On 6 October 2022 the Ministry of Public Health of Lebanon notified the World Health Organization of two laboratory culture-confirmed Cholera cases reported from the northern part of the country. As of 13 October, a total of 18 cases have been confirmed, including two probable deaths (an 11.1% mortality rate), According to a press release issued by the World Health Organization on 19 Octotber 2022. This represents the first cholera outbreak in Lebanon since 1993. Responding to the current cholera outbreak may overwhelm the already fragile health system in the country.
The first case, a 51-year-old Syrian man living in an informal settlement in Minieh-Danniyeh District of North Governorate, was reported to the Ministry of Public Health on 5 October 2022. The patient was admitted to a hospital on 1 October with rice water stool and dehydration. Following a possible healthcare-associated transmission, the second case, a 47-year-old health worker, was reported, representing the first hospital-acquired infection of this outbreak.
Immediately following the confirmation of the first two cases, active case finding in the informal settlement where the patient lived, identified 10 additional cases confirmed by Bacteria culture test. In addition, Vibrio cholerae was found in potable water sources, irrigation, and sewage. These positive cultures were confirmed on 9 October.
In Halba, the capital of Akkar Governorate, an additional two cases were culture-confirmed among Lebanese nationals. On 10 October, an additional four cases were culture-confirmed among Syrian nationals living in an informal settlement in Aarsal town in Baalbek District.
As of 13 October, a total of 18 confirmed cases have been reported. The most affected age group are children under 5 years (8 of 18 cases), followed by persons aged 45 to 64 years (4 cases), 25-44 years (3 cases) and 5-15 years (3 cases). Females are disproportionately affected in the outbreak (13 of 18 cases). Of the total cases, 11 were reported from the District of Minieh-Danniyeh, four cases from Baalbek District and three cases from Akkar District.
In parallel, sewage water testing conducted in Ain Mraisseh in Beirut, Ghadir station in Mount Lebanon, and Bourj Hammoud also in Mount Lebanon, confirmed the presence of Vibrio cholerae in all three sources, indicating that Cholera has spread to two other regions of the country (Beirut Area and Mount Lebanon) located far from the initial confirmed cases.
This is the first outbreak of cholera in Lebanon since the last case was reported in 1993 with no local transmission documented since then.
At this stage of the outbreak, laboratory confirmation of cases is done by Bacterial culture and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (an ionization technique that uses a laser energy absorbing matrix to create ions from large molecules with minimal fragmentation) which is conducted at the Department of Experimental Pathology, Immunology, and Microbiology at the American University of Beirut, a World Health Organization collaborating centre.
Cholera is an acute enteric infection caused by ingesting the Bacterium Vibrio cholerae, a Gram-negative, comma-shaped Gammaproteobacteria, related to other pathogenic Bacteria such as Yersinia pestis (Bubonic Plague), and Esherchia coli (food poisoning), which present in contaminated water or food. It is mainly linked to insufficient access to safe drinking water and inadequate sanitation. It is an extremely virulent disease that can cause severe acute watery diarrhoea resulting in high morbidity and mortality, and can spread rapidly, depending on the frequency of exposure, the exposed population and the setting. Cholera affects both children and adults and can be fatal if untreated.
The incubation period is between 12 hours and five days after ingestion of contaminated food or water. Most people infected with Vibrio cholerae do not develop any symptoms, although the Bacteria are present in their faeces 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 diarrhoea with severe dehydration. Cholera is an easily treatable disease. Most people can be treated successfully through prompt administration of oral rehydration solution.
Cholera can be endemic or epidemic. A Cholera-endemic area is an area where confirmed Cholera cases were detected during the last three years with evidence of local transmission (cases are not imported from elsewhere). A Cholera epidemic can occur in both endemic countries and in non-endemic countries. Uninfected dead bodies have never been reported as the source of epidemics.
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.
A multi-sectoral approach including a combination of surveillance, improving access to clean water, sanitation, and hygiene promotion, rapid access to treatment, risk communication and community engagement and oral Cholera vaccines is essential to control cholera outbreaks and to reduce deaths.
Lebanon’s health system has been hard-hit by a three-year financial crisis and an explosion at the port of Beirut in August 2020 that destroyed essential medical infrastructure in the capital. In this context, responding to a cholera outbreak may overwhelm the already fragile health system in the country.
According to the United Nations High Commissioner for Refugees, Lebanon hosts the largest number of refugees in the world per capita and square kilometre, with 1.5 million Syrian refugees and about 13 715 refugees of other nationalities. Additionally, there is a large population of Palestinian refugees that are particularly exposed due to unsafe water, sanitation, and hygene services in various camps (Beqaa, Trablos, Beirut, Saida, Sour), possibly with limited medical services provided.
Due to porous borders allowing free movement between Lebanon and neighbouring countries, the exportation of Cholera cases is highly likely.
The current Cholera outbreak in Lebanon was reported six weeks after a Cholera outbreak was declared in neighbouring Syria. On 15 September 2022, the World Heath Organization assessed the risk of the Cholera outbreak in Syria and predicted that due to shortages of drinking water and a fragile and limited health system in Lebanon, there was a risk of a Cholera outbreak should the disease be introduced into the country.
Power cuts, water shortages, and inflation have strained the already fragile health system in Lebanon. Poverty has also worsened for many Lebanese, with many families frequently rationing water, unable to afford private water tanks for consumption and domestic use.
Since the last cholera outbreak in Lebanon occurred in 1993, there is a need to update Cholera surveillance and case management guidelines and re-train healthcare workers.
