"Yemen’s War Against Cholera" by Aleks Recupero
The Yemeni civil war, which began in 2015, is a humanitarian crisis that had remained largely ignored by international media until late 2017. Along with continued violence, the war-torn country faces one of the largest cholera outbreaks in history . This man-made crisis largely stems from the damaging consequences of the war including destruction of waste disposal plants and widespread malnutrition . Scientists have attempted to forecast the spread of the bacteria while humanitarian groups continue to work relentlessly to help the Yemeni people, but there appears to be no end in sight for this unprecedented crisis.
Cholera is a diarrhea-inducing disease caused by infection with the bacteria Vibrio cholera . The most common mode of infection is by ingestion of contaminated food and water . When improperly disposed, feces from infected individuals can seep into food and water sources to spread the bacterium V. cholera . In this way, clean water sources and proper sanitation are crucial to mitigate the transmission of the water-borne disease. As seen in Yemen, humanitarian crises that disrupt water systems and dislocate people tend to increase the risk of cholera transmission . With proper medical treatment, cholera is rarely fatal, as most people simply require oral rehydration solutions to treat the dehydration associated with diarrhea .
Initial efforts to contain the cholera outbreak in Yemen appeared to be successful. Cholera is believed to be endemic to Yemen with about 17,546 cases each year and a case fatality rate (CFR) of 3.20% . After confirming eleven cholera infections in Sana’a and four infections in the Al-Bayda governorate, Yemen’s Ministry of Public Health and Population (MoPHP) was forced to declare an epidemic on October 6th, 2016 . The non-governmental organization Action Contre la Faim (ACF) led the aid efforts in Hodeidah city, the capital of the Al Hudaydah Governorate . ACF initially worked with Yemen’s Ministry of Public Health and Population to support cholera and Acute Watery Diarrhea (AWD) case management structures . These case management centers provided a cholera treatment center (CTC) for more severe cases, oral rehydration therapy corners (ORTCs) for those with less extensive dehydration, and active case finding in attempt to control the outbreak . ACF also sought to increase access to potable water and improve hygienic practices in the disposal of waste .
The success of the ACF’s involvement was measured from October 28th, 2016 to February 28th, 2017 . Over this time period, 8,720 people sought health care for acute watery diarrhea, of which 5,210 were believed to have contracted cholera . The number of patients admitted to the CTC decreased steadily over time, which suggested better control of the disease . The median age of the patients was eleven years old with 27.3% of the patients that were between one and five years old . Eight percent of the cholera-infected children also had severe acute malnutrition, illustrating how a blockade preventing imported food to enter Yemen has led to adverse effects on the health of the citizens, especially children . The critical fatality rate at the CTC was 0.07%, much lower than the regular CFR of 3.20% . These promising statistics of the treatment of patients by the ACF as well as the overall decrease in cholera cases prompted the ACF to end its intervention in Yemen . However, on April 27th, 2017, the World Health Organization declared a resurgence of the outbreak, illustrating the quick reemergence of cholera cases given disrupted access to clean water, improper sanitation, and widespread malnutrition.3
Following the huge outbreak in late April of 2017, Japanese scientist, Hishiro Nishiura, and his research group began tracking the dynamics of cholera transmission in Yemen to determine the progression of the disease in the war-torn country. The number of infected individuals began increasing once again starting from April 16th, 2017, which was used as an initial date for this second wave of cholera outbreak . Accounting for the delay in reporting cholera cases, Nishiura et al. produced a model that suggested that Yemen had passed through the epidemic peak in the 26th week of 2017 . In this way, Nishiura et al. believed that with the epidemic peak in the past, the continuing large number of cases should not worry the Yemeni population . Instead, Nishiura’s research group focused on spreading awareness throughout the country to prevent reemergence of the outbreak . Cholera’s disease incidence was predicted to be between 690 to 910 cases at the end of the epidemic, having already passed through the peak in July 2017 . Some limitations to the model were noted, such as its inability to address the patients’ quality of health at an individual level, the validity of the model, the dependence on the overall dataset of Yemen, and the inability to account for interventions in the model .
The limitations of Nishiura’s study may account for the fact that the incidence of cholera did not actually decrease over the remainder of 2017. In fact, as of October 2017 815,000 people in Yemen were believed to be infected with cholera, a figure that is now predicted to exceed one million at the start of 2018 . With only 45% of hospitals operational in Yemen and a persisting lack of access to clean water and sanitation, cholera has and will continue to devastate Yemen . In August 2017, the International Committee of the Red Cross was providing for 20% of cholera cases by contributing supplies such as IV fluids, oral rehydration salts, antibiotics, and chlorine tablets . Even with the support of the Red Cross, an unending humanitarian crisis looms over Yemen. With the Yemen’s economic blockade placing increasing pressure on a limited food supply, malnutrition and starvation among the Yemeni people is expected to drag on. The transmission of cholera exceeding models illustrates the Yemen’s dire state due to the current lack of control over the disease. Greater international reporting on this epidemic provides the sole hope for what may become the largest humanitarian crisis in history.
Amidst the Yemeni civil war, one of the largest cholera epidemics remains largely unchecked, precipitating a humanitarian crisis that requires immediate attention.
 Alia Allana, “How war created the cholera epidemic in Yemen,” New York Times, November 12, 2017, https://www.nytimes.com/2017/11/12/opinion/cholera-war-yemen.html
 World Health Organization. 2017. “Cholera.” Accessed December 16. http://www.who.int/mediacentre/factsheets/fs107/en/
 Altmann, Mathias et al. 2017. “First Wave of the 2016-2017 Cholera Outbreak in Hodeidah City, Yemen- ACF Experience and Lessons Learned.” PLOS Currents Outbreaks. Edition 1.
 Nishiura, Hiroshi et al. 2017. “Transmission dynamics of cholera in Yemen, 2017: a real time forecasting.” Theoretical Biology and Medical Modelling. 14:14.
 Lyons, Kate, “Yemen’s cholera outbreak now the worst in history as millionth case looms,” The Guardian, October 12, 2017, https://www.theguardian.com/global-development/2017/oct/12/yemen-cholera-outbreak-worst-in-history-1-million-cases-by-end-of-year
 International Committee of the Red Cross. 2017. “Yemen: War in the time of cholera.” Accessed January 2. https://www.icrc.org/en/document/yemen-war-time-cholera