Cholera in Yemen: a case study of the epidemic

Summary of key findings and recommendations

Paul Spiegel, Johns Hopkins Bloomberg School of Public HealthRuwan Ratnayake, ConsultantDaniele Lantagne, ConsultantNora Hellman, Johns Hopkins Bloomberg School of Public HealthMija Ververs, Johns Hopkins Bloomberg School of Public HealthPaul Wise, Stanford UniversityMoise Ngwa, Johns Hopkins Bloomberg School of Public Health

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Key Findings and Recommendations

1. Surveillance and laboratory2. Preparedness, strategy and funding3. Case management and health and nutrition4. Water, sanitation, and hygiene (WASH) 5. Integrated health and WASH strategies and interventions6. Oral cholera vaccination (OCV)7. Cross-cutting issues:

a) Communication and social mobilizationb) Coordinationc) Insecurity

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1. Surveillance and Laboratory

Key Findings1. Early warning surveillance present, but not optimized for outbreak control2. Improvement of data quality could have been better addressed after 1st wave3. Laboratory and epidemiological investigation were inadequate for monitoring the outbreak

Key Recommendations1. Early warning alert and response functions of surveillance system should be evaluated and primed

to handle outbreak detection and response (global)2. Early priority needed to increase capacity to culture cholera through the est. and/or

rehabilitation of peripheral laboratories (global)• Lab monitoring needed including improvements in transport of specimens (Yemen)

3. Data monitoring plan to improve data collection and identification of challenges at field level should be implemented jointly by partners (Yemen)

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2. Preparedness, Strategy and Funding

Key Findings1. Prior to outbreak, Yemen did not have adequate cholera preparedness and response plan 2. Initial plans did not prioritize standard components 3. Subsequent iterations of plans were detailed ,but late to address acute phase of the 2nd wave4. RRTs showed importance of decentralizing core early response functions (in 2nd wave)5. Funding was overall adequate and rapidly accessible for cholera

Key Recommendations1. Improved cholera preparedness and response planning would have improved strategy and

response (Yemen) 2. Small set of RRTs should be pre-emptively trained and placed on standby to enable early targeting

of localized response and containment (global & Yemen)• Health and WASH RRTs should be implemented early (global & Yemen)

3. Improve supervision to improve knowledge, data, and quality of care in more remote areas (global & Yemen) • TPM results from UNICEF need to be examined to understand monitoring and supervision (Yemen)

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3. Case Management (Health & Nutrition)

Key Findings1. DTC and ORC networks were insufficiently decentralized with inadequate access for pop.2. Challenges in maintaining IPC standards and likely caused disruption to PHC services3. Quality of case management was difficult to monitor4. High-risk groups incl. pregnant women and SAM children require clear case mgt protocols

Key Recommendations1. DTC & ORC networks should be mapped acc. to pop. and epi needs, esp. in 2nd & 3rd zones (Yemen)

• Smaller treatment units with less bed capacity should be considered for locations closer to communities (global & Yemen)

2. Cholera plans need to consider contexts with high burden of acute malnutrition & cholera, and consider protocols, data, health infrastructure, expertise and materials for both cholera and SAM (global & Yemen)

3. Build up function of the health RRTs to provide basic supervision and monitoring of DTCs and ORCs in their catchment areas (Yemen)

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4. WASH

Key Findings1. WASH activities remained inappropriately comprehensive and generalized after onset of

cholera outbreak2. Cholera-specific WASH response was operationalized very late3. Monitoring use of FRC as primary outcome remained a gap 4. Main reported barriers to operationalizing cholera-specific WASH response were insecurity,

coordination, line-list access, and funding to NNGOs and government

Key Recommendations1. Need strategy as early as possible that provides decentralized, targeted WASH responses to

interrupt transmission related to confirmed and suspected cholera cases (global)2. Consider appropriate role of all partners in response & alternative remote support approaches

(Yemen)3. Donors, WASH cluster, and Ministry of Water should complete rapid work on water supply

and sanitation infrastructure while simultaneously advocating and partnering with donors on repairing and maintaining infrastructure for medium to long-term (Yemen)

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5. Integrated Health and WASH Strategies and Interventions

Key Recommendations

1. Planning should always be integrated bw health and WASH sectors including: a) decentralized health and WASH RRTs; b) joint planning of OCV; c) provision of IPC in health facilities; and (d) water quality surveillance supporting epi surveillance (global &Yemen)

2. Given context, decentralization of care with community-based approaches to treatment, referral and WASH should be focus in rural and remote areas (Yemen)

3. Model for remote technical assistance needs to be more effective, accessible, and timely (Yemen)4. After-action reviews should be standard practice for each responding organization (global)

• After-action review for each agency after 1st wave would have been beneficial for 2nd wave (Yemen)5. NGOs should develop remote monitoring processes (e.g., field procedures, tools and checklists,

accountability mechanisms) for assuring quality and scale of intervention in remote and insecure sites (global & Yemen)

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6. Oral Cholera Vaccination (OCV)

Key Findings1. Introduction of OCV faced significant challenges that delayed its use; reasons incl. those

common to countries that lack OCV experience, and those with complex environments2. Response in 1st wave did not favor integration of OCV; cholera preparedness plan did not

reference OCV and was lack of familiarity and knowledge about OCV among key players3. WHO-led efforts to strategically use OCV to interrupt spread of 2nd wave occurred late

(May/Jun 2017)4. Eventual use of OCV was related to prevention of anticipated endemic transmission of cholera

Key Recommendations1. Different scenarios for OCV acc. to varying contexts should be integrated ahead of time into

national cholera preparedness plans; esp. for ‘fragile’ countries with possibility of humanitarian emergencies developing or continuing (global)

2. In complex and insecure environments like Yemen, smaller, geographically-targeted OCV campaigns should be anticipated and planned (global and Yemen)

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7. Cross-Cutting Issue:a) Communication and Social Mobilization

Key Findings1. Severe insecurity made it difficult to organize community services, incl. social mobilization 2. CHVs supported separately by MoPHP, YRCS and UNICEF were not mobilized under single

program

Key Recommendations1. Single program for consistent social mobilization, referral and surveillance activities should

be mobilized for CHVs2. Registration of CHVs, and supporting mass trainings as well as supervision of CHVs across these

systems needs to occur in preparation for future epidemics

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7. Cross-Cutting Issue: b) Coordination

Key Findings1. Cluster approach showed agility in coordinating initial response, but could not alone provide all

technical, strategic, and multi-sector input for large-scale outbreak2. Cholera Task Force, which normally guides strategy and technical decision-making, did not have

technical working groups or generate timely guidance3. Technical advice was delivered remotely from HQ and not always followed4. IMS was implemented by WHO and the MoPHP at start of 2nd wave and suffered from lack of

clear mandate and technical support

Key Recommendations1. Mandates, roles, and reporting lines of various coordination structures including clusters,

CTF, and IMS urgently require clarification, harmonization, and agreement by the government(s) and partners (global)

2. In future, IMS should be implemented at beginning of epidemic, and much earlier than during peak of 2nd wave (Yemen)

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7. Cross-Cutting Issue: c) Insecurity

Key Findings1. Repeated airstrikes on water infrastructure, including several desalination facilities, strongly

suggests that these sites were purposefully targeted

Key Recommendations1. Attacks on health, water and sanitation infrastructure should be terminated (Yemen)2. UN should adopt stronger stance on protection of health facilities and watsan infrastructure

(Yemen) 3. Monitoring and documenting attacks against infrastructure using a geo-located database

system with systematic reporting should be undertaken together with proactively sharing locations with the Saudi-led Coalition (Yemen)

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