Zambia's battle against cholera outbreaks and the path to public health resilience: a narrative review

Cholera, an ancient adversary of public health, persistently underscores the quintessential need for clean water and sanitation access worldwide (Morris 2011). This formidable disease is caused by the bacterium Vibrio cholerae and manifests through severe diarrhea and dehydration (Keen & Bujalski 1992). Cholera is a bacterial infection that affects humans, and its etiological agent is V. cholerae, a gram-negative bacteria. Cholera is mainly transmitted through the fecal-oral route (contaminated hands, ingestion of contaminated food or water) (Ganesan et al. 2020).

Cholera poses an immediate threat to public health, especially in communities lacking robust health infrastructure (Keen & Bujalski 1992). Despite significant strides made in the fight against cholera over the years, the world has witnessed a resurgence of the disease beginning in 2021 (WHO 2022). It is estimated that cholera affects over a million individuals annually globally (Gulumbe & Danlami 2022; WHO 2023).

In 2015, it was estimated that the annual number of cholera cases was 1.3–4.0 million, which led to 21,000 to 143,000 deaths globally (Ganesan et al. 2020). Cholera is endemic in South and Southeast Asia, Sub-Saharan Africa (SSA), and some parts of South America (Ganesan et al. 2020). For instance, countries like Afghanistan and Syria have been overwhelmed by substantial outbreaks, and in 2023, more than half of the countries across the globe reporting cholera cases were in Africa (Gulumbe & Danlami 2022; WHO 2023). SSA accounts for most of the cases of cholera in Africa (Ali et al. 2015). Cholera outbreaks have been reported in Zimbabwe, Kenya, Nigeria, Mozambique, Zambia, and many other countries within SSA (Ali et al. 2015). In Zambia, the first cholera outbreak was recorded in 1977, and outbreaks have been reported in subsequent years (Olu et al. 2013).

Zambia is an inland country in Southern Africa located between latitudes 8° and 18° south and longitudes 22° and 34° east of the equator, covering a total area of 752,612 km. It shares its border with Tanzania, Zimbabwe, Angola, the Democratic Republic of the Congo (DRC), Namibia, Malawi, and Mozambique (Sasaki et al. 2009; Mwaba et al. 2020). Since 1977, Zambia has experienced cholera outbreaks during the rainy season, which runs from between November and April (Sasaki et al. 2009). In 2024, Zambia grappled with its most severe outbreak in 20 years and faced challenges in its vaccination campaign due to heightened global demand for vaccines and limited supplies (Rigby et al. 2024). Zambia's experience with cholera has been marked by fluctuating case numbers and dramatic increases since 1977 (Olu et al. 2013).

Yet, the recent outbreak eclipses prior occurrences in both mortality and morbidity, setting a new precedent in the country's public health challenges. The recent outbreak in Zambia, as of 21 February 2024, with over 19,719 confirmed cases and 682 deaths (Ministry of Health Zambia 2024), highlights the severity of this ongoing challenge. Most of the cholera cases that were reported in 2024 were from the capital city, Lusaka. Other provinces where a high number of cholera cases and outbreaks have been reported in the Southern, Copperbelt, and Northern provinces (Ministry of Health Zambia 2024). Lusaka and other densely populated areas have borne the brunt of the crisis, revealing the critical link between cholera's spread and socio-economic disparities. This situation has catalyzed both national and international response efforts, including substantial support from the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF), leading to the distribution of over 1.5 million doses of the oral cholera vaccine (Muyebe 2024; WHO 2024). Such collaborative measures accentuate the global health community's dedication to combating cholera. However, the outbreak's magnitude has sharply highlighted the fragility of Zambia's public health infrastructure, underscoring the urgent need for systemic improvements to enhance resilience against future health threats.

The path toward resilience in public health necessitates a comprehensive approach. This involves not only immediate outbreak response efforts but also long-term investments in water and sanitation infrastructure, enhanced disease surveillance systems, and community-based hygiene education. Additionally, it requires addressing the broader socio-economic factors that underlie health disparities, recognizing that diseases like cholera are deeply entwined with issues of social injustice. The 2024 cholera outbreak in Zambia, therefore, serves as a critical learning opportunity for global health governance. It highlights the imperative for a proactive global health system, capable of not only responding to but also anticipating and mitigating public health threats through comprehensive infrastructure, education, and equitable resource allocation.

