Recent crises involving zoonotic diseases (Ebola, COVID-19, Mpox) have highlighted the limitations of fragmented public health systems for the prevention and response to health emergencies, at the international, continental – particularly in Africa – and more specifically in the Democratic Republic of Congo (DRC). In this context, the One Health approach and its extension One Digital Health (ODH), articulated with the FAIR (Findable, Accessible, Interoperable, Reusable) principles, offer a framework for rethinking the digital transition in health in the DRC. This study analyzes the reality of this transition in Kinshasa and questions the feasibility of ODH in this context. This study aimed to (1) identify the structural, institutional, and technical constraints hindering digitalization and data interoperability across health sectors in Kinshasa; (2) examine how current digital governance and cross-sectoral practices facilitate or obstruct collaborative data sharing; and (3) analyze the sociotechnical and systemic conditions required for the successful implementation of the One Digital Health (ODH) framework. A qualitative study was conducted in Kinshasa (DRC) between 10 and 25 November 2025, combining 22 semi-structured interviews with key actors (health professionals, administrative officials, digital experts, and engaged citizens) and a documentary analysis of strategic and regulatory texts in digital health in the DRC. The data were analyzed using a thematic approach to identify the representations, uses, and constraints related to digital health and the operationalization of ODH in the DRC and, more broadly, in Africa. Twenty-two stakeholders participated (40.9% human health; 36.4% animal health; 18.2% environmental health; 4.5% digital sector), predominantly male (68.2%) and mainly in operational roles (54.5%). Three interrelated topics emerged. First, a dual-track digital ecosystem characterized by the coexistence of formal platforms (eg, DHIS2, electronic records) and informal tools (eg, WhatsApp), with persistent paper-digital double entry generating inefficiencies. Second, structural and governance bottlenecks, including electricity instability, limited connectivity, software incompatibility, external data hosting concerns affecting sovereignty, and institutional silos privileging human health over animal and environmental sectors. Third, prerequisites for operationalizing ODH, emphasizing foundational infrastructure (energy and internet), sustainable capacity building beyond one-off training, interoperable “bridges” between fragmented systems, and high-level political leadership. These elements were synthesized into an ODH-FAIR DRC conceptual model structured around three enabling pillars linking sectors for integrated zoonotic surveillance. Operationalizing ODH in DRC requires addressing foundational enablers beyond tools: synchronized energy-digital policies, decompartmentalized governance, and context-adapted capacity building. These insights inform LMIC digital health strategies, urging donors and ministries to prioritize interoperability over isolated pilots to achieve sustainable zoonotic surveillance.

Road congestion is a chronic crisis in African megacities and can put significant psychological pressure on road users. However, local data on its influence on mental health remains limited. This study aimed to assess the association between repeated exposure to traffic congestion and symptoms of mental health disorders among road users in Kinshasa. A cross-sectional study was conducted in 2025 among road users in Kinshasa, the capital and largest city of the Democratic Republic of Congo, between November 3 and December 20, 2025. A two-phase sequential protocol was adopted. First, a spatial analysis of road congestion was carried out based on systematic traffic observations, using real-time traffic data from Google Maps during peak hours, i.e. from 05:00 to 10:00 and from 15:00 to 21:00, over a period of four weeks. The observed congestion points were geolocated and then analyzed in QGIS version 3.44.6-Solothurn using a density estimate per core, in order to identify the main congestion hotspots. This analysis made it possible to select five highly congested roads as study sites. In a second step, the participants were recruited using a spatio-temporal sampling approach. The sampling units were defined by the combination of location, day and time slot on each selected axis. A minimum size of 427 participants was calculated using the Schwartz formula and increased to 430 participants to facilitate distribution among the sites. Road users included drivers of private vehicles, drivers of public transit vehicles, transit passengers, motorcyclists, and pedestrians. Data were collected using a structured questionnaire that assessed sociodemographic characteristics, exposure to traffic congestion, and symptoms of depression, anxiety, and stress using the DASS-21 scale. After quality control, 404 participants were included in the final analysis. A total of 404 participants were included in the analysis. The prevalences of stress, depression and anxiety symptoms were 45.3, 36.9 and 25.9

