Original Research

A proposed framework for the evaluation of cholera surveillance systems in Africa

Kyeng Mercy, Ganesh Pokhariyal, Noah Takah Fongwen, Nicaise Ndembi, Lucy Kivuti-Bitok

Received: 19 July 2025; Accepted: 10 Oct. 2025; Published: 02 Dec. 2025

Copyright: © 2025. The Authors. Licensee: AOSIS.
This work is licensed under the Creative Commons Attribution 4.0 International (CC BY 4.0) license (https://creativecommons.org/licenses/by/4.0/).

Abstract

Background: Despite the global roadmap to end cholera by 2030, the disease remains a major public health challenge in Africa, compounded by weak surveillance systems, inadequate multisectoral coordination and delayed case detection. A significant impediment is the absence of a comprehensive surveillance evaluation framework for African nations to systematically identify and address these critical capacity deficits.

Aim: This study builds upon prior research that highlighted the wide variations in existing surveillance evaluation frameworks, aiming to propose a comprehensive conceptual framework for assessing cholera surveillance systems in Africa.

Setting: This study focused on empirical data and feedback gathered from eight cholera-affected countries: Democratic Republic of Congo, Nigeria, Zambia, Zimbabwe, Mozambique, Somalia, Kenya, and Ethiopia.

Methods: This was a mixed-method study and leveraged insights from a previous systematic review lasted 7 months (July 2024 to January 2025). The approach involved a detailed assessment of existing frameworks and consultations with eight cholera-affected countries.

Results: The assessment of 10 existing frameworks revealed consistent gaps, notably the absence of essential components such as cross-border surveillance, digitisation, effective linkages between surveillance and laboratory systems, and sustainable financing mechanisms. Our conceptual framework is structured around three key pillars: resource allocation, system structures and core functions, all underpinned by strong governance and leadership.

Conclusion: This study recommends the adaptation and integration of our proposed comprehensive framework into broader surveillance strategies and guidelines to significantly improve cholera surveillance across Africa, thereby enhancing early detection and response capabilities.

Contribution: This study presents a novel comprehensive framework for cholera surveillance system evaluation and recommends its adaptation and integration into broader surveillance strategies and guidelines to significantly improve cholera surveillance in Africa.

Keywords: cholera; surveillance; system evaluation; detection; Africa; public health; outbreak; framework.

Introduction

Despite the World Health Organization’s (WHO) goal to halve cholera cases reported in 2018 by 2022, the past decade has witnessed a global rise in the disease. From January 2013 to February 2024, 1 224 997 cases and 75 784 deaths (case fatality rate [CFR]:6.2%) were recorded across 30 African Union Member States.^1,2,3 As of February 2024, six African Union Member States are currently in an ‘acute crisis’ because of cholera: Democratic Republic of the Congo, Ethiopia, Mozambique, Tanzania, Zambia and Zimbabwe.⁴ Weak surveillance systems resulting in late detection has been reported as one of the critical gaps in the fight against cholera in Africa.⁵ In addition, cross-border transmission within the region continues to propagate the spread of cholera even in non-endemic countries.⁶

In response to the increasing global burden of cholera, the Global Task Force on Cholera Control (GTFCC) developed a global roadmap to end cholera by 2030.⁷ One of the challenges this roadmap highlighted was the issue of weak coordination across sectors and borders and under-reporting. The inadequate availability of trained staff at the peripheral level and limited or poor cross-border surveillance for early detection of cases were also mentioned as major surveillance gaps that should be addressed. While several tools exist to guide the establishment of disease surveillance systems including the Integrated Disease Surveillance and Response (IDSR) strategy, the monitoring and evaluation (M&E) tool for communicable diseases, the Africa Centres for Disease Control and Prevention (CDC) event-based surveillance M&E tool, there is wide variation on recommended core components for surveillance across these tools. There is also limited information on the availability of a cholera surveillance evaluation framework that is comprehensive enough to guide countries on cholera surveillance evaluation.⁸ This gap has led to several public health practitioners using multiple tools to increase the spectrum of the surveillance capacities evaluated, which may be subjective and not standardised. Our primary goal was to assess critical components across the different existing frameworks and create a comprehensive framework for evaluating cholera surveillance systems in Africa.

