The country of Yemen has been in a civil war for many years. Over two million people have abandoned their homes and remain displaced within the country (World Health Organization [WHO], 2017b). More than eight million people are facing acute shortages of clean water for drinking and do not have access to sanitation facilities (WHO, 2017b). Consequently, many waterborne diseases have spread rapidly through the country.

Cholera has struck Yemen particularly hardCholera has struck Yemen particularly hard (WHO, 2017a). More than one million cases have been reported in Yemen, making it the largest epidemic of cholera in modern history (Dwyer, 2017). Because of ongoing conflict within the country, it has been difficult for humanitarian aid to reach the parts of the country most affected by the war (United Nations [UN], 2017). This article presents the factors associated with the cholera outbreak, areas of greatest need, and the challenges of providing aid to these areas. Recommendations are based upon current literature addressing cholera outbreaks with particular emphasis on the advocacy role of public health nurses.

Conflict in Yemen

The health system...has worsened to the point where it is now on the brink of collapseIn March 2015, fighting broke out between two factions within Yemen, leading to a major political upheaval (Raslan et al., 2017). The upheaval developed into a civil war between the Yemeni government, led by a Saudi coalition, and the Houthi rebels, supported by Iran (Kennedy, Harmer, & McCoy, 2017). Both sides of the conflict have been accused of breaching international humanitarian law and disregarding the well-being of Yemeni civilians (Kennedy et al., 2017). The health system, which was already fragile before the war, has worsened to the point where it is now on the brink of collapse (Raslan et al., 2017). Many hospitals within the country were destroyed by airstrikes from both sides of the war, leaving many without a place to go for medical care. Only 45% of Yemen’s healthcare facilities are functional, and many healthcare workers have not been paid in over a year (The Lancet Infectious Diseases, 2017).

...about two thirds of the population [are] without potable water and access to sanitation facilitiesMany people have been displaced from their homes due to the civil war. Approximately 2.2 million of the 27 million people living in Yemen currently reside in temporary camps (The Lancet Infectious Diseases, 2017). Yemen is a country that experiences regular droughts and periods of limited water availability. That, coupled with the current climate of conflict, has placed an estimated 19.3 million people, about two thirds of the population, without potable water and access to sanitation facilities (Lyons, 2017). About 17 million are also at high risk for food insecurity (The Lancet Infectious Diseases, 2017). This food insecurity is a result of the growing famine that has been spreading across Yemen over the past few years and continues to spread as the conflict within the country continues.

A Brief History of Cholera

Cholera was first identified as a disease in the 19^th century by John Snow. He contested the commonly held theory that cholera was caused by “bad air” with the theory that it was caused by “bad water” (Chiappelli, Khakshooy, & Balenton, 2017). He advocated for clean drinking water and put a stop to the cholera outbreak in London by identifying one water pump as the cause of the outbreak (Chiappelli et al., 2017).

Cholera has reached pandemic levels seven times in known history...Filippo Pacini first identified the “germ” vibrio cholerae (vCh) in contaminated stool and water samples (Chiappelli et al., 2017). Robert Koch was the bacteriologist who “discovered and characterized the causative agent for cholera” (Chiappelli et al., 2017, p. 353). Cholera has reached pandemic levels seven times in known history, most recently in 1961 affecting between three and five million people (Chiappelli et al., 2017). Cholera is endemic in over 50 countries (Chiappelli et al., 2017). The majority of cholera cases and deaths have taken place in Sub-Saharan Africa, though the disease is also prevalent in other parts of Asia and the Caribbean (Kuna & Gajewski, 2017). Cholera results from a “toxic mix of conflicts, civil war, famine, deteriorating hygiene and sanitation conditions.” (Kuna & Gajewski, 2017, p. 165).

Clinical Manifestation of Cholera

The disease known as “cholera” is caused by the bacteria vibrio cholerae (vCh). The incubation period of vCh can vary between a few hours and five days (Kuna & Gajewski, 2017). Symptoms of a cholera infection include diarrhea, dehydration, vomiting, and abdominal cramping. The diarrhea that accompanies a cholera infection is often described as “rice-water stool” because of its extreme wateriness (Kuna & Gajewski, 2017). A diagnosis of cholera is normally presumed if a patient has watery diarrhea and has been in an area where cholera is endemic, though diagnosis can also be made through laboratory testing (Kuna & Gajewski, 2017). In resource-limited areas, laboratory testing is not common because of the difficulty of purchasing and importing the number of tests needed to screen everyone presenting with cholera symptoms (Kuna & Gajewski, 2017).

