Cholera is an acute, enteric infection caused by bacteriumVibrio cholerae. It provokes a severe watery diarrhoea upon ingestion of contaminated food or water, i.e. it is transmitted via the faeco-oral route. Cholera epidemics, caused primarily by serotypes O1 and O139, continue to be a public health problem in developing countries, and is a strong indicator for lack of social development and inequity. It is estimated that each year there are 1.3-4.0 million cases, and 21,000-143,000 deaths worldwide (1). In April 2017 until now, Yemen has been facing one of the worst cholera epidemics in recent history, with 1.2 million cases and 2515 deaths (2). Since March 2015 Yemen has been ravaged by war, and this conflict has contributed to the magnitude and severity of the epidemic. Organisations from the International Coordination Group (ICG), comprising UNICEF, WHO, MSF and ICRC, have all been involved in the response to the outbreak.
Cholera is a preventable disease, that continues to exist because of inappropriate access to clean water, sanitation and hygiene (WASH). As a self-resolving diarrhoeal disease, deaths occur due to a dehydration that can be easily treated with oral rehydration salts (ORS). Yet roughly 14.8 million people in Yemen, more than half the population, have no access to healthcare (3). In situations such as these, organisations such as Médecins Sans Frontières (MSF) can intervene, and they have treated 100,000 patients since the start of the outbreak (4). Security however is still a huge concern, and MSF have reported being attacked at least six times since the outbreak of war, and even a newly constructed cholera treatment centre was destroyed in an airstrike in Abs (5).
It was therefore quite an achievement when WHO-UNICEF’s joint campaign managed to reach and agreement with parties of conflict, in order to carry out a mass vaccination campaign in the four “Days of Tranquility”. Health workers managed to reach 306,000 people in Yemen between 2-5 October 2018, using the oral cholera vaccine (OCV) provided by the global stockpile (6).
Vaccination is extremely useful as a tool to control the epidemic by strategically targeting areas of high risk, but it is not a long-term solution. It must be used as an adjunct, together with proper surveillance and promotion of WASH. During the first semester of 2018, ICRC provided relief aid to 500,000 Yemenis, and helped 2 million people to access clean water and better sanitation in the wake of this humanitarian crisis (7). Yet the country itself will need to develop its infrastructure to provide appropriate sanitation and hygiene to its population in the long-term.
It is also interesting that in a study between a few international organisations and the Yemen Health Authorities, they have found a correlation between the rainy season in the country and the upsurge in the number of cholera cases (8). Currently, an international collaboration has resulted in the development of a new cholera forecast tool, whereby NASA satellites’ information is combined with information of sanitation and clean water infrastructure in order to predict the likelihood of an outbreak (9). We are yet to see to what extent this form of surveillance will have in controlling cholera.
The number of cases is accelerating once again, with the WHO reporting that in a single week in late 2018 there were 10,000+ cases (2). More needs to be done, in order to control the spread of this disease. It is unacceptable that people continue to die of cholera when it is entirely preventable, and this epidemic has served to show the atrocious repercussions of war.
Reference
WHO (2018) “Cholera” https://www.who.int/news-room/fact-sheets/detail/cholera
Reuters (2018) “Yemen cholera outbreak accelerates to 10,000+ cases per week: WHO” https://www.reuters.com/article/us-yemen-security-cholera/yemen-cholera-outbreak-accelerates-to-10000-cases-per-week-who-idUSKCN1MC23J
MSF “The crisis in Yemen” https://www.msf.org.uk/content/crisis-yemen
MSF (2017) “Yemen: this crisis is not getting the international response it deserves” https://www.msf.org.uk/article/yemen-crisis-not-getting-international-response-it-deserves
MSF (2018) “MSF Cholera Treatment Centre attacked in Abs Yemen” https://prezly.msf.org.uk/msf-cholera-treatment-centre-attacked-in-abs-yemen
WHO (2018) “Health workers in Yemen reach more than 306,000 people with cholera vaccines during four-day pause in fighting – WHO, UNICEF” https://www.who.int/news-room/detail/05-10-2018-health-workers-in-yemen-reach-more-than-306-000-people-with-cholera-vaccines-during-four-day-pause-in-fighting-who-unicef
ICRC (2018) “Displaced in Yemen where the needs continue to grow” https://www.icrc.org/en/document/untold-stories-yemens-internally-displaced
Camacho et al (2018) “Cholera epidemic in Yemen, 2016-2018: an analysis of surveillance data” https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30230-4/fulltext
NASA (2018) “NASA investment in cholera forecasts helps save lives in Yemen” https://www.nasa.gov/press-release/nasa-investment-in-cholera-forecasts-helps-save-lives-in-yemen