{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,7]],"date-time":"2026-09-07T11:26:32Z","timestamp":1788780392373,"version":"build-2803163510"},"reference-count":35,"publisher":"Public Library of Science (PLoS)","issue":"6","license":[{"start":{"date-parts":[[2025,6,5]],"date-time":"2025-06-05T00:00:00Z","timestamp":1749081600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosntds.org"],"crossmark-restriction":false},"short-container-title":["PLoS Negl Trop Dis"],"abstract":"<jats:p>Cholera remains a significant public health challenge in Africa, with the continent recording the highest Case Fatality Ratio of 1.9% among all regions from 2014 to 2023. Despite ongoing efforts, the true burden of cholera is substantially underestimated due to poor quality and incomplete data. This article aims to review the factors contributing to the underestimation of cholera in Africa and explore potential solutions to better characterize the disease epidemiology and burden on the continent. We drew on our field experiences and existing literature to identify the key factors responsible for cholera underestimation in Africa. We also propose strategies to improve cholera surveillance and reporting. We identified several factors contributing to cholera underestimation, including weaknesses in the Integrated Disease Surveillance and Response system, insecurity due to conflict situations, limited healthcare access, and the politicization of cholera outbreak data. We propose a comprehensive approach to address these challenges, including strengthening disease surveillance, adopting digital technologies to improve data collection and management, improving healthcare access, increasing public awareness and enhancing community engagement and participation in cholera reporting, and fostering political commitment to transparent data reporting. We urge African ministries of health and public health stakeholders to increase their commitment to and investment in strengthening cholera data management on the continent.<\/jats:p>","DOI":"10.1371\/journal.pntd.0013128","type":"journal-article","created":{"date-parts":[[2025,6,5]],"date-time":"2025-06-05T17:32:05Z","timestamp":1749144725000},"page":"e0013128","update-policy":"https:\/\/doi.org\/10.1371\/journal.pntd.corrections_policy","source":"Crossref","is-referenced-by-count":3,"title":["Unmasking and tackling the underestimation of the cholera burden in Africa: A viewpoint"],"prefix":"10.1371","volume":"19","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6832-873X","authenticated-orcid":true,"given":"Olushayo Oluseun","family":"Olu","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sylvester","family":"Maleghemi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adebola","family":"Olayinka","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Argata Guracha","family":"Guyo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Solomon Fisseha","family":"Woldetsadik","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1839-5664","authenticated-orcid":true,"given":"Ida-Marie","family":"Ameda","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chinwe","family":"Iwu-Jaja","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amos","family":"Petu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abdulmumini","family":"Usman","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2025,6,5]]},"reference":[{"key":"pntd.0013128.ref001","author":"Global Taskforce on Cholera Control","year":"2017"},{"issue":"1","key":"pntd.0013128.ref002","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2024-016168","article-title":"An assessment of the progress made in the implementation of the regional framework for cholera prevention and control in the WHO African region","volume":"10","author":"F Kapaya","year":"2025","journal-title":"BMJ Glob Health"},{"issue":"3","key":"pntd.0013128.ref003","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2020-044615","article-title":"Model-based estimation of the economic burden of cholera in Africa","volume":"11","author":"V Mogasale","year":"2021","journal-title":"BMJ Open"},{"key":"pntd.0013128.ref004","article-title":"Cholera in Africa: a closer look and a time for action","author":"ED Mintz","year":"2013","journal-title":"J Infect Dis"},{"key":"pntd.0013128.ref005","unstructured":"World Health Organization. Cholera in the WHO African Region. AFRO-Cholera Monthly Bulletin-July 2024.pdf"},{"issue":"1","key":"pntd.0013128.ref006","article-title":"Exploring