In resource-limited areas, laboratory testing is not common...The primary concern with cholera is massive fluid and electrolyte loss (Kuna & Gajewski, 2017). Such fluid loss can cause severe dehydration which can be especially difficult to treat in areas where water is scarce or unfit for drinking. When cholera goes untreated, the associated dehydration results in a 50-70% mortality rate (Kuna & Gajewski, 2017). This drops significantly, to less than 0.5%, when patients are treated within the first 24 hours (Kuna & Gajewski, 2017).

Transmission of Cholera
For an outbreak of cholera to occur, there must be a combination of contaminated water and susceptible peopleCholera is spread from one person to another through water that has been infected by cholera-infested stool. For an outbreak of cholera to occur, there must be a combination of contaminated water and susceptible people (Zaidi, 2017). One of the difficulties in containing an outbreak of cholera is that vCh can be found in a person’s stool up to ten days after they have recovered from the infection and can be shed back into the environment (Kuna & Gajewski, 2017). This, combined with the short incubation period, means that cholera can spread quickly through a community and escalate into an epidemic in a short amount of time. According to WHO (2017a), weather is also an important factor in the transmission of cholera as rain can wash waste into drinking water sources. Therefore, rainy climates are more likely to experience cholera outbreaks.

Treatment of Cholera
Cholera is an easily treatable disease. Approximately 80% of cases can be treated with basic oral rehydration (Kuna & Gajewski, 2017). More severe cases may need treatment with antibiotics and IV rehydration therapy (Kuna & Gajewski, 2017). For adults, it is recommended that rehydration therapy consists of more than six liters of oral rehydration within the first 24 hours of a cholera infection (Kuna & Gajewski, 2017). Most people begin to recover quickly after the first two days of treatment. Cholera can however be fatal in just a few hours if not treated quickly (Kuna & Gajewski, 2017).

The most effective way to treat an outbreak of cholera is to focus on prevention.In more severe cases antibiotics may be required. The recommended antibiotics to treat cholera include fluoroquinolones, tetracyclines, and macrolides (Kuna & Gajewski, 2017). It is not, however, recommended that antibiotics be distributed in mass to everyone who has cholera, because there is a high risk of regions developing antibiotic resistance (Kuna & Gajewski, 2017). The most effective way to treat an outbreak of cholera is to focus on prevention. Some prevention strategies include: providing safe drinking water, constructing sanitation facilities, and promoting breastfeeding for infants (Kuna & Gajewski, 2017). Most people who have recovered from cholera develop an immunity to further cholera infections which helps to limit the spread of the disease (Kuna & Gajewski, 2017).

The Cholera Epidemic in Yemen

The current cholera outbreak in Yemen began in late October of 2016 (Qadri, Islam, & Clemens, 2017). Due to fighting in the capital city of Sana, the sewer system failed (The Lancet Gastroenterology & Hepatology, 2017). The situation magnified when sanitation workers went on strike because of unpaid salaries, resulting in uncontained garbage being washed into the water supply (Lyons, 2017). Cholera spread quickly, with urban areas being most affected and Sana at the epicenter. The scarcity of fuel within the country has made it difficult to power hospitals, transport imported water, and sanitize the little water that is available (Erickson, 2017). Water is one of the most important issues in this discussion because more than 80% of Yemen’s water is imported due to its scarcity (Erickson, 2017).

The epidemic in Yemen has now surpassed one million people with over 2,000 dead Prior to the outbreak in Yemen, the worst cholera outbreak in modern history occurred in Haiti after the 2010 earthquake which affected 815,000 people over the course of seven years (Lyons, 2017). The epidemic in Yemen has now surpassed one million people with over 2,000 dead (Erickson, 2017). One quarter of the reported cholera cases have been in children under five years old (Ververs & Narra, 2017). McCarthy (2017) stated that it is the “fastest growing cholera outbreak ever recorded”. The UN is referring to the epidemic in Yemen as a “man-made humanitarian disaster” and many international aid groups are referring to it as the “worst humanitarian crisis in the world” (Lancet Gastroenterology & Hepatology, 2017; Dwyer, 2017). While the rate of infection has begun to slow somewhat, doctors working in Yemen are concerned that the decrease will be short-lived and that there could be a resurgence of the disease (Dewan & Pettersson, 2017).

