The data used in the study was a secondary data obtained from the World Health Organization (WHO) [21] . Variables in the dataset include country, sub-region, year, total cases, deaths, imported cases, autochthonous cases, and case fatality rates (CFR) of all Sub-Saharan African countries member states reported to WHO from 2000 to 2023. All member states are expected to report annually the occurrence or absence of cholera case in their countries. The data was gathered as part of WHO’s collaboration with Global Taskforce on Cholera Control (GTFCC) to strengthen cholera surveillance [22] .

The study adhered to ethical principles by respecting individuals as autonomous agents and protecting their rights and privacy using the WHO dataset, which ensured anonymity. To uphold beneficence, the potential for harm from misinterpretation or misuse of data was mitigated by accurately reporting findings that benefit stakeholders. Equity was promoted by considering the representativeness of the secondary data, avoiding bias towards specific demographics, and ensuring diverse representation to fill gaps in prior research. Overall, the selected WHO data adhered to ethical collection standards, including informed consent and anonymization, while the statistical analysis avoided selective reporting and maintained representation of the population, with integrity supported by transparent documentation of assumptions and limitations.

The data was processed and analyzed using statistical software such as R programming language, and SPSS software which are well-equipped to handle large datasets and conduct the variety of statistical tests. Descriptive statistics to understand the distribution of the variables and appropriate statistical test (e.g., time plots, ANOVA for comparisons, Correlation, etc) were carried out at 5% level of significance.

The findings from this study provide critical insights into the temporal and geographic trends of cholera burden and case fatality rates (CFR) in sub-Saharan Africa (SSA) from 2000 to 2023. The results reveal notable shifts in cholera incidence across different countries and regions, with significant increases in cases observed in Kenya, Niger, Mozambique, Zambia, Zimbabwe, Somalia, Tanzania, and Malawi post-2020. Meanwhile, countries such as Benin, Nigeria, and Uganda have demonstrated a downward trend. These trends align with previous studies that highlight the role of environmental factors, healthcare infrastructure, and socioeconomic conditions in cholera transmission [6] [13] . One of the key findings is the weak negative correlation (−0.082) between total cholera cases and CFR, suggesting that higher case numbers do not necessarily lead to higher fatality rates. A potential explanation for the weak correlation between rising case numbers and mortality rates may be the disparate efficacy of cholera interventions applied in various regions. Research indicates that the effectiveness of interventions like vaccination, surveillance, and enhancements in water and sanitation can vary considerably depending on local conditions, including health infrastructure, socio-economic status, and community involvement. For example, during the 2017-2018 cholera outbreak in Kinshasa, targeted interventions, including specific water, sanitation, and hygiene (WaSH) strategies, effectively halted transmission, demonstrating the necessity of localized responses adapted to particular contexts. [23] [24] . This supports the notion that effective outbreak response measures, improved healthcare access, and vaccination campaigns may mitigate mortality despite increasing case numbers [19] . The resilience of local healthcare systems in managing cholera cases may conceal the expected correlation between case numbers and case fatality rates (CFRs). For instance, despite extraordinary case numbers in specific regions, effective case management and timely access to treatment can lower mortality rates, as demonstrated in scenarios where healthcare resources are rapidly and efficiently utilized [25] [26] . However, exceptions were noted in Malawi, where a moderate positive correlation (0.512) indicated that increased case numbers were associated with higher CFR, potentially due to overwhelmed healthcare systems during outbreaks. In contrast, Niger exhibited a moderate negative correlation (−0.570), reflecting improved outbreak management or underreporting of deaths.

The study further highlights significant regional disparities in cholera mortality trends. Statistical analysis (F = 7.592, p = 0.001) confirmed that sub-regional differences play a major role in shaping mortality trends, while temporal factors alone do not significantly impact CFR. This reinforces previous research emphasizing that localized factors such as conflict, access to clean water, and emergency response efficiency are critical determinants of cholera mortality [14] [15] . For instance, Central Africa experienced frequent mortality peaks, likely due to conflict-related disruptions, while West Africa saw a sharp rise post-2022, which can be linked to the broader impact of the COVID-19 pandemic on healthcare systems.

