Link Found Between Multidrug-Resistant Cholera Cases in Europe and Contaminated Holy Water from Ethiopia

Recent research has established a connection between cases of multidrug-resistant cholera in Europe and the consumption of contaminated holy water from Ethiopia. This finding, published in Eurosurveillance, highlights serious public health implications following reports of cholera infections in Germany and the United Kingdom (UK).

According to the study, four patients in Europe contracted cholera after exposure to holy water imported from Ethiopia, while an additional three had traveled to the region. The research identified a strain of multidrug-resistant Vibrio cholerae O1, associated with ongoing outbreaks in Eastern and Middle Africa, in both clinical samples and the contaminated water.

The cholera outbreak in Ethiopia, which began in 2022, has seen a staggering total of 58,381 reported cases and 726 deaths as of February 9, 2025. On February 6, 2025, a resurgence of cases was reported in the Amhara region, resulting in 163 new infections and three fatalities, with current data remaining unavailable.

One significant source of contamination has been traced to the Bermel Giorgis holy well located in the Quara district, a revered pilgrimage site attracting visitors from around the globe. Pilgrims often consume or bathe in this water, believing it offers both physical and spiritual healing, frequently taking some home with them.

In Germany, the first report of suspected cholera cases emerged on February 25, 2025, through the European surveillance portal for infectious diseases (EpiPulse). All three affected individuals were of Ethiopian descent. Two had traveled to Ethiopia in January and returned with a small container of water from the Bermel Giorgis holy well. Upon returning to Germany, they consumed the water. The third individual was splashed with the water, which may have led to ingestion.

Following their return, all three developed symptoms of diarrhea and vomiting, necessitating hospitalization. While one patient required intensive care, all ultimately recovered.

In the UK, the United Kingdom Health Security Agency (UKHSA) identified four patients linked to the cholera outbreak. Two had traveled to Ethiopia's Amhara region, with one specifically mentioning a nine-day visit to Bermel Giorgis. The third patient, who had not traveled to Ethiopia, consumed holy water brought back by the fourth patient, who had also fallen ill after ingesting the water in the UK.

Among the four patients, three were hospitalized, with one requiring intensive medical care. Another individual who traveled to Ethiopia experienced symptoms consistent with cholera but was not tested and recovered without treatment.

Genetic analysis of stool samples from the UK cases confirmed that the bacteria belonged to a multidrug-resistant clade of Vibrio cholerae O1 previously associated with cholera outbreaks in Kenya and sub-Saharan Africa, as well as in Eastern and Middle Africa. The strains isolated in Ethiopia and those identified in Europe showed matching profiles of antimicrobial resistance.

Despite advancements in surveillance, there remains a pressing need for enhanced support aimed at preventing and controlling outbreaks in low-income countries. Consumption of holy water has been previously recognized as a potential risk factor for cholera in Ethiopia, prompting public health authorities to implement preventive measures during religious observances. The Ethiopian National Guideline for Cholera Surveillance and Outbreak Response has also addressed these associated risks. However, the emergence of cholera cases in Europe stemming from an African outbreak is notably unusual.

Improving genetic data has bolstered surveillance and case identification efforts. Still, effective prevention requires substantial investment in water, sanitation, and hygiene (WASH) initiatives. Experts emphasize the necessity for ongoing overseas development aid to support low-income countries in managing outbreaks and epidemics through comprehensive WASH programs, enhanced surveillance, effective communication strategies, diagnostics, and timely countermeasure deployment.