Genomic insights into the 2022-2023Vibrio cholerae outbreak in Malawi.

Malawi experienced its deadliest Vibrio cholerae (Vc) outbreak following devastating cyclones, with >58,000 cases and >1700 deaths reported between March 2022 and May 2023. Here, we use population genomics to investigate the attributes and origin of the Malawi 2022-2023 Vc outbreak isolates. Our results demonstrate the predominance of ST69 clone, also known as the seventh cholera pandemic El Tor (7PET) lineage, expressing O1 Ogawa (~ 80%) serotype followed by Inaba (~ 16%) and sporadic non-O1/non-7PET serogroups (~ 4%). Phylogenetic reconstruction revealed that the Malawi outbreak strains correspond to a recent importation from Asia into Africa (sublineage AFR15). These isolates harboured known antimicrobial resistance and virulence elements, notably the ICEGEN/ICEVchHai1/ICEVchind5 SXT/R391-like integrative conjugative elements and a CTXφ prophage with the ctxB7 genotype compared to historical Malawian Vc isolates. These data suggest that the devastating cyclones coupled with the recent importation of 7PET serogroup O1 strains, may explain the magnitude of the 2022-2023 cholera outbreak in Malawi.

Healthcare Seeking Behavior and Disease Perception Toward Cholera and Acute Diarrhea Among Populations Living in Cholera High-Priority Hotspots in Shashemene, Ethiopia.

BACKGROUND: Healthcare seeking behavior (HSB) and community perception on cholera can influence its management. We conducted a cross-sectional survey to generate evidence on cholera associated HSB and disease perception in populations living in cholera hotspots in Ethiopia. METHODS: A total of 870 randomly selected households (HHs) in Shashemene Town (ST) and Shashemene Woreda (SW) participated in our survey in January 2022. RESULTS: Predominant HHs (91.0%; 792/870) responded "primary health center" as the nearest healthcare facility (HCF). Around 57.4% (247/430) of ST HHs traveled <30 minutes to the nearest HCF. In SW, 60.2% (265/440) of HHs travelled over 30 minutes and 25.9% (114/440) over 4 km. Two-thirds of all HHs paid

Coverage of Two-Dose Preemptive Cholera Mass Vaccination Campaign in High-Priority Hotspots in Shashemene, Oromia Region, Ethiopia.

BACKGROUND: Cholera is a public health priority in Ethiopia. The Ethiopian National Cholera Plan elaborates a multi-year scheme of oral cholera vaccine (OCV) use. Aligned with this, a preemptive OCV campaign was conducted under our Ethiopia Cholera Control and Prevention project. Here, we present the OCV vaccination outcomes. METHOD: Cholera high-priority hotspots in the Oromia Region, Shashemene Town (ST) and Shashemene Woreda (SW), were selected. Four kebelles (Abosto, Alelu, Arada, and Awasho) in ST and 4 clusters (Faji Gole, Harabate, Toga, and Chabi) in SW were study sites with OCV areas nested within. A total of 40 000 and 60 000 people in ST and SW, respectively, were targeted for a 2-dose OCV (Euvichol-Plus) campaign in 11-15 May (first round [R1]) and 27-31 May (second round [R2]) 2022. Daily administrative OCV coverage and a coverage survey in 277 randomly selected households were conducted. RESULTS: The administrative OCV coverage was high: 102.0% for R1 and 100.5% for R2 in ST and 99.1% (R1) and 100.0% (R1) in SW. The coverage survey showed 78.0% (95% confidence interval [CI]: 73.1-82.9) of household members with 2-dose OCV and 16.8% (95% CI: 12.4-21.3) with no OCV in ST; and 83.1% (95% CI: 79.6-86.5) with 2-dose OCV and 11.8% (95% CI: 8.8-14.8) with no OCV in SW. The 2-dose coverages in 1-4-, 5-14-, and ≥15-year age groups were 88.3% (95% CI: 70.6-96.1), 88.9% (95% CI: 82.1-95.7), and 71.3% (95% CI: 64.2-78.3), respectively, in ST and 78.2% (95% CI: 68.8-87.7), 91.0% (95% CI: 86.6-95.3), and 78.7% (95% CI: 73.2-84.1) in SW. CONCLUSIONS: High 2-dose OCV coverage was achieved. Cholera surveillance is needed to assess the vaccine impact and effectiveness.

