Cholera Case in Syrian Refugee Camp: Ominous Signals

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According to a report disseminated by the ProMED mail service, a case of cholera has been detected in a refugee camp housing displaced people from Homs. The translated report reads as below:

The 1st case of cholera has been recorded in Zogra camp near Jarabulus city (125 km or 78 mi north of Aleppo) at the Syrian-Turkish border, which accommodates people displaced from Homs. A medical source told Smart News on [Thu 19 Oct 2017] that cholera symptoms have been identified in a 4-month-old girl who had a severe form of rice water diarrhea, accompanied by dehydration and hypotension.

The cause of the cholera outbreak is possibly related to polluted water sources in the camp and the exposed sewage system that provides a source for flies to transmit the disease. The source pointed out that they have communicated with the Directorate of Health, which promised to take appropriate action. The source warned of the spread of infection among a larger number of people if preventive measures are not taken through awareness campaigns and maintenance of sewage networks as soon as possible.

The 10 200 persons living in Zogra camp have previously complained of lack of food and health assistance and lack of water and electricity in the camp.

As the experience from Yemen has adequately demonstrated, a broken healthcare system, in conflict situations, with risks of water contamination and inadequate food and water supply provides the perfect storm for cholera to manifest as explosive outbreaks.

Image Credits: AA

The Global Task Force for Cholera Control highlights the following for cholera control:


Control

Among people developing symptoms, 80% of episodes are of mild or moderate severity. The remaining 10%-20% of cases develop severe watery diarrhoea with signs of dehydration. Once an outbreak is detected, the usual intervention strategy aims to reduce mortality – ideally below 1% – by ensuring access to treatment and controlling the spread of disease. To achieve this, all partners involved should be properly coordinated and those in charge of water and sanitation must be included in the response strategy. Recommended control methods, including standardized case management, have proven effective in reducing the case-fatality rate.

The main tools for cholera control are:

  • proper and timely case management in cholera treatment centres;
  • specific training for proper case management, including avoidance of nosocomial infections;
  • sufficient pre-positioned medical supplies for case management (e.g. diarrhoeal disease kits);
  • improved access to water, effective sanitation, proper waste management and vector control;
  • enhanced hygiene and food safety practices;
  • improved communication and public information.

WHO recommendations to unaffected neighbouring countries

Countries neighbouring an area affected by cholera should implement the following measures:

  • improve preparedness to rapidly respond to an outbreak, should cholera spread accross borders, and limit its consequences;
  • improve surveillance to obtain better data for risk assessment and early detection of outbreaks, including establishing an active surveillance system.

However, the following measures should be avoided, as they have been proven ineffective, costly and counter-productive:

  • routine treatment of a community with antibiotics, or mass chemoprophylaxis, has no effect on the spread of cholera, can have adverse effects by increasing antimicrobial resistance and provides a false sense of security;
  • restrictions in travel and trade between countries or between different regions of a country;
  • set up a cordon sanitaire at borders, a measure that diverts resources, hampers good cooperation spirit between institutions and countries instead of uniting efforts.

Image Credits: Oxfam on Medium
Drawing on the Yemen experience, and recent experience from conflict-ridden areas of South Sudan, using a single-dose based approach with oral cholera vaccines potentially presents a strategy to contain potential explosive outbreaks. On the bright side, the early detection of the case could help to staunch the potential cascade of cases that could follow. The appropriate actions being taken need to be established on an emergency basis so that the situation does not spiral out of control.
A girl fills a container with water from a public tap in the old city of Sanaa, Yemen (AP Photo/Hani Mohammed) Image Credits: Center for International Governance Innovation
The worry is that once an outbreak of cholera is in full swing, too much of effort and resources get redirected to case detection and management, and prevention of mortality, and little is left over to dedicate to preventive actions, especially to break the transmission cycle, which means not only interrupting transmission of infections, but also ensuring safe water provision across the board, which is, even at the best of times, a challenging affair.

Skeptic Oslerphile, Scientist at the Indian Council of Medical Research, National Institute of Cholera and Enteric Diseases. Interests include: Emerging Infections, Public Health, Antimicrobial Resistance, One Health and Zoonoses, Diarrheal Diseases, Medical Education, Medical History, Open Access, Healthcare Social Media and Health2.0. Opinions are my own!

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