Kőrösi: Cholera in Lebanon Won’t Become Epidemic

The number of cholera cases in Lebanon has exceeded 1,400 with over 17 deaths according to the latest official figures, while the President of the United Nations General Assembly, Csaba Kőrösi, said Wednesday in a statement to Asharq Al-Awsat he was very confident that cholera will not become a major epidemic in the country. Lebanon has recorded more than 1,400 cholera cases and 17 deaths as of Tuesday, since the first case appeared in the country on the fifth of October, according to the “World Health Organization” (WHO).

Commenting on this outbreak, Kőrösi expressed to Asharq Al-Awsat his confidence that despite the major crises that Lebanon is experiencing, cholera will be contained in the country. “I am very confident that cholera is not going to become a major epidemic in Lebanon, it should be contained,” he stated. He also pointed out that there might be some other very dangerous outbreaks that need to be prevented worldwide.

Concurrently, cholera continues to spread in Syria on a large scale, bringing the number of infections to about 25,000 cases, according to the latest figures, with more than 80 deaths.

Origins of Cholera

As reported by WHO, cholera transmission is closely linked to inadequate access to clean water and sanitation facilities. Menaced areas include outskirts slums, and camps for displaced persons or refugees, where clean water and sanitation lack the minimum requirements. The consequences of a humanitarian crisis, such as disruption of water and sanitation systems, or the displacement of populations to inadequate and overcrowded camps, can increase the risk of cholera transmission, should the bacteria be present or introduced.

Symptoms

According to WHO, cholera is an extremely virulent disease that can cause severe acute watery diarrhea. It takes between 12 hours and 5 days for a person to show symptoms after ingesting contaminated food or water. It affects both children and adults and can kill within hours if untreated. Most people infected with cholera do not develop any symptoms, although the bacteria are present in their body for 1-10 days after infection and are shed back into the environment, potentially infecting other people. Among people who develop symptoms, the majority have mild or moderate symptoms, while a minority develop acute watery diarrhea with severe dehydration. This can lead to death if left untreated.

Cholera spread in Syria and Lebanon

In Syria, the outbreak has likely started, according to the international NGO “Save the Children”, due to communities consuming contaminated water and food irrigated by the Euphrates River, which is experiencing historic low water levels mainly due to Syria’s worst drought in decades.

In Lebanon, cholera has been diagnosed firstly in rural areas bordering Syria, and is "probably due to population movements," according to the head of World Health Organization (WHO) technical team in Lebanon, Alissar Rady. “Most cholera cases in Lebanon have been in the camps, among the roughly 1 million Syrians who have taken refuge over the past decade from the conflict in their homeland”, according to Lebanese Health Minister Firass Abiad. While the outbreak was initially confined to northern districts, it has spread rapidly, said WHO’s office in Lebanon on Tuesday, with laboratory-confirmed cases reported from all eight governorates and 18 out of 26 districts.In Syria, cholera has already spread over the 14 Governorates of the country.

Tackling the disease

To contain the spread of the disease, the World Health Organization recommends improving access to proper and timely case management of cholera cases, prevention, and control in healthcare facilities, improving access to safe drinking water and sanitation infrastructure, as well as, improving hygiene practices and food safety in affected communities, with these counting as the most effective means of controlling cholera.

Oral cholera vaccine should be used in conjunction with improvements in water and sanitation to control cholera outbreaks and for prevention in targeted areas known to be at high risk for cholera. Key public health communication messages should be provided to the population.

Surveillance for early case detection, confirmation, and response in other provinces and regions of Lebanon should be reinforced especially at the district level while expanding community-based surveillance.

According to information provided by Hala Habib, the communications officer of WHO Lebanon, the long-term solution for Cholera control lies in economic development and universal access to safe drinking water and adequate sanitation. Actions targeting environmental conditions include the implementation of adapted long-term sustainable WASH solutions to ensure the use of safe water, basic sanitation, and good hygiene practices in cholera hotspots.

