The cholera outbreak in Yemen: lessons learned and way forward

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cholera 28 Title: BMC Public HealthThe cholera outbreak in Yemen: lessons learned and way forwardFrederik FederspielMohammad AliPublication date (epub):
cholera 242 12/2018Publication date (pmc-release): 12/2018Publication date (collection): /2018AbstractThe Yemen cholera outbreak has been driven by years of conflict and has now become the largest in epidemiologically recorded
cholera 491 cases since the beginning of the outbreak in April, 2017. In this report we review and discuss the cholera management strategies applied by the major international humanitarian health organizations present in
cholera 1072 Continuous funding to this stockpile will be crucial to maintain this option for prevention and control of cholera outbreaks. Of equal importance will be the timely recognition of the need for mass OCV deployment and
cholera 2054 world’s worst humanitarian crisis [[1]]. In the midst of this, the largest and fastest spreading cholera outbreak recorded since the WHO began recording cholera outbreaks in 1949 has erupted [[2], [3]]. As
cholera 2110 of this, the largest and fastest spreading cholera outbreak recorded since the WHO began recording cholera outbreaks in 1949 has erupted [[2], [3]]. As of October 7, 2018, the WHO estimates a cumulative total
cholera 2251 [[2], [3]]. As of October 7, 2018, the WHO estimates a cumulative total of 1,236,028 reported cases of cholera to have occurred in Yemen since the beginning of the outbreak in April, 2017 [[4]]. 2556 of these cases
cholera 2698 were stunted reflecting a high prevalence of chronic malnutrition, lowering their resilience towards cholera [[6], [7]]. Water, Sanitation and Hygiene (WaSH) infrastructure was limited [[8]]. Destruction of the
cholera 3037 infrastructure in Yemen has been destroyed, hampering the possibility of prevention and control of cholera in the country. The main seaport to Yemen, Al-Hudeydah, has been bombed and later blocked, disrupting
cholera 3765 other basic commodities have increased dramatically [[16]–[18]], lowering overall resilience towards cholera in Yemen even further.It is clear that such a collapse of infrastructure has created fertile ground
cholera 3879 Yemen even further.It is clear that such a collapse of infrastructure has created fertile ground for a cholera outbreak, and that the critical triggering cause was conflict [[9], [15], [17], [19]–[22]]. Both this
cholera 4216 resolution with involvement from a so far neglectful international community [[23]–[25]]. However, cholera outbreaks frequently occur on the backdrop of conflict and/or poor WaSH infrastructure yet fail to spread
cholera 5029 databases published from 2015 and onward until submission in May 2018 (search string: “Yemen AND cholera ”), to inform a discussion of potential shortcomings and lessons to be learned from the humanitarian
cholera 6047 mobile teamsDelivered health and nutrition services, essential drugs and medical suppliesEstablished 37 cholera treatment centers and oral rehydration pointsDelivered child and nutrition interventions in 323 districtsDeployed
cholera 6203 pointsDelivered child and nutrition interventions in 323 districtsDeployed mobile health teamsEstablished 36 cholera treatment centersEstablished community health volunteer networks for referral of malnourished children
cholera 6503 health systemSustained functionality of 414 health facilitiesSee “Health infrastructure”Supported 17 cholera treatment facilitiesHealth infrastructureDistributed more than 2 million liters of fuel for hospital
cholera 6880 infrastructureSent medical supplies including IV fluids, ORS, antibiotics and chlorine tablets for cholera managementDelivered 1 million bags of IV fluidsDistributed 158 cholera kitsSent 1450 cholera cotsShipped
cholera 6951 antibiotics and chlorine tablets for cholera managementDelivered 1 million bags of IV fluidsDistributed 158 cholera kitsSent 1450 cholera cotsShipped in ambulancesWaSHProvided safe water to over one million peopleDelivered
cholera 6973 tablets for cholera managementDelivered 1 million bags of IV fluidsDistributed 158 cholera kitsSent 1450 cholera cotsShipped in ambulancesWaSHProvided safe water to over one million peopleDelivered WaSH servicesDispatched
cholera 7389 community hygiene promoters (part of awareness campaigns below)Staff trainingTrained 900 health workers in cholera managementTrained health staff on cholera treatmentEpidemiological activitiesExpanded disease surveillance
cholera 7431 campaigns below)Staff trainingTrained 900 health workers in cholera managementTrained health staff on cholera treatmentEpidemiological activitiesExpanded disease surveillance capacityManagementCoordination of Health
