Article: Cross-Border Socio-Economic Dynamics, community vulnerabilities and the Threat of Cholera Resurgence in Uganda: Insights from Kasese, Hoima, and Kikuube districts

Background Cholera remains a global public health threat, causing an estimated 1.3-4 million cases and up to 143,000 deaths annually, mostly in low- and middle-income countries with poor water, sanitation, and hygiene (WASH) systems. In sub-Saharan Africa, outbreaks are driven by poverty, displacement, climate change, and weak health systems. In Uganda, border districts such as Kasese, Kikuube, and Hoima remain vulnerable despite no reported cases since 2018 following vaccination campaigns. Socio-economic activities like fishing, cross-border trade, and seasonal farming continue to heighten exposure. These districts exemplify how livelihoods, mobility, and inadequate infrastructure converge to sustain cholera risks and threaten resurgence even after periods of apparent control. Methods A qualitative study was conducted in the three districts of Hoima, Kikuube and Kasese in the Albertine region to explore the socio-economic and structural drivers of vulnerability to cholera resurgence. Data were collected through Focus Group Discussions (FGDs), Key Informant Interviews (KIIs), In-Depth Interviews (IDIs), and direct observation. Participants aged 18-77 years included community members, caregivers, health workers, and district officials. Nine FGDs, eleven KIIs, and ten IDIs were conducted. Analysis followed manifest and latent content approaches using open, axial, and selective coding, complemented by ChatGPT 4.5 for verification of meaning units. Results Inadequate sanitation (open defecation and lack of toilets), unsafe drinking water, seasonal farming settlements without latrines, cross-border movements from the Democratic Republic of Congo (DRC), crowded or makeshift housing, and weak surveillance were identified as underlying vulnerabilities that erode the benefits of vaccination hence drugging these districts to a possible cholera resurgence. Conclusion The drivers of cholera vulnerability are deeply interconnected: Cholera vulnerability in these districts is rooted in systemic inequities in sanitation, water access, and health infrastructure. Strengthening WASH systems, promoting hygiene behavior change, and improving cross-border surveillance are essential to achieving sustainable cholera elimination and resilience.