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Oromia, Somali regions worst affected as 521 killed by disease in 18 months

Vaccine shortages, lack of funding, insecurity, climate fluctuations, and poor infrastructure have led to an alarming rise in cholera outbreaks across Ethiopia claiming the lives of more than 500 people over the span of a year and a half. No less than 54 woredas or 2,798 kebeles in five regional states and Dire Dawa are struggling to contain the disease.  Last week alone saw 238 cases reported, largely in the Oromia and Somali regions, which are also home to the heaviest caseloads and death rates. There were more than 36,898    cases of cholera reported between August 2022 and February 2024, according to the Bacterial Disease Surveillance report published by the Ministry of Health and Ethiopian Public Health Institute on March 6, 2024. The waterborne disease claimed 521 lives over the same period, making Ethiopia home to the second-most cholera deaths in Africa after Malawi, which saw close to 1,800 casualties.

Ethiopia also ranks fourth in Africa in terms of cholera case count, trailing Malawi, DRC, and Mozambique, according to the World Health Organization (WHO). Cholera haunts 28 woredas in Somalia, 18 in Oromia, five each in Harari and Dire Dawa, as well as three in Amhara and one woreda in Afar.

The outbreaks in Ethiopia are part of a larger trend – cholera cases have gone up by 40 percent globally while deaths have risen by 80 percent. Nearly 41,000 cholera cases and 775 deaths were reported globally in January 2024 alone.

Vaccine shortage, lack of operational finance, conflict, floods, vehicle shortages, communication delays, lack of spray chemicals and clean water, and difficulties in accessing health facilities and equipment are persistent obstacles to national efforts to contain cholera outbreaks.

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Insecurity in Amhara, Oromia (Guji, West Guji, East Borena) and Benishangul-Gumuz are also mentioned as difficulties in the ministry report. It recommends fostering cross-border collaboration with Kenya, Somalia, South Sudan and other countries to fight cholera.

Eastern and southern Ethiopia are most affected by the outbreaks, which experts believe are being exacerbated by climate fluctuations in the region. Parts of Ethiopia, Kenya, and Somalia have been experiencing excessive rainfall since November 2023, with runoff hastening the spread of cholera by contaminating water sources.

The WHO has designated the cholera outbreak a ‘Grade-3’ emergency, and warned there is high risk of further spread in refugee camps and among IDPs as a result of ongoing insecurity.

Treating the afflicted has proved a difficult task owing to poor health infrastructure and a depleted stock of pharmaceuticals.

Ethiopia has run out of cholera vaccines, and though the government has lodged vaccine requests to the WHO, prompt delivery seems unlikely as shortages persist around the world.

All doses of oral cholera vaccine (OCV) expected from global production until mid-March have already been allocated to affected countries, but demand for doses keeps growing with current world reserves at zero, according to the WHO.

Ethiopia is one of three African countries (with Somalia and Zambia) to place a request with the WHO for the supply of a combined six million doses so far in 2024. Burundi and Yemen are considering submitting an OCV request for a reactive campaign.

However, the global OCV stockpile is currently depleted, with no doses available until the beginning of March, according to a WHO report. The report also reveals the organization could only meet half of the requests for 76 million vaccine doses globally in 2023.

Still, there are vaccination campaigns underway in Ethiopia, Mozambique, Zambia, and Zimbabwe.

“There is a massive global oral cholera vaccine shortage. . . equating to demand exceeding up to four times global production capacity for the past two years. There is an urgent need for affected countries to adapt their existing approaches for responding to outbreaks,” reads a