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Yemen: Cholera Outbreak

Changes from June 29, 2017 to August 2, 2017

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Overview

Yemen is facing an unprecedented humanitarian crisis due to an ongoing international conflict that began in March 2015 and has killed over 10,000 people. More than half of Yemen's estimated 25 million population lackhas killed more than 10,000 people since 2015 and left more than half of its 24.7 million population with no access to basic health care. Roughly, and roughly 15 million people lackare without access to clean water, sanitation, and hygiene services, which has manifested in the largest cholera outbreak in Yemen's history(WASH) services. Only 45% of health facilities in the country are functional, and many have limited access to medicines, medical equipment, and clean water and sanitation, further complicating efforts to control the outbreak. Yemen is experiencing the world's largest ongoing cholera outbreak. The outbreak began in October 2016, tapered off in December, and surged in April 2017 (Figure 1). Cholera has been detected in most of Yemen's 22 governorates.

The World Health Organization (WHO) estimates that as of June 26August 1, 2017, more than 20over 440,000 Yemenis have contracted cholera, of whom over 1,9001,400 have died. Children younger than 15 years old and the elderly are particularly vulnerable, together accounting for roughly 80% of all cholera deaths. Case counts continue to rise, with an average of 5,000 cases daily. Only 45% of health facilities in the country are functional and have limited access to medicines, medical equipment, and clean water and sanitation, further complicating efforts to control the outbreak.

What Is Cholera?

Cholera is a diarrheal infection that is contracted by ingesting food or water contaminated with the bacterium Vibrio cholerae. WHO estimates that there are up to 4 million annualglobal cholera cases worldwideoccur annually, causing 21,000-143,000 deaths annually. The disease is primarily found in countries and areas that commonly lack sufficient access to clean water, sanitation, and hygiene (WASH)with poor WASH conditions, such as urban slums, camps for internally displaced persons or refugees, and areas under conflict.

About 75% of people who are infected with cholera do not exhibit any symptoms, although infected peoplethey can spread the bacterium for up to two weeks if others ingest food or water contaminated with their fecal matter. Cholera can cause acute diarrhea and vomiting, which can lead to severe dehydration and death within hours if not immediately treated. People with suppressed immune conditions, such as malnourished children and HIV-positive individuals, are more likely to die from cholera. Common treatments include oral rehydration salts and antibiotics. Cholera vaccines provide protection for up to five years. Long-term prevention of the disease requires the establishment and proper maintenance of clean water systems, wastewater treatment plants, and sanitary facilities.

Figure 1. Estimated Suspected Cholera Cases and Deaths: Yemen

(October 7, 2016-June 26 - August 1, 2017)

Sources: Created by CRS from WHO, Yemen: Cholera Outbreak, Weekly Epidemiology Bulletin, Week 25 and WHO, Yemen: Cholera Outbreak, Daily Epidemiology Update, June 27, 2017.

webpage for Situation Reports, accessed on August 2, 2017.

Note: The figures were calculated with data provided in WHO's Epidemiology Bulletins and reflect estimates at the time of each update.

The conflict in Yemen is primarily a battle between a coalition of nations led by Saudi Arabia that seek, which seeks to restore the rule of Yemen's internationally recognized President,powers of President Abdu Rabbu Mansour Hadi, who was overthrown in 2015 by an alliance composed of the Iran-supported Houthi movement and loyalists of the previous President, Ali Abdullah Saleh.

After more than two years of war, the country has fractured and the economy has been devastated, creating conditions conducive to the spread of cholera. When. In 2016, President Hadi moved the Central Bank from Sana'a, the capital, to the city of Aden in 2016 (reportedly to exert control over Yemen's finances), that. That action cut payments to thousands of civil servants in Houthi-Saleh -controlled territory, including for municipal services such as garbage collection. For the past nine months, waste has gone uncollected and untreated, polluting water supplies and contributing to the ongoing cholera outbreak. To restore the salaries of front-line public health workers combating the cholera crisis, the Government health workers have reportedly worked without pay for more than 10 months. WHO and the United Nations Children's Fund are reportedly paying allowances to supplement lost wages.United Nations Children's Fund (UNICEF) recently announced that it has started paying medical workers about 70% of their salaries. International human rights organizations also have accused warring factions of conducting airstrikes that have unlawfully targeted civilian infrastructure, such as water wells, bottling facilities, health facilities, and water treatment plants. As ofBy October 2016, at least 274 health facilities havehad been reportedly damaged or destroyed.