In addition to cholera, such interventions prevent a wide range of other water-borne illnesses, as well as contribute to achieving goals related to poverty, malnutrition, and education. The WASH solutions for cholera are aligned with those of the Sustainable Development Goals (SDG) number 6.

Vaccination

WHO recently announced that the standard two-dose vaccination for cholera will be suspended temporarily to allow for the available doses to be used in more countries, although Lebanon took delivery on Monday of its first vaccines to combat the worsening cholera outbreak from donor nation France. However, despite global shortages in cholera vaccines, WHO is supporting the Lebanese Ministry of Public Health to secure 600,000 doses for those most at risk, including frontline workers, prisoners, refugees, and their host communities.

Humanitarian Aids

In Lebanon, WHO is joining with the Ministry of Public Health and other health partners to curb the evolving cholera outbreak. For instance, WHO and other humanitarian partners have supported the Ministry to develop a national cholera preparedness and response plan, outlining the most urgent response interventions required, while scaling up surveillance and active case-finding in hotspot areas. UNICEF distributed thousands of liters of fuel to water pumping stations and waste-water treatment stations in locations with confirmed and suspected cholera cases. It has procured emergency medical supplies to support the treatment of several thousands of cholera cases and symptoms including moderate to severe diarrhea. It delivered Chlorinated Trucked water, wastewater desludging, and ensured disinfection in informal settlements with suspected or confirmed cases.

UNICEF trained over 4000 frontline workers and partners on cholera awareness, including transmission, symptoms, treatment, prevention, and referral mechanisms, scaled up safe water deliveries, and increased desludging to over 250,000 people living in informal settlements. In Lebanon also, the “Save the Children” organization is responding with partners through the interagency cholera prevention, preparedness, and response Plan. “Save the Children” will be working to ensure children in schools and communities are protected from possible water-related outbreaks, have access to safe water, sanitation, and hygiene, and affirm that their well-being is maintained. This includes awareness messaging, health hygiene promotion in schools, and distribution of soap, hygiene kits, and chlorination tablets for supported communities, as well as providing support for sustainable solutions such as UV solar-powered systems for cleaning water.

In Syria, UNICEF is distributing millions of water treatment tablets to more than 350,000 people in affected governorates. It distributed over 400 tons of sodium hypochlorite during the first two weeks of October to increase chlorine dosages and concentration, as chlorine is often distributed in cholera response because it effectively inactivates the Vibrio cholerae bacteria, that causes cholera. Since the beginning of the cholera response, more than a ton of sodium hypochlorite has been distributed, providing more than 13 million people with safe and clean water. UNICEF delivered acute watery diarrhea (AWD) kits to support treating thousands of moderate and severe Cholera cases. UNICEF also trained hundreds of healthcare workers and hygiene promotion teams across Syria.

Save the Children’s response to cholera in Syria, is helping the restoration of basic services, including water and sanitation, as key to helping communities recover from the impact of conflict. Save the Children’s response plan includes chlorination of restored water, water quality monitoring, distribution of hygiene and cleaning kits, as well as hygiene promotion.