Comprehensive Review on the Use of Oral Cholera Vaccine (OCV) in Ethiopia: 2019 to 2023.

BACKGROUND: Cholera outbreaks in Ethiopia necessitate frequent mass oral cholera vaccine (OCV) campaigns. Despite this, there is a notable absence of a comprehensive summary of these campaigns. Understanding national OCV vaccination history is essential to design appropriate and effective cholera control strategies. Here, we aimed to retrospectively review all OCV vaccination campaigns conducted across Ethiopia between 2019 and 2023. METHODS: The OCV request records from 2019 to October 2023 and vaccination campaign reports for the period from 2019 to December 2023 were retrospectively accessed from the Ethiopia Public Health Institute (EPHI) database. Descriptive analysis was conducted using the retrospective data collected. RESULTS: From 2019 to October 2023, Ethiopian government requested 32 044 576 OCV doses (31 899 576 doses to global stockpile; 145 000 doses to outside of stockpile). Around 66.3% of requested doses were approved; of which 90.4% were received. Fifteen OCV campaigns (12 reactive and 3 pre-emptive) were conducted, including five two-dose campaigns with varying dose intervals and single-dose campaigns partially in 2019 and entirely in 2021, 2022 and 2023. Overall vaccine administrative coverage was high; except for Tigray region (41.8% in the 1st round; 2nd round didn't occur). The vaccine administrative coverage records were documented, but no OCV coverage survey data was available. CONCLUSIONS: This study represents the first comprehensive review of OCV campaigns in Ethiopia spanning the last five years. Its findings offer valuable insights into informing future cholera control strategies, underscoring the importance of monitoring and evaluation despite resource constraints. Addressing the limitations in coverage survey data availability is crucial for enhancing the efficacy of future campaigns.

Dissecting Water, Sanitation, and Hygiene (WaSH) to Assess Risk Factors for Cholera in Shashemene, Oromia Region, Ethiopia.

BACKGROUND: Cholera outbreaks have afflicted Ethiopia, with nearly 100 000 cases and 1030 deaths reported from 2015 to 2023, emphasizing the critical need to understand water, sanitation, and hygiene (WaSH) risk factors. METHODS: We conducted a cross-sectional household (HH) survey among 870 HHs in Shashemene Town and Shashemene Woreda, alongside extracting retrospective cholera case data from the Ethiopian Public Health Institute database. Relationships between WaSH and sociodemographic/economic-levels of HHs were examined. WaSH status and cholera attack rates (ARs) were described at kebele-level using geospatial mapping, and their association was statistically analyzed. RESULTS: Access to basic drinking water, sanitation, and hygiene facilities was limited, with 67.5% (95% confidence interval, 64.4-70.6), 73.4% (70.3-76.3), and 30.3% (27.3-33.3) of HHs having access, respectively. Better WaSH practices were associated with urban residence (adjusted odds ratio, 1.7, [95% confidence interval, 1.1-2.7]), higher educational levels (2.7 [1.2-5.8]), and wealth (2.5 [1.6-4.0]). The association between cholera ARs and at least basic WaSH status was not statistically significant (multiple R2 = 0.13; P = .36), although localized effects were suggested for sanitation (Moran I = 0.22; P = .024). CONCLUSIONS: Addressing gaps in WaSH access and hygiene practices is crucial for reducing cholera risk. Further analyses with meaningful covariates and increased sample sizes are necessary to understand the association between cholera AR and specific WaSH components.

Ethiopia National Cholera Elimination Plan 2022-2028: Experiences, Challenges, and the Way Forward.