Research methods and design

This study was a mixed-methods study that built up on a previous systematic review that assessed M&E frameworks that have been deployed in Africa for the assessment of cholera surveillance systems.⁸ It followed a three-step approach that lasted 6 months (July 2024 – January 2025) including: framework assessments (strengths and weaknesses), consultation with countries for the mapping of critical variables for the proposed framework and the validation of the new framework with country surveillance focal persons (Figure 1). The strengths and weaknesses of existing frameworks were assessed based on a consolidated list of parameters proposed by Mercy et al.⁸ Critical parameters included in the proposed framework were identified through a consultative process with surveillance focal points from eight African Union Member States (Democratic Republic of Congo, Nigeria, Zambia, Zimbabwe, Mozambique, Somalia, Kenya and Ethiopia) reporting cholera cases in February 2024. During the development of the conceptual framework, four assumptions were made. The first assumption was that a country’s national policies and capacities are homogenous nationwide, and there is a central coordination mechanism in charge of developing and enforcing surveillance policies. The second is that the public health surveillance pillar is not a stand-alone ministry but embedded within the national public health institute, the ministry of health or equivalent structures. The third is that all African countries are signatories to the Abuja declaration and committed to achieving its target. Lastly, surveillance systems are agile and flexible to adapt to new recommendations and changes.

FIGURE 1: Framework development steps.

Study setting

The study setting for this research is Africa, specifically focusing on the evaluation of cholera surveillance systems across the continent. The core setting for gathering empirical data and feedback involved eight cholera-affected African countries: Democratic Republic of Congo, Nigeria, Zambia, Zimbabwe, Mozambique, Somalia, Kenya and Ethiopia.

Data collection

Data on key parameters available in existing surveillance framework were obtained from a previous systematic review conducted by Mercy et al.⁸ Disease surveillance experts reviewed and proposed other evaluation tools missing in the systematic review. Information on the title, the targeted threat (or disease under study), objective of the framework and the strength and weaknesses of the framework was entered into an Excel tool.

Data analysis

We consolidated and summarised results in a tabular form to facilitate the visualisation of the availability of key elements evaluated: type of framework, objective of the framework, and strength and weaknesses. The strengths and weaknesses were assessed based on the literature review of articles that deployed them as well as expert opinions.

Ethical considerations

Ethical approval to conduct this study was obtained from Kenyatta National Hospital (KNH), University of Nairobi (UoN) Ethical Review Committee (Ref: No. No. KNH/ERC/R/71).

Results

A total of 10 frameworks or guidelines were assessed (Table 1). Five from the systematic review study and the other five from other sources. Three were tailored specifically for cholera, while seven had a broader scope of hazards and risks of which cholera was included.

Proposed framework for cholera surveillance

This framework composed of three key pillars (see Figures 2 and 3): resource allocation, system structures and core functions, is anchored on good governance and leadership. To ensure that the system constantly remains relevant and is meeting its set objectives, it is continuously monitored for the system attributes (see Figure 1).

FIGURE 2: Interaction of different core components of the proposed cholera framework.

FIGURE 3: A proposed framework for the evuluation of cholera surveillance.

Key parameters often missed across frameworks assessed

Digital system and interoperability

This was 2 out of 10 (20%) framework but was found very critical by 100% of the surveillance focal points for inclusion in the proposed framework:

‘Linkage between surveillance and lab systems is crucial for timely confirmation and monitoring of cholera strains. Improved coordination can enhance data completeness, timeliness of response, and analysis by ensuring a seamless flow of information between surveillance and laboratory teams.’ (Nigeria surveillance focal point, ID-002, Male)

As countries continue to embrace digitalisation with the on-boarding of new technologies, the interoperability of such systems with existing ones should be assessed.