The primary aim of this narrative review is to conduct a thorough examination of Zambia's recurring cholera outbreaks, focusing on assessing the effectiveness and challenges of the public health responses deployed. Insights from this analysis will be used to suggest strategic and enduring methods to bolster public health system resilience, both within Zambia and in comparable settings worldwide. This discourse aims to illuminate the complex relationship between public health strategies and cholera control efforts, highlighting the critical need for robust infrastructure, active community involvement, and proactive health governance. Ultimately, this review seeks to contribute to the global conversation on managing and preventing infectious diseases, offering valuable insights for policymakers, health professionals, and stakeholders engaged in public health planning and interventions.

To gain a comprehensive understanding of the cholera outbreaks and management in Zambia, a meticulously curated selection of sources was utilized, encompassing peer-reviewed journal articles, governmental and non-governmental reports, and publications from global health agencies. Searches were conducted using key databases such as PubMed, Google Scholar, and specific public health organization websites. A general search strategy was enriched by keywords including ‘cholera prevention effectiveness,’ ‘public health responses,’ ‘Zambia,’ ‘epidemic control,’ ‘community health strategies,’ and ‘cholera vaccination impacts.’ This review focused on literature published in English from the year 2000 onwards to capture the most recent and relevant data reflecting the current dynamics and challenges in public health related to cholera. Additionally, a specific search on cholera outbreaks in Zambia was conducted on two databases, i.e., Google Scholar and PubMed. The search was conducted using the keywords ‘Cholera’, ‘Outbreak’, and ‘Zambia’. The search on Google Scholar yielded 26 results, while that on PubMed yielded 51 results. Only articles published in English that specifically address cholera outbreaks in Zambia were included. Articles describing outbreaks in other countries and/or published in other languages other than English were excluded. After excluding duplicates, articles published before 2000, and articles irrelevant to this study, a total number of 30 articles on cholera outbreaks were selected for this study.

The selected literature was rigorously analyzed to identify patterns, trends, and critical gaps that could inform future public health initiatives and influence policy-making. This involved a detailed examination of the methodologies and conclusions of key studies to assess the robustness and effectiveness of various public health practices in cholera management, particularly prevention strategies.

The synthesis aimed to create a narrative that presents a comprehensive overview of historical and contemporary public health responses to cholera outbreaks in Zambia. The review specifically focused on the effectiveness of prevention programs, discussing the biological and socio-economic dimensions of cholera and how these factors have influenced the success of public health strategies. It also critically evaluated the interaction between these strategies and broader health determinants, highlighting the complexities and challenges inherent in managing such outbreaks.

The findings are synthesized to articulate a detailed examination of the successes and limitations of past and present public health strategies, with particular emphasis on prevention measures. The concluding report contextualizes the Zambian experience within a global health framework, offering insights into the lessons learned and their relevance to similar epidemiological settings. This section not only underscores the achievements and shortcomings of existing strategies but also proposes recommendations for enhancing public health resilience against cholera and other related health threats. It suggests avenues for strategic improvements in prevention programs, informed by the synthesis of the gathered literature, and emphasizes the need for robust, scalable solutions to bolster public health defenses globally.

The years devoid of cholera cases, notably 1984–1988 (Olu et al. 2013), 1994–1995 (Olu et al. 2013), 2013–2015 (WHO 2017), and 2020–2021 (Olu et al. 2013), perhaps reflect the triumphs of public health endeavors, infrastructural advancements, or other mitigating factors. Conversely, years with mild outbreaks, such as 1977, 1978, and 1982 (Olu et al. 2013; WHO 2017), hint at the partial success of health interventions or less favorable conditions for cholera's spread. However, the chronicle of significant outbreaks highlights the recurrent challenge cholera poses to Zambia. The escalation from 44 cases in 1989 to a crisis peaking with 13,154 cases in 1991, alongside substantial outbreaks in the late 1990s and early 2000s (Olu et al. 2013; WHO 2017), delineates a severe public health quandary.

Transitioning to the post-2019 era, a noteworthy hiatus in outbreaks ensued, attributable to the cholera preventive measures ingrained within Zambia's Multi-sectoral Cholera Elimination Plan (OCHA 2023). This strategic pause underlines the endemic nature of cholera in Zambia while highlighting the efficacy of concerted public health interventions aimed at disease management and prevention. The resurgence in 2022, with 16 reported cases, albeit mild, reiterates the constant vigilance required to combat cholera (OCHA 2023).

The most recent outbreak, spanning from October 2023 to February 2024, with an alarming 19,719 cases (Ministry of Health Zambia 2024), marks a pivotal moment in Zambia's public health narrative. This outbreak, the worst in recent decades, signals an urgent need for a reassessment of strategies and a reinforced commitment to cholera prevention (Muyebe 2024). It emphasizes the continuous threat that cholera poses, challenging the gains made over the years and emphasizing the imperative for sustained, innovative public health strategies to combat this enduring menace.

