Infectious diseases specialist Diyani Dewasurendra is on assignment in South Sudan when the first cholera cases arrive at the hospital. It’s time to act fast!
Every epidemic begins with a suspicion – a sudden rise in illness, recurring symptoms and the first severely ill patients. In crisis zones, infectious diseases can spread at lightning speed. Every minute counts when trying to contain them. The first 72 hours are critical: we need to act fast and strategically to save lives and prevent a disaster.
In 2023, I was on assignment in Malakal, South Sudan, when a cholera outbreak hit...
Cholera response in South Sudan
The first 72 hours are critical.
We need to act fast and strategically to save lives and prevent a disaster. Below are the key steps we took in response to the cholera outbreak in South Sudan:
Nov 2023
Hour 0–12: first signs and initial measures
In a region with limited access to safe water, that’s a red flag. On top of that, it was March – the final month of the dry season. Since November, there had been almost no rainfall and many water sources had dried up. This region often sees no rain at all between November and March.
We knew cholera was a possibility – but we had to be sure.
We collected samples and sent them to the lab. At the same time, we began monitoring case numbers. As soon as the first tests came back positive for cholera, we had to act quickly. The outbreak was now officially confirmed – and every minute counted.
In a region where many people lack access to clean water, a disease like cholera can escalate quickly. One of the most dangerous aspects is that the only available water source is often a river – the same river where animals bathe, where people wash themselves, and from which they drink. In situations like this, contamination with germs can have catastrophic consequences.
Nov 2023
Hour 12–24: isolation and protection measures
We immediately set up a cholera isolation ward at the hospital.
In Malakal, this was especially challenging, as we already had a separate isolation area for measles. We had to ensure that patients with the two highly contagious diseases wouldn’t come into contact and that other patients would remain protected from infection.
At the same time, we started prevention efforts: we installed additional handwashing stations and educated the public about the importance of hygiene and handwashing.
Our health promoters went into surrounding communities to explain the early symptoms of cholera and when to seek treatment. Cholera is a severe diarrhoeal illness and diseases like this are especially dangerous for small children. Though treatable, an infection can lead to death within just a few hours if left untreated.
Nov 2023
Hour 24–48: treating patients and identifying the source
In many parts of South Sudan, there are no wells or pumps – people collect water from rivers or ponds, which are often contaminated.
I remember one situation where a mass cattle die-off occurred and hundreds of carcasses were left lying along the riverbank. Yet people had no choice – they had to continue drinking from the river. Many didn’t realise that the water could be dangerous.
Together with the World Health Organization (WHO) and other partners, we tested the water quality and investigated potential sources of contamination. We knew we couldn’t just treat the disease – we had to prevent more people from getting infected.
That’s why we started distributing clean water. In some villages, we used charcoal filters or chlorine treatment to improve the water supply in the long term. We also installed sanitation facilities like latrines.
Nov 2023
Hour 48–72: vaccination campaign and epidemic control
In addition to treating those already infected, the next major step was vaccination. Cholera can be contained with an oral vaccine – a major advantage, as it allows us to quickly and efficiently vaccinate large groups of people.
Before starting the vaccination campaign for the community, we had to protect our medical teams. Doctors, nurses and support staff are in direct contact with patients, so vaccination is essential for their survival. Only after that could we begin the large-scale rollout for the affected population.
Education also played a crucial role. In crisis areas, people are not generally sceptical of vaccines – but often, they simply don’t know that a vaccine exists. As soon as we explained the purpose and benefits of the vaccine to the first groups, acceptance increased rapidly.
Acting fast saves lives
The first 72 hours of an epidemic determine whether it can be contained or spirals into a disaster. In the case of the 2023 cholera outbreak, we were able to respond quickly and limit the number of cases to 1,471. After 90 days, on May 16th 2023, intervention was closed as the cases decreased significantly and the outbreak was contained.
This outbreak once again showed how crucial are early diagnosis, isolation, identifying the source of infection and fast vaccination. Each of these steps is vital to saving lives.