Cross-border surveillance coordination mechanisms

Cross-border was missing in 100% of all the frameworks assessed but surveillance focal points indicated that this was one of the major surveillance gaps leading to cross-border spread of cholera both in the horn of Africa and in Southern Africa:

‘Gaps currently exist in strengthening screening at cross-border points [especially ground-crossing points] especially for porous borders. We also need more cross-border collaboration meetings and creating forums for sharing data across countries.’ (Uganda event-based surveillance focal point, 1D-004, Male)

Cross-border surveillance is thus a key mechanism for information sharing and coordinating response and hence should be considered when evaluating the effectiveness of a surveillance system.

Laboratory and surveillance networks

While laboratory confirmation capacity is one of the core functions of a surveillance system listed by several frameworks, laboratory and surveillance networks that are key mechanisms towards achieving optimal laboratory performance (such as whole genome sequencing) were often not included in the frameworks assessed.^8,9 All the surveillance experts agreed that laboratory networks could play a critical role in improving the weak testing capacity as well as validation of testing at lower levels:

‘While there is an elaborate laboratory network within the country, most of them are poorly resourced in terms of technical capacities, supplies, equipment, and infrastructure that weaken the capacity to support surveillance. Weak links exist in validated POS screening field RDTs, sample management [collection, packaging, storage, and shipment facilities], Confirmation capacities at the lowest level possible, surveillance and laboratory information linkages and Genomic surveillance.’ (Kenya event-based surveillance focal point, 1D-001, Male)

Prediction and forecasting

While all (100%) the frameworks included data analyses and interpretation as a core function, this analysis is mainly limited to trend lines, case distribution maps and other basic epidemiological analysis.¹⁰ This currently represents a gap that Zimbabwe focal point attested to. Given that the current outbreaks in the southern Africa region is driven by climate change, improving predictive analysis using weather and other relevant surveillance data would improve country planning and preparedness efforts:

‘Prediction analytics would greatly help us to prepare for the seasonal occurrence of cholera outbreaks. This would also be added onto the national and sub-national seasonal calendars.’ (Zambia event-based surveillance focal point, ID-003, Male)

Governance and legislation

The main legislative reference made by several frameworks was compliance with IHR,^11,12 which urged countries to build core capacities to prevent, detect, notify and respond to health threats. It also urged countries to establish data sharing frameworks to improve information exchange across the borders for improved coordinated response to health threats. Kenya focal point expressed concerns about the lack of data sharing frameworks as one of the gaps that needs to be addressed to improve cross border surveillance for cholera and other infectious diseases and recommended the inclusion of this parameter in the proposed framework:

‘Lack of data sharing frameworks and regulations remains a critical gap that needs to be addressed to facilitate information sharing across countries’ (Kenya event-based surveillance focal point, 1D-001, Male).

Compliance with government financial investments in healthcare such as the ‘Abuja declaration’ was also not included by any of the frameworks.

Discussion

There is a wide diversity in the parameters included in the different frameworks assessed. Within the resource pillar, human resources remained one of the vital components of the performance of any surveillance system highlighted by the existing frameworks as well as expert opinions. Other studies have demonstrated the critical role human resource coordination plays in the control of cholera outbreaks.⁹ This ranges from community health workers at the lowest level of the health system to modellers, mentors/supervisors and decision-makers at all levels. However, it is important to ensure that these workforces acquire the necessary skills to enable them to optimally perform. Guidelines and standard operating procedures, including standard case definitions, signals (data and/or information considered by the Early Warning and Response System as representing potential acute health risk, such as an outbreak, namely, cluster of cases presenting with similar signs and symptoms, change in watercolour, taste and smell), definitions and reporting timelines should be available at all levels. Laboratory capacity is also one of the critical resources that would determine timely confirmation of cholera cases. However, it is recommended that such capacities must be decentralised to achieve the desired results.¹⁴ To ensure that the system can meet up with the timeline matrix, functional and sustainable digital infrastructure should be established.