U.S. and International by the conflict and only 1,579 (45%) were fully functional and accessible. Due to inadequate access to health services and supplies, deaths from treatable health conditions, such as childhood pneumonia, malaria, high blood pressure, and diabetes, are reportedly rising. International and U.S. Response

In 2016, the United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA) issued a $2.1 billion appeal to fund the 2017 Yemen Humanitarian Response Plan (YHRP). More than $1.5 billion would be used to provide nutrition ($1.1 billion), health ($332.1 million), and clean water and sanitation ($127.7 million) to almost 20 million people. As of June 14July 23, 2017, the international community has provided nearly $600900 million to the plan, including roughly $145 million from the United States (the largest donor).

for the plan. In May 2017, the WASH Clusters in Yemen—composed of 180 partners from the United Nations, nongovernmental organizations, foreign nations, and the Yemen government—released an integrated cholera response plan. The plan initially called for $66.7 million to control the outbreak from May through October 2017. The cluster released a new cholera control plan in July following the continued spread of the disease. The new plan sought $254 million to staunch the cholera outbreak. The July plan indicated that donors had contributed almost $50 million.

Intense fighting (particularly near ports and major access points), attacks on health facilities and humanitarian convoys, and mistrust of the United Nations have limited humanitarian access. Cholera control efforts are also complicated by the rapidly deteriorating health conditions of the population. The disease can usually be treated with antibiotics and oral rehydration salts, though the diseasebut it is more deadly for people with compromised immune systems, such as those who are undernourished. About 3.3 million children and pregnant or lactating women in Yemen are acutely malnourished, including 462,000 children who are younger than five years old. Health experts are also concerned about the onset of the rainy season, which may increase the pace of cholera transmission.

In June 2017, the International Coordinating Group (ICG) on vaccine provision for cholera announced that it was shipping 1 million doses of cholera vaccine to Yemen. The vaccines may arrive in July, though observers are concerned about Saudi-led blockades that have limited access to Yemen's air and sea ports. Saudi officials express concern that shipments of goods to Yemen may be exploited by their adversaries.vaccination campaign has been postponed "at the request of the health authorities, in favor of a much larger preventive campaign next year." Additional efforts by U.S., U.N., and international partners to control the cholera outbreak and address other health issuesprovide health support and control the cholera outbreak have included

  • the rehabilitation of the water supply system in Ta'iz City and surrounding districts, providing access to safe drinking water for more than 400,000 people;
  • the provision of medical supplies to treat approximately 60,000 patients;
  • the dissemination of more than 115,000 bags of intravenous fluids;
  • the establishment of nearly 2,000 cholera treatment beds and 200 oral rehydration points to treat suspected cases; and
  • the provision of one-month supplies of chlorine tablets for 580,000 people.

Since the conflict began in March 2015more than 400 tons of life-saving supplies, including more than 820,000 bags of intravenous fluids and nearly 160 cholera treatment kits;

  • chlorinated water supplies that benefitted over 5 million people;
  • the delivery of 30 ambulances; and
  • the establishment of over 1,000 diarrhea treatment centers and oral rehydration corners and 3,000 cholera treatment beds.
  • Since the conflict began, the United States has been the largest contributor of humanitarian aid to Yemen., having provided more than $467.2 million in humanitarian aid in FY2017. Funds were provided to international aid organizations from USAID's Office of Foreign Disaster Assistance (OFDA), USAID's Food for Peace (FFP), and the U.S. Department of State's Bureau of Population, Refugees, and Migration (State/PRM).

    CRS fellow Dr. Giorleny Altamirano, Global Health Fellow, contributed to this Insight.