Cholera outbreak: “The situation in Lebanon is fragile”

"The fast pace of the cholera outbreak in Syria and Lebanon is alarming and the risks of the disease further spreading to other countries in the region call for immediate action. Urgent support is needed to respond and contain the spread of the disease", says Bertrand Bainvel, UNICEF Deputy Regional Director for the Middle East and North Africa.

cholera lebanon
“Cholera is deadly, but it’s also preventable through vaccines and access to safe water and sanitation. It can be easily treated with timely oral rehydration or antibiotics for more severe cases,” opined Dr. Abdinasir Abubakar, a WHO Representative.

According to records from Lebanon’s Public Health Ministry, there are upwards of 2,524 confirmed cases of Cholera, a bacterial illness which spreads through contaminated water, sewage and food. Already there have been eighteen deaths due to the outbreak. To combat it, Lebanon’s Public Health Ministry, headed by Firass Abiad, has requested international aid while health officials continue to keep the numbers down.

The government has reacted quickly to contain the outbreak and has requested the population to remain calm as it strives to mitigate the crisis. Luckily, the number of those affected aren’t high so as to overwhelm hospitals.

“Since the numbers are not yet very high, hospitals are able to treat the infected patients,” said Abiad while adding, “If the case numbers rise significantly, hospitals won’t be able to cover it anymore”.

A Situation Report by the World Health Organization notes that the “overall risk of the Cholera outbreak in Lebanon [is] very high at the national level [as well as] at the regional level.”

How did Lebanon land in this situation?

Looking back at the last three years, Lebanon was swamped by a range of crises including economic and political; to make matters worse, these were further exacerbated by climate change, and the COVID-19 pandemic. As if that wasn’t enough, the conflict between Russia and Ukraine resulted in a shortage of grain which further acted as a drag on Lebanon’s economy. The lack of governance added fuel to the fire: in early November, the president stepped down leaving Beirut without a head of state, and with just a caretaker government.

The outbreak of cholera essentially underscores years of neglect to the country’s maintenance of infrastructure. The gross mismanagement across several years, along with a series of crises have in combination, led to this crisis.

“The water sector was already fragile before the start of the crisis in 2019”, observed Beirut-based Ferrando while adding a positive note.

“On the other hand, the mere fact that water and sanitation infrastructure exist reduces the risk of widespread contamination”.

The outbreak of cholera in Lebanon comes after nearly three decades.

The first case of cholera was reported by Lebanon’s Ministry of Public Health to the World Health Organization on October 6, 2022; since then there have been at least 381 laboratory-confirmed cases.

While initially, the outbreak was confined only to the northern districts, it has rapidly spread across the country, said WHO’s office in Lebanon. Laboratory-confirmed cases are now being reported from 18 out of 26 districts.

The cholera strain, Serotype Vibrio cholerae O1 El-Tor Ogawa, was identified as the one in circulation, which is similar to the one going around in Syria.

Cholera is preventable

“Cholera is deadly, but it’s also preventable through vaccines and access to safe water and sanitation. It can be easily treated with timely oral rehydration or antibiotics for more severe cases,” opined Dr. Abdinasir Abubakar, a WHO Representative. “The situation in Lebanon is fragile as the country already struggles to fight other crises – compounded by prolonged political and economic deterioration.”

“Cholera, and other infectious diseases that could be usually prevented by sanitary and public health measures, are not in general considered endemic to Lebanon,” said Farah Nasser, a medical coordinator at Médecins Sans Frontières (MSF). “The current economic and energy crisis in Lebanon has further exacerbated access to safe water supply and sanitation services in the country”.

The WHO is working alongside Lebanon’s public health ministry and other humanitarian partners to curb the outbreak.

Together they have drawn up a national cholera preparedness and response plan, outlining an urgent response of interventions that are required to mitigate the issue while scaling up responses in hotspots areas.

Cholera is typically contracted by ingesting contaminated food or drinking unclean water. These cause intestinal problems as well as dehydration, the combination of which can be fatal unless treated quickly.

Those residing in Lebanon’s remote and underdeveloped areas, especially in the north and northeast of the country, rely on polluted rivers and ponds to cover their water needs. Such conditions are favorable for the vibrio cholerae bacterium, the bacteria which spreads cholera. When people drink this contaminated water, cholera infection spreads.

While many cases are mild to moderate, the infection can result in death if it is left treated or ignored.

To fight the disease, a good hygiene regimen is required along with access to clean water. This is why it is critical that in remote and undeveloped areas, access to clean water and cleanliness in general should be maintained to get a fighting chance of stopping the spread of the disease. Not doing so could potentially see cases soar.

In the wake of rising cases in Lebanon, UN Officials have urged the international community to donate generously, to stop the spread of cholera.

The lack of public funding for proper water systems along with Lebanon’s crippled health system compounded the outbreak.

The exodus of doctors and nurses along with the destruction of critical medical infrastructure in the August 2020 Beirut port blast have made the situation more difficult to handle especially since people in Lebanon were heavily dependent on these core non-governmental organizations for medical aid and treatments.

