The Problem
The war-torn country of Yemen has been battling a significant cholera outbreak since mid-October of 2016. The number of suspected cases doubled over the course of 12 days from 2,070 cases on November 1st, to 4,119 cases on November 13th [2,3,5]. As of November 14th, there has been eight confirmed deaths from cholera and 56 from acute diarrhea across the country (2,5). This cholera outbreak is mostly affecting children, with half of the suspected cases being reported in children under 10 years old [4,6].
What is Cholera?
Cholera is an acute diarrheal disease caused by ingesting food or water contaminated with the bacterium Vibrio cholera, or from coming in close contact with an infected individual. The food or water often becomes contaminated with V. cholerae through fecal contamination from already infected persons [8]. Most people infected with cholera experience mild or no symptoms [8]. Thus, those who are unaware of their cholera infection living in locations with poor water and sanitation infrastructure can contribute to spread of the disease [7]. Cholera more commonly affects individuals living in slums or refugee camps, due to reduced access to clean water and sanitation facilities [7]. Only one in ten people infected with cholera will experience severe symptoms including severe watery diarrhea and vomiting [8]. Consequently, these symptoms cause severe dehydration, which can be deadly. Symptoms often take between 12 hours and five days to occur after ingestion of V. cholerae bacteria [7]. If left untreated, cholera can result in death within hours after symptoms commence [7].
Cholera is diagnosed through identification of V. cholerae in stool samples [7,8]. Treatment for cholera consists of an oral rehydration solution, which aims to replace the fluids and electrolytes lost as a result of the diarrhea [8]. The oral rehydration solutions consist of sugar and salts that is mixed with clean water for consumption [8]. More severe cases may require intravenous fluid replacement and antibiotics [8]. Treatment must be prompt to avoid death. If immediate treatment is received, the case fatality rate is below 1% [7].
Prevention of cholera includes adequate water and sanitation infrastructure, adequate hygiene practices, and oral vaccines. According to the World Health Organization (WHO), piped water systems and treatment facilities, water chlorination, water filtration, chemical or solar disinfection of water, safe water storage, and construction of adequate sewage disposal systems are all ways to prevent the spread of cholera at a community level [7]. This infrastructure often takes time to implemented and can be very costly, making it difficult for developing countries to execute and maintain [7]. At the individual level, the WHO suggests appropriate hygiene practices and oral vaccination to prevent cholera [7]. Adequate hygiene practices include handwashing with soap and water, safe preparation of food, and appropriate disposal of feces [7]. The oral vaccination is another method of prevention for cholera. In 2013, the WHO acquired two million doses of these oral vaccinations to control outbreaks in emergency settings [7]. Currently, three oral vaccines exist and all are 65% effective at protecting against cholera [7]. Each type of oral vaccination requires two doses to be the most effective (7). Thus, full vaccination can be difficult to administer in developing countries due to a lack of access and the need for more than one dose.
The Conflict in Yemen
Causes of the War
The current conflict in Yemen began on March 25th, 2015 between a Saudi Arabian-led coalition and the Huthi’s [9]. The Saudi Arabian-led coalition is anti-Huthi individuals in favor of the current President of Yemen, Abd Rabbu Mansour Hadi [9]. The Huthi group is an armed group of individuals who belong to Zayidism, a branch of Shi’a Islam [9]. These Huthi’s are in support of the former President of Yemen, Ali Abdullah Saleh [9]. Approximately 7,070 people have been killed and 36,818 have been injured thus far during this conflict [11].
Devastating Effects of the Conflict on the Health System
According to a recent article in TIME Magazine, Yemen was ranked the poorest Middle Eastern country prior to the beginning of the conflict [10]. Their economic and health condition of the country has only worsened since the commencement of the conflict. More than 19 million Yemenis lack access to clean water (about 66% of the population), 14 million people are now suffering starvation or malnutrition, and over three million are internally displaced [2,10]. Furthermore, the conflict has had drastic effects on Yemen’s health system. The United Nations released a report stating that only 45% of Yemen’s health facilities are fully functional and that 274 health facilities have been damaged or destroyed due to conflict violence [11]. Shortages of medical doctors and communicable disease management are also occurring as a consequence of the conflict [11].
Cholera Outbreak in Yemen
Yemen is more adversely impacted by cholera due to a lack of appropriate water and sanitation infrastructure and adequate health facilities – issues exacerbated by the ongoing conflict. The recent cholera outbreak has been spreading at an incredible rate, affecting thousands of people. With limited access to potable water and medical care, cholera is expected to continue infecting people unless something is done. However, due to the ongoing conflict and limited financial support, Yemen has struggled to control the outbreak.
What is being done?
Yemen has limited means to control the outbreak by itself and has received various foreign aid as a result. The WHO has donated one million USD towards response efforts [12]. The Emirates Red Crescent (ERC) has specifically helped the Yemen province, Aden, through the distribution of 20 barrels of chlorine for its water authority and sufficient oral rehydration solution for its hospitals [4]. In addition, UNICEF is assisting in the chlorination of water sources, administering hygiene kits, and informing families about cholera and how to protect themselves [4].
Despite these efforts to control the cholera outbreak, Yemen still needs to accomplish a lot more to prevent further spread of cholera or other health issues for its civilians. One can only hope that the conflict will end soon so that Yemen can begin its efforts to restoring its country to a peaceful and healthier environment for its civilians.
References:
1.http://www.who.int/mediacentre/news/notes/2016/cholera-yemen/en/
2.http://www.reuters.com/article/us-yemen-security-cholera-idUSKBN1391H5
3.http://www.who.int/hac/crises/yem/en/
4.http://www.thenational.ae/world/middle-east/cholera-outbreak-deals-war-torn-yemen-yet-another-blow
5.http://presstv.ir/Detail/2016/11/14/493595/Yemen-WHO-Cholera-outbreak-Saudi-Arabia
7.http://www.who.int/mediacentre/factsheets/fs107/en/
8.https://www.cdc.gov/cholera/general/
9.https://www.amnesty.org/en/latest/news/2015/09/yemen-the-forgotten-war/
10.http://time.com/4531649/yemen-conflict/
11.http://www.un.org/apps/news/story.asp?NewsID=55490#.WDx266IrLVo
12.http://www.emro.who.int/media/news/who-releases-emergency-funds-to-support-cholera-response-in-yemen.html