Current Efforts to Combat Cholera in Yemen

The international community has been working to stop the epidemic of cholera in Yemen.The international community has been working to stop the epidemic of cholera in Yemen. Organizations such as WHO, the United Nations Children’s Fund (UNICEF), various non-governmental organizations (NGOs), international agencies, and the Yemeni healthcare system are all working together to respond to the crisis (Qadri, Islam, & Clemens, 2017). Most of the healthcare is coming from international organizations because the Yemeni government stopped funding the public health department in 2016 (Lyons, 2017). This stop in funding is largely due to the civil war within the country. Much of the country, including the capital city of Sana, is no longer under the control of the Yemeni government, so the government has little motivation to fund public health efforts in these parts of the country. Furthermore, only 45% of Yemen’s pre-existing healthcare facilities are still operational because the fighting has destroyed much of the country’s infrastructure (Dwyer, 2017). Aid workers from around the world have become the backbone of healthcare in Yemen during this time of crisis.

Many organizations have been supplying water that has been treated with chlorine to people in refugee camps and in other distressed communities.WHO (2017a) claims to have established cholera treatment centers in almost all the affected provinces and have distributed a large quantity of emergency supplies through these centers. Hundreds of tons of water purification and medical supplies have been air-lifted into the country, and treatment centers specifically providing rehydration to cholera patients have been established (The Lancet Infectious Diseases, 2017). Much of the focus of these organizations has been on preventing the spread of cholera. Many organizations have been supplying water that has been treated with chlorine to people in refugee camps and in other distressed communities. Some are working to repair water-treatment plants, provide hygiene kits to the community, and teach the community how to purify their water to prevent the spread of cholera (Qadri et al., 2017). These efforts have reduced the overall case-fatality from this epidemic to a mere 0.5% (Qadri et al., 2017).

In June 2017, a request was made for cholera vaccinations for Yemen to conduct a widescale vaccine campaign throughout the country, but the request came late (Qadri et al., 2017). Initially one million vaccines were scheduled to be deployed, but the plan was canceled. The reason for the cancellation was because of how widespread the epidemic had already grown (Qadri et al., 2017). Experts deemed that a vaccine campaign would not have a significant impact on limiting the spread of the disease, and that resources would be better used elsewhere (Qadri et al., 2017).

...fighting within the country makes it difficult for these organizations to reach the areas of greatest need. While these international organizations are working hard to stop the spread of cholera, the mission has not been easy. Blockades on seaports and airports controlled by Saudi Arabia make it difficult for medicines and humanitarian aid to reach the neediest parts of the country (The Lancet Gastroenterology & Hepatology, 2017). Moreover, fighting within the country makes it difficult for these organizations to reach the areas of greatest need. El Hage (2017) stated that “only 30% of the country’s needed medicines and medical supplies are getting in.” Twice as many beds are needed in cholera treatment facilities, but there is not enough funding available to cover the needs presented by this epidemic (The Lancet Gastroenterology & Hepatology, 2017). On top of all this, because of cholera, funds have been diverted from fighting the famine within the country and the rate of malnutrition is rising rapidly among the Yemeni (The Lancet Gastroenterology & Hepatology, 2017).

Recommendations to Manage the Cholera Epidemic

...most cases of cholera outbreaks occur in regions rocked by wars, drought, and displacement of people from their homes.Cholera is easy to treat and has a very high survival rate when treated appropriately, therefore, in theory, outbreaks should not be very difficult to manage. Unfortunately, most cases of cholera outbreaks occur in regions rocked by wars, drought, and displacement of people from their homes. Nigeria, Somalia, South Sudan, and Sudan are also experiencing cholera outbreaks, and are countries that have fighting, drought, and displacement (The Lancet Infectious Diseases, 2017). Until these issues of war, drought, and displacement can be addressed, cholera outbreaks will continue to occur around the world.

Despite the conflict, many aid groups continue to work in Yemen setting up clinics and rehydration centers. Unfortunately, there are far too few available (Erickson, 2017). The Red Cross has dispatched engineers into the country to help fix local water systems (The Lancet Gastroenterology & Hepatology, 2017). Since cholera is passed through contaminated water, providing stable and clean water sources and functioning sanitation facilities for the country should be one of the top priorities for relief efforts.

Despite the conflict, many aid groups continue to work in Yemen...While vaccination is not considered an option for the current crisis because of concerns of effectiveness, vaccines for cholera are available and could help limit the spread of disease for future outbreaks (Qadri et al., 2017). Clinics and rehydration centers could stock vaccinations to give to relatives of patients, especially young children, the elderly, and others at high risk of complications due to cholera.