The establishment of coordination mechanisms including architecture of reporting and flow of information across different levels and relevant sectors (e.g., ministries of human, environment, water and town planning) has been shown to be vital for ensuring better collaboration on strengthening preventive, preparedness and response measures.^15,16,17 The absence of these mechanisms in frameworks has hindered the ability for countries to evaluate these systems as an integral component of a functional surveillance system making it difficult for the identification of gaps for improvements. Within the International Health Regulation (IHR), coordination and legislation are a recommended core capacity, however, all countries but Ethiopia, South Africa and Mauritius had limited or no capacity in both areas during the last joint external evaluation.¹⁸ The establishment of solutions, systems and networks that allow the use of data across multiple sectors is also key to advancing collaboration and coordination. Expert forums which is one of the recommended mechanisms in this framework has shown to support the analyses and interpretation of complex data sets for early detection, prediction and risk mapping.¹⁹ Laboratory and surveillance networks have also been instrumental in improving quality control on procedures and peer to peer support on data interpretation.²⁰ Cross-border committees have been established in the Eastern Africa for diseases such as Tuberculosis.²¹ However, the integration of this parameter in the proposed framework would provide an opportunity for the evaluation of the actual functionality of these cross-border committees.

Some limitations of this study such as a focus on English frameworks and only on the surveillance component in the entire detection and response spectrum may limit the generalisability of the study. Despite the weaknesses, our study is the first to synthesise the evidence on the evaluation frameworks for cholera surveillance in Africa and the framework proposed is the first of its kind to be developed, drawing from the caveats of other frameworks. Furthermore, the feedback obtained from countries provided a representative country feedback that enhanced the robustness and potential relevance of the proposed framework in the field.

The proposed framework provides guidance to public health practitioners on critical parameters to consider during the evaluation of cholera surveillance systems in Africa. To better understand the feasibility in implementing the proposed parameters in this conceptual framework, future research should focus on piloting this framework in selected African countries. In addition, the response component should be incorporated to complete the surveillance and response spectrum.

Conclusion

Several guidelines exist for cholera, some of which include guidance for cholera surveillance as well as a monitoring framework for national cholera plans that could be adapted for the evaluation of cholera surveillance systems. However, the current surveillance frameworks are missing critical indicators of core functions and mechanisms that are critical to the optimal functioning of a good cholera surveillance system such as digital infrastructure and system interoperability, cross-border surveillance, predictive and forecasting capabilities, laboratory and surveillance networks, system financing. This study assumes that if these components are considered and integrated within the framework of surveillance system evaluations for cholera and other communicable diseases, countries would be better placed to understand where the surveillance gaps are and work towards addressing them. The IDSR strategy implemented by the WHO Africa region and the integrated disease surveillance strategy implemented by the WHO EMRO (Eastern Mediterranean) region could be a good way to start.

Acknowledgements

The authors would like to thank Moses Otieno for facilitating some of the focus group discussions in Nairobi and all the focal points from the different facilities who took part in the study. They would also like to acknowledge the insights provided by Dr Philip Ngere (National event-based surveillance focal point) for his valuable contributions. We also acknowledge the contributions of all key informants as well as participants of the focus group discussions.

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

K.M. developed the original idea for this study including the study design and methodology. K.M., N.T.F. and L.K.B. analysed the data. K.M., G.P., N.N. and L.K.B. reviewed and improved the article. All authors provided feedback and approved the content of the final article.

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

All data analysed and discussed are included in this article.

The views and opinions expressed in this article are those of the authors and are the product of professional research. The article does not necessarily reflect the official policy or position of any affiliated institution, funder, agency, or that of the publisher. The authors are responsible for this article’s results, findings and content.

References