Cholera remains a significant public health concern in Ethiopia. More than 15.9 million Ethiopians, constituting 15% of the total population, live in areas with a history of recurrent cholera outbreaks. The last 9 years of national cholera surveillance data show the country has been experiencing cholera outbreaks every year. The current cholera outbreak, starting in August 2022, has affected the entire country, with 841 reported cases and a 3.13% case fatality rate (CFR) in 2022, and >30 000 cases with nearly a 1.4% CFR in 2023. In line with "Ending Cholera-A Global Roadmap to 2030," the government of Ethiopia is committed to eliminate cholera in the country and has prepared its "National Cholera Elimination Plan (NCP): 2022-2028" with aims to achieve zero local transmission in cholera hotspot areas by 2028 and 90% fatality reduction from the recent (2020-2022) average of 1.8% CFR. The plan is multisectoral, has a clear coordination platform, contains all interventions with in-depth situational analysis, is concordant with existing plans and strategies, and is cascaded at the regional level and implemented with existing government and public structures. Nationwide, total 118 cholera hotspot woredas (districts) were identified, and a comprehensive situation analysis of the existing cholera outbreak response capacity was assessed. This multisectoral and multiyear NCP has forecasted around US$404 million budget estimates with >90% allocated to improving the country's water, sanitation, and hygiene (US$222 million; 55% of total NCP budget) and case management (US$149 million; 37%). The cholera vaccination strategy included in the NCP exhibited a 5-year oral cholera vaccine (OCV) introduction plan with 2 doses (30 604 889 doses) and single dose (3 031 266 doses) in selected cholera hotspot areas. However, its implementation is challenged due to a lack of financial support, inability to get the requested vaccine for targeted hotspot woredas (due to the current shortage of doses in the OCV global stockpile), recurrent cholera outbreaks, and high humanitarian needs in the country. It is recommended to have a sustainable financial mechanism to support implementation, follow the requested vaccine doses, and reorganize the planned coordination platform to foster the implementation.

Retrospective Analysis of Cholera/Acute Watery Diarrhea Outbreaks in Ethiopia From 2001 To 2023: Incidence, Case Fatality Rate, and Seasonal and Multiyear Epidemic Patterns.

BACKGROUND: The Ethiopian government has developed the multisectoral cholera elimination plan (NCP) with an aim of reducing cholera incidence and case fatality rate (CFR). To better understand and monitor the progress of this plan, a comprehensive review of national cholera epidemiology is needed. METHODS: Reported data on cholera/acute watery diarrhea (AWD) cases in the past 20 years were extracted from the Ethiopian Public Health Institute and World Health Organization databases. Descriptive statistics, Pearson χ2, and logistic regression analyses were conducted. RESULTS: From January 2001 to November 2023, a total of 215 205 cholera/AWD cases, 2355 deaths with a cumulative CFR of 1.10% (95% confidence interval [CI], 1.092-1.095), and a mean annual incidence rate of 8.9/100 000 (95% CI, 6.5-11.3) were reported. Two major upsurges of cholera epidemics were found in the last two decades with mean attack rate (AR) of 20.57/100 000 in 2006-2010 and 14.83/100 000 in 2016-2020. Another resurgence of outbreaks occured in 2021-2023 (mean AR, 8.63/100 000). In 2015-2023, 54.0% (53 990/99 945) of cases were aged 15-44 years. National cholera CFR (3.13% [95% CI: 2.1-4.5]) was the highest in 2022. The 2015-2023 cumulative cholera CFR was different across regions: Benishangul Gumuz (6.07%), Gambela (1.89%), Sidama (1.42%), Southern Nation, Nationalities, and Peoples' (1.34%), Oromia (1.10%), and Amhara (1.09%). Cholera/AWD patients in older adults (≥45 years), severe dehydration, peak rainy season (June-August), and outpatients were associated with higher risk of death. CONCLUSIONS: Cholera has been a public health problem in Ethiopia with case fatalities still above the global target. Case management needs to be improved particularly in outpatients and older populations. Outbreak preparedness should be rolled out well in advance of the typical rainy seasons. Significant investments are essential to advance the cholera surveillance system at healthcare setting and community level. Underlying factors of cholera deaths per areas should be further investigated to guide appropriate interventions to meet the NCP target by 2028.

[The history of the fight against cholera epidemics in the Krasnodar territory in 1892 and 1910 (based on archival data)].

Epidemics of a wide variety of infectious diseases were constantly recorded in Russia. Asian cholera occupied a special place among epidemic diseases. In 1892, cholera was imported into the Russian Empire through the Black Sea ports, which reached the territory of the Kuban region by the summer of the same year. In 1892, about 300 thousand people died of cholera in Russia. They still did not know how to treat this terrible disease, did not know its mechanism of spread, as well as the peculiarities of its course. The article, prepared on the basis of an analysis of documentary data from the Archive Department of the administration of the municipal formation of the city of Novorossiysk and the archival Department of the Administration of the municipal formation of the Mostovsky district, examines the cholera epidemic that swept the territories of the Kuban region in 1892 and 1910. The authors characterize the main factors that contributed to the rapid spread of infection and assess the measures that were taken to combat the disease: the implementation of anti-cholera measures organized by the authorities was greatly hampered by the lack of education, prejudices and superstitions of the vast majority of the population; representatives of the nonresident population not only did not comply with basic standards of personal hygiene, but also expressed distrust, and sometimes and hostility towards doctors. Using archival data, the authors investigate the impact of infectious diseases on the demographic indicators of these settlements.

