A decision to postpone what would have been the largest ever global delivery of the cholera vaccine to Yemen reveals the extent to which the crisis has already outpaced efforts to contain it, experts say.
The number of cholera cases in the country could reach 600,000 by the end of 2017, or 1 in every 45 Yemenis, the International Committee of the Red Cross said on Sunday. The World Health Organization has documented 368,207 suspected cases and 1,828 deaths, 60 percent of them children, since April 27.
The International Coordinating Group overseeing global vaccine stockpiles had approved a shipment of 1 million doses of cholera vaccine to Yemen in June. However, the plan was cancelled earlier this month over concerns it would fail to help contain the outbreak — and that an unsuccessful effort could undermine future vaccination campaigns in the war-torn country.
Those worries boil down to a combination of epidemiological reality, overwhelming logistical constraints, and a volatile political situation in which Yemen is effectively controlled by two rival government administrations. Both authorities — the internationally recognized government of President Abdrabbuh Mansour Hadi in the south and an alliance of Houthi rebels and former President Ali Abdullah Saleh in the north — agreed to cancel the vaccination campaign, WHO told Devex.
“Experience shows that vaccinating once a cholera outbreak is well established in a community has little to no impact on preventing further spread and on the course of the outbreak itself.”— Christian Lindmeier, WHO spokesperson
“Now that cholera has reached 91 percent of Yemen’s governorates, the health authorities have decided against a vaccination campaign at this time as it might not have the expected impact,” WHO spokesperson Christian Lindmeier told Devex by email. “The authorities in the north and the south both requested to postpone this campaign.”
The cholera response will now pivot from prevention to containment, a complicated effort in a country in the midst of civil war. Lindmeier said efforts would focus on health worker training, setting up treatment centres, reinforcing surveillance, working with communities on prevention, and providing safe water.
Prevention and treatment
Yemen’s latest cholera outbreak began in late April and has surprised health workers with its rapid spread. The government of Yemen initially requested 3.5 million doses of the vaccine — an amount larger than the entire global stockpile. One million were approved for delivery.
The cholera vaccine is usually a two-dose regimen, but to stretch the shipment, health workers had planned a one-dose campaign, which had shown as much as 80 percent efficacy after two months in a previous 2015 study. The doses were to be divided equally between rival government administrations in the north and south.
In the weeks after the ICG approval, however, debate erupted in the humanitarian community. The logistics for delivery would be complicated, requiring health workers to reach into at risk communities that are outside the major outbreak zones but vulnerable to the spread of the bacterial disease. Many of those areas are difficult to access by road.
Along a complex journey, the vaccines would have to be in cold storage — a difficult ask in a country experiencing an acute fuel shortage and only intermittent electricity in major metropolises.
In one bright spot, several relief organizations told Devex that warring parties had improved community access since May, when the magnitude of the outbreak became clear. “We have been seeing a little bit better positive trends in terms of our local access,” said Hannah Hilleson, senior program officer at Mercy Corps.
By the time cholera struck Yemen, its coping mechanisms were exhausted. Public services have collapsed to an extent that it could take months or longer to contain the outbreak.
Still, the logistical constraints didn’t match up with the epidemiological challenge, experts warned. The vaccine is not immediately effective and doesn’t prevent recipients from carrying cholera. As the outbreak has spread, there are now few communities that have not been effected.
“[E]xperience shows that vaccinating once a cholera outbreak is well established in a community has little to no impact on preventing further spread and on the course of the outbreak itself,” Lindmeier of WHO said.
Although not the main reason the vaccination was cancelled, numerous parties operating on the ground confirmed significant concerns that any vaccine campaign could have been politicized or mismanaged — potentially undermining future efforts.
The comparatively scarce doses of vaccine available could open the door for real or perceived politicization or favoritism in distribution, said Monica Ramos, regional water, sanitation and hygiene expert at the European Civil Protection and Humanitarian Aid Operations.
“From our point of view, we questioned the effectiveness and could it be used to polarize, or not used for the best [outcomes,]” she said.
Yemen analysts told Devex the political risks were even more acute. “One of the major concerns would be that the vaccines would not reach the people who need it most,” said Anthony Biswell, senior analyst focusing on Yemen at the Abu Dhabi-based Delma Institute. “It wouldn’t be surprising if several local armed groups in Yemen sought to profit from the world’s worst cholera epidemic by seizing the vaccines and then trying to sell them on the black market.”
The implications of a poorly carried out vaccination could enhance polarization, undermine humanitarian neutrality, or even jeopardize United Nations-led efforts to find a political settlement to the conflict, he said.
Asked if the political risk figured into the vaccination decision, Lindmeier told Devex: “Mass vaccination campaigns are difficult, even in less complicated contexts than Yemen, and perceptions of a less-than-optimal campaign among the Yemeni population may jeopardise future vaccination activities.”
Health in conflict
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Foregoing the vaccination campaign hasn’t entirely mitigated the political risks for ongoing humanitarian work. Aid groups report continued challenges navigating the frontline of conflict and moving between rival-controlled administrations. Relief efforts also face different conditions depending on who runs the area in question.
“What is clear, is that the cholera outbreak has been politically managed differently between south and north,” said Caroline Seguin, deputy program manager at Médecins Sans Frontières. “In the north, they declared the outbreak and the state under crisis very soon after the first cases, while it was not the case in the south.”
Conflict more generally clouds the response as it moves forward, with a focus on treating cases and ensuring safe access to water. Less than half of Yemen’s health facilities are operational; many of the rest have been damaged or destroyed during the conflict. Sewage systems, water treatment plants and transport networks have also been severely damaged.
“The great tragedy is that this cholera outbreak is a preventable, man-made humanitarian catastrophe. It is a direct consequence of a conflict that has devastated civilian infrastructure and brought the whole health system to its knees,” ICRC President Peter Maurer said in a statement Sunday during a visit to the country.
“I find this needless suffering absolutely infuriating. The world is sleepwalking into yet more tragedy.”
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