Literature on cholera outbreaks in Zambia was analyzed and studies were grouped into eight thematic areas as shown in Table 1. The thematic areas are (1) geospatial distribution pattern of cholera outbreaks, (2) prevention of and response to cholera outbreaks, (3) sources, risk factors and transmission of V. cholerae during outbreaks, (4) characterization of V. cholerae isolates collected during outbreaks, (5) monitoring of strains and antibiotic resistance among isolates collected during outbreaks, (6) vaccination conducted during cholera outbreaks, (7) rapid diagnosis during cholera outbreaks, and (8) general epidemiology and description of cholera outbreaks. The information obtained from these studies is presented in Table 1.

Cholera outbreaks in Zambia have demonstrated recurrent patterns, with variability in both severity and geographic distribution. These outbreaks are influenced by a range of environmental and infrastructural factors that exacerbate the spread of V. cholerae. In this section, we outline the principal characteristics of cholera outbreaks since the 1990s, detailing their seasonal occurrence and spatial determinants. The current outbreak, which began in October 2023, is analyzed in comparison to previous outbreaks, with a focus on its unprecedented scale and rapid geographic spread. The findings provide crucial insights into the persistent vulnerability of certain regions and populations, underlining the need for targeted interventions and improved public health strategies.

Cholera outbreaks in Zambia since 1990 have demonstrated significant variability in both intensity and frequency. Major outbreaks, such as the 1991 peak with 13,154 cases, were followed by intermittent periods of lower incidence or no cases, notably between 1994–1995 and 2013–2015. Factors influencing these fluctuations include environmental conditions, public health interventions, and socio-economic challenges. The implementation of Zambia's Multi-sectoral Cholera Elimination Plan after 2019 led to a temporary pause in outbreaks, but cholera reemerged in 2022 with 16 reported cases. The most severe outbreak occurred between October 2023 and February 2024, with 19,719 cases, underlining the persistent threat cholera poses and the need for continuous vigilance and robust public health measures.

This historical and current data on cholera outbreaks in Zambia underlines the successes and setbacks in the ongoing struggle against cholera, highlighting the need for robust, adaptable public health frameworks capable of preempting future outbreaks. The tale of cholera in Zambia is not merely one of recurrent outbreaks; it is a testament to resilience, the evolution of public health strategies, and the unwavering quest for a future where cholera no longer threatens the nation's well-being. Additionally, the emergence of antibiotic resistance among V. cholerae isolates during outbreaks is also posing serious threats to public health.

Studies have shown that V. cholerae isolated from clinical, food, and environmental samples during cholera outbreaks demonstrate resistance to clinically relevant antibiotics (Mwape et al. 2020). For instance, among the isolates from the 2016 cholera outbreak, 98% (51/52) were resistant to nalidixic acid and 60% (31/52) to ampicillin (Mwape et al. 2020). Another study reported that V. cholerae serogroup O1 isolates during eight cholera outbreaks between 1990 and 2004 showed a low level of resistance (2–3%) to tetracycline. However, an increase in resistance to tetracycline (95%), chloramphenicol (78%), doxycycline (70%), and trimethoprim–sulphamethoxazole (97%) was observed in subsequent outbreaks. Similarly, a multidrug-resistant plasmid was found to encode tetracycline resistance in strains from the 1996/1997 outbreak, while strains from 2003/2004 were resistant to furazolidone (Mwansa et al. 2007). The emergence of antibiotic resistance among V. cholerae isolates is a public health threat as it may become difficult to treat cholera infections (Dixit et al. 2014).

This historical and current data on cholera outbreaks in Zambia underlines the successes and setbacks in the ongoing struggle against cholera, highlighting the need for robust, adaptable public health frameworks capable of preempting future outbreaks. The tale of cholera in Zambia is not merely one of recurrent outbreaks; it is a testament to resilience, the evolution of public health strategies, and the unwavering quest for a future where cholera no longer threatens the nation's well-being. Additionally, it is important to note that there were disparities in the surveillance and reporting of cholera cases and fatalities over the decades. In some years, insufficient data were available to calculate accurate mortality rates, as not all outbreaks had both confirmed case numbers and death counts reported consistently. This variability in data reporting, influenced by differences in healthcare infrastructure and surveillance systems, may have impacted the accuracy of the figures reflecting the evolving capacity of the public health system during this period. We have taken this into consideration in our analysis.

