Infection Control & Hospital Epidemiology Table 1. Cholera Outbreaks Associated with Conflict in the Middle East
Infectious Disease
Cholera
Year 2015
Geographic Area
Iraq
Est. No. of Cases
5,000
Source of Outbreak
∙ Overpopulated communities and refugee settings
∙ Heavy rain/flood ∙ Destruction of infrastructure
Exacerbating Factors
∙ Inadequate sanitation ∙ Contaminated sanitary and water supplies
Proposed Interventions
∙ Treatment of drinking water (boiling, water purification tablets)
∙ Hygiene promotion ∙ Vaccinations campaigns ∙ Introducing the 1-dose cholera vaccine to improve compliance
∙ Cook food and consume immediately
∙ Avoid raw food ∙ Boil unpasteurized milk
2016–ongoing Yemen 1,051,789
and inadequate access to clean drinking water.9 This setting has been the hallmark of the perpetuating civil wars in Iraq, Syria, and Yemen, whereby water and sanitation management as well as infrastructure have been damaged either intentionally or acci- dently. For example, the 2015 cholera outbreak in Iraq is thought to be related to the low water levels in the Euphrates10 as well as the winter flooding, which likely contaminated the Euphrates River and shallow wells with sewage water (Table 1). Two pre- vious outbreaks in Iraq, noted to be of a lesser severity, were reported during 2007 and 2012 and had similar environmental commencements. They affected the northern governorates including Babel, Baghdad, and Kerbala.11 Between September and November 2015, the WHO reported a
cholera toxin variant; both of these are major concerns and could lead to a global public health disaster.8 Cholera outbreaks occur in the background of poor sanitation
severe cholera outbreak in Iraq, with >5,000 confirmed cases and several deaths.12,13 However, the WHO representatives in these areas admit to underreporting because of logistic surveillance difficulties, particularly in the active war zones. Some reports indicate that this cholera outbreak has spread
to neighboring Syria, Kuwait, and Bahrain, with a risk of turning this localized outbreak into a region-wide epidemic.14 Theareas wherethe largest numbers of cholera cases have been detected include the Shiite cities of Najaf and Karbala, where millions of Shiite Muslims travel annually on religious pilgrimages to their holy shrines. In response to the 2015 outbreak, the Iraqi Ministry of Help
with the assistance of international governmental agencies (IGOs), initiated a vaccination campaign targeting at least 255,000 people, mobilizing the largest oral cholera vaccine (OCV) stock- pile and providing supportive care and educational benefits to raise awareness.13 The outbreak seemed to have subsided by December 2015.13 However, among the people who received immunization, the proportion that received the 2 full vaccinations was estimated to range from 21% to 90%. This lack of vaccination coverage is thought to have been influenced by several critical factors including lack of compliance, the continuing displacement of individuals, and the shortage of the vaccination supplies.13 For the past 3 years, the ongoing civil war in Yemen has
highly impacted the basic public health sanitation infrastructure of this country, manifesting a cholera outbreak. This outbreak was first reported in October 2016, and the number of suspected cases exceeded 1,051,789 individuals by January 2018. This phenomenal increase reported by the WHO and the Yemen Ministry of Public Health makes this cholera outbreak the lar- gest epidemic in the world.15 Vital public health infrastructures
15,19
in civilian areas have been totally destroyed or made inoperable, resulting in massive displacement of the affected population into crowded and unsanitary conditions.16 Currently, ~2,000 attri- butable deaths have been reported, and the outbreak has extended geographically, affecting nearly all the governorates in the country.15,17 The WHO and Yemen partners in the Global Health and
Global Water Sanitation and Hygiene Cluster (WASH) or Global WASH cluster (GWC) have responded by providing medical supplies such as diagnostic kits, rehydration solutions, and chlorination tablets, to hospitals handling cholera cases. Small interventions like these are not costly and are capable of decreasing fatality rates among infected patients by 50-fold.18 These organizations have also supported the opening, rehabili- tation, and maintenance of more than 39 diarrheal treatment centers.19 As a result of these interventions, the incidence of cholera began declining and continued to decline until May 2017, when an upsurge in cases was noted. This reversal is believed to have occurred after a catastrophic failure of the sewer system in Sanaa was caused by continuous airstrikes on the city coincident with the beginning of the rainy season. These factors, in addition to severe malnutrition, contributed to the increased morbidity of the disease.16,20 The weekly surveillance cases had been decreasing for the preceding 20 weeks, as reported in late January 2018.15 This decreasing trend occurred despite the fact that the 1 million doses of the oral cholera vaccine that had been allocated from the global stockpile were cancelled in July 2017 due to fear of the vaccine’s ineffectiveness and the realization that the large volume of people at risk dramatically exceeded the supply.21 This move could have been of benefit had it been done earlier in the course of the crisis. Apparently, vaccination plans withamoreadequateamount of vaccine to be allocated are still being researched.22 One potential solution to the previous vaccination issues is the
newly approved single-dose oral cholera vaccine (Vaxchora), which could provide the needed efficacy23 and improve com- pliance by providing a single dose of the vaccine rather than the conventional 2 separate dose vaccinations required. This solution has been hindered, however, because the effectiveness of Vax- chora has not been established in persons living in cholera- affected areas, and the vaccine’s effectiveness has not been established in persons who have pre-existing immunity due to previous exposure to V. cholerae or who previously received a cholera vaccine. The WHO, in collaboration with United Nations Office f
or the Coordination of Humanitarian Affairs (UNOCHA), the European Commission’s Humanitarian Aid Office (ECHO), and
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