the burden of cholera in the WHO African region: patterns and trends from 2000 to 2023 cholera outbreak data","volume":"10","author":"EL Koua","year":"2025","journal-title":"BMJ Glob Health"},{"issue":"8","key":"pntd.0013128.ref007","doi-asserted-by":"crossref","first-page":"521","DOI":"10.1016\/S1473-3099(07)70138-X","article-title":"The true burden and risk of cholera: implications for prevention and control","volume":"7","author":"JN Zuckerman","year":"2007","journal-title":"Lancet Infect Dis"},{"key":"pntd.0013128.ref008","first-page":"117","article-title":"Cholera outbreaks in Africa","volume":"379","author":"MA Mengel","year":"2014","journal-title":"Curr Top Microbiol Immunol"},{"issue":"6","key":"pntd.0013128.ref009","article-title":"Updated global burden of cholera in endemic countries","volume":"9","author":"M Ali","year":"2015","journal-title":"PLoS Negl Trop Dis"},{"issue":"6","key":"pntd.0013128.ref010","doi-asserted-by":"crossref","first-page":"1085","DOI":"10.4269\/ajtmh.2009.09-0400","article-title":"High mortality in a cholera outbreak in western Kenya after post-election violence in 2008","volume":"81","author":"O-T Shikanga","year":"2009","journal-title":"Am J Trop Med Hyg"},{"issue":"1","key":"pntd.0013128.ref011","doi-asserted-by":"crossref","first-page":"22","DOI":"10.1186\/s42522-021-00052-9","article-title":"Twenty years of integrated disease surveillance and response in Sub-Saharan Africa: challenges and opportunities for effective management of infectious disease epidemics","volume":"3","author":"IR Mremi","year":"2021","journal-title":"One Health Outlook"},{"issue":"5","key":"pntd.0013128.ref012","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pntd.0004679","article-title":"Cholera incidence and mortality in sub-Saharan African sites during multi-country surveillance","volume":"10","author":"D Sauvageot","year":"2016","journal-title":"PLoS Negl Trop Dis"},{"key":"pntd.0013128.ref013","article-title":"Cholera surveillance and estimation of burden of cholera","author":"D Ganesan","year":"2020","journal-title":"Vaccine"},{"key":"pntd.0013128.ref014","doi-asserted-by":"crossref","first-page":"11786329231211964","DOI":"10.1177\/11786329231211964","article-title":"The chronic cholera situation in Africa: why are African countries unable to tame the well-known lion?","volume":"16","author":"OO Olu","year":"2023","journal-title":"Health Serv Insights"},{"key":"pntd.0013128.ref015","unstructured":"ACAPS Analysis Hub. Ethiopia2014drivers of the cholera outbreak. 2024. 20240118_ACAPS_thematic_report_Ethiopia_drivers_of_cholera_outbreak.pdf"},{"key":"pntd.0013128.ref016","author":"World Health Organization African Regional Office","year":"2019"},{"issue":"2","key":"pntd.0013128.ref017","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0245457","article-title":"Systematic review of Integrated Disease Surveillance and Response (IDSR) implementation in the African region","volume":"16","author":"CM Wolfe","year":"2021","journal-title":"PLoS One"},{"issue":"1","key":"pntd.0013128.ref018","doi-asserted-by":"crossref","first-page":"131","DOI":"10.1093\/heapol\/czt097","article-title":"Challenges with the implementation of an Integrated Disease Surveillance and Response (IDSR) system: systematic review of the lessons learned","volume":"30","author":"RK Phalkey","year":"2015","journal-title":"Health Policy Plan"},{"issue":"3","key":"pntd.0013128.ref019","article-title":"A systematic review on improving implementation of the revitalised integrated disease surveillance and response system in the African region: a health workers\u2019 perspective","volume":"16","author":"AKS Ng\u2019etich","year":"2021","journal-title":"PLoS One"},{"issue":"4","key":"pntd.0013128.ref020","article-title":"Integrated Disease Surveillance and Response (IDSR) strategy: current status, challenges and perspectives for the future in Africa","volume":"4","author":"IS Fall","year":"2019","journal-title":"BMJ Glob Health"},{"issue":"12","key":"pntd.0013128.ref021","doi-asserted-by":"crossref","first-page":"2472","DOI":"10.3201\/eid2812.212398","article-title":"Association between conflict and cholera in Nigeria and the Democratic Republic of the Congo","volume":"28","author":"GEC Charnley","year":"2022","journal-title":"Emerg Infect Dis"},{"key":"pntd.0013128.ref022","author":"World Bank","journal-title":"FY25 List of Fragile and Conflict-affected Situations."