29 June 2017 – The Ministry of Public Health and Population of Yemen has recorded a total of 39 688 suspected cholera cases and 183 associated deaths during the period 22 to 27 June 2017. A cumulative total of 224 989 suspected cases of cholera and 1416 associated deaths have been recorded as of 27 June during the outbreak which started in October 2016.

The overall case-fatality rate is 0.6% although it is higher in some areas and among certain age groups. While cholera is endemic in Yemen, the country has experienced a surge in cholera cases since 27 April 2017, with nearly 5000 cases reported per day. Ongoing conflict, destroyed health, water and sanitation infrastructure and malnutrition have caused the people to be more vulnerable to diseases, including cholera.

WHO and health partners are actively supporting the Ministry through a cholera task force to improve cholera response efforts at the national and local levels. This includes the establishment of diarrhoea treatment facilities, oral dehydration centres, training of health workers to manage cases, water purification in communities, deployment of rapid response team to manage cholera cases investigations and respond to the outbreak, enhancement of Yemen’s disease early warning surveillance systems, and provision of emergency medical supplies to treatment facilities.

2 July 2017 – Twenty ambulances, 100 cholera kits, hospital equipment and 128 000 bags of intravenous fluids – these are just some of the supplies which arrived in Hodeida, Yemen, Friday, as part of a 403-tonne shipment sent by the World Health Organization (WHO). An additional 10 ambulances were delivered through the Port of Aden 3 weeks ago with 10 more due to arrive in coming weeks.

“We needed a special kind of ship to carry the ambulances and luckily we found one in the region,” explained Dr Nevio Zagaria, WHO Representative in Yemen. “It was absolutely enormous. But so are the needs in Yemen right now. So we loaded as many supplies as possible onto it, including some therapeutic feeding items that our sister agency UNICEF will use for children suffering from malnutrition.”

Getting medical supplies to vulnerable people across Yemen is no easy task, with active conflict, damaged port infrastructure and logistical difficulties impeding access. The flow of medicines into the country has dried up by more than 70%.

“People are dying in Yemen right now because they cannot access health care,” continued Dr Zagaria. “The most visible example of the health system's inability to respond to the needs of the population is the ongoing cholera outbreak, which has resulted in the deaths of 1500 Yemenis in just over 2 months. But people are also dying of things like childhood pneumonia, malaria, complications around childbirth, high blood pressure and diabetes because they cannot access treatment. The medicines and equipment delivered today will save lives.”

The delivery of these life-saving health supplies is thanks to support from the Emirates Red Crescent, the United Kingdom’s Department for International Development, the United Nations Central Emergency Response Fund and the World Bank.

WHO recommendations

Fluid management in children with severe malnutrition and dehydration without shock

1. Children with severe acute malnutrition who present with some dehydration or severe dehydration but who are not shocked should be rehydrated slowly, either orally or by nasogastric tube, using oral rehydration solution ORS (5–10 mL/kg/h up to a maximum of 12 h).

2. ReSoMal (or locally prepared ReSoMal using standard WHO low-osmolality oral rehydration solution) should not be given if children are suspected of having cholera or have profuse watery diarrhea (Three or more loose or watery stools in a day, for more than 14 days). Such children should be given standard WHO low-osmolality oral rehydration solution that is normally made, i.e. not further diluted.

3. Any Child with acute diarrhea should go to the oral rehydration center (ORC), in which MUAC screening is ensured, if the child is malnourished, he should be shifted to Dirrhea treatment center (DTC) to be rehydrated, once rehydrated and diarrhea & vomiting improved, he should be referred to OTP or TFC/SC as per his malnutrition condition

4. Child with severe acute malnutrition should be rehydrated by using ORS in the diarrhea treatment centers as per WHO guidelines till he becomes rehydrated, (no use for IV fluids unless it is required as per the guidelines), once rehydrated, the child with SAM should be referred to TFC/SC.

Additionally (2-6):

• Children with severe acute malnutrition and who have some or severe dehydration but no shock should receive 5 mL/kg ORS every 30 min for the first 2 h. Then, if the child is still dehydrated, 5–10 mL/kg/h ORS should be given in alternate hours with F-75, up to a maximum of 10 h;

• Signs of improved hydration status and over hydration should be checked every half hour for the first 2 h, then hourly;

• ORS can either be prepared from a ready-to-dilute sachet (as per supplier’s instructions).