Improved water supply infrastructure to reduce acute diarrhoeal diseases and cholera in Uvira, Democratic Republic of the Congo: Results and lessons learned from a pragmatic trial.

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.

Non-O1 and non-O139 Vibrio cholerae Septicemia and Cellulitis: a Case Report.

Non-O1 and non-O139 Vibrio cholerae (NOVC) are serogroups that do not produce cholera toxin and are not responsible for epidemics. Even though rarely encountered in clinical practice, they can cause a spectrum of different conditions ranging from mild gastrointestinal syndrome to extraintestinal diseases, of which bacteremia and wound infections are the most severe. Risk factors for severe disease are cirrhosis, neoplasms, and diabetes mellitus. The mortality rate of NOVC bacteremia in hospitalized patients ranges from 24 to 61.5%. Incidence of NOVC infections is still rare, and consensus recommendations on treatment are not available. We report a case of NOVC bacteremia associated with severe cellulitis in an immunocompetent 75-year-old man who had eaten raw seafood in a location by the northern Adriatic Sea (Italy). Twenty-four hours after intake, he developed a high fever and vomiting. Afterwards, he started noticing the appearance of cellulitis in his right leg, which worsened in a matter of hours. The patient had a history of compensated type 2 diabetes mellitus. NOVC was isolated from both blood cultures and the leg ulcer. The non-O1, non-O139 serogroup was confirmed, and the detection of the cholera toxin gene was negative. Both tests were performed by the Reference National Laboratory of Istituto Superiore di Sanità (ISS). Multiple antimicrobial regimens were administered, with complete recovery. In conclusion, considering the severity of NOVC-associated manifestations, it is of pivotal importance to reach etiological diagnosis for a target antimicrobial therapy and to consider V. cholerae infection in the differential diagnosis in the presence of risk factors and potential exposure.

Participatory Disease Surveillance for the Early Detection of Cholera-Like Diarrheal Disease Outbreaks in Rural Villages in Malawi: Prospective Cohort Study.

BACKGROUND: Cholera-like diarrheal disease (CLDD) outbreaks are complex and influenced by environmental factors, socioeconomic conditions, and population dynamics, leading to limitations in traditional surveillance methods. In Malawi, cholera is considered an endemic disease. Its epidemiological profile is characterized by seasonal patterns, often coinciding with the rainy season when contamination of water sources is more likely. However, the outbreak that began in March 2022 has extended to the dry season, with deaths reported in all 29 districts. It is considered the worst outbreak in the past 10 years. OBJECTIVE: This study aims to evaluate the feasibility and outcomes of participatory surveillance (PS) using interactive voice response (IVR) technology for the early detection of CLDD outbreaks in Malawi. METHODS: This longitudinal cohort study followed 740 households in rural settings in Malawi for 24 weeks. The survey tool was designed to have 10 symptom questions collected every week. The proxies' rationale was related to exanthematic, ictero-hemorragica for endemic diseases or events, diarrhea and respiratory/targeting acute diseases or events, and diarrhea and respiratory/targeting seasonal diseases or events. This work will focus only on the CLDD as a proxy for gastroenteritis and cholera. In this study, CLDD was defined as cases where reports indicated diarrhea combined with either fever or vomiting/nausea. RESULTS: During the study period, our data comprised 16,280 observations, with an average weekly participation rate of 35%. Maganga TA had the highest average of completed calls, at 144.83 (SD 10.587), while Ndindi TA had an average of 123.66 (SD 13.176) completed calls. Our findings demonstrate that this method might be effective in identifying CLDD with a notable and consistent signal captured over time (R2=0.681404). Participation rates were slightly higher at the beginning of the study and decreased over time, thanks to the sensitization activities rolled out at the CBCCs level. In terms of the attack rates for CLDD, we observed similar rates between Maganga TA and Ndindi TA, at 16% and 15%, respectively. CONCLUSIONS: PS has proven to be valuable for the early detection of epidemics. IVR technology is a promising approach for disease surveillance in rural villages in Africa, where access to health care and traditional disease surveillance methods may be limited. This study highlights the feasibility and potential of IVR technology for the timely and comprehensive reporting of disease incidence, symptoms, and behaviors in resource-limited settings.

