Armed Conflicts, Natural Disasters, and Cholera Burden: Evidence From 152 Countries, 1980–2022

Armed conflicts, floods, droughts, and earthquakes are suggested as potential drivers in cholera transmission. However, the extent to which the occurrence and intensity of these events are associated with cholera outbreaks is unknown. We collected cholera reports, genetic records, armed conflict, natural disaster, socioeconomic, geographical, and climate data of 152 countries from 1980 to 2022. A modified Poisson generalized additive mixed model (GAMM) was applied to estimate the impact of armed conflicts and natural disasters on cholera occurrence. The cholera burden attributed to these events was further estimated and aggregated by region to analyze geographical inequality. Three-year cumulative armed conflicts and earthquakes were significantly associated with cholera, with prevalence ratios (PR) of 1.03 (95% CI: 1.02–1.04) and 1.04 (95% CI: 1.03–1.06) respectively. Countries with high-intensity armed conflicts (i.e., the upper tertile of three-year cumulative armed conflict counts) had a PR of 1.27 (95% CI: 1.16–1.39) for cholera. High-intensity natural disasters were also positively associated with cholera risk: floods (PR=1.24, 95% CI: 1.16–1.32), earthquakes (PR=1.31, 95% CI: 1.19–1.44), and drought (PR=1.06, 95% CI: 1.02–1.11). Furthermore, regional disparities in the frequency of armed conflicts and natural disasters exacerbated inequalities in cholera burden, with Sub-Saharan Africa bearing the greatest number of cholera occurrences attributed to armed conflicts, floods, and droughts, with attributable fractions (AFs) of 6.05%, 11.39%, and 2.14%, respectively. Our findings underscore the necessity of maintaining stable social conditions and strengthening disaster preparedness, early warning, and response capacity in the effort to eradicate cholera, particularly in high-burden areas. • Armed conflicts and natural disasters are positively correlated with cholera. • Cholera risk rose along with the severity of extreme events. • Regional disparities in extreme events exacerbated cholera burden inequalities. • Sub-Saharan Africa had the highest cholera burden from conflicts, floods, and droughts.