Table 2 Impact of conflict on Cholera outbreaks

Center for Disease Control and Prevention (CDC) 2003 [17]

Monrovia, Liberia,

June 2003 –September 2003

Population of Monrovia, Liberia

• Acute shortage of clean water as the piped water distribution system was deemed inactive

• Poor sanitation

• Crowded living conditions

• Weather conditions as regional flooding washed contamination into shallow, unprotected wells

Implemented:

International and Liberian organisations attempted to supply IDP settlements with sufficient potable water and began chlorinating wells

Suggested:

• Provision of increased amounts of clean water

• Health education

• Chlorination of water in protected household containers

Altmann et al., 2017 [24]

Hodeidah city, Yemen, Al Thowra hospital,

28 October 2016–28 February 2017

Population of Hodeidah city, Yemen

• 2 million IDPs

• 462,000 children with Severe Acute Malnutrition

• Half of its population without access to safe drinking water and

• 14.8 million with no access to health care services (only 45% of health facilities are functional).

Implemented:

NGO Action Contre la Faim with Yemen’s Ministry of Public Health and Population responded to the epidemic:

• Provided physical space and key staff,

• The construction and/or rehabilitation of

health centres,

• Staff recruitment (nurses, cleaners, pharmacists, logisticians, WASH workers),

• Supervision and training,

• Supply chains for drugs and medical materials,

• Set up support systems (logistics, WASH, data entry and analysis),

• Human Resource management, financial resources to roll out the intervention and clinical supervision

• Access to safe water through water trucking

• Provision of hygiene education including hand washing and waste disposal at water points

Suggested:

Not mentioned

Lam et al., 2017 [15]

Iraq,

Refugee camps,

2015

People from 27 refugee camps in 10

governorates

• Large numbers of IDPs residing in camps, informal settlements, or temporary placement sites (collective centres)

• Influx of Syrian refugees

• Overcrowded, inadequate shelter arrangements and limited access to sanitation facilities, safe drinking water, safe food, and basic healthcare services

Implemented:

• Implemented WASH and other cholera control measures

• Oral cholera vaccines uptake in IDP camps at full capacity or overcrowded and to all refugee camps and collective centres

• The use of the global OCV stockpile intended to provide rapid deployment of OCVs in emergency and outbreak situations managed by an International Coordination Group

Qadri et al., 2017 [16]

Yemen,

December 2016 – September 2017

Yemenis

• Inadequate shelter

• Inadequate sanitation

• Shortages of water

• Shortages of food

• Shortages of medical supplies

• Shortages of fuel

• Destructed healthcare facilities

• Disruption of sewage management and wastewater treatment facilities

• Lack of electricity to run water pumps

Implemented:

Cooperation between WHO, UNICEF, other international agencies, nongovernmental organisations, and Yemeni healthcare providers to restore the operationalisation of water-treatment plants, provide hygiene kits with soap and chlorination tablets, and provide training in water-sanitation–hygiene behaviours to help prevent cholera

Suggested:

• To create and deploy the OCV global stockpile

• Develop predictive tools to identify humanitarian emergencies posing a high risk of cholera

Al-Mekhlafi, 2018 [18]

Yemen,

Civil war in Yemen,

2 October 2016–14 January 2018

Population of Yemen

• 7.3 million severely food insecure

• 3.3 million IDPs

• 55% of health facilities partially functioning or destroyed

• Airport closures

• Severe shortages of fuel, food, drinking water, and medication

• Existing shortage of water before the conflict

• Clogged sewage and drainage systems

• Waste disposed of in the streets

• Underground water in all Yemeni cities is contaminated with sewage and treatment plants are not functioning because of lack of fuel and maintenance

Implemented:

Yemen government, United Nations, and WHO stated that they should be focused on a WASH intervention to provide safe water and sanitation, setting up diarrhoea treatment centres, and improving the

population’s awareness about the disease.

Suggested:

• An intense vaccination strategy and provision of stockpiled vaccines was suggested

• Continuation of the WASH programme

• Timely establishment of diarrhoea treatment centres and oral rehydration points

• Provision of therapeutic and diagnostic supplies and fuel to health facilities

• Community mobilisation through awareness campaigns

• Assessment of strains and dynamics to evaluate spatial and temporal transmission (monitoring)

Dureab et al., 2018 [19]

Yemen,

17 directorates,

2016 (Week 39–52, 2016)

Population of Yemen (n = 15,074 cholera cases)

• Conflict related factors (destruction, casualties),

• IDPs (outgoing and returning)

• Water and sanitation disruption

• Poor infrastructure

Implemented:

Not mentioned

Suggested:

• Distributing public awareness materials on proper personal hygiene, food and water safety

• Improving the preparedness of the public health authorities for surveillance (including public health laboratories at central and regional levels) and response systems

• Arrangements for leadership and coordination

• Preparedness of case definitions, rapid testing kits, case management procedures,

• Stockpiles of medical supplies

• Establishment of a community surveillance system with an awareness and prevention component would aid in spotting the early indicators of morbidity and mortality and slow the spread of cholera, especially in the context of Yemen.

