“Yemen’s health workers are operating in impossible conditions. Thousands of people are sick, but there are not enough hospitals, not enough medicines, not enough clean water. These doctors and nurses are the backbone of the health response — without them we can do nothing in Yemen. They must be paid their wages so that they can continue to save lives.”

– Tedros Adhanom Ghebreyesus, the WHO director-general

Cholera outbreak in Yemen, currently the largest in the world, has shown its fangs among the population. Began in late October of 2016, this outbreak has given rise to 700,000 cases of cholera and has taken the life of more than 2000 people—in addition to 10.000 death occurred and more than 45.000 injured due to the conflict. To note, even before the conflict, Yemen was among the poorest of Arab countries.

A Condition Like You Never Seen Before: What it’s Like Living In Between Conflicts in Yemen

Considered to be one of the most water-stressed countries in the world, Yemen is highly vulnerable to epidemic attack of cholera. This waterborne disease is transmitted through fecal-oral route—making the current exposure to droughts and lack access to clean water experienced by people of Yemen to be highly hazardous. It is estimated that 7 until 14 million, out of the total 25 million population, have been infected with cholera—creating a major need of health care assistance. Yet, destruction of about half of Yemen’s health care facilities has led to the limited delivery of health care; furthermore, 30.000 health care workers have not yet received their salaries during the past year and many have fled the country.

Blockade of rebel-controlled area has intensified the problems, where the flow of food, medical supplies and fuel are all detained. Bombing has led to the destruction of water and sanitation infrastructures. In addition, lack access to fuel has disrupted the management of water waste facilities and electricity to run the water. These problems, which are currently occurring in Yemen, have created a pool of 15 million people to have lack access to basic health care. Currently, it is estimated that there are at least 17 million people facing food insecurity, 7 million are at risk food shortage, and 2 million children are left malnourished.

Cholera — Why is it Dangerous and A Worldwide Response

Cholera is an acute infection of the gut that is caused by the ingestion of pathogenic bacteria called the Vibrio cholerae. It takes approximately 12 hours until 5 days until a person who has ingested contaminated food or water to develop any symptoms. Infection can lead to the occurrence of acute severe watery diarrhea, which if left untreated, may cause rapid dehydration. This disease may affect both children and adults and can be life-threatening, even only within hours after the onset of the symptoms.

Worldwide, it is estimated that this disease has caused up to 143.000 death per year. The transmission of this disease is closely related to inadequate access to clean water and safe sanitation, thus showing the reason why conditions of living currently faced by the Yemen people have made them extremely vulnerable to cholera infections.

In response to this hazardous state faced by war-ravaged countries, WHO, UNICEF, other international agencies, non-governmental organizations, and Yemeni health care providers have been trying to provide better care for patients and limit the overall case fatality rate of reported cholera cases until 0.5%. Other efforts include supplying chlorinated water, restoring operations of the water-treatment plants, providing hygiene kits and training of water-sanitation-hygiene behaviors in attempt to prevent future infection of cholera.

Oral Cholera Vaccines (OCVs) are now internationally accepted as a regimen for controlling epidemic and endemic threats. Management of these vaccines are handled by the International Societies of the Red Cross and Red Crescent, UNICEF, WHO, and Doctors without Borders (Médecins sans Frontières), with WHO as the secretariat, and funded by Gavi, the vaccine alliance. This stockpile of vaccines has been allocated to many places around the world to control of endemic and epidemic cases, some of which include Africa, Asia, Haiti and the Middle East.

Request of the OCVs had been made on behalf of Yemen in the late of June 2017. As many as 3.4 million stocks were proposed, and the decision was made to release 1 million—of which are currently the largest doses ever made in its 4-year history. However, several weeks later the request was retracted. The reason is due to the consideration made in a meeting in Sana’a, attended by local ministries and the United Nations as well as other aid agencies; explaining that the resource would be better spent on existing preventive and therapeutic approaches, as mass immunization would be logistically difficult in the current setting. Moreover, the impact produced would be minimal since the epidemic had spread so widely—with a total of 25 million population, where roughly 7 until 14 million have been infected, a million dose would be far too few to bring optimal impact in controlling the nationwide cases of cholera.

References

1. Qadri F, Islam T, Clemens J. Cholera in Yemen — An Old Foe Rearing Its Ugly Head. New England Journal of Medicine. 2017;377(21):2005-2007.
2. 10 facts on cholera [Internet]. World Health Organization. 2017 [cited 10 December 2017]. Available from: http://www.who.int/features/factfiles/cholera/en/

Alessa Fahira
Indonesia One Health University Network
Communication and Networking Team