It has been reported that weather conditions influence the proliferation of V. cholerae in aquatic environments and increase contamination of food and water sources (Mengel et al. 2014). The occurrence of cholera outbreaks has been associated with the hot and rainy seasons in parts of Africa such as Zanzibar, DRC, Angola, Senegal, Cameroon, Zimbabwe, Nigeria, and Zambia (Mengel et al. 2014). Changes in weather and climate, such as heavy rainfall and flooding, may lead to contamination of water supplies, draining of sewage into rivers and lakes, and increased runoff from latrines or pit toilets, which then subsequently contaminates shallow and uncovered wells. Outbreaks of cholera in Zambia have mainly occurred in the rainy season, often between October and February (Sasaki et al. 2009). This correlates with what has been reported in Senegal, Cameroon, and Zimbabwe (Mengel et al. 2014).

Similarly, in Zambia, climate-related events, such as floods and natural disasters, have contributed to a surge in cholera cases, highlighting the significant role climate change plays in the spread of the disease (Alliance for Science 2024). Mweetwa Mudenda, a climate change and public health expert at Lusaka Apex Medical University, emphasizes the need for greater efforts to address the health risks linked to climate change. He notes that the effects of climate change reach beyond individual health, influencing community resilience, social cohesion, and sustainable development. ‘Understanding the impact of climate change on the health sector is crucial for developing effective public health strategies,’ he said (Alliance for Science 2024).

In Zambia, cholera outbreaks have mainly originated from the peri-urban areas within urban areas. For instance, in Lusaka, cholera outbreaks mainly originate from peri-urban areas that are characterized by overcrowding and poor water, sanitation, and hygiene (WASH). Intermittent availability of municipal water leads to the use of water from unprotected water sources, such as shallow wells. Additionally, the peri-urban areas of Lusaka are also characterized by a high density of pit latrines; hence, the risk of cross-contamination of groundwater is high (Nanzaluka et al. 2020). The limestone karst geology of Lusaka City also allows contaminants to flow unfiltered into the aquifer, increasing the risk of fecal contamination of groundwater (Nanzaluka et al. 2020). Cholera outbreaks have also been linked to proximity to waterbodies and border towns. Cholera outbreaks have been in fishing camps and other locations near water bodies (Sasaki et al. 2009). Districts near the border with the DRC, Tanzania, Mozambique, and Zimbabwe have been identified as high-risk districts for cholera outbreaks. This demonstrates that the cross-border movement of people may contribute to cholera endemicity in Zambia (Mwaba et al. 2020).

Outbreaks have frequently been reported in urban areas in Lusaka, Central, and Copperbelt provinces (Sasaki et al. 2009). In the 2005–2006 cholera season, 6,045 cases and 148 deaths (Case Fatality Rate = 2.45%) were reported between 26 August 2005, and 9 April 2006. V. cholerae O1 biotype El Tor Ogawa was confirmed at the University Teaching Hospital and Lusaka District Health Management Team laboratories, with confirmation rates of 68 and 71% for the 2003–2004 and 2005–2006 seasons, respectively (Gama et al. 2017). In another study involving fishing camp dwellers, rectal swabs were collected from three confirmed cases, and 73 suspected cases were identified, with 76% of cases from Chienge district. Interviews with 60 patients revealed that 27% did not use soap for handwashing, and 75% used stagnant water. Fecal contamination was found in 7 of 12 tested water points. V. cholerae O1, serotype Inaba, was isolated from the samples (Gama et al. 2017).

Studies have shown that V. cholerae isolated from clinical, food, and environmental samples are demonstrating resistance to clinically relevant antibiotics (Mwape et al. 2020). For instance, among the clinical isolates collected from stool and rectal swabs from the 2016 cholera outbreak, 98% (51/52) were resistant to nalidixic acid and 60% (31/52) to ampicillin (Mwape et al. 2020). Another study reported that V. cholerae serogroup O1 isolates during eight cholera outbreaks between 1990 and 2004 showed a low level of resistance (2–3%) to tetracycline. However, an increase in resistance to tetracycline (95%), chloramphenicol (78%), doxycycline (70%), and trimethoprim–sulphamethoxazole (97%) was observed in subsequent outbreaks. Similarly, a multidrug-resistant plasmid was found to encode tetracycline resistance in strains from the 1996/1997 outbreak while strains from 2003/2004 were resistant to furazolidone (Mwansa et al. 2007). The emergence of antibiotic resistance among V. cholerae isolates is a public health threat as it may become difficult to treat cholera infections (Dixit et al. 2014).

