By Dr. Jennifer Sedillo
Faculty Member, Public Health at American Public University, and Shawn Granato, AMU Master’s Student, Homeland Security Emergency Management and Health Services
Will Yemen soon see relief from the massive cholera epidemic that has taken hold there? Cholera, a severe and deadly diarrheal disease caused by the bacterial contamination of water, has been endemic (a small number of cases usually occurring) in Yemen.
However, two years of civil war has worsened health and sanitation conditions in Yemen, leading to an exponential increase in cholera cases. On July 2, the World Health Organization (WHO) sent much-needed medical supplies to Yemen. WHO also plans to commence a door-to-door cholera awareness campaign in late July.
Cholera Relief Efforts Are in Progress, but New Cases Still Occurring
Despite the insurmountable task of getting medical supplies to the people in need in Yemen, 47 cholera centers have been successfully established and 278 treatment corners (facilities that provide oral rehydration) are operative.
Currently, the case fatality rate (CFR) of Yemen’s cholera epidemic is 0.5%, which is below the acceptable 1% CFR for a cholera outbreak. But a large number of cases have shown only little relief so far.
The current outbreak began last April. As of July 19, 362,545 suspected cases have been reported with 1,817 deaths. It is estimated that 5,000 new cases occur per day with deaths occurring disproportionately among children.
The attack rate (the risk of getting the cholera disease) has been steadily increasing. It is currently at 12%, with some areas having attack rates of up to 26%. This is the second wave of an epidemic that began in September 2016, but showed signs of slowing until April of this year.
Destruction Caused by Yemen’s Civil War Led to Cholera Outbreak
The current epidemic is directly due to the civil war in Yemen that began in 2015. This war destroyed the country’s infrastructure, including sanitation and health facilities.
Shortages make access to clean water difficult and food is scarce, so the population is malnourished and susceptible to disease outbreaks. Medical aid cannot reach the most affected populations, which diminishes the chances of ending outbreaks of the disease. Also, healthcare and sanitation workers are not being paid in Yemen, which further escalates the situation.
How Does Cholera Occur and Spread?
Cholera is a disease that has been endemic in parts of the world for centuries. But frequent cholera epidemics, and even pandemics, do occur.
Cholera epidemics often happen after a natural disaster or social conflict, which causes a breakdown in infrastructure. That breakdown leads to unsanitary food and water sources.
Cholera occurs when the bacterium Vibrio cholerae enters the body via the ingestion of contaminated food and water. When this bacterium is in the intestine, it releases a toxin that causes severe diarrhea and dehydration, which in turn can lead to death if a patient remains untreated. The transmission cycle continues when infected persons defecate the bacteria into water sources that are used for drinking.
How Is Cholera Treated?
Oral or intravenous rehydration is the preferred treatment for cholera. That reduces case fatality rates during outbreaks, but rehydration does not end cholera transmission. To prevent the spread of cholera in communities, traditional health prevention techniques such as hand washing and sanitizing water sources are commonly used.
Can a Cholera Vaccine Campaign End the Yemen Epidemic?
A national vaccine campaign in Yemen was planned to begin in July, but authorities have postponed it due to a worldwide vaccine shortage. The campaign planned for next year will seek to vaccinate more than 1 million people with the recommended two doses.
Previously, vaccination in response to cholera outbreaks was not recommended due to limited resources in developing countries and other nations experiencing civil unrest.
Currently, a massive vaccination campaign is under way to end the most recent cholera outbreak in Haiti following Hurricane Matthew. This treatment change is the result of the success of the vaccine in Iraq in response to the 2015 cholera outbreak.
In Iraq, all at-risk persons over the age of one year were vaccinated with two oral doses of cholera vaccine and other prevention methods.
Previously, it was not believed that vaccination was cost-effective or realistic, given that the vaccine requires refrigerated storage and the logistics of administering a two-dose schedule.
We will not know if the vaccine can effectively stop the transmission of cholera in Yemen until next year. But the success in Iraq and the trials in Haiti provide hope of preventing future cholera epidemics.
About the Author
Dr. Jennifer Sedillo is an associate professor in the Public Health program at American Public University. She recently received her doctorate from the University of South Florida, where she was involved in infectious disease research. She has been involved in biomedical and environmental microbiology research for the past 12 years.