Recommendations for Policy Planning and Management

The UN security council has called for a stop to the fighting in Yemen and for all involved parties to begin communicating about creating peace within the country (The Lancet Gastroenterology & Hepatology, 2017). Unfortunately, there is no sign of the conflict ending anytime soon. Lyons (2017) stated that the cholera situation will continue as long as the war continues; peace is the only cure to this epidemic. Saudi Arabia’s blockade of ports in and out of Yemen makes it difficult for relief organizations to bring supplies into the country, meaning that many supplies have to be smuggled over the border (Erickson, 2017). Both sides of the war need to allow for relief workers and supplies to reach the areas of greatest need in the country.

...the cholera situation will continue as long as the war continues; peace is the only cure to this epidemic.WHO has begun a campaign to eliminate cholera outbreaks worldwide by the year 2030 (Zaidi, 2017). While cholera is not difficult to prevent or treat under normal circumstances, unstable governments and natural disasters play a major role in perpetuating cholera outbreaks. Infection is strongly correlated with conflicts that result in displaced people, drought, and poor sanitation and hygiene (The Lancet Infectious Diseases, 2017). Ververs and Narra (2017, p. 1945) stated, “we encourage the international community to make a concerted effort to re-examine protocols currently in use and develop improved and standardized guidelines to support best practice in managing patients with cholera and SAM (severe acute malnutrition)”. Creating these standardized guidelines would allow relief organizations across the board to adhere to the same guidelines as they work together to solve the problem of cholera.

Role of Public Health Nurses

More workers are needed in Yemen to work with the relief organizations...Public health nurses can play an important role in resolving the problem of the cholera epidemic in Yemen. On-the-scene workers are the ones making the biggest difference and who are responsible for keeping the mortality rate low from this epidemic (Lyons, 2017). More workers are needed in Yemen to work with the relief organizations already struggling in the battle against cholera, and public health nurses are perfect for the job.

Public health nurses can fill several roles in the fight against cholera. For those interested in direct involvement in Yemen, it is wise to partner with an organization that is already established within the country. WHO and UNICEF use nurses as key members of their in-country teams. Nurses partnering with these organizations can work at the cholera treatment facilities and use their hands-on nursing skills to care for patients. Nurses can also lead the way to train volunteers in Yemen on how to effectively care for patients with cholera. Educating family members and friends of patients with cholera is also very important, and nurses provide quality education regarding disease transmission, rehydration treatment, and other pertinent issues.

Public health nurses can affect change from home through advocacy.Public health nurses can affect change from home through advocacy. Zaidi (2017) stated that one of the main barriers to eradicating cholera is stigma. Governments often do not want to admit that cholera is in their territory, which makes for delayed interventions (Zaidi, 2017). For other countries where cholera is a risk, nurses can advocate for deploying vaccines where cholera is endemic and advocate for strengthening the infrastructure within at-risk countries to provide clean water and sanitation (Zaidi, 2017).

Fundraising is a practical way to help support the organizations fighting cholera...Besides advocacy for awareness and policy change, there are other ways for nurses to help the cause in Yemen. Donating supplies donation through the organizations working within the country will help this resource poor country. Fundraising is a practical way to help support the organizations fighting cholera while promoting awareness of the issue at home. And lastly, nurses can help with the fight against cholera in Yemen through research. While cholera has been around for centuries, more research is needed to effectively manage this disease worldwide. Nurses can provide a holistic approach to this research that considers the history, social issues, cultural dynamics, and biological factors of the disease.

Conclusion

While many aid organizations are working hard to combat the issue, much more is needed.Yemen is facing a massive humanitarian crisis because of conflict in the country. The displacement of many people from their homes and the deterioration of sanitation and healthcare facilities have contributed to the cholera epidemic that is sweeping through the country. While many aid organizations are working hard to combat the issue, much more is needed. Ultimately, the best solution to this problem is to bring peace to the region. But until peace is achieved, efforts should be focused on providing clean water, preventing the spread of cholera, researching vaccine effectiveness, and treating those affected by the disease.

Authors

Lydia Lindsay, MS, BSN, RN, PHN
Email: lydia.m.lindsay@gmail.com

Lydia Lindsay is a foster care advocate in San Antonio, Texas. She is formerly an adjunct professor in public health nursing at Biola University. She attended Biola University, where she earned a Bachelor of Science in Nursing. She earned a Master of Science in Nursing in Advanced Public Health Nursing from the University of North Dakota.