The current cholera epidemic in Zambia has resulted from a complex interaction of variables ranging from socio-economic circumstances to a lack of adequate sanitation infrastructure. This is a general analysis based on past trends and typical causes of cholera outbreaks. Contaminated water sources and poor sanitation are frequently associated with cholera. In Zambia, cholera outbreaks occur in areas with poor access to sanitary facilities and clean water. Urban areas are more vulnerable, especially informal settlements that are crowded and unhygienic. Improper food handling and handwashing are two examples of inadequate hygiene practices that have aided the spread of cholera. Campaigns to raise awareness and provide education about good hygiene are essential to containing outbreaks. High rainfall, flooding, and inadequate drainage have made it easier for cholera bacteria to contaminate water sources, which increases the disease's transmission. These risks have been made worse by environmental degradation and climate variability. Frequent migrations from rural to urban areas and high population densities have hastened the spread of cholera both within communities and between regions. One of the most important ways to lessen the effects of outbreaks is to have access to healthcare services, which include quick diagnosis and treatment of cholera cases. Response efforts may be hampered by inadequate personnel, a deficient medical supply chain, and a weak healthcare infrastructure. Poverty, socio-economic inequality, and restricted access to basic services have made most of the community members in Zambia more susceptible to cholera epidemics (Gething et al. 2023).

This latest data suggest that, while the spread of cholera has been swift, the public health response is having a significant impact, as evidenced by the high discharge rate. However, the persistent new cases signify that cholera remains a considerable threat, and the situation requires ongoing, aggressive public health interventions to manage effectively.

The geographical spread across the high-density regions, specifically the Lusaka, Central, and Copperbelt provinces, and the affected fishing camps/districts, underlines the endemic nature of cholera in these areas. The seasonal extension of cholera, which traditionally lasts until June, means that the risk of transmission remains high, and these regions will likely continue to be the focal points of the outbreak.

Before advancing to an analysis of the specific factors driving the cholera outbreak in Zambia, it is essential to contextualize the broader framework within which these outbreaks occur. The recurrent nature of cholera in Zambia is not merely a tale of a pathogen and its host but a complex interplay of environmental, socio-economic, and infrastructural dynamics that facilitate the disease's spread. This backdrop sets the stage for understanding the nuanced drivers of cholera outbreaks (Sinyange et al. 2018; Ajayi & Smith 2019; Muyebe 2024), underlining the critical vulnerabilities within the public health system and the environmental conditions that exacerbate the risk of disease transmission. The environmental context of this outbreak is telling. Zambia's cholera cases have surged in specific locales known for their inadequate WASH facilities (Ajayi & Smith 2019). The bacterium finds a conducive environment in the water sources tainted by fecal contamination, a common problem in the unplanned and overcrowded settlements of Lusaka and other affected provinces (Sinyange et al. 2018; Mwaba et al. 2020; WHO 2024). Moreover, seasonal variations, such as the rains, which are often a welcome respite in this region, have instead compounded the crisis by facilitating the spread of the pathogen through flooding and contaminated water supplies (Luque Fernández et al. 2009; Mwaba et al. 2020).

Socio-economically, the regions affected by the outbreak are characterized by high levels of poverty (Muyebe 2024). The disease's burden is thus disproportionately borne by those least equipped to manage its consequences – both in terms of health and economic stability (Ajayi & Smith 2019; Muyebe 2024). In the absence of a robust infrastructure, the rapid urban sprawl has led to the creation of settlements where public health measures struggle to keep pace with the growing population demands, thus exacerbating the risk and spread of cholera.

Infrastructure, or the lack thereof, is a critical determinant in this equation. The absence of a systematic waste management system, coupled with limited access to safe drinking water, creates an almost inevitable cycle of disease proliferation (Phiri et al. 2015; Nanzaluka et al. 2020). The informal settlements, which house a significant portion of the city's population, are particularly susceptible. Here, the convergence of poor living conditions and inadequate public health infrastructure creates a perfect storm for the transmission of cholera (Phiri et al. 2015; Nanzaluka et al. 2020).

The impact of the outbreak is far-reaching, affecting not only the health but also the economic fabric of the nation. Cholera, by its nature, can cripple community functions, halt productivity, and overburden healthcare services (Greenough 2004; Legros 2018). It is a crisis that extends beyond the individual, impacting societal structures and requiring a response that is as systemic as the factors contributing to its spread (Greenough 2004; Legros 2018).

The recent unprecedented outbreak, therefore, is a clarion call highlighting the urgent need to address the environmental, socio-economic, and infrastructural factors that have coalesced to create a public health emergency of this scale in Zambia. It is a stark reminder of the pressing need for comprehensive strategies that do more than just address the symptoms of the crisis but instead tackle the root causes to prevent future outbreaks, thus paving the way toward a more resilient public health framework in the country.