• Zinc (10–20 mg per day) should be given to all children as soon as the duration and severity of the episodes of diarrhea start to reduce, thereby reducing the risk of dehydration. By continuing supplemental zinc for 10–14 days, this will also reduce the risk of new episodes of diarrhea in the following 2–3 months. (Note, WHOrecommended therapeutic foods already contain adequate zinc, and children with severe acute malnutrition receiving F-75, F-100 or ready-to-use therapeutic food should not therefore receive additional zinc).

Fluid management of children with severe acute malnutrition and shock

4. Children with severe acute malnutrition and signs of shock or severe dehydration and who cannot be rehydrated orally or by nasogastric tube should be treated with intravenous fluids, either:

• half-strength Darrow’s solution with 5% dextrose, or
  
• Ringer’s lactate solution with 5% dextrose.
  

If neither is available, 0.45% saline + 5% dextrose should be used.

Additionally (2-6):

• the general principles of resuscitation, in particular providing oxygen and improving breathing, similarly apply to children with severe acute malnutrition;

• the only indication for intravenous infusion in a child with severe acute malnutrition is circulatory collapse caused by severe dehydration or septic shock when the child is lethargic or unconscious (excluding cardiogenic shock);

• in case of shock with lethargy or unconsciousness, intravenous rehydration should begin immediately, using 15 mL/kg/h of one of the recommended fluids;

• it is important that the child is carefully monitored every 5–10 min for signs of over hydration and signs of congestive heart failure. If signs of over hydration and congestive heart failure develop, intravenous therapy should be stopped immediately;

• if a child with severe acute malnutrition presenting with shock does not improve after 1 h of intravenous therapy, a blood transfusion (10 mL/kg slowly over at least 3 h) should be given;

• children with severe acute malnutrition should be given blood if they present with severe anemia, i.e. Hb <4 g/dL or <6 g/dL if with signs of respiratory distress;

• Blood transfusions should only be given to children with severe acute malnutrition within the first 24 h of admission.

* This is an extract from relevant guidelines and guidance documents as listed in ‘References’.
Additional guidance information can be found in these documents.

** A specific electrolyte–micronutrient product formulated according to WHO specifications for use in the management of children with severe acute malnutrition.

*** ReSoMal is a powder for the preparation of an oral rehydration solution exclusively for oral or nasogastric rehydration of people suffering from severe acute malnutrition. It must be used exclusively under medical supervision in inpatient care, and must not be given for free use to the mother or caregiver.

**** Three or more loose or watery stools in a day, for more than 14 days.

Highlights

From 27 April to 3 July 2017, 269 608 suspected cholera cases and 1 614 deaths (CFR: 0.6%) have been reported in 91.0% (21/23) of Yemen governorates, and 86.2% (287/333) of the districts.

Geographical distribution of cases

The four most affected governorates were Amanat Al Asimah, Al Hudaydah, Hajjah and Amran with 48.0% (129 524/269 608) of the cases reported since 27 April 2017. Amran, Al Mahwit and Sana’a governorates had the highest attack rates (18.9‰, 17.7‰ and 17.5‰ respectively), and Raymah and Ibb governorates the highest case fatality ratios (1.5% and 1.1% respectively).

Al Hali (Al Hudaydah gov., 11 676 cases, 21 deaths), Bani Al Harith (Amanat Al Asimah gov., 7 626 cases, 10 deaths), Ma’ain (Amanat Al Asimah gov., 7 476, 7 deaths) and As Sabain (Amanat Al Asimah gov., 5 864 cases, 9 deaths) were still the four most affected districts.

Highlights

From 27 April to 4 July 2017, 275 987 suspected cholera cases and 1 634 deaths (CFR: 0.6%) have been reported in 91.0% (21/23) of Yemen governorates, and 86.2% (287/333) of the districts.

Geographical distribution of cases

The four most affected governorates were Amanat Al Asimah, Al Hudaydah, Hajjah and Amran with 47.9% (132 265/275 987) of the cases reported since 27 April 2017. Amran, Al Mahwit and Sana’a governorates had the highest attack rates (19.3‰, 18.2‰ and 17.8‰ respectively), and Raymah, Hajjah and Ibb governorates the highest case fatality ratios (1.5%, 1.0% and 1.0% respectively).

Al Hali (Al Hudaydah gov., 11 749 cases, 21 deaths), Bani Al Harith (Amanat Al Asimah gov., 7 789 cases, 10 deaths), Ma’ain (Amanat Al Asimah gov., 7 564, 7 deaths) and As Sabain (Amanat Al Asimah gov., 5 971 cases, 9 deaths) were still the four most affected districts.

