Armed conflict and cholera outbreaks: a narrative review of epidemiology, challenges, and responses

Background: Cholera remains a significant global public health threat, with its burden disproportionately affecting regions experiencing humanitarian crises. Armed conflict, through the disruption of infrastructure and governance, creates ideal conditions for cholera transmission. This narrative review synthesizes evidence on the epidemiological patterns, underlying challenges, and response strategies of cholera outbreaks in conflict settings. Methods: A systematic search was conducted across PubMed, WHO IRIS, EM-DAT, ReliefWeb, and Google Scholar for studies published from 1990 to the present. Studies were included if they discussed cholera outbreaks in the context of armed conflict, detailed epidemiological patterns, or described outbreak responses. A six-step thematic analysis was employed to identify and synthesize key themes from the included literature. Results: Thirty-six studies were included. The analysis identified six interrelated themes: (1) the breakdown of public health infrastructure; (2) acute vulnerabilities in refugee and internally displaced person (IDP) camps due to overcrowding and poor WASH (Water, Sanitation, and Hygiene); (3) the role of political instability and the weaponization of health infrastructure; (4) critical delays in surveillance and response; (5) the influence of environmental factors; and (6) the challenges of coordinating interventions. Findings from countries like Yemen, Sudan, and Syria demonstrate that conflict is a primary catalyst for outbreaks, leading to recurrent epidemic waves and protracting crises. Response efforts are often hampered by aid obstruction, politicization, and a reactive focus on case management over prevention. Conclusions: Cholera outbreaks in conflict zones are not incidental but are direct and predictable consequences of war. Effective control requires an integrated approach that combines rapid deployment of oral cholera vaccines (OCVs) with sustainable WASH interventions. However, long-term solutions depend on rebuilding infrastructure, ensuring neutral humanitarian access, and strengthening local health systems. Ultimately, addressing cholera in conflict is as much a political challenge as a public health one, necessitating greater accountability and adherence to international humanitarian law.