To systematically address the challenges posed by the cholera outbreak, the Zambian government, alongside international partners, enacted a series of strategic interventions (Muyebe 2024; UNICEF 2024; WHO 2024). These interventions include enhanced surveillance and notification systems to track the spread of cholera, improved organization of case management and treatment facilities, and widespread vaccination campaigns targeting at-risk populations. Additionally, efforts were made to improve access to clean water and sanitation, crucial measures to limit contamination. Public education and community involvement initiatives were also prioritized to raise awareness and promote hygiene practices (Muyebe 2024; UNICEF 2024; WHO 2024). Together, these actions form a comprehensive approach to cholera prevention and control in Zambia. The details of these concerted efforts are outlined in text Box 1, which provides an at-a-glance overview of the key components of the outbreak response strategy.

The Zambian government has implemented enhanced surveillance systems to improve the monitoring and reporting of cholera cases. These systems are crucial for tracking the spread of the disease in real time and enabling rapid response efforts. The establishment of an efficient notification framework has allowed health authorities to identify high-risk areas quickly and mobilize resources effectively (Muyebe 2024; UNICEF 2024; WHO 2024). Surveillance is supported by international partners, including the deployment of 23 experts from WHO to assist with case tracking and coordination efforts (WHO 2024).

The organization of cholera case management has been central to Zambia's response strategy. Cholera treatment centers were established in key locations, including the largest facility at the National Heroes Stadium in Lusaka, to provide specialized care for severe cases (UNICEF 2024). The centers are equipped with oral rehydration points, ensuring that mild cases receive prompt care, reducing the burden on hospitals. Medical supplies, including cholera kits, were distributed by the WHO to ensure healthcare facilities were equipped to manage the influx of patients (WHO 2024). Despite the challenges posed by high transmission rates, these organized efforts in case management have been critical in containing the outbreak.

A key component of the response has been the rollout of an oral cholera vaccination (OCV) campaign targeting 1.5 million individuals, particularly in high-risk areas (WHO 2024). The campaign has been carried out in partnership with Gavi, the Vaccine Alliance, and UNICEF, who provided more than 1.4 million vaccine doses, with an additional 200,000 doses approved by WHO to meet increasing demand (UNICEF 2024). This large-scale vaccination effort aimed to reduce transmission and protect vulnerable populations, including health workers. Despite logistical challenges, the vaccination campaign significantly contributed to a 50% reduction in new cases within 3 weeks (Ministry of Health Zambia 2024).

The geographical and temporal dynamics of the outbreak were also influenced by the targeted nature of the vaccination campaign. High-density regions and border areas with high transmission rates, such as Lusaka and the Southern Province, saw a more rapid decline in cases post-vaccination. However, delays in reaching more remote communities contributed to the slower reduction of cases in those areas. The campaign's impact highlights the importance of timely and widespread vaccination coverage in controlling cholera outbreaks and limiting their geographical spread.

Access to clean water and improved sanitation has been critical to limiting the spread of cholera, particularly in high-density and peri-urban areas where contamination is more likely. The Zambian government, with support from international partners, has provided water tanks to affected communities to ensure access to safe drinking water (UNICEF 2024). Additionally, efforts were made to improve waste management and drainage systems to prevent contamination during the rainy season. The importance of these interventions is underscored by the recurring association of cholera outbreaks with poor sanitation and limited access to clean water (Muyebe 2024).

Public education campaigns have been central to Zambia's cholera response, with a focus on raising awareness of hygiene practices and the importance of safe water storage. Information, Education, and Communication (IEC) materials were distributed widely, targeting schools and communities (UNICEF 2024). Training programs, such as the Training of Trainers (ToT) sessions for community-based volunteers (CBVs), were launched to ensure local capacity to manage oral rehydration points and provide community-based care (WHO 2024). Community involvement was also fostered through feedback mechanisms and public service announcements, which aimed to ensure compliance with health advisories and encourage proactive participation in prevention efforts (Muyebe 2024).

These strategic interventions highlight the importance of a coordinated and comprehensive approach to public health emergencies, combining immediate interventions with long-term strategies for prevention.

In response to recurrent cholera outbreaks, Zambia has strategically implemented a series of prevention and containment measures. These measures seamlessly integrate immediate medical responses with sustained public health initiatives, forming a comprehensive approach to epidemic management. Key interventions have included widespread vaccination campaigns, enhancements in WASH practices, and the establishment of rapid response teams. Following the implementation of these strategies, several studies have been conducted to assess their effectiveness and overall impact on public health outcomes.