Vibrio mimicus Lineage Carrying Cholera Toxin and Vibrio Pathogenicity Island, United States and China.

Vibrio mimicus bacteria have caused sporadic cases and outbreaks of cholera-like diarrhea throughout the world, but the association of lineages with such events is unexplored. Genomic analyses revealed V. mimicus lineages carrying the virulence factors cholera toxin and toxin coregulated pilus, one of which has persisted for decades in China and the United States.

Spatiotemporal Modeling of Cholera, Uvira, Democratic Republic of the Congo, 2016-2020.

We evaluated the spatiotemporal clustering of rapid diagnostic test-positive cholera cases in Uvira, eastern Democratic Republic of the Congo. We detected spatiotemporal clusters that consistently overlapped with major rivers, and we outlined the extent of zones of increased risk that are compatible with the radii currently used for targeted interventions.

Outbreaks of faecal-orally transmitted diseases in displacement camps: A scoping review of pathogens, risk factors, exposure routes, and drivers of transmission.

Many forcibly displaced people reside in camps characterised by precarious living conditions, exposing them to numerous health risks. This scoping review elucidated the risk factors and exposure routes implicated in outbreaks of faecal-oral pathogens in camps, as well as the context-specific drivers of transmission that shape these outbreaks. Journal articles were identified from PubMed, Embase, Scopus, and Web of Science. Portals for grey literature were also searched. A total of 48 records, published between 1937 and 2022, were included in the analysis. Cholera outbreaks were the most frequently reported. Risk factors included drinking water from shallow wells and rivers, consuming ice and leftover food, and inconsistent handwashing. These indicate exposure through vehicles of transmission in both public and domestic domains, emphasising the importance of a multipronged approach to outbreak prevention and control. Outbreaks were often exacerbated by extreme weather events and acute population influxes that damage or overwhelm water and sanitation facilities. Such shocks warrant explicit recommendations in preparedness and response guidelines. Development projects and outbreak response measures in surrounding areas may reduce the risk of importing pathogens into camps. Future research could further investigate faecal-oral pathogens other than Vibrio cholerae and analyse the co-occurrence of the identified transmission drivers.

Investigation of potentially pathogenic Vibrionaceae in Saint-Louis city, Senegal.

Introduction: as cholera, due to toxigenic bacteria Vibrio cholera (serogroups O1 and O139), is a major public health threat in Africa, the aim of this work was to investigate potentially pathogenic Vibrionaceae bacteria firstly from human stool samples, and secondly from various environmental water points of Saint-Louis city in Senegal. Methods: a hospital-based study was conducted between 2013 and 2015. Stool samples were taken and cultured from daily incoming patients or hospitalized for acute diarrhea at Saint-Louis´ regional hospital. For environment, a monthly longitudinal sampling from January to October 2016 was carried out at 10 sites in the city. We used total DNA extracted from APW (alkaline peptone water) broth solutions and on suspect bacterial colonies to run PCR Multiplex targeting specific DNA fragments to detect Vibrio genus and specific species. In case of positivity, a simplex PCR was performed to test for cholera toxins Ctx, and V. parahaemolyticus TRH and TDH. Results: for 43 patients screened, bacterial culture was positive in 6% of cases but no strain of V. cholerae or other Vibrio sp. was isolated. PCR on 90 APW solutions were positive for Vibrio sp.(n = 43), V. cholera(n = 27), V. mimicus(n = 16), V. parahaemolyticus(8), V. alginolyticus(n = 4), and V. vulnificus(n = 2). Unlike for those on suspected colonies which were positive for a majority of V. parahaemolyticus (n = 40) and V. cholerae non-O1 / O139 (n = 35). Six strains of V. parahaemolyticus carried TRH gene, 3 of which expressed simultaneously virulence TRH and TDH genes. For physicochemical parameters, all temperatures varied similarly according to a unimodal seasonality, as well as salinity. Conclusion: despite the presence of natural populations of Vibrionaceae, even toxigenic ones, was noted in water environment, along with favorable habitat conditions that could play a role in transmission of Vibriosis in the Saint Louis population, we did not isolate any of them from patients screened at the hospital.