Forced displacement due to armed conflict is associated with a substantial burden of mental health disorders, particularly among internally displaced persons (IDPs) living in camps. In eastern Democratic Republic of the Congo (DRC), ongoing insecurity and protracted displacement expose IDPs to repeated traumatic events and chronic stressors. However, data remain limited on the prevalence of common mental disorders and their associated factors among camp-based IDPs in North Kivu, especially when accounting for heterogeneous exposure profiles. A community-based cross-sectional study was conducted between November and December 2025 among adult IDPs residing in the Nyanzale displacement camp, North Kivu. Anxiety, depression and post-traumatic stress disorder (PTSD) were assessed using the GAD-7, PHQ-9 and PCL-5 scales, respectively. Exposure to potentially traumatic events before and during camp residence was analyzed using multiple correspondence analysis followed by hierarchical clustering to identify homogeneous exposure profiles. Multivariable logistic regression models were fitted separately for each mental health outcome. A total of 385 participants were included. Prevalences of moderate to severe anxiety, depression and probable PTSD were 56.2

BackgroundRecent crises involving zoonotic diseases (Ebola, COVID-19, and Mpox) have highlighted the limitations of fragmented public health systems for the prevention and response to health emergencies at the international and continental level, and particularly in Africa, more specifically in the Democratic Republic of the Congo (DRC). In this context, the One Health (OH) approach and its extension, One Digital Health (ODH), articulated with the findable, accessible, interoperable, reusable (FAIR) principles, offer a framework for rethinking the digital transition in health in the DRC. This study analyzes the reality of this transition in Kinshasa, DRC, and questions the feasibility of ODH in this context. ObjectiveThis study aimed to (1) explore how stakeholders across human, animal, and environmental health sectors perceive and experience digital tool integration and data interoperability in Kinshasa; (2) identify structural, institutional, and technical constraints affecting cross-sectoral data sharing; and (3) analyze the sociotechnical conditions required for the operationalization of ODH in a fragmented digital health (DH) context. MethodsA qualitative study was conducted in Kinshasa, DRC, between November 10, 2025, and November 25, 2025, combining semistructured interviews with key actors (health professionals, administrative officials, digital experts, and engaged citizens) and a document review of strategic and regulatory texts related to DH in the DRC. The data were analyzed using a thematic approach to identify the representations, uses, and constraints related to DH and the operationalization of ODH. ResultsOverall, 22 stakeholders participated (n=9, 40.9% human health; n=8, 36.4% animal health; n=4, 18.2% environmental health; n=1, 4.50% digital sector), predominantly male (n=15, 68.2%) and mainly in operational roles (n=12, 54.5%). Three interrelated topics emerged. First, a dual-track digital ecosystem characterized by the coexistence of formal platforms (eg, District Health Information Software 2 and electronic records) and informal tools (eg, WhatsApp [Meta]), with persistent paper-digital double-entry generating inefficiencies. Second, structural and governance bottlenecks, including electricity instability, limited connectivity, software incompatibility, external data-hosting concerns that affect sovereignty, and institutional silos that privilege human health over animal and environmental sectors. Third, prerequisites for operationalizing ODH emphasize foundational infrastructure (energy and internet), sustainable capacity building beyond one-off training, interoperable “bridges” between fragmented systems, and high-level political leadership. These elements were synthesized into an ODH-FAIR DRC conceptual model structured around three enabling pillars linking sectors for integrated zoonotic surveillance. ConclusionsOperationalizing ODH in DRC requires addressing foundational enablers beyond tools: synchronized energy-digital policies, decompartmentalized governance, and context-adapted capacity building. These insights inform low- and middle-income countries’ DH strategies, urging donors and ministries to prioritize interoperability over isolated pilots to achieve sustainable zoonotic surveillance.

