Table 1

Challenges during the cholera epidemic in Yemen, their impacts, and opportunities for FCAS

Sector and challengeImpacts in YemenOpportunities for FCAS
1. Cholera preparedness and planning was lacking.
  • Scenarios and strategies for the 2016 cholera response plan were under-developed and prevented a comprehensive early response.

  • OCV was not included in a preparedness plan resulting in less technical knowledge and differing expectations among MoPHP and partners and prolonged delays for use.

  • Develop multisector preparedness and response plans for cholera.

  • Introduce OCV, and its use cases for crises (eg, use of the polio vaccination network amd single-dose strategies), through preparedness planning.

  • Donors should prioritise and finance preparedness planning in FCAS.

2. Epidemic detection and monitoring could not be scaled.
  • eDEWS was not primed for data management, and the laboratory network was not capacitated for monitoring.

  • Efforts concentrated on improving data management over surveillance.

  • Epidemiological and laboratory data to guide response was lacking.

  • Ensure that surveillance systems have effective early warning, alert, response as well as robust data management capacity.

  • Preparedness plans should evaluate the capacity to expand laboratory and specimen transport given the degradation of infrastructure.

3. WASH and health cholera-specific strategies did not have a decentralised, community-based and intersectoral response.
  • The WASH strategy did not target cholera-specific activities until late in the second wave.

  • The health strategy was centralised to health facilities, and ORCs were underused.

  • The intersectoral WASH–health response to interrupt transmission was lacking until the late implementation of RRTs.

  • WASH and health strategies require decentralisation and judicious targeting of transmission in hotspots.

  • Cholera specialists should be prioritised for entry in country early on for risk assessment and strategy development.

  • Technical bodies should provide cholera outbreak trainings and adapted guidelines for staff.

4. Coordination systems operated with limited success and complementarity.
  • As cluster system was already operating, the mandate for IMS was unclear.

  • Oversight of key areas for Yemen (eg, cohesive third-party monitoring) were missed.

  • WHO, UNICEF and the cluster system should codevelop global guidance on IMS/cluster integration for epidemics in humanitarian crises.

  • In insecure areas, coordination mechanisms should oversee a system for third-party monitoring.

5. Protection of health facilities and WASH infrastructure during conflict.
  • Infrastructure repeatedly attacked.

  • Reduced protection of civilians and partners.

  • No specific UN agency was responsible for recording and reporting attacks on WASH infrastructure.

A specific UN agency (likely UNICEF) should be chosen and provide surveillance of these attacks and stronger advocacy to prevent direct harm (eg, killings) and indirect harm (eg, damage to WASH infrastructure) to civilians.
  • FCAS, fragile and conflict-affected states; IMS, incident management system; MoPHP, Ministry of Public Health and Population; OCV, oral cholera vaccination; ORCs, oral rehydration corners; RRT, rapid response team; WASH, water, sanitation and hygiene; eDEWS, electronic Disease Early Warning System.