Discussion

Cholera is a waterborne disease with fecal–oral mode of transmission. Following the ingestion of contaminated food, water, and shellfish in rare cases, Vibrio cholera can cause intestinal infection. Cholera usually manifests as severe watery diarrhea, which can lead to dehydration, hypovolemic shock, and even death just hours after the onset of symptoms. ^{Reference Ahmed and Nashwan5,8} Disease transmission is usually linked to insufficient access to clean water sources; an increased risk of transmission can be due to humanitarian crises such as population displacement, settlement in camps or overcrowded areas, and disruptions in water systems and sanitation. The World Health Organization (WHO) observed that cholera cases have continued to rise over the last few years; in 2020, a total of 323369 cases and 857 deaths were reported in 24 countries. ⁹

In 2022, a cholera outbreak occurred in Syria, with a total of 936 suspected cases and 8 deaths reported between August 25 and September 10. ^{Reference Ahmed and Nashwan5,8} Immediately afterward, cases began to emerge in Lebanon, and the numbers started to rise. The economic crisis and limited access to clean water and proper sanitation exacerbated the vulnerability of both the host and refugee populations in the country. ^8,10 As stated by Fabrizzio Carboni (Regional Director, Near and Middle East, International Committee of the Red Cross), ‘A public health emergency is the last thing these 2 countries need.’ ¹¹ The first case of cholera in Lebanon was confirmed on October 6, 2022. ^8,12 As of December 9, 2022, the country had reported a total of 5105 suspected cholera cases (of which 600 were laboratory-confirmed) and 23 associated deaths. ^8,12 The outbreak was initially confined to the northern districts but rapidly spread to all other governorates. ^8,12 As of December 20, 2022, the majority of cholera cases were predominantly reported from Akkar and the Northern Governorates and a lesser proportion was from Mount Lebanon, Bekaa, and Baalbek. ⁸ Among those affected, those below the age of 15 years accounted for more than 50% of these cases: under 5 years (25%), between 5 and 14 years (19%), between 15 and 24 years (15%), between 25 and 44 years (22%), and above the age of 44 years (19%). ⁸

A report dated December 9, 2022, stated that 21% of the suspected and confirmed cholera cases required hospitalization. ⁸ On that date, 25 hospital beds were allocated for cholera patients in the country. ⁸ It was reported that 97% of patients presenting to the hospital setting for suspected cholera were symptomatic. The serotype Vibrio cholera O1 was identified as the V. cholera strain, similar to the one in Syria. ⁸

The actual public health concern in Lebanon is the country’s inability to curb the outbreak and manage the cases. While treating cholera patients, the country must also decrease the incidence of the resistance and growth of multidrug-resistant organisms. Some reports have been published about multi drug-resistant cholera. ^{Reference Alam, Mavian and Paisie13–Reference Taviani, van den Berg and Nhassengo15} The challenge surrounding this disease is that its organism can become resistant and then transmit such resistance through plasmids to other organisms, aggravating the threat of antimicrobial resistance globally.

As cases started to rise in Lebanon, the United Nations International Children’s Emergency Fund, the WHO, non-governmental organization (NGO) partners, and the Ministry of Public Health (MOPH) developed a joint response plan to control the situation. ⁸ This led to the establishment of the National Cholera Task Force, headed by the MOPH, including specialists from other ministries along with representatives from various NGOs. ⁸ Despite shortages in cholera vaccines, the WHO supported the MOPH in securing enough doses for high-risk cases. ¹⁰ The vaccination campaign was launched on November 4, 2022, starting with prisoners and followed by frontline healthcare workers in endemic-affected areas. The campaign will continue with larger populations of refugees and host communities. ⁸

Meanwhile, rehabilitation efforts have begun with targeting water supply systems in the most affected areas. Items for water testing were provided, and water purification tablets were distributed to 2700 households throughout the country. ¹¹ The hospitals receiving cholera cases, mainly the national public hospitals, were instructed on the new protocols for infection control and case management. ¹¹ The WHO has also provided these hospitals with laboratory reagents, treatment kits, and rapid diagnostic tests.

The WHO task force also conducted training sessions at the national level for the early detection of suspected cases, adequate isolation, and rapid initiation of treatment. ¹⁰