Human mobility is a major determinant of the spatial spread of emerging infectious diseases. In Maï-Ndombe province, Democratic Republic of the Congo, dependence on waterways as the primary transport network, combined with a degraded road infrastructure and marked environmental constraints, creates profound heterogeneity in spatial connectivity between health zones. In this context, the spread of Mpox shows an irregular spatial distribution whose structural mechanisms remain poorly understood, partly due to the scarcity of mobility data and the fragility of surveillance systems. To quantify the intra-provincial spatial connectivity of Maï-Ndombe by simultaneously integrating road and river networks, and to assess its influence on the spread of Mpox between 2022 and 2025. A spatial connectivity analysis based on an enhanced gravity model integrating demographic attractiveness and a distance-cost factor accounting for slope and land use via the Fuzzy-AHP method was combined with a spatialized metapopulation SEIR model. Inter-zone flows, centrality, and accessibility were quantified. The performance of SEIR models with and without connectivity was compared using RMSE, MAE, and precision gain per zone. Flows are strongly concentrated around pivotal zones (Bokoro, Nioki, Mushie), while peripheral areas (Mimia, Oshwe, Kiri) remain structurally isolated, with accessibility provided primarily by river corridors (Gini index = 0.65; CV = 1.52). The integration of connectivity degrades the overall model fit (ΔRMSE = -0.468), reflecting the predominance of local transmission at the provincial scale. However, this aggregate degradation conceals marked spatial heterogeneity: connectivity significantly improves predictions in highly connected zones (Bokoro: +59.8

BACKGROUND:Contact tracing remains a pillar public health strategy for containing Ebola virus disease (EVD). During the 2018-2020 EVD outbreak in the Democratic Republic of the Congo (DRC), contact tracing was implemented on an unprecedented scale. Here, we assessed performance of contact tracing implemented in affected health zones, and identified risk factors associated with incomplete follow-up. METHODS:We performed a retrospective descriptive data analysis of 129,749 contacts in the contact line lists of North Kivu province between August 1, 2018 to June 25, 2020. Coverage, completeness, timeliness, and duration of contact tracing were determined to assess the performance of contact tracing implemented by field actors. Bivariate and multivariate logistic regression models were used to identify factors associated with incomplete contact tracing. RESULTS:Overall, more than 90% of all contacts initially identified and listed were monitored. However, 9.1% of contacts who had monitoring initiated had completed the 21 days follow-up. The median days between identification and the start of follow-up and duration contact follow-up were 3 (1-6) and 17 (12-19), respectively. The risk of incomplete follow-up was higher among contacts from urban and conflict-affected health zones. CONCLUSION:Our findings indicate the necessity of prioritizing contact tracing in urban areas. This can be achieved by engaging locally trusted stakeholders to build community confidence. Furthermore, integrating digital contact tracing solutions may enhance the efficacy of traditional manual contact tracing.

BACKGROUND:Vaccination against COVID-19 has been the primary public health measure implemented to limit the spread of the disease. However, there is still considerable scope for improvement in vaccine coverage, particularly in sub-Saharan African countries. The factors influencing the acceptance or reluctance of the COVID-19 vaccine have been widely studied, but there is a gap in the literature with regard to dynamic populations, particularly travelers, who are one of the priority target groups for vaccination. This study assessed the perceptions, attitudes and practices regarding the COVID-19 vaccine, and explored factors associated with vaccination status among travelers. METHODS:A cross-sectional survey was conducted at several points of entry (PoEs) selected for six survey sites (N'djili airport, Ngobila beach, Lufu, Boma, Moanda, and Kananga), located in three provinces of the Democratic Republic of the Congo (Kinshasa, Kongo Central and Kasaï Central), from February 20 to March 05, 2023. The data were summarized and logistic regression models were performed to assess factors associated with vaccination status. RESULTS:A total of 2742 travelers were included in this survey. Of these, 54% had received at least one dose of COVID-19 vaccine. Multivariable logistic regression analyses revealed that that several factors were significantly associated with vaccination status. These included age (under 60 years), marital status (single), occupation (other than healthcare worker), mode of travel (other than airplane), and poor perceptions of the vaccine. The most frequently cited reasons for vaccination among respondents who had received the vaccine were the prevention of COVID-19 infection and the ease of travel. In contrast, unvaccinated participants expressed greater concern about the safety and effectiveness of the vaccine, as well as vaccine-related side effects. Furthermore, travel disruption and inappropriate vaccination sites have been identified as significant obstacles to the acceptance of vaccination at the PoEs. CONCLUSIONS:It is essential that awareness initiatives address concerns and misconceptions about vaccine safety and effectiveness. The influence of social media platforms may be harnessed for the dissemination of accurate information from the most trusted information sources, including healthcare professionals, to the target population. In addition, accompanying measures should be considered to facilitate vaccination compliance at different PoEs.