cholera 7596 surveillance capacityManagementCoordination of Health Cluster YemenWaSH cluster leadAwarenessRan several cholera awareness campaignsPlanned to conduct awareness-raising via radio stations and mosquesAdvocacyAdvocated
cholera 7822 humanitarian air service and for peaceSummary output of activitiesTreated 700,000 suspected cases of cholera Provided care to nearly one in five cholera cases in YemenAdmitted more than 103,000 patientsAbbreviations:
cholera 7865 peaceSummary output of activitiesTreated 700,000 suspected cases of choleraProvided care to nearly one in five cholera cases in YemenAdmitted more than 103,000 patientsAbbreviations: WHO World Health Organization, UNICEF
cholera 8506 Health and Water Sanitation and Hygiene (WaSH) Clusters in Yemen published a response plan for the cholera outbreak [[32]]. The plan included two principal approaches to cholera management: a) treating all cases
cholera 8577 published a response plan for the cholera outbreak [[32]]. The plan included two principal approaches to cholera management: a) treating all cases of Acute Watery Diarrhea (AWD) as cholera without the need for lab
cholera 8653 principal approaches to cholera management: a) treating all cases of Acute Watery Diarrhea (AWD) as cholera without the need for lab confirmation in areas where cholera has been previously culture confirmed,
cholera 8714 cases of Acute Watery Diarrhea (AWD) as cholera without the need for lab confirmation in areas where cholera has been previously culture confirmed, and b) early response epidemiological and case management activities
cholera 9274 mobile teams and delivery of child and nutrition interventions in 323 districts, having established 36 cholera treatment centers, expanded disease surveillance capacity and having distributed more than 2 million
cholera 9575 reported having established 139 oral rehydration corners, trained 900 health workers in the management of cholera , delivered 1 million bags of IV fluids, distributed 158 cholera kits and sent 1450 cholera cots [[34]],
cholera 9639 health workers in the management of cholera, delivered 1 million bags of IV fluids, distributed 158 cholera kits and sent 1450 cholera cots [[34]], and they had shipped in ambulances as well [[22]]. Through these
cholera 9666 management of cholera, delivered 1 million bags of IV fluids, distributed 158 cholera kits and sent 1450 cholera cots [[34]], and they had shipped in ambulances as well [[22]]. Through these and other interventions
cholera 9836 [[22]]. Through these and other interventions the WHO described having treated 700,000 suspected cases of cholera [[34]].UNICEF described having provided safe water to over one million people and delivered 40 tons
cholera 10125 fluids and diarrhea kits [[35]]. UNICEF serves as the WaSH cluster lead and reported having run several cholera awareness campaigns including the deployment of 20,000 community hygiene promoters [[35], [36]].On their
cholera 10416 delivering health, nutrition, WaSH services, essential drugs and medical supplies, training health staff on cholera treatment and advocating for a direct humanitarian air service and for peace [[37]]. In a Lancet appeal,
cholera 10930 reported having sent medical supplies including IV fluids, ORS, antibiotics and chlorine tablets for cholera management, supported 17 cholera treatment facilities and provided care to nearly one in five cholera
cholera 10963 supplies including IV fluids, ORS, antibiotics and chlorine tablets for cholera management, supported 17 cholera treatment facilities and provided care to nearly one in five cholera cases in Yemen, and they had dispatched
cholera 11032 cholera management, supported 17 cholera treatment facilities and provided care to nearly one in five cholera cases in Yemen, and they had dispatched engineers to restore water supply systems in the country [[22],
cholera 11242 [[22], [39]].Médecins Sans Frontières (MSF) described having admitted more than 103,000 patients to 37 cholera treatment centers and oral rehydration points [[40]] and planning to conduct outreach activities including
cholera 13059 Yemen” [[22]]. An additional funding appeal at the event for $250 million specifically for combatting cholera yielded only $47 million [[22]]. This was eventually followed up by a US$2 billion funding pledge at
cholera 13480 the United States, the United Kingdom and France, which are supporting countries [[44]–[50]].Oral cholera vaccinesA striking observation from our review of the humanitarian response is the absence of delivering
