Consumption of holy water from Ethiopia has recently led to several cases of cholera in Germany and the United Kingdom (UK) with a multidrug-resistant Vibrio cholerae strain, according to a study published in Eurosurveillance. Four patients were infected through imported water, while three patients had travelled in Ethiopia. Researchers detected multidrug-resistant Vibrio cholerae O1 linked to recent outbreaks in Eastern and Middle Africa in clinical specimens and the holy water.
The ongoing cholera outbreak in Ethiopia began in 2022, and by 9 February 2025 a total of 58,381 cases and 726 deaths had been reported. There was a resurgence of the outbreak on 6 February 2025 reported in the Amhara region leading to 163 cases and 3 deaths, with more recent numbers being unavailable. One identified contamination source is the Bermel Giorgis holy well, which is located in the Quara district and is a site of pilgrimage attracting visitors worldwide. Pilgrims consume or bathe in the water for physical or spiritual healing, and often take it home.
Cholera infected patients required hospitalization and intensive care
In Germany, three people were initially reported via the European surveillance portal for infectious diseases (EpiPulse) as suspected of having cholera on 25 February 2025. All patients were identified as being of Ethiopian ethnicity. Two had travelled to Ethiopia in January, and acquired a small plastic bottle of water with water from the holy well in Bermel Giorgis. Upon their return to Germany, both people consumed the water. A third person received splashes of water to the face, including the lips, and possibly ingested some of it. In early February, all three individuals developed diarrhoea and vomiting, and were hospitalised. One patient required intensive care, but all recovered.
In the UK, the United Kingdom Health Security Agency (UKHSA) identified four patients, among which two reported recent travel to Ethiopia to the Amhara region, and one specifically mentioning a 9-day trip to Bermel Georgis. A third patient had not travelled to Ethiopia, but reported that they had drank holy water from the well that had been brought back by the fourth patient, who had also become ill after consuming the water in the UK. Three were admitted to hospital, with one requiring intensive care. One person who had also travelled to Ethiopia also had symptoms of cholera, but was not tested and recovered without medical treatment.
Analysis of bacteria samples indicates link to recent outbreaks in Eastern and Middle Africa
Genetic analysis of the bacteria in stool samples from the UK cases showed that they belonged to a multidrug-resistant clade of Vibrio cholerae O1 previously linked to outbreaks of cholera in Kenya and Sub-Saharan Africa, as well as in Eastern and Middle Africa. Ethiopian V. cholerae isolates sequenced in Germany and the UK had the same antimicrobial resistance profile as the bacteria samples obtained recently from UK residents. The similarities in these isolates, as well as among the Kenyan and sub-Saharan African strains in England, indicated that multidrug-resistant V. cholerae O1 circulating in Africa were transmitted into Europe.
Though surveillance has improved, support for prevention and control of outbreaks is needed in low-income countries
Consumption of holy water has been previously identified as a risk factor for cholera in Ethiopia. Public authorities have taken preventive measures during religious holidays, and the Ethiopian National Guideline for Cholera Surveillance and Outbreak response has also addressed the associated risks. However, the spread of cases into Europe related to a cholera outbreak in Africa is unusual.
While genetic data have improved surveillance and identification of cases, prevention requires investment in water, sanitation and hygiene. According to Frank et al.: "Low-income countries will continue to need overseas development aid support to control outbreaks and epidemics using effective WASH, surveillance, communications, diagnostics and countermeasure programmatic delivery."
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