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.

Scientists studying the new mpox strain that has spread out of Democratic Republic of Congo say the virus is changing faster than expected, and often in areas where experts lack the funding and equipment to properly track it.

That means there are numerous unknowns about the virus itself, its severity and how it is transmitting, complicating the response, half a dozen scientists in Africa, Europe and the United States told Reuters.

Mpox, formerly known as monkeypox, has been a public health problem in parts of Africa since 1970, but received little global attention until it surged internationally in 2022, prompting the World Health Organization to declare a global health emergency. That declaration ended 10 months later.

A new strain of the virus, known as clade Ib, has the world's attention again after the WHO declared a new health emergency.

The strain is a mutated version of clade I, a form of mpox spread by contact with infected animals that has been endemic in Congo for decades. Mpox typically causes flu-like symptoms and pus-filled lesions and can kill.

Congo has had more than 18,000 suspected clade I and clade Ib mpox cases and 615 deaths this year, according to the WHO. There have also been 222 confirmed clade Ib cases in four African countries in the last month, plus a case each in Sweden and Thailand in people with a travel history in Africa.

"I worry that in Africa, we are working blindly," said Dr. Dimie Ogoina, an infectious diseases expert at Niger Delta University Hospital in Nigeria who chairs the WHO's mpox emergency committee. He first raised the alarm about potential sexual transmission of mpox in 2017, now an accepted route of spread for the virus.

"We don’t understand our outbreak very well, and if we don't understand our outbreak very well, we will have difficulty addressing the problem in terms of transmission dynamics, the severity of the disease, risk factors of the disease," Ogoina said. "And I worry about the fact that the virus seems to be mutating and producing new strains."

He said it took clade IIb in Nigeria five years or more to evolve enough for sustained spread among humans, sparking the 2022 global outbreak. Clade Ib has done the same thing in less than a year.

MUTATING 'MORE RAPIDLY'

Mpox is an orthopoxvirus, from the family that causes smallpox. Population-wide protection from a global smallpox vaccine campaign 50 years ago has waned, as the vaccinating stopped when the disease was eradicated.

Genetic sequencing of clade Ib infections, which the WHO estimates emerged mid-September 2023, show they carry a mutation known as APOBEC3, a signature of adaptation in humans.

The virus that causes mpox has typically been fairly stable and slow to mutate, but APOBEC-driven mutations can accelerate viral evolution, said Dr. Miguel Paredes, who is studying the evolution of mpox and other viruses at Fred Hutchison Cancer Center in Seattle.

"All the human-to-human cases of mpox have this APOBEC signature of mutations, which means that it's mutating a little bit more rapidly than we would expect," he said.

Paredes and other scientists said a response was complicated by several mpox outbreaks happening at once.

In the past, mpox was predominantly acquired through human contact with infected animals. That is still driving a rise in Congo in clade I cases – also known as clade Ia - likely due in part to deforestation and increased consumption of bushmeat, scientists said.

The mutated versions, clade Ib and IIb, can now essentially be considered a sexually transmitted disease, said Dr. Salim Abdool Karim, a South African epidemiologist and chair of the Africa CDC’s mpox advisory committee. Most of the mutated clade Ib cases are among adults, driven at first by an epidemic among female sex workers in South Kivu, Congo.

The virus also can spread through close contact with an infected person, which is likely how clusters of children have been infected with clade Ib, particularly in Burundi and in eastern Congo’s displacement camps, where crowded living conditions may be contributing.

Children, pregnant women and people with weakened immune systems or other illnesses may be at greater risk of serious mpox disease and death, say the WHO and mpox scientists.

Clade I has typically caused more severe disease, with fatality rates of 4%-11%, compared to around 1% for clade II. Ogoina said data from Congo suggests few have died of the new Ib version, but he feared some data is being mixed up.

More research is urgently needed, but three teams tracking mpox outbreaks in Africa say they cannot even access chemicals needed for diagnostic tests. Clade Ib can also be missed by some diagnostic tests.

Planning a response, including vaccination strategies, without this is difficult, the scientists said.

Karim said around half of cases in eastern Congo, where Ib is particularly prevalent, are only being diagnosed by doctors, with no laboratory confirmation.

Getting samples to labs is difficult because the healthcare system is already under pressure, he said. And around 750,000 people have been displaced amid fighting between the M23 rebel group and the government.

Many African laboratories cannot get the supplies they need, said Dr. Emmanuel Nakoune, an mpox expert at the Institut Pasteur in Bangui, Central African Republic, which also has clade Ia cases.

"This is not a luxury," he said, but necessary to track deadly outbreaks.

Kőrösi: Cholera in Lebanon Won’t Become Epidemic

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