The One Health framework endorsed by the quadripartite (World Health Organization, World Organisation for Animal Health, Food and Agriculture Organization, and United Nations Environment Program) is defined, in part, as an "integrated, unifying approach that aims to sustainably balance and optimize the health of people, animals, and ecosystems," and it explicitly refers to the health of plants as part of the whole interrelated system to consider. Although the ultimate issue is the planet's habitability for humans, the definition introduces a shift in perspective-human health is no longer the sole priority but must be balanced and optimized alongside the health of animals, plants, and ecosystems. This raises some practical and ethical questions. Drawing on case studies and the framework of the IPBES (Intergovernmental Science-Policy Platform on Biodiversity and Ecosystem Services) on the values of nature, this study explores the implications of a global approach to health, with the ethical and practical questions that it raises.

The North Kivu province, located in the eastern Democratic Republic of the Congo (DRC), had the second highest disease incidence of COVID-19 during the successive waves observed between March 2020 and September 2023. However, a comprehensive understanding of the geographical trends and underlying mechanisms influencing the epidemiology of COVD-19 at a fine administrative scale is required to guide public health strategies. This first sub-provincial risk-factor modeling framework integrating conflict, forced migrations, epidemiological, demographic, socio-economic, and health-system variables was implemented at the health zone level. Hierarchical Clustering on Principal Components (HCPC) analysis was employed on the independent variables to cluster the health zones. Furthermore, multivariable negative binomial regression models were performed to identify significant predictors of high numbers of cases of COVID-19 recorded across the health zones. Of the five waves observed, the number of COVID-19 cases increased substantially during the third and fourth waves, with outbreak peaks exceeding 200 and 900 cases per week, respectively. HCPC resulted in five major clusters for the 34 health zones, and the number of cases varied significantly across clusters. In the final multivariable model, the number of COVID-19 cases was found to be significantly higher in heath zones with a history of Ebola virus disease outbreak (Risk Ratio [RR] = 2.69; 95

Cholera is a bacterial water-borne diarrheal disease transmitted via the fecal-oral route that causes high morbidity in sub-Saharan Africa and Asia. It is preventable with vaccination, and Water, Sanitation, and Hygiene (WASH) improvements. However, the impact of vaccination in endemic settings remains unclear. Cholera is endemic in the city of Kalemie, on the shore of Lake Tanganyika, in the Democratic Republic of Congo, where both seasonal mobility and the lake, a potential environmental reservoir, may promote transmission. Kalemie received a vaccination campaign and WASH improvements in 2013-2016. We assessed the impact of this intervention to inform future control strategies in endemic settings. We fit compartmental models considering seasonal mobility and environmentally-based transmission. We estimated the number of cases the intervention avoided, and the relative contributions of the elements promoting local cholera transmission. We estimated the intervention avoided 5,259 cases (95% credible interval: 1,576.6-11,337.8) over 118 weeks. Transmission did not rely on seasonal mobility and was primarily environmentally-driven. Removing environmental exposure or contamination could control local transmission. Repeated environmental exposure could maintain high population immunity and decrease the impact of vaccination in similar endemic areas. Addressing environmental exposure and contamination should be the primary target of interventions in such settings.

BACKGROUND:Safely managed drinking water is critical to prevent diarrhoeal diseases, including cholera, but evidence on the effectiveness of piped water supply in reducing these diseases in low-income and complex emergency settings remains scarce. METHODS:We conducted a trial of water supply infrastructure improvements in Uvira (DRC). Our primary objective was to estimate the relationship between a composite index of water service quality and the monthly number of suspected cholera cases admitted to treatment facilities and, as a secondary analysis, the number of cases confirmed by rapid diagnostic tests. Other exposures included the quantity of supplied water and service continuity. We used Poisson generalised linear models with generalised estimating equations to estimate incidence rate ratios. FINDINGS:Associations between suspected cholera incidence and water service quality (RR 0·86, 95% CI 0·73-1·01), quantity (RR 0·80, 95% CI 0·62-1·02) and continuity (RR 0·81, 95% CI 0·77-0·86) were estimated. The magnitudes of the associations were similar between confirmed cholera incidence and water service quality (RR 0·84, 95% CI 0·73-0·97), quantity (RR 0·76, 95% CI 0·61-0·94) and continuity (RR 0·75, 95% CI 0·69-0·81). These results suggest that an additional 5 L/user/day or 1.2 hour per day of water production could reduce confirmed cholera by 24% (95% CI 6-39%) and 25% (95% CI 19-31%), respectively. INTERPRETATION:Ensuring a sufficient and continuous piped water supply may substantially reduce the burden of endemic cholera and diarrhoeal diseases but evaluating this rigorously is challenging. Pragmatic strategies are needed for public health research on complex interventions in protracted emergency settings. TRIAL REGISTRATION:The trial is registered in ClinicalTrials.gov ID NCT02928341. https://classic.clinicaltrials.gov/ct2/show/NCT02928341.