06 July 2017 – The Ministry of Public Health and Population of Yemen has recorded a total of 50,998 suspected cholera cases and 218 associated deaths during the period 28 June to 04 July 2017. A cumulative total of 27,5987 suspected cases of cholera and 1634 associated deaths have been recorded as of 04 July during the outbreak which started in October 2016.

The overall case-fatality rate remains 0.6%, although it is higher in some regions. The four most affected governorates are Amanat Al Asimah, Al Hudaydah, Hajjah and Amran where 47.9% of cases have been reported since 27 April 2017.

WHO and health partners support the Ministry through the cholera task force to improve cholera response efforts at the national and local levels. More than 660,000 bags of IV fluids, 525 cholera beds and 112 kits containing supplies for the treatment of cholera and diarrhoea were delivered to health facilities to support response efforts. Other response efforts include the establishment of diarrhoea treatment facilities, oral dehydration centres, training of health workers to manage cases, water purification in communities, deployment of rapid response team to manage cholera cases investigations and respond to the outbreak, and enhancement of Yemen’s disease early warning surveillance systems.

While cholera is endemic in Yemen, the country has experienced a surge in cholera cases since April, with nearly 5000 cases reported per day. Ongoing conflict, destroyed health, water and sanitation infrastructure and malnutrition have caused the people to be more vulnerable to diseases, including cholera.

Highlights

• From 27 April to 6 July 2017, 291 554 suspected cholera cases and 1 678 deaths (CFR: 0.6%) have been reported in 95.6% (22/23) of Yemen governorates, and 86.5% (288/333) of the districts.

• For the first time since the beginning of this outbreak second wave, four cases have been reported in Say’on governorate. All were adults. Two of these cases were confirmed with rapid diagnostic tests.

Geographical distribution of cases

The four most affected governorates were Amanat Al Asimah, Al Hudaydah, Hajjah and Amran with 47.4% (138 279/291 554) of the cases reported since 27 April 2017. Amran, Al Dhaele’e and Al Mahwit governorates had the highest attack rates (20.2‰, 19.4‰ and 19.2‰ respectively), and Raymah, Hajjah and Ibb governorates the highest case fatality ratios (1.4%, 1.0% and 1.0% respectively) (see table).

Al Hali (Al Hudaydah gov., 12 245 cases, 21 deaths), Bani Al Harith (Amanat Al Asimah gov., 8 004 cases, 10 deaths), Ma’ain (Amanat Al Asimah gov., 7 800, 7 deaths) and As Sabain (Amanat Al Asimah gov., 6 097 cases, 9 deaths) were still the four most affected districts.

Highlights

• From 27 April to 7 July 2017, 297 438 suspected cholera cases and 1 706 deaths (CFR: 0.6%) have been reported in 95.6% (22/23) of Yemen governorates, and 86.5% (288/333) of the districts.

Geographical distribution of cases

The four most affected governorates were Amanat Al Asimah, Al Hudaydah, Hajjah and Amran with 47.3% (140 750/297 438) of the cases reported since 27 April 2017. Amran, Al Dhaele’e and Al Mahwit governorates had the highest attack rates (20.5‰, 20.1‰ and 19.6‰ respectively), and Raymah, Hajjah and Ibb governorates the highest case fatality ratios (1.4%, 1.0% and 1.0% respectively) (see table).

Number of suspected cholera cases & deaths, AR and CFR by governorate, Yemen, 27 April – 7 July 2017

Highlights

From 27 April to 30 June 2017, 246 867 suspected cholera cases and 1 517 deaths (CFR: 0.6%) have been reported in 87% (20/23) of Yemen governorates, and 86% (285/333) of the districts.

Geographical distribution of cases

The four most affected governorates were Amanat Al Asimah, Al Hudaydah, Hajjah and Amran with 48.7% (120 289/246 867) of the cases reported since 27 April 2017. Amran, Al Mahwit and Sana’a governorates had the highest attack rates (17.6‰, 16.6‰ and 16.3‰ respectively), and Raymah and Ibb governorates the highest case fatality ratios (1.5% and 1.2% respectively)

Al Hali (Al Hudaydah gov., 10 945 cases, 21 deaths), Bani Al Harith (Amanat Al Asimah gov., 7 133 cases, 10 deaths), Ma’ain (Amanat Al Asimah gov., 7 029, 7 deaths) and As Sabain (Amanat Al Asimah gov., 5 566 cases, 9 deaths) were still the four most affected districts.