Existence of cholera outbreak, challenges, and way forward on public health interventions to control cholera outbreak in Guraghe Zones, southern Ethiopia, 2023.

Introduction: In Ethiopia, despite major improvements seen in health service delivery system, the country continues to be significantly affected by cholera outbreaks. Cholera remains a significant public health problem among the vulnerable populations living in many resource-limited settings with poor access to safe and clean water and hygiene practices. Recurring cholera outbreaks are an indication of deprived water and sanitation conditions as well as weak health systems, contributing to the transmission and spread of the cholera infection. Objective: To assess the cholera outbreak, its challenges, and the way forward on public health interventions to solve the knowledge and health service delivery gaps related to cholera control in Guraghe Zone, Ethiopia, 2023. Methods: Active surveillance of the cholera outbreak was conducted in all kebeles and town administrative of Guraghe zone from 7/8/2023 to 30/10/2023. A total of 224 cholera cases were detected during the active surveillance method. Data obtained from Guraghe zone offices were exported to SPSS version 25 for additional analysis. The case fatality rate, incidence of the cases, and other descriptive variables were presented and described using figures and tables. Result: A total of 224 cholera cases were detected through an active surveillance system. In this study, the case fatality rate of cholera outbreak was 2.6%. To tackle the cholera outbreak, the Guraghe zone health office collaborated with other stakeholders to prepare four cholera treatment centers. The absence of OCV, inaccessible safe water, low latrine coverage, inappropriate utilization of latrines, and absence of cholera laboratory rapid diagnostics test in Guraghe Zone are barriers to tackling the outbreak. Conclusion: Ethiopia National Cholera Plan targeted eradicating cholera by 2030, 222 cholera outbreak occurred in Guraghe Zone, Ethiopia. To minimize and control cholera mortality rate oral cholera vaccinations should be employed in all areas of the region. Sustainable WASH measures should be guaranteed for the use of safe water and good hygiene practices. Early diagnosis and treatment should be initiated appropriately for those who are infected.

Effect of a Water, Sanitation, and Hygiene Program on Handwashing with a Cleansing Agent among Diarrhea Patients and Attendants in Healthcare Facilities in the Democratic Republic of the Congo: A Randomized Pilot of the PICHA7 Program.

Healthcare-acquired infections are a major problem in healthcare facility settings around the world. The Democratic Republic of the Congo (DRC) has over 2 million diarrhea patients hospitalized each year. These healthcare settings become high-risk environments for spreading diarrheal illnesses such as cholera. The objective of the Preventative Intervention for Cholera for 7 Days (PICHA7) program is to develop evidence-based water, sanitation, and hygiene (WASH) interventions to reduce cholera and other severe diarrheal diseases in the DRC. The study objective was to evaluate the effectiveness of PICHA7 program delivery in increasing handwashing with a cleansing agent at stool/vomit- and food-related events in a healthcare facility setting among diarrhea patients and patient attendants. A pilot of the PICHA7 program was conducted among 284 participants in 27 healthcare facilities from March 2020 to November 2021 in urban Bukavu in the South Kivu Province of the DRC. The standard arm received the standard message provided in the DRC to diarrhea patients on the use of oral rehydration solution and a basic WASH message at healthcare facility discharge. The PICHA7 arm received the PICHA7 WASH pictorial module delivered by a health promoter focused on handwashing with a cleansing agent at the bedside of the diarrhea patient in the healthcare facility and provision of a soapy water bottle (water and detergent powder). Within 24 h of intervention delivery, a three-hour structured observation of handwashing practices at stool/vomit- and food-related events (key events) was conducted in healthcare facilities of diarrhea patients and their attendants. Compared to the standard arm, there was significantly more handwashing with a cleansing agent at key events in the PICHA7 arm (40% vs. 15%) (odds ratio: 5.04; (95% confidence interval (CI): 2.01, 12.7)). These findings demonstrate that delivery of the PICHA7 WASH pictorial module and provision of a soapy water bottle to diarrhea patients and their attendants presents a promising approach to increase handwashing with a cleansing agent among this high-risk population in healthcare facilities in the eastern DRC.