We work under extremely difficult conditions in crisis zones, but access to vaccines remains one of our most powerful tools in the fight against epidemics. At the same time, we must not forget that long-term solutions – such as access to clean water – are just as important to prevent future outbreaks.
When Every Minute Counts, The First 72 Hours of an Epidemic
Cholera vaccination
Cholera is an acute bacterial infection caused by Vibrio cholerae. It primarily spreads through contaminated water and food, particularly in regions with limited access to clean drinking water and inadequate hygiene infrastructure.
Every year, millions of people become infected with cholera. However, a vaccination can significantly reduce the risk of infection and provide long-lasting protection.
At Doctors Without Borders (MSF), we are actively engaged in the global fight against cholera. We run vaccination campaigns, educate communities, improve access to clean water, sanitation services and provide hygiene kits. And of course, we treat patients with cholera in our treatment centres during outbreaks.
An effective cholera vaccination provides important protection, particularly for people living in or travelling to endemic or high-risk areas. In addition to vaccination, preventive hygiene measures are essential to control the spread of the disease.
Cholera occurs worldwide, with the highest numbers of cases in regions with poor water systems and sanitation. According to the World Health Organization (WHO), up to 4 million people are infected with cholera every year, and up to 140,000 die from its consequences. (See: https://www.who.int/health-topics/cholera).
The disease is particularly prevalent in parts of Africa, Asia, and Latin America. In humanitarian emergencies, such as conflict zones or after natural hazards, the risk of outbreaks increases significantly, as people are often crowded together without access to clean water.
Symptoms of cholera can appear within just a few hours and up to a few days after infection. The disease is characterised by severe watery diarrhoea, which can lead to extreme dehydration, circulatory collapse, and – if left untreated – death.
However, with early treatment using oral rehydration solutions or intravenous fluids, over 99 per cent of patients recover fully.
In our medical projects, we operate specialised cholera treatment centres to care for infected patients and help stop the spread of the disease. These centres are structured to ensure isolation and safe care.
In acute emergencies, our teams can set up these treatment centres within days to respond quickly to outbreaks.
The cholera vaccination is a proven and effective tool for preventing infection. It is administered orally and is considered a live vaccine. The WHO recommends the vaccine for people living in endemic areas or travelling to high-risk regions.
After two doses, the vaccine provides around 85% protection, which remains at approximately 60% after three years. In outbreak situations, a single dose may be administered to protect as many people as possible quickly
The cholera vaccination is generally well tolerated. As with any vaccination, mild side effects may occur – such as stomach discomfort, nausea or diarrhoea.
In rare cases, patients may experience headaches or mild abdominal cramps. People with weakened immune systems or children under one year of age should speak to a GP before receiving the vaccine.
There is currently no useful replacement for the vaccination – the oral vaccine remains the most effective protection.
The World Health Organization strongly supports broader access to cholera vaccination, especially in crisis zones where outbreaks are common and health systems are overwhelmed.
We work closely with the WHO to coordinate vaccination efforts and improve access to vaccines. However, vaccine production remains a major challenge: demand often exceeds supply, particularly in emergencies. Global stock is kept at a level to respond to epidemics, but to not allow preventive campaigns.
Access to the vaccine is especially limited in humanitarian crises. In many cases, vaccines cannot be produced or delivered quickly enough. Logistical hurdles, such as disrupted supply chains or lack of refrigeration, further complicate vaccination campaigns, especially in remote areas.
A limited number of manufacturers and high production costs add to the global supply shortage.
Affordability is also an issue. In Austria, the cholera vaccine costs around 70 euros. While prices vary by country and provider, they remain out of reach for many people worldwide.
We advocate for better distribution and more flexible vaccination strategies, working with governments and the WHO to improve access to vaccines for all.
MSF is active worldwide in the fight against cholera. In 2023 alone, our teams supported the administration of over 36,000 cholera vaccinations in various countries.
In addition, we treated more than 70,000 cholera patients and distributed clean water to help prevent further infections.
Beyond emergency care, we work closely with local authorities to develop long-term solutions, including better access to clean water and improved hygiene infrastructure. In many of our project areas – such as in Lebanon and the Democratic Republic of Congo – our mobile teams provide daily education and treatment.
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