BACKGROUND:Since the early 1970s, cholera outbreaks have been a major public health burden in the Democratic Republic of Congo (DRC). Cholera cases have been reported in a quasi-continuous manner in certain lakeside areas in the Great Lakes Region. As these cholera-endemic health zones constitute a starting point for outbreaks and diffusion towards other at-risk areas, they play a major role in cholera dynamics in the country. Monitoring the spatiotemporal dynamics of cholera hotspots and adjusting interventions accordingly thus reduces the disease burden in an efficient and cost-effective manner.METHODS:A literature review was conducted to describe the spatiotemporal dynamics of cholera in the DRC at the province level from 1973 to 1999. We then identified and classified cholera hotspots at the provincial and health zone levels from 2003 to 2022 and described the spatiotemporal evolution of hotspots. We also applied and compared three different classification methods to ensure that cholera hotspots are identified and classified according to the DRC context.RESULTS:According to all three methods, high-priority hotspots were concentrated in the eastern Great Lakes Region. Overall, hotspots largely remained unchanged over the course of the study period, although slight improvements were observed in some eastern hotspots, while other non-endemic areas in the west experienced an increase in cholera outbreaks. The Global Task Force on Cholera Control (GTFCC) and the Department of Ecology and Infectious Disease Control (DEIDC) methods largely yielded similar results for the high-risk hotspots. However, the medium-priority hotspots identified by the GTFCC method were further sub-classified by the DEIDC method, thereby providing a more detailed ranking for priority targeting.CONCLUSIONS:Overall, the findings of this comprehensive study shed light on the dynamics of cholera hotspots in the DRC from 1973 to 2022. These results may serve as an evidence-based foundation for public health officials and policymakers to improve the implementation of the Multisectoral Cholera Elimination Plan, guiding targeted interventions and resource allocation to mitigate the impact of cholera in vulnerable communities.

Vibrio cholerae has caused seven cholera pandemics in the past two centuries. The seventh and ongoing pandemic has been particularly severe on the African continent. Here, we report long read-based genome sequences of six V. cholerae strains isolated in the Democratic Republic of the Congo between 2009 and 2012.

BackgroundThe WHO Emergency Medical Teams (EMT) Initiative coordinates the deployment of qualified medical teams who promptly respond to public health emergencies (PHEs) and provide quality service during emergencies whilst strengthening capacity. Globally, 40 EMTs have been classified between 2016 and the present (as of the writing of this article in December 2023) and are from across all the WHO regions except the WHO Africa Region (AFRO). However, WHO Africa has prioritised the implementation of EMTs in 10 priority countries to address the public health emergencies (PHEs) affecting the region.ObjectiveThis article describes the development and progress of national EMTs in the WHO African Region over the past 7 years and elucidates the main lessons learned and the complexity and challenges in the process.MethodsThis study employed a case study approach because of its appropriateness in examining a complex social phenomenon in a socio-political context in depth, using multiple lenses simultaneously. Data and information were obtained through document reviews and key informant interviews (KIIs) (n = 5) with the members of the EMT Initiative on shared field experiences. Data were systematically analysed using the Stages of Implementation Completion (SIC) framework, and the lessons learnt were presented using components of a framework from Adini et al.ResultsThe Initiative commenced in the WHO African Region following its launch in December 2017 in Senegal. The assessments of the concept’s engagement (involved learning and deciding), feasibility (reviewing expectation and capacity), and readiness planning (collaborating and preparing) showed that the context-specific (African context) challenges, lessons from different emergency response actions mainly guided the Initiative’s pre-implementation phase in the region and prompted the WHO emergency leadership on the urgency and need for the EMT concept in the region. The assessment of the implementation processes showed progress in key areas, with staff demonstrating improved competency, EMT services maintaining high fidelity, effective consultation launching critical components, and ongoing services providing successful support and monitoring. Creating the N-EMTs and revitalising the EMT concept required an aligned strategy with other regional emergency programmes and a futuristic vision. Proposed sustainability and governance components include creating N-EMT, developing a coordination structure, collaborating with partners, and finalising the N-EMT.ConclusionThe Initiative is an imperative component that would allow better-targeted management of health emergencies in the region. The continuous refinement of the EMT initiative is crucial. There is a need to work on additional components, such as a context-specific framework for collaborations and partnerships that would enhance deployment and procurement modalities and the complementarity between other regional initiatives to improve the work. Emphasis should be placed on strengthening local health systems, enhancing training and capacity-building programmes, and fostering regional and international collaborations. Additionally, sustainable funding and resource allocation are essential to ensure the resilience of EMTs in the African region and their long-term success.