The Euvichol-plus oral cholera vaccine's effectiveness, as rigorously evaluated by Sialubanje et al. (2022) during the 2017/2018 outbreak in Lusaka, demonstrated a high efficacy rate. They reported an adjusted odds ratio of 81.0% for full vaccination (95% CI 66.0–78.0%; p < 0.01), and 74.0% effectiveness for partial vaccination (95% CI 50.0–6.0%; p < 0.01), showcasing substantial efficacy in controlling the disease. Poncin et al. (2018) further explored the operational aspects of this vaccination campaign, noting that approximately 424,100 doses were administered to a target population of 578,043, achieving an estimated coverage of 73.4%. The campaign was not only effective in drastically reducing new cholera cases but also cost-effective, with an expenditure of only $2.31 per dose, which included a mere $0.41 for local delivery. Ferreras and colleagues emphasized the direct protective impact of the vaccine, observing no significant bias from healthcare-seeking behavior in their results (Ferreras et al. 2020).

Despite the notable successes of these interventions, such as the high efficacy of the Euvichol-plus oral cholera vaccine and the relatively low cost of the vaccination campaigns, there remain areas that require improvement. Challenges persist in maintaining comprehensive WASH infrastructure, particularly in underserved regions, and ensuring that public health systems are agile enough to respond to outbreaks in a timely manner. While the vaccination campaigns have significantly reduced cholera cases, gaps in coverage and logistical hurdles in reaching remote areas need to be addressed.

The recent cholera outbreaks in Zambia have provided valuable insights into the effectiveness of various prevention and containment strategies. Building on the theme of effective public health practices, DuBois et al. (2006) underlined the significance of hygiene in controlling transmission. Their study found that the presence of hand soap was a strong protective factor against cholera – observed in 90% of control homes compared to 58% of case homes. This study also pointed to the potential role of foodborne transmission of cholera and suggested further research into local dietary factors, including a specific type of local fish that might have protective properties against the disease.

The effectiveness of rapid response strategies was vividly illustrated by Mwambi et al. (2016) in their analysis of the 2016 cholera outbreak in Northern Zambia. They documented that the outbreak, which affected 66 individuals, eight of whom were laboratory-confirmed for strain 01 Ogawa, was contained within 24 days with a case fatality rate of 4.5% (3/66). This swift and decisive action was pivotal in curtailing the spread of the outbreak, demonstrating the importance of preparedness and rapid mobilization.

Ajayi and Smith's review of strategic response strategies and modeling approaches provides a broader context for understanding the dynamics of epidemic control and the importance of tailored interventions based on specific outbreak characteristics and local conditions (Ajayi & Smith 2019). Their insights contribute to a comprehensive understanding of how a coordinated approach that combines vaccination, rigorous public health education, prompt outbreak response, and ongoing research into transmission dynamics can effectively manage and prevent cholera outbreaks, ensuring public health resilience in Zambia.

These studies collectively illustrate the complex yet effective array of strategies employed to combat cholera in Zambia. They underline the importance of a coordinated approach that combines vaccination, rigorous public health education, prompt outbreak response, and ongoing research into transmission dynamics to effectively manage and prevent cholera outbreaks.

While Zambia has implemented a range of effective prevention and containment strategies to manage cholera outbreaks, the disease remains a recurring public health issue. This persistence highlights the need for continual evaluation and enhancement of these strategies to ensure they adapt to changing conditions and effectively address the root causes of cholera's persistence in the region. This requires taking a multifaceted approach to prevention, preparedness, response, and recovery. This is a strategy for dealing with cholera outbreaks that build resilience. Building public health resilience, particularly in the wake of the cholera outbreak in Zambia, necessitates a comprehensive approach that transcends immediate crisis management. The outbreak has starkly illuminated the vulnerabilities within the country's health and sanitation infrastructure, pointing toward an urgent need for systemic change (Muyebe 2024). Strengthening the health system, enhancing WASH initiatives, fostering community engagement, and developing robust infrastructure are pivotal to preempting future outbreaks. This discourse aims to outline strategies and offer concise policy recommendations to fortify public health resilience in Zambia.

Central to enhancing public health resilience is the fortification of the health system (Muyebe 2024). This involves increasing the capacity of health facilities, ensuring the availability of essential medicines, and improving disease surveillance systems. Training healthcare workers in outbreak response and management is imperative, as is the integration of digital health technologies for real-time disease tracking and reporting (Mustafa et al. 2023). Establishing a national stockpile of essential medical supplies and vaccines can significantly reduce response times in future outbreaks.

