduce the risk of transmission [49]. Health promotion strategies, including public awareness campaigns, are vital to ensure community compliance and participation [49]. Furthermore, deploying additional environmental health personnel to enforce hygiene and sanitation regulations within communities will contribute to the sustained containment of cholera epidemics [49].

Study limitation

This study provides a comprehensive review of cholera in Nigeria, highlighting the interplay of various factors that have contributed to the increasing frequency and scale of outbreaks. It analyzes data spanning from 1970 to 2024 and includes a comparative assessment of Nigeria’s public health response strategies relative to those of other African countries. However, the study is limited by the lack of access to comprehensive datasets from the NCDC and other official government repositories. As a result, the analysis relies solely on publicly available information, which constrains the ability to present a detailed and consistent year-by-year trend of cholera outbreaks across the review period.

Conclusion

Cholera continues to pose a serious public health threat in Nigeria, perpetuated by inadequate WASH infrastructure, weak health systems, poor surveillance, and compounding effects of climate change and armed conflict. Despite national and international efforts, including OCV campaigns and emergency response interventions, the country’s cholera mortality rates remain unacceptably high.

Addressing this challenge requires a shift from reactive to preventive strategies. Strengthening surveillance systems, decentralizing healthcare delivery, investing in local vaccine production, and improving access to safe water and sanitation are critical steps. Moreover, building climate-resilient infrastructure and fostering intersectoral collaboration under the One Health approach will be key to mitigating future outbreaks.

For Nigeria to meet the WHO 2030 targets of reducing cholera deaths by 90% and ultimately eliminating the disease, there must be sustained political commitment, increased funding, and robust community engagement. Cholera is preventable and controllable, but only through coordinated, long-term investment in public health infrastructure and proactive disease control strategies.

Author contributions

TJO: Writing of the original draft, editing, proofreading and compilation of the manuscript. APM: Writing of the original draft, and revising the manuscript. FN: Writing of the original draft and revising of the manuscript. SSY: Writing of the original draft and revising of the manuscript. OAO: Conceptualization, review, editing, proofreading and supervised the work.

Funding

Not applicable.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethical approval

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.