Cholera in Yemen: A Case Study of Epidemic Preparedness and Response

Cholera in Yemen: A Case Study of Epidemic Preparedness and Response
Johns Hopkins Center for Humanitarian Health
2018 :: 108 pages
In 2015, the United Nations declared Yemen a Level 3 emergency. On September 28, 2016, a large-scale cholera outbreak began. Between April 27, 2017 and July 1, 2018, more than one million suspected cases in two waves were reported. In the last decade, several large-scale and high-mortality cholera outbreaks have occurred during complex humanitarian emergencies including in Iraq, Somalia, and South Sudan. While the issues of “what to do” to control cholera are largely known, context-specific practices on “how to do it” in order to surmount challenges to coordination, logistics, insecurity, access, and politics, remain needed. During the Yemen cholera outbreak response, questions arose on how to effectively respond to a cholera outbreak at a national scale during an existing emergency. The main objective of this report was to identify lessons learned from the preparedness and detection phase to the end of second wave of the cholera epidemic in Yemen to better prepare for future outbreaks in Yemen and similar contexts.

Excerpts from Executive Summary
…The use of the oral cholera vaccine (OCV) was slowed by the lack of cholera response planning and technical knowledge among the Ministry of Public Health and Population (MoPHP) and partners. The lack of an updated cholera preparedness and response plan meant that OCV was not integrated into the response mindset and thus, there was a lack of technical knowledge and familiarly with OCV. OCV was not sufficiently discussed during the first wave, and was requested then rejected by the MoPHP during the second wave based on differing conceptions of the overall scale of distribution. The March 2018 plan is the first document that mentions
an OCV strategy, based on a January 2018 risk assessment. The MoPHP then made a successful
request to the Global Task Force for Cholera Control in April 2018 for 4.6 million doses for preventative use against future surges of cholera….

The cholera response in Yemen was and remains extremely complicated and challenging for a variety of political, security, cultural, and environmental reasons. The study team recognizes these challenges and commends the government, international and national organizations, and the donors for working to find solutions in such a difficult context. There are no easy fixes to these challenges, and the conclusions and recommendations are meant to be constructive and
practical, taking into account the extreme limitations of working in Yemen during an active conflict.

The findings were consistent across respondents and methods. The study team found that several areas gained strength throughout the second wave, including: an extensive operational footprint which reached into insecure areas; the strengthening of the collaborations between WHO and UNICEF and the health and WASH clusters; the initiation of a funding mechanism through the World Bank which enabled a timely response at scale; the revitalization of the WASH strategy; and, eventual consensus and use of OCV.

Conversely, the major gaps of this response are rooted in weaknesses in preparedness and the early strategies developed in the first wave. An after-action review after the first wave could have institutionalized these areas in order to prevent a much larger second wave.

The World Bank’s commitment to the cholera response provides the rationale for major investment in bolstering the preparedness activities in Yemen and other conflict-affected
contexts which would go far for addressing the foundational gaps discussed in this case study.


18. Global recommendation: Different scenarios for OCV according to varying contexts should be integrated ahead of time into national cholera preparedness plans in general. This is especially important for “fragile” countries where there is a possibility of humanitarian emergencies developing or continuing.

19. Global and Yemen-specific recommendation: In complex and insecure environments like Yemen, smaller, geographically-targeted OCV campaigns should be anticipated and planned