Abstract Background: Severe and critical forms of COVID-19 require early conventional oxygen therapy. Objective: The aim of this study was to analyze the evolution of Severe and critical COVID-19 patients treated at the University Hospital of Kinshasa according to News score. Methods: This was a historical cohort study carried out at the COVID-19 Treatment Center (of the University Hospital of Kinshasa (UHK) from March 24, 2020 to December 12, 2022. The target population was all patients (1159) admitted to the intensive care unit of the COVID-19 Treatment Center of the UHK. All tests were two-tailed with 95% CI and considered significant when P-value was < 0.05. Results: Of a total of 1159 patients, severe and critical forms accounted for 84.2% (n=976), with the age category of patients over 60 years the most represented at 52.2% (n=605), with a mean age of 58.1±17.3 years. Severe and critical patients with at least one comorbidity 74.2% (n=724) were admitted to CTCO CUK and 84.6% (n=981) of these patients required respiratory support with conventional oxygen therapy. Factors predictive of lethality were the use of CPAP and mechanical ventilation with HRa (95% CI) of 0.001 and 0.002 respectively, age> 60 years and late referral to UHK. Conclusion: Ultimately, this study showed that severe COVID-19 patients require early and effective management.

Objective:This study describes the progress that the World Health Organization (WHO) African (AFRO) region has made in establishing National Emergency Medical Teams (N-EMTs), the coordination mechanisms of the EMTs, and the regional training centers.Methods:It used a retrospective descriptive analysis of the formulation and implementation of the EMTs Initiative from an insider perspective. The analysis is based on the review of available documents such as EMTs mission reports, assessments, surveys, EMT monthly bulletins, and meeting minutes in addition to key informant interviews (n = 5) with the EMT teams' members to validate the findings and share field experiences.Results:The emergence of coronavirus disease 2019 (COVID-19) acted as an accelerator for the implementation of the EMT initiative in the AFRO region. A total of 18 EMT deployments were carried out in 16 countries in the AFRO region through the WHO EMT-network during COVID-19, providing support to countries in managing severe and critical COVID-19 cases.Conclusions:A Regional Training Center for N-EMTs is being set up in Addis Ababa to train the N-EMTs and strengthen local capacity of health personnel in the region. Challenges include unavailability of mentors to support countries in implementing N-EMTs and the Regional Simulation Training Center, poor funding, and coordination in the rolling out of the N-EMTs.

A resurgence in cholera cases has been observed throughout Africa during the first half of 2023. Among the many factors that drive cholera transmission, the ongoing climate phenomenon El Nino is likely to continue until March to May 2024. To prevent further cholera spread, it is critical to strengthen cholera control efforts in Africa.