The baby in Gaza who was recently paralyzed by polio was infected with a mutated strain of the virus that vaccinated people shed in their waste, according to scientists who say the case is the result of “an unqualified failure” of public health policy.
The infection, which marked the first detection of polio in the war-torn Palestinian territory in more than 25 years, paralyzed the lower part of one leg in the unvaccinated 10-month-old child. The baby boy was one of hundreds of thousands of children who missed vaccinations because of the fighting between Israel and Hamas.
Scientists who have been monitoring polio outbreaks said the baby's illness showed the failures of a global effort by the World Health Organization and its partners to fix serious problems in their otherwise largely successful eradication campaign, which has nearly wiped out the highly infectious disease. Separately, a draft report by experts deemed the WHO effort a failure and “a severe setback.”
The polio strain in question evolved from a weakened virus that was originally part of an oral vaccine credited with preventing millions of children worldwide from being paralyzed. But that virus was removed from the vaccine in 2016 in hopes of preventing vaccine-derived outbreaks.
Public health authorities knew that decision would leave people unprotected against that particular strain, but they thought they had a plan to ward off and quickly contain any outbreaks. Instead, the move resulted in a surge of thousands of cases, The Associated Press reported.
“It was a really horrible strategy,” said Columbia University virologist Vincent Racaniello, who was not involved with the report or the WHO. “The decision to switch vaccines was based on an incorrect assumption, and the result is now we have more polio and more paralyzed children.”
A draft copy of the report commissioned by the WHO and independent experts said the plan underestimated the amount of the strain in the environment and overestimated how well officials would be able to squash outbreaks.
The plan led to vaccine-linked polio outbreaks in 43 countries that paralyzed more than 3,300 children, the report concluded.
Even before the Gaza case was detected, officials reviewing the initiative to tinker with the vaccine concluded that “the worst-case scenario has materialized,” the report said.
The report has not yet been published, and some changes will likely be made before the final version is released next month, the WHO said.
The strain that infected the baby in Gaza had lingered in the environment and mutated into a version capable of starting outbreaks. It was traced to polio viruses spreading last year in Egypt, according to genetic sequencing, the WHO said.
In 2022, vaccine-linked polio viruses were found to be spreading in Britain, Israel and the US, where an unvaccinated man was paralyzed in upstate New York.
Scientists now worry that the emergence of polio in a war zone with an under-immunized population could fuel further spread.
Racaniello said the failure to track polio carefully and to sufficiently protect children against the strain removed from the vaccine has had devastating consequences.
“Only about 1% of polio cases are symptomatic, so 99% of infections are silently spreading the disease,” he said.
The oral polio vaccine, which contains a weakened live virus, was withdrawn in the US in 2000. Doctors continued to vaccinate children and eventually moved to an injected vaccine, which uses a dead virus and does not come with the risk that polio will be present in human waste. Such waste-borne virus could mutate into a form that triggers outbreaks in unvaccinated people.
The report's authors faulted leaders at the WHO and its partners, saying they were unable or unwilling “to recognize the seriousness of the evolving problem and take corrective action.”
WHO spokesman Oliver Rosenbauer acknowledged that the vaccine strategy “exacerbated” the risk of epidemics linked to the vaccine.
He said in an email that immunization “was not implemented in such a way to rapidly stop outbreaks or to prevent new strains from emerging.” Rosenbauer said not hitting vaccination targets was the biggest risk for allowing vaccine-linked viruses to emerge.
“You need to reach the children with the vaccines ... regardless of which vaccines are used,” he said.
The WHO estimates that 95% of the population needs to be immunized against polio to stop outbreaks. The UN health agency said only about 90% of Gaza’s population was vaccinated earlier this year.
To try to stop polio in Gaza and the wider region, the WHO and its partners plan two rounds of vaccination campaigns later this week and next month, aiming to cover 640,000 children. Authorities will use a newer version of the oral polio vaccine that targets the problematic strain. The weakened live virus in the new vaccine is less likely to cause vaccine-derived outbreaks, but they are still possible.
Racaniello said it was “unethical” that the WHO and its partners were using a vaccine that is unlicensed in rich countries precisely because it can increase the risk of polio in unvaccinated children.
The oral polio vaccine, which has reduced infections globally by more than 99%, is easy to make and distribute. Children require just two drops per dose that can be administered by volunteers. The oral vaccine is better at stopping transmission than the injected version, and it is cheaper and easier to administer.
But as the number of polio cases caused by the wild virus have plummeted in recent years, health officials have been struggling to contain the increasing spread of vaccine-linked cases, which now comprise the majority of polio infections in more than a dozen countries, in addition to Afghanistan and Pakistan, where transmission of the wild virus has never been stopped.
“This is the result of the Faustian bargain we made when we decided to use" the oral polio vaccine, said Dr. Paul Offit, director of the Vaccine Education Center at the University of Philadelphia. “If we really want to eradicate polio, then we need to stop using the vaccine with live (weakened) virus.”

Kőrösi: Cholera in Lebanon Won’t Become Epidemic

Cases exceeded 1,400 with over 17 deaths in the country