While most assumptions are that improved water access leads to lower cholera transmission rates, this result suggests that other local factors may play a more critical role in the dynamics of cholera outbreaks than previously considered. Studies have indicated that cholera outbreaks do not solely occur due to lack of water access but rather due to poor water quality associated with environmental contamination. Therefore, factors like water contamination and the interactions of water supplies with unsanitary conditions can create a conducive environment for the Vibrio cholerae growth [27] . Furthermore, sanitation infrastructure is frequently poorly maintained or completely absent in numerous areas, intensifying the hazards linked to contaminated water [28] . There is evidence that improved sanitation and hygiene practices exert a more significant influence on cholera prevalence than mere access to water [27] [29] . This also aligns with our observation where there were no differences in the CFR in coastal and inland regions. The study also highlights the role of climate variability and extreme weather events in shaping cholera outbreaks. The observed fluctuations in cholera cases across different periods, particularly the spikes in cases between 2010 and 2013 and again post-2020, align with findings from Rieckmann and others [6] , who demonstrated that both droughts and floods exacerbate cholera transmission by affecting water availability and quality. Mozambique, which recorded one of the highest case counts in 2023, has faced recurrent cyclones and flooding, conditions that create ideal environments for cholera outbreaks [1] . Similarly, the recent increase in cholera cases in East African nations such as Kenya and Somalia coincide with prolonged droughts and water shortages, further reinforcing the link between environmental factors and cholera resurgence. These findings stress the need for integrating climate resilience strategies into cholera prevention programs, including improved water management, early warning systems, and emergency preparedness plans.

Another critical issue revealed in the study is the impact of antimicrobial resistance (AMR) on cholera case management. The increasing emergence of multidrug-resistant Vibrio cholera strains in SSA has raised concerns about the effectiveness of conventional treatment protocols [16] . While the study does not directly assess AMR patterns, the persistently high CFR in certain regions suggests that treatment inefficacy may be contributing to mortality rates. Previous research by [17] , emphasizes that limited access to second-line antibiotics and delayed treatment due to overwhelmed healthcare systems can lead to poor outcomes. Addressing this challenge requires strengthening laboratory surveillance for cholera resistance patterns, ensuring adequate stockpiles of effective antibiotics, and promoting the use of oral cholera vaccines [20] . Strengthening AMR monitoring and response efforts is essential to improving case management and reducing mortality rates in cholera-endemic regions. The study’s findings highlight the need for region-specific public health interventions, including enhanced water and sanitation infrastructure, increased investment in healthcare capacity, and expanded cholera vaccination campaigns.

This study provides a more granular, data-driven analysis of cholera trends in SSA, highlighting key temporal patterns, country-specific dynamics, and regional disparities. Unlike previous studies that focused on broad trends, it uncovers significant differences between countries, challenges assumptions about case fatality rates, and identifies areas where intervention strategies need to be tailored. These findings offer actionable insights for policymakers to prioritize resources where they are most needed to control cholera outbreaks effectively. The findings from this study provide strong evidence that cholera remains a persistent public health challenge in SSA, with notable regional disparities in case burden and CFR. While improved healthcare responses and vaccination programs have helped reduce overall fatality rates, localized vulnerabilities—such as overwhelmed health systems in Malawi and underreporting concerns in Niger—highlight the need for targeted interventions. The study further confirms the critical role of environmental factors and climate events in cholera resurgence, reinforcing the urgency of climate-adaptive public health strategies. Additionally, the growing threat of antimicrobial resistance calls for stronger surveillance and treatment protocols to ensure effective case management.

Moving forward, cholera control efforts in SSA must focus on strengthening health systems by investing more in training of health workers for cholera diagnostics and management, expanding access to safe water and sanitation, and enhancing climate resilience in high-risk areas by implementing policies which ensures regular maintenance and monitoring of water and sanitation infrastructures, and embark on regular awareness programs of the effects of climate change on health and hygiene practices. A multifaceted approach that includes early detection, rapid response mechanisms, and sustained investment in oral cholera vaccination will be crucial in achieving long-term cholera reduction. Future research should explore the impact of socioeconomic factors, AMR trends, and regional health policies on cholera epidemiology to further refine intervention strategies.