Background The dynamics of the spread of cholera epidemics in the Democratic Republic of the Congo (DRC), from east to west and within western DRC, have been extensively studied. However, the drivers of these spread processes remain unclear. We therefore sought to better understand the factors associated with these spread dynamics and their potential underlying mechanisms. Methods In this eco-epidemiological study, we focused on the spread processes of cholera epidemics originating from the shores of Lake Kivu, involving the areas bordering Lake Kivu, the areas surrounding the lake areas, and the areas out of endemic eastern DRC (eastern and western non-endemic provinces). Over the period 2000–2018, we collected data on suspected cholera cases, and a set of several variables including types of conflicts, the number of internally displaced persons (IDPs), population density, transportation network density, and accessibility indicators. Using multivariate ordinal logistic regression models, we identified factors associated with the spread of cholera outside the endemic eastern DRC. We performed multivariate Vector Auto Regressive models to analyze potential underlying mechanisms involving the factors associated with these spread dynamics. Finally, we classified the affected health zones using hierarchical ascendant classification based on principal component analysis (PCA). Findings The increase in the number of suspected cholera cases, the exacerbation of conflict events, and the number of IDPs in eastern endemic areas were associated with an increased risk of cholera spreading outside the endemic eastern provinces. We found that the increase in suspected cholera cases was influenced by the increase in battles at lag of 4 weeks, which were influenced by the violence against civilians with a 1-week lag. The violent conflict events influenced the increase in the number of IDPs 4 to 6 weeks later. Other influences and uni- or bidirectional causal links were observed between violent and non-violent conflicts, and between conflicts and IDPs. Hierarchical clustering on PCA identified three categories of affected health zones: densely populated urban areas with few but large and longer epidemics; moderately and accessible areas with more but small epidemics; less populated and less accessible areas with more and larger epidemics. Conclusion Our findings argue for monitoring conflict dynamics to predict the risk of geographic expansion of cholera in the DRC. They also suggest areas where interventions should be appropriately focused to build their resilience to the disease.

Background The Democratic Republic of the Congo (DRC) implemented the first strategic Multisectoral Cholera Elimination Plan (MCEP) in 2008–2012. Two subsequent MCEPs have since been implemented covering the periods 2013–2017 and 2018–2021. The current study aimed to assess the spatiotemporal dynamics of cholera over the recent 22-year period to determine the impact of the MCEPs on cholera epidemics, establish lessons learned and provide an evidence-based foundation to improve the implementation of the next MCEP (2023–2027). Methods In this cross-sectional study, secondary weekly epidemiological cholera data covering the 2000–2021 period was extracted from the DRC Ministry of Health surveillance databases. The data series was divided into four periods: pre-MCEP 2003–2007 (pre-MCEP), first MCEP (MCEP-1), second MCEP (MCEP-2) and third MCEP (MCEP-3). For each period, we assessed the overall cholera profiles and seasonal patterns. We analyzed the spatial dynamics and identified cholera risk clusters at the province level. We also assessed the evolution of cholera sanctuary zones identified during each period. Results During the 2000–2021 period, the DRC recorded 520,024 suspected cases and 12,561 deaths. The endemic provinces remain the most affected with more than 75% of cases, five of the six endemic provinces were identified as risk clusters during each MCEP period (North Kivu, South Kivu, Tanganyika, Haut-Lomami and Haut-Katanga). Several health zones were identified as cholera sanctuary zones during the study period: 14 health zones during MCEP-1, 14 health zones during MCEP-2 and 29 health zones during MCEP-3. Over the course of the study period, seasonal cholera patterns remained constant, with one peak during the dry season and one peak during the rainy season. Conclusion Despite the implementation of three MCEPs, the cholera context in the DRC remains largely unchanged since the pre-MCEP period. To better orient cholera elimination activities, the method used to classify priority health zones should be optimized by analyzing epidemiological; water, sanitation and hygiene; socio-economic; environmental and health indicators at the local level. Improvements should also be made regarding the implementation of the MCEP, reporting of funded activities and surveillance of cholera cases. Additional studies should aim to identify specific bottlenecks and gaps in the coordination and strategic efforts of cholera elimination interventions at the local, national and international levels.

In March 2022, WHO, WOAH, FAO, and UNEP jointly advocated a rebalancing of the multiple components of One Health, explicitly including the notion of equity between sectors and disciplines, and a clearer ecological vision of the whole. Here we illustrate the vital need for this shift based on the multi-decadal experience of the authors in this field of research. We explain why One Health research still crucially requires the expansion of the current collaborations between disciplines and sectors to achieve its goals, and to release significant funding in each field for a successful transformational change. If not, ‘One Health’ will still stay as an aspiration and will not hit its promised targets. One Health Impact Statement In March 2022, WHO, WOAH, FAO, and UNEP jointly advocated a rebalancing of the multiple components of One Health, explicitly including the notion of equity between sectors and disciplines, and a clearer ecological vision of the whole. Here we illustrate the vital need for this shift based on the multi-decadal experience of the authors in this field of research. We explain why One Health research still crucially requires the expansion of the current collaborations between disciplines and sectors to achieve its goals, and to release significant funding in each field for a successful transformational change. If not, ‘One Health’ will still stay as an aspiration and will not hit its promised targets.