cholera 15013 trials and six observational studies estimates the mean effectiveness of standard two-dose killed oral cholera vaccination at 76% and mean efficacy at 58%, with protection lasting for at least 3 years [[56]]. Oral
cholera 15124 vaccination at 76% and mean efficacy at 58%, with protection lasting for at least 3 years [[56]]. Oral cholera vaccination has been demonstrated to be safe, logistically feasible and acceptable by the recipient
cholera 15542 unacceptable premise that the Yemeni conflict became reality, the question that arises is: Could the largest cholera outbreak ever recorded have been avoided or at least managed, had enough OCVs been deployed earlier
cholera 17167 reflected by the impressively low case fatality rate of 0.21%, but ill-equipped in terms of preventing a cholera outbreak in the approximately 2 years of conflict and humanitarian presence that preceded the outbreak
cholera 18440 current breakdown of sanitation systems [[15]] and the key importance of sanitation for prevention of a cholera outbreak in areas where the population has not been exposed and has no immunity to cholera, as well
cholera 18531 prevention of a cholera outbreak in areas where the population has not been exposed and has no immunity to cholera , as well as for prevention of other water-borne disease outbreaks, sanitation has to be a key priority
cholera 19158 decision makers. Whatever the reasons, OCVs were not distributed until nearly 16 months into the cholera outbreak by which time more than a million cases had accumulated. Neither were they in the two years
cholera 19408 preceded the outbreak. This should serve as a historic example of the failure to control the spread of cholera given the tools that are available. Today, “cholera outbreaks are entirely containable” (The Lancet
cholera 19462 example of the failure to control the spread of cholera given the tools that are available. Today, “ cholera outbreaks are entirely containable” (The Lancet editorial, 2017) [[6]].Based on their experience with
cholera 19578 outbreaks are entirely containable” (The Lancet editorial, 2017) [[6]].Based on their experience with the cholera outbreak in Juba, South Sudan, Parker et al. (2017) advocate among other things for improved laboratory
cholera 19912 access the ICG stockpile to allow for timely deployment of vaccines [[69]].Single-dose killed oral cholera vaccination has been attempted, and the strategy has shown a mean short-term effectiveness of 69% in
cholera 21100 from 2018 and onwards [[77]]. This scale-up will be a crucial improvement of the ability to control cholera in emergency settings, and sustained funding to maintain this stockpile will be essential for controlling
cholera 21648 notion we do support, whilst acknowledging the difficulty of the task of predicting the outbreak of cholera [[53], [69]]. The current WHO framework for decision-making on vaccination in acute humanitarian emergencies
cholera 21814 decision-making on vaccination in acute humanitarian emergencies offers a tool for assessing the risk level for a cholera outbreak, and in the case of Yemen, the high-risk criteria were fulfilled [[78]]. The current WHO position
cholera 21938 the case of Yemen, the high-risk criteria were fulfilled [[78]]. The current WHO position paper on cholera vaccines offers general advice in four sentences on which factors to consider regarding the use of OCVs
cholera 22054 offers general advice in four sentences on which factors to consider regarding the use of OCVs for cholera control in humanitarian emergencies [[79]], while the available draft of the 2018 Sphere Handbook offers
cholera 23766 human rights consequences of their actions.ConclusionsThe conflict in Yemen has caused the largest cholera outbreak in epidemiologically recorded history. OCVs were not delivered pre-emptively, nor until nearly
cholera 24210 funding to the ICG OCV stockpile will be crucial to maintain this option for prevention and control of cholera outbreaks. Of equal importance will be the timely recognition of the need for mass OCV deployment and
cholera 24475 actionable evidence-based frameworks to help guide this decision, however difficult this may be. The Yemen cholera outbreak highlights the importance for international humanitarian health organizations to have a continuous
diarrhea 6717 generators, ambulances etc.Delivered 40 tons of medical equipment including medicine, ORS, IV fluids and diarrhea kits.Provided seven hospitals with drugs, supplies and infrastructureSent medical supplies including
diarrhea 10032 delivered 40 tons of medical equipment including medicine, Oral Rehydration Solution (ORS), IV fluids and diarrhea kits [[35]]. UNICEF serves as the WaSH cluster lead and reported having run several cholera awareness

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