Cholera prevention and control in refugee settings: Successes and continued challenges

Cholera has long been viewed as a serious threat for refugee populations [1, 2]. In the 1980s and 90s, refugee camps proliferated in Africa and Asia as a result of large civil wars and environmental disasters. These camps experienced large-scale cholera outbreaks with regularity because of overcrowding, scarce clean water, and poor sanitation and hygiene practices [2–4]. Death rates were often high because of preexisting malnutrition, comorbidities, and limited access to medical care. With appropriate clinical management, cholera mortality can be well below 1%, but it can be as high as 50%–60% without proper care [3, 5–7]. During this time, humanitarian organizations developed a variety of guidelines and standards to reduce morbidity and mortality during cholera outbreaks in these populations [8, 9]. Mobilization around these issues was greatly accelerated in 1994, when a particularly massive outbreak occurred among Rwandan refugees in the Lake Kivu region of Zaire (now the Democratic Republic of the Congo), and approximately 42,000 people died [10]. In response to this unprecedented tragedy, the humanitarian community developed and adopted the Sphere standards for the minimum acceptable living conditions and availability of health services in refugee camps and other humanitarian responses [11]. Since this time, the Sphere standards have been updated, and additional coordinating systems have been developed, including the cluster approach to humanitarian response, the Transformative Agenda, and the adaptation of United Nations High Commissioner for Refugees’ (UNHCR) refugee coordination in the context of the Transformative Agenda [12–14]. With the recent goal to reduce cholera deaths 90% by 2030 set by the Global Task Force on Cholera Control, there is a renewed urgency to examine successes and address remaining gaps in cholera control [15]. Although refugee camps continue to experience many vulnerabilities, the increased focus on improved camp coordination, preparedness, timely multisectoral response, and adherence to minimum standards has resulted in a notable decrease in the number and size of camp-based cholera outbreaks and associated mortality.