Note: This report is an update to the weekly epidemiology bulletin.

Highlights

From 27 April to 1 July 2017, 252 816 suspected cholera cases and 1 560 deaths (CFR: 0.6%) have been reported in 87% (20/23) of Yemen governorates, and 86% (285/333) of the districts.

Geographical distribution of cases

The four most affected governorates were Amanat Al Asimah, Al Hudaydah, Hajjah and Amran with 48.5% (122 668/252 816) of the cases reported since 27 April 2017. Amran, Al Mahwit and Sana’a governorates had the highest attack rates (17.8‰, 17.0‰ and 16.4‰ respectively), and Raymah and Ibb governorates the highest case fatality ratios (1.5% and 1.1% respectively)

Al Hali (Al Hudaydah gov., 11 292 cases, 21 deaths), Bani Al Harith (Amanat Al Asimah gov., 7 264 cases, 10 deaths), Ma’ain (Amanat Al Asimah gov., 7 111, 7 deaths) and As Sabain (Amanat Al Asimah gov., 5 657 cases, 9 deaths) were still the four most affected districts.

Note: This report is an update to the weekly epidemiology bulletin.

Highlights

• During week 26 (from 25 June to 1 July 2017), 43 282 suspected cholera cases and 147 deaths were reported in Yemen.

• Since the beginning of this outbreak second wave (from 27 April to 2 July 2017), 262,650 suspected cholera cases, and 1 587 deaths (CFR: 0.6%) have been reported in 21 of the country 23 governorates (91%), and in 86% of the districts (287/333).

• For the first time since the beginning of the outbreak second wave, two cases were reported in Mukkala governorate, and tested positive with rapid diagnostic tests.

• The apparent overall decline of suspected cases reported in the last weekly bulletin was not confirmed, and the apparent decline in the curve shown figure 1 should be interpreted with caution1. But a decline seems to have started since week 25 in the two most affected governorates, Amanat Al Asimah and Al Hudaydah.

10 July 2017 – With increasing numbers of people in some countries of the World Health Organization’s Eastern Mediterranean Region affected by acute watery diarrhoea and cholera, WHO in the Region is working with partners, including UNICEF, to save lives in areas where outbreaks are active, and reduce the risk of these diseases crossing into unaffected areas and neighbouring countries.

“The situation has reached a critical point. The number of people with acute watery diarrhoea/cholera in countries in the Region in 2017 alone is higher than the number of people affected worldwide in 2016. Infectious diseases know no borders, and can quickly spread if they are not effectively contained. As the numbers of cases grow day by day, it is imperative that we exert all efforts to make sure populations in cholera-endemic countries and neighbouring countries are protected,” said Dr Mahmoud Fikri, WHO Regional Director for the Eastern Mediterranean.

Population movement is increasing the risk of epidemic-prone diseases crossing into unaffected areas. In Somalia, the cholera outbreak has spread to the northern region, which had previously been cholera-free for more than 10 years. In Sudan, cases of acute watery diarrhoea have appeared for the first time in camps hosting internally displaced Sudanese in Darfur. Increasing numbers of people are expected to be affected during the current high season for transmission of waterborne disease due to deteriorating humanitarian conditions and lack of access to safe water and sanitation.

Acute watery diarrhoea/cholera are easily treatable, but it can be life-threatening without immediate medical care. National health authorities in affected countries, supported by WHO and partners, are responding to the current outbreaks through disease surveillance for the early detection of cases, improving case management and infection control through the establishment of treatment centres, improving and monitoring water quality, providing medicines and supplies, introducing the oral cholera vaccine, and promoting safe hygiene practices in communities.

WHO and UNICEF co-hosted a sub-regional meeting region from 8 to 9 July 2017 in Beirut, Lebanon, on scaling up preparedness and response to acute watery diarrhoea/cholera in the Region. The meeting was attended by health officials from affected and neighbouring countries, as well as key partners involved in the health response.

A regional roadmap was developed during the meeting focusing on the areas of (a) strengthening coordination at sub-national level; (b) enhancing integrated, multi-sector rapid response teams in affected areas; (c) decentralising and expanding laboratory testing; (d) reinforcing guidelines for case management and infection prevention and control; (e) scaling up water and sanitation activities at household level; and (f) enhancing risk communications at community level.