Jones et al., 2020 [20]

South Sudan,

June 2014 – December 2017

People in South Sudan

• Large-scale population movements between counties of South Sudan with cholera outbreaks

• Movement from neighbouring countries

• Large-scale population displacement

and movement partially explained the differences in the number of cases between years

• Synergistic effects with precipitation and climatic determinants

• Cholera control efforts during these outbreaks was continually hampered by conflicts and restricted access to areas with ongoing transmission

Implemented:

• Case management, surveillance,

• WASH interventions, hygiene promotion, and enforcement of sanitation standards

• Chlorination of public water sources,

in public areas

• OCV was administered in South Sudan through 36 vaccine campaigns

• Phylogenetic analyses to trace the geographical spread of infection

Suggested:

• Regional-level responses to curb outbreaks of cholera in humanitarian settings.

• OCV campaigns

• Interventions to improve water, sanitation, and hygiene in vulnerable settings,

• Controlling cholera in nearby countries that have the potential to introduce cholera might be an effective additional strategy

• Increased whole genome sequencing to support surveillance and understanding the spread of infections

• Improved methods for measuring population movement within and between countries during complex emergencies is needed

Simpson et al., 2022 [14]

Yemen,

Yemen and 20 Yemeni governorates,

4 September 2016–29 December 2019

Yemenis

• Limited access to health care and damaged health infrastructure depleted medical resource stockpiles

• Limited access to safe and affordable water

• Growing malnourished and immunocompromised population increased the risk of infection

• Compounding environmental factors with the underlining conflict related damage (i.e. rainfall, flooding and water contamination).

• Reduced availability of resources due to other epidemics (i.e. SARS-CoV-2)

Implemented:

Not mentioned

Suggested:

• Utility of surveillance data to characterise, classify, and compare infectious disease outbreak signatures to examine spatiotemporal patterns and perform a vulnerability mapping of outbreak hotspots to improve resource management and mobilisation during humanitarian aid responses.

• Public sharing of epidemiological information

Ahmed et al., 2022 [21]

Syrian Arab Republic

Syrian population

• Numerous laboratory facilities, healthcare units, water plants, and sewerage systems were compromised due to airstrikes, and millions left displaced and forced to reside in overcrowded, poorly hygienic refugee camps

• Increasing water scarcity, due to drought and reduced groundwater, and escalating dependence on unsafe water due either to armed encroachment of power supplies to central water stations or to the dependence on unmonitored resources such as private vendor trucks

Implemented:

Not mentioned

Suggested:

• Government and opposition groups must be convinced to ease passages of assistance

• Importance of cumulative efforts to improve safe water access, sewerage systems, healthcare facilities, nationwide surveillance system, and infrastructure.

• In times of instability and conflict, the expansion of the water supply by private trucks appears to be the only feasible option to meet the population’s demands.

• The local population must be encouraged to ensure optimal hygiene by boiling and chlorinating the water, if available.

Al-Tammemi & Sallam 2023 [22]

Syria

September 2022- November 2022

Syrian population

• War and its violence collapsed infrastructure, affecting water and sanitation infrastructure forcing people to rely on unsafe water sources resulting in rapid spread of cholera to many governorates

Implemented:

Not mentioned

Suggested:

• A WASH response must be implemented with inter-agency and multisectoral coordination.

• Humanitarian agencies should assist by providing medical and laboratory supplies (including cholera vaccines)

Ahlaffar, et al., 2023 [23]

Syria

August 2022- April 2023

Syrian population

• The armed conflict resulted in a destroyed and understaffed healthcare system with limited resources and lack of coordinated response, as well as population displacement

Implemented:

Not mentioned

Suggested:

• The provision of safe water and improved sanitation and hygiene practices must be urgently implemented to prevent further spread of the disease and reduce preventable deaths

• improve the testing and reporting capacity of the health system and strengthen the surveillance systems to detect and respond to outbreaks promptly

• Coordinated efforts and collaboration between local health authorities and international organisations working in Syria are important.

• International organisations should provide technical and financial support to strengthen the country’s response, including training and equipping healthcare workers, improving disease surveillance, and expanding access to testing and treatment.

• Effective community engagement is critical for the success of any disease prevention and control program, particularly in conflict-affected settings where trust in government and healthcare systems may be low

• Economic development and universal access to sustainable safe drinking water and adequate sanitation, including the improvement of environmental conditions, the rehabilitation of damaged health facilities, and the improvement of early warning systems should be prioritised

• The main priority must be rebuilding the country’s health system and increasing access to safe drinking water and sanitation facilities, particularly in conflict-affected areas