“Due to the international shortage of cholera vaccines, the two-dose strategy was modified and one dose will be used, so the coverage will increase and last for a shorter duration, hoping this will help contain the cases and limit the spread,” said Hasan Ismail, a medical coordinator at Amel Association.

Health authorities in Lebanon are now focusing on increasing awareness on the cholera symptoms and treatments.

When UNICEF’s Higgins visited Lebanon’s northern areas she was surprised to find that “People are very aware about COVID symptoms but they don’t know that cholera is different and that as soon as symptoms start showing, they cannot wait because it has to be treated immediately.”  

“There is a lack of understanding on the ground because Lebanon has been without cholera for 30 years.”

Syrian source

While cholera was absent in Syria for at least 14 years, the ravaging affect of war on the Syrian economy, led to widespread mass contamination of the Euphrates River with sewage water and the subsequent usage of unclean water to irrigate crops led to the rapid spread of an outbreak. The scarce health services that were there in Syria were already stretched beyond their limits.

“It’s not normal to have this many cases. There is a fundamental problem with the water supply affecting certain foods. We tried to tell people, to raise awareness, but it hasn’t been successful. Some [people] don’t even get checked; they struggle with the dehydration. Others even got cholera and thought they had the coronavirus,” said Randa Youssef, a healthcare worker in Damascus.

“We need a strategy and a nationwide effort to make people aware of what cholera is firstly and then enforce the right action. Food must not be contaminated, while water must be clean at the source, or it will only get worse,” he added.

Earlier this September, thousands Syrians started complaining of acute diarrhea; the number of such cases have grown multifold since then. In the Syrian village of al-Bayadia, in Homs Province, there have been more than 140 cases of hepatitis, which is yet again related to a lack of clean water, poor sanitation and hygiene practices.

“The outbreak [in Syria] was a result of drinking from unreliable water sources [wells] due to the scarcity of water in the village. We analyzed the wells and found that they are not suitable for drinking,” said Dr. Maad Choubasi, a director of health at Homs Province.

He went on to add, water tanks in schools must be inspected and sterilized.

“We need to find solutions for water in these villages to avoid injuries later. Hepatitis infections are periodically recorded as a result of water scarcity, and it decreases with the progression of the winter season and heavy rains.”

According to the International Rescue Committee (IRC), one of the reasons for the cholera outbreak were the cowboy merchants: they were running a water scam whereby they sold unclean water from unregulated trucks while billing it as clean.

According to official numbers, the number of cholera related deaths is more than 90 while the unofficial total expected to be significantly higher with 35,000 suspected cases.

The speed and scale of the outbreak prompted the EU to act swiftly with a €700,000 humanitarian aid package.

“Almost half of Syrians rely on unsafe water sources for their daily needs. This is the result of almost 12 years of conflict made worse by a severe economic crisis and prolonged drought. The EU is joining efforts to curb the epidemic,” said Janez Lenarčič, the EU commissioner for crisis management.

Syria’s water treatment infrastructure is unfortunately significantly lower than its current capacity. A 2022 report from the Syria Humanitarian Needs Overview notes, 70% of sewage is discharged untreated, contaminating the source of drinking water for millions of Syrians. Given the scale of the issue, a lot needs to be done to boost Syria’s water treatment capacity, failing which cholera will continue to spread to surrounding regions.

There is no doubt that the outbreak of cholera in Syria spread to Lebanon, a country which was facing an economic cliff, midst political indecision and indifference midst and a plethora of other systemic issues.

The transmission of the disease was further facilitated by the lack of border control. Incidentally, Lebanon is home to a large number of Syrian refugees, estimated to be 1.5 million, one-fourth of its total population.

Following the spread of cholera to Lebanon from Syria, the WHO assessed the risk of an outbreak citing shortage of drinking water and Lebanon’s fragile and overburdened health infrastructure. A shortage of electricity compounded the issue.

The first cases of cholera in Lebanon were reported in early October.

“The common point between these cases is the majority of patients are displaced Syrians,” said Lebanese Health Minister Firas Abiad.

“The absence of basic services, like safe water and sewage networks, in places where refugees gather constitutes a fertile ground for the epidemic too.”

On its part, UNICEF was quick to help Lebanon: it distributed 80,000 liters of fuel so that water pumps and wastewater treatment stations in contaminated locations can be run. It also helped procure emergency medical supplies to treat the outbreak with oral rehydration salts and treatment kits.

The WHO also chipped in and arranged a shipment of 600,000 doses of cholera vaccine. On November 12, it launched vaccination campaign targeting both Lebanese and Syrian refugees.

“Electricity cuts, low socioeconomic levels, the absence of sewer systems in rural areas and the refugee crisis are all essential factors regarding the spread of cholera, which is transmitted by water sources contaminated by the bacteria coming from stagnant waters and infecting peoples’ stools,” opined Hasan Ismail, Amel Association’s medical coordinator.

“With all preventive measures absent in most Lebanese cadasters, the infection continues to spread, especially with vegetables and agricultural products irrigated with infected waters,” he added.

Before the outbreak turns into an epidemic, it is critical that the fundamental drivers of the outbreak are addressed, and that water treatment plants and facilities in Syria and Lebanon are improved, so as to curb and stop its further spread in the short and long term.