In line with the International Health Regulations (IHR 2005), WHO will also closely with neighbouring countries to reinforce disease surveillance, laboratory and preparedness capacity, including at Points of Entry, to rapidly detect potential cases and ensure that all suspected acute watery diarrhoea/cholera cases are referred to appropriate health facilities.

To help people living in some of the world’s most dire emergency situations, WHO relies on funding from Member States. In 2017, WHO has asked for US$ 547 million to deliver health services to more than 66 million people in 28 countries. However, to date, WHO has received less than a quarter of the funds required. Without a significant increase in funding, the health of millions of people will be neglected and many will die needlessly.

Yemen

In Yemen, people are facing a massive cholera outbreak. More than 300 000 suspected cholera cases have been reported, including more than 1700 deaths. This is considered the world’s largest cholera outbreak right now in what was already the world’s largest humanitarian crisis. WHO and partners are in a race against time to ensure that people can access clean water, appropriate sanitation and cholera treatment.

Somalia

Somalia is on the brink of famine. Disease outbreaks are on the rise amongst malnourished people, especially children. Measles is a major killer of children during emergencies. Immunizing against measles in emergencies saves lives. It is one of the most cost-effective preventive public health measures. WHO and partners need more funds to undertake a nationwide measles campaign to vaccinate 4.4 million children.

North-eastern Nigeria

In north-eastern Nigeria, some 5.2 million people face food insecurity. When people are malnourished, preventable diseases like cholera and malaria can turn deadly. The biggest killer is often malaria. WHO and health sector partners are working with the Nigerian Government to support malaria control efforts, such as distribution of bed nets and providing malaria drugs. However, efforts will fall short without more funds, especially for health sector partners. More than 10 000 people could die from preventable deaths due to malaria in the coming months.

South Sudan

South Sudan is dealing with a several complex health emergencies, including famine, conflict and disease outbreaks. Some 6 million people are at risk of starvation. To coordinate an effective response, WHO leads the Health Cluster, a group of 35 humanitarian and emergency partners working together to provide health services. Without new funds, the Health Cluster risks losing four critical sub-national health cluster coordinator functions. These roles are essential for taking actions to deliver health services in some of the country’s worst affected areas, including counties struck by famine.

Syrian Arab Republic

The current fighting around Ar-Raqqa, Syria has displaced some 150 000 people. Many are living in temporary camps with limited access to health services, water and sanitation services. WHO and partners are working to improve the health of displaced people and those caught in the cross fire. For example, in May, WHO airlifted supplies sufficient for more than 360 000 medical treatments for distribution to camps hosting displaced people and Ar-Raqqa once access is gained. In June, WHO filled gaps in acute shortages of lifesaving medicines in the two main camps hosting displaced persons in rural Ar-Raqqa by delivering a shipment of more than 12 000 treatments for chronic diseases, infectious and diarrhoeal diseases.

Health advisories for travelers to Saudi Arabia, Hajj, 1438 H

Hajj, the pilgrimage to Mecca, Saudi Arabia, is one of the largest and most longstanding annual mass gathering event in the world. Saudi Arabia’s Ministry of Health has issued Health conditions for travelers to Saudi Arabia for the pilgrimage to Mecca (Hajj) – health requirements and recommendations in connection with performing hajj in 2017 (1438 H)

Editorial note

Every year, at the request of the Government of the Kingdom of Saudi Arabia (KSA), the World Health Organization (WHO) publishes travel advice based on Saudi Arabia’s travel advisory that informs visitors of the requirements for entry into Saudi Arabia for Hajj and Umrah. However, these stipulated requirements and conditions do not imply an endorsement by WHO.

This year, the Hajj is expected to take place during the first week of September 2017, from the 9th to the 13th of Dhu'lHijjah (the 12th and last month of the Islamic calendar). Hajj draws about 2 to 4 million Muslim pilgrims every year; at least 1.5 to 2 million pilgrims are foreign visitors.

The inevitable overcrowding due to the presence of such large numbers of people in a relatively confined area poses a unique health risk. Large mass gatherings such as Hajj and Umrah bring together people from all around the world, thus increasing the risk of infectious diseases of pandemic potential, and may amplify many infections.

During the current year, some infectious diseases continue to pose an additional health risk to pilgrims. These diseases include Middle East respiratory syndrome (MERS), which emerged 5 years ago in Arabian Peninsula, and remains a health threat to pilgrims. Although no domestic transmission of Zika virus has been reported in Saudi Arabia, dengue fever which is transmitted through the same vector (Aedes mosquitoes) is endemic in cities around hajj premises.