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Responding to epidemics in large-scale humanitarian crises: a case study of the cholera response in Yemen, 2016–2018
  1. Paul Spiegel1,2,
  2. Ruwan Ratnayake3,
  3. Nora Hellman1,2,
  4. Mija Ververs1,2,
  5. Moise Ngwa1,
  6. Paul H Wise4,5,
  7. Daniele Lantagne6
  1. 1Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
  2. 2Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
  3. 3Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
  4. 4Department of Pediatrics, Stanford University School of Medicine, Stanford University, Stanford, California, USA
  5. 5Freeman Spogli Institute for International Studies, Stanford University, Stanford, California, USA
  6. 6Department of Civil and Environmental Engineering, Tufts University, Medford, Massachusetts, USA
  1. Correspondence to Dr Paul Spiegel; pbspiegel{at}
  • Present affiliation The present affiliation of Nora Hellman is: Emergency Health Unit, Save the Children UK, London, United Kingdom


Background Large epidemics frequently emerge in conflict-affected states. We examined the cholera response during the humanitarian crisis in Yemen to inform control strategies.

Methods We conducted interviews with practitioners and advisors on preparedness; surveillance; laboratory; case management; malnutrition; water, sanitation and hygiene (WASH); vaccination; coordination and insecurity. We undertook a literature review of global and Yemen-specific cholera guidance, examined surveillance data from the first and second waves (28 September 2016–12 March 2018) and reviewed reports on airstrikes on water systems and health facilities (April 2015–December 2017). We used the Global Task Force on Cholera Control’s framework to examine intervention strategies and thematic analysis to understand decision making.

Results Yemen is water scarce, and repeated airstrikes damaged water systems, risking widespread infection. Since a cholera preparedness and response plan was absent, on detection, the humanitarian cluster system rapidly developed response plans. The initial plans did not prioritise key actions including community-directed WASH to reduce transmission, epidemiological analysis and laboratory monitoring. Coordination was not harmonised across the crisis-focused clusters and epidemic-focused incident management system. The health strategy was crisis focused and was centralised on functional health facilities, underemphasising less accessible areas. As vaccination was not incorporated into preparedness, consensus on its use remained slow. At the second wave peak, key actions including data management, community-directed WASH and oral rehydration and vaccination were scaled-up.

Conclusion Despite endemicity and conflict, Yemen was not prepared for the epidemic. To contain outbreaks, conflict-affected states, humanitarian agencies, and donors must emphasise preparedness planning and community-directed responses.

  • armed conflicts
  • cholera
  • communicable disease control
  • emergencies
  • epidemics

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  • PS and RR are joint first authors.

  • Handling editor Seye Abimbola

  • Contributors PS, RR and DL designed the study and took the lead in the interpretation of the results and the drafting of the manuscript. NH, MN, MV and PHW provided substantial contributions to the data collection and interpretation and the drafting the manuscript. All authors made significant content contributions to the final draft of the report and critically reviewed and approved the final version.

  • Funding The Office of U.S. Foreign Disaster Assistance (OFDA) provided funding to the Johns Hopkins Center for Humanitarian Health for an unsolicited proposal for a case study of the response (supported non-financially by the Department for International Development (DFID) and the Directorate-General for European Civil Protection and Humanitarian Aid Operations (ECHO). All authors had full access to all the data in the study and had the final responsibility for the decision to submit for publication.

  • Disclaimer The funder had no role in study design, data analysis, data interpretation or writing of the report.

  • Competing interests RR and DL declare personal fees from the Johns Hopkins Bloomberg School of Public Health for conducting the study.

  • Patient consent for publication Not required.

  • Ethics approval The study protocol was determined by Johns Hopkins Bloomberg School of Public Health not to be human subjects research and was exempted from review.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available.

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