Enhancing the infrastructure for WASH and maintaining safe water supply systems, encouraging appropriate waste disposal, and guaranteeing hygienic practices in communities are all essential components of improving access to clean water and adequate sanitation facilities (Hutton & Chase 2017). The cholera outbreak underlined the critical role of WASH initiatives in disease prevention (Muyebe 2024; UNICEF 2024). Access to clean water, adequate sanitation facilities, and the promotion of good hygiene practices are foundational to preventing waterborne diseases. Investment in WASH infrastructure must be prioritized, with a focus on rural and underserved urban areas (Muyebe 2024). Public health campaigns should promote handwashing, safe water storage, and the use of latrines, alongside the construction of community water points and sanitation facilities.

Community engagement is crucial for the successful implementation of public health measures. Empowering communities with knowledge about disease prevention and control fosters a culture of health and hygiene (Cyril et al. 2015). Community-based programs can facilitate the dissemination of health information, encourage the adoption of safe practices, and mobilize local resources for health initiatives. Establishing feedback mechanisms where communities can express their health concerns and needs ensures that interventions are responsive and tailored to the local context.

The development of robust health and sanitation infrastructure is essential for long-term resilience (Gulumbe et al. 2023). This includes the construction and maintenance of water treatment facilities, sewage systems, and healthcare facilities that are equipped to manage outbreaks. Infrastructure development should be guided by environmental sustainability and resilience to climate change, considering the increasing frequency of extreme weather events that can exacerbate the spread of waterborne diseases.

To mitigate future outbreaks and build public health resilience, the following policy recommendations are proposed:

• 1. Increase funding for public health: Allocate increased government and international funding for public health initiatives, focusing on WASH projects, health system strengthening, and infrastructure development.

• 2. Implement comprehensive disease surveillance: Enhance disease surveillance systems to enable early detection and response to outbreaks. This includes investing in digital health technologies and training for healthcare workers in epidemiological tracking.

• 3. Promote intersectoral collaboration: Foster collaboration between health, water, and sanitation sectors, alongside environmental and educational departments, to ensure a coordinated approach to public health.

• 4. Prioritize education and awareness campaigns: Implement ongoing public health education campaigns to raise awareness about disease prevention, focusing on hygiene practices, water safety, and the importance of vaccination.

• 5. Strengthen legal and regulatory frameworks: Develop and enforce regulations related to water quality, waste management, and public health. This includes revising building codes to ensure WASH facilities are incorporated into all public and private buildings.

• 6. Invest in research and development: Support research into waterborne diseases, vaccine development, and public health interventions to inform evidence-based policies and practices.

• 7. Encourage community-based health initiatives: Support the development of community health programs that empower local populations to participate in health promotion and disease prevention activities.

• 8. Tailoring cholera prevention and control programs must be tailored to local epidemiological, sociodemographic, and climatic characteristics.

Building public health resilience in Zambia requires a strategic integrated approach that addresses the root causes of vulnerability to disease outbreaks. Through strengthening the health system, enhancing WASH initiatives, fostering community engagement, and developing robust infrastructure, Zambia can mitigate the impact of future public health crises. These strategies, underpinned by targeted policy changes and interventions, are essential for safeguarding the health and well-being of the Zambian population.

The recurring outbreaks of cholera in Zambia have served as a poignant reminder of the fragility of public health systems in the face of emerging infectious diseases. This crisis has highlighted the critical intersections between health, infrastructure, and socio-economic conditions, highlighting the complex nature of public health resilience. The response to the outbreak, while robust and comprehensive, revealed essential lessons in the importance of preparedness, community engagement, and the need for sustainable infrastructure to prevent future health emergencies. The strategies delineated throughout this discourse – ranging from strengthening the health system, enhancing WASH initiatives, and fostering community engagement, to developing robust infrastructure – offer a blueprint for building a more resilient public health framework. These interventions are not just about responding to the immediate crisis but are fundamental to preempting future outbreaks and safeguarding the health and well-being of the Zambian population. Policy recommendations aimed at increasing funding for public health, implementing comprehensive disease surveillance, promoting intersectoral collaboration, and investing in research and development, are critical steps toward a resilient health system. The importance of education and awareness campaigns, alongside the strengthening of legal and regulatory frameworks, cannot be overstated. Moreover, the encouragement of community-based health initiatives represents a vital approach to empowering local populations in disease prevention and health promotion activities. The cholera outbreak in Zambia is a stark illustration of the broader challenges facing public health globally. As we move forward, the lessons learned from this outbreak must inform future strategies, ensuring that resilience becomes a cornerstone of public health policy and practice. Building public health resilience is a complex, ongoing process that requires commitment, collaboration, and innovation. Embracing a comprehensive and forward-thinking strategy, Zambia can navigate the path toward a healthier, more resilient future, setting a precedent for public health efforts worldwide.

All relevant data are included in the paper or its Supplementary Information.

The authors declare there is no conflict.