Responding to epidemics in large-scale humanitarian crises: a case study of the cholera response in Yemen, 2016–2018

Abstract

BackgroundLarge epidemics frequently emerge in conflict-affected states. We examined the cholera response during the humanitarian crisis in Yemen to inform control strategies.MethodsWe conducted interviews with practitioners and advisors on preparedness; surveillance; laboratory; case management; malnutrition; water, sanitation and hygiene (WASH); vaccination; coordination and insecurity. We undertook a literature review of global and Yemen-specific cholera guidance, examined surveillance data from the first and second waves (28 September 2016–12 March 2018) and reviewed reports on airstrikes on water systems and health facilities (April 2015–December 2017). We used the Global Task Force on Cholera Control’s framework to examine intervention strategies and thematic analysis to understand decision making.ResultsYemen is water scarce, and repeated airstrikes damaged water systems, risking widespread infection. Since a cholera preparedness and response plan was absent, on detection, the humanitarian cluster system rapidly developed response plans. The initial plans did not prioritise key actions including community-directed WASH to reduce transmission, epidemiological analysis and laboratory monitoring. Coordination was not harmonised across the crisis-focused clusters and epidemic-focused incident management system. The health strategy was crisis focused and was centralised on functional health facilities, underemphasising less accessible areas. As vaccination was not incorporated into preparedness, consensus on its use remained slow. At the second wave peak, key actions including data management, community-directed WASH and oral rehydration and vaccination were scaled-up.ConclusionDespite endemicity and conflict, Yemen was not prepared for the epidemic. To contain outbreaks, conflict-affected states, humanitarian agencies, and donors must emphasise preparedness planning and community-directed responses.

The multi-sectorial emergency response to a cholera outbreak in Internally Displaced Persons camps in Borno State, Nigeria, 2017

“…In sum, quantitative studies have analysed humanitarian crises-related cholera intervention measures in isolation focusing on sanitation54 55 in refugee camps, water/hygiene/treatment,56 57 and OCV6–10 58 in IDP camps. Without down playing the rigour of these quantitative studies, excepting Spiegel et al, 11 qualitative studies are needed to explore comprehensive cholera emergency response measures in humanitarian crises including IDPs camps, WASH, case management, surveillance, OCV, coordination, logistics and communication.…”

“…Quantitative studies have looked into OCV interventions in IDPs camps 6–10. However, excepting Spiegel et al, 11 there is scarcity in qualitative comprehensive analysis of cholera emergency response measures in humanitarian crises setting with focus on IDPs camps.…”

An Overview of Cholera Epidemiology: A Focus on Africa; with a Keen Interest on Nigeria

“…Most frequently, cholera outbreaks occur in regions of the world devoid of knowledge about cholera, those having pets at home, conflicts and wars zones, those with increased population growth, climate change, urbanization, overcrowding, inadequate water and sanitation, lack of social amenities (like waste management systems, good accommodation with toilet facilities, and good health facilities) [17,9].…”

“…Cholera (a "disease of the poor") [17,9], was reported by Richterman et al [10], to have affected 550,106 people from thirty low or middle-income countries with available Global Food Security Index [GFSI] from 2012 to 2015. The median yearly incidence rate recorded during this period was 3.1 cases per 100 000 people for a total of 120 country-years.…”

“…Furthermore, Legros [16], stated that as of date forty-seven countries were still affected by cholera whose major route of transmission remains the raw or undercooked contaminated seafood, especially to non-endemic areas [6]. Cholera in some cases is regarded as a "disease of the poor" because, the people who are affected the most are those who cannot afford to provide the basic social facilities for themselves [17,9]. For example, waste management systems and good accommodation with toilet facilities (the living and health conditions of the people).…”