},{"issue":"13","key":"pntd.0013128.ref023","doi-asserted-by":"crossref","DOI":"10.3201\/eid2313.170446","article-title":"Real-time surveillance in emergencies using the early warning alert and response network","volume":"23","author":"KM Cordes","year":"2017","journal-title":"Emerg Infect Dis"},{"key":"pntd.0013128.ref024","unstructured":"World Health Organization. The status of health in the WHO African Region. State of health in the African Region.pdf"},{"issue":"1","key":"pntd.0013128.ref025","doi-asserted-by":"crossref","first-page":"99","DOI":"10.1186\/s40249-016-0192-z","article-title":"Assessment of the response to cholera outbreaks in two districts in Ghana","volume":"5","author":"S-A Ohene","year":"2016","journal-title":"Infect Dis Poverty"},{"issue":"12","key":"pntd.0013128.ref026","doi-asserted-by":"crossref","first-page":"6078","DOI":"10.1097\/MS9.0000000000001470","article-title":"Stigma and infectious diseases in Africa: examining impact and strategies for reduction","volume":"85","author":"PO Omosigho","year":"2023","journal-title":"Ann Med Surg (Lond)"},{"key":"pntd.0013128.ref027","first-page":"1","article-title":"Whose health matters: trust and mistrust in humanitarian crisis and global health interventions","volume-title":"Handbook of Global Health","author":"A Steinke","year":"2020"},{"issue":"6","key":"pntd.0013128.ref028","doi-asserted-by":"crossref","first-page":"1007","DOI":"10.1016\/0277-9536(96)00083-4","article-title":"\u201cI\u2019m not dog, no!\u201d: cries of resistance against cholera control campaigns","volume":"43","author":"MK Nations","year":"1996","journal-title":"Soc Sci Med"},{"issue":"11","key":"pntd.0013128.ref029","first-page":"1358","article-title":"Impediments to global surveillance of infectious diseases: consequences of open reporting in a global economy","volume":"78","author":"RA Cash","year":"2000","journal-title":"Bull World Health Organ"},{"issue":"8051","key":"pntd.0013128.ref030","doi-asserted-by":"crossref","first-page":"623","DOI":"10.1038\/s41586-024-08564-w","article-title":"Artificial intelligence for modelling infectious disease epidemics","volume":"638","author":"MUG Kraemer","year":"2025","journal-title":"Nature"},{"issue":"1","key":"pntd.0013128.ref031","doi-asserted-by":"crossref","first-page":"36","DOI":"10.1016\/j.imed.2022.10.003","article-title":"Application of big data and artificial intelligence in epidemic surveillance and containment","volume":"3","author":"Z Jiao","year":"2023","journal-title":"Intell Med"},{"issue":"1","key":"pntd.0013128.ref032","doi-asserted-by":"crossref","first-page":"120","DOI":"10.1186\/s12992-020-00652-6","article-title":"Integrating the social sciences in epidemic preparedness and response: a strategic framework to strengthen capacities and improve Global Health security","volume":"16","author":"KL Bardosh","year":"2020","journal-title":"Global Health"},{"key":"pntd.0013128.ref033","first-page":"120","article-title":"The ebola virus disease outbreak in West Africa: a wake-up call to revitalize implementation of the international health regulations","volume":"4","author":"OO Olu","year":"2016","journal-title":"Front Public Health"},{"issue":"12","key":"pntd.0013128.ref034","first-page":"2869","article-title":"Community participation in primary healthcare in the South Sudan Boma Health Initiative: a document analysis","volume":"11","author":"L Belaid","year":"2022","journal-title":"Int J Health Policy Manag"},{"issue":"6","key":"pntd.0013128.ref035","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2018-001312","article-title":"Joint external evaluation of the International Health Regulation (2005) capacities: current status and lessons learnt in the WHO African region","volume":"4","author":"A Talisuna","year":"2019","journal-title":"BMJ Glob Health"}],"container-title":["PLOS Neglected Tropical Diseases"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pntd.0013128","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,6,5]],"date-time":"2025-06-05T17:32:16Z","timestamp":1749144736000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pntd.0013128"}},"subtitle":[],"editor":[{"given":"Ben","family":"Pascoe","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2025,6,5]]},"references-count":35,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2025,6,5]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pntd.0013128","relation":{},"ISSN":["1935-2735"],"issn-type":[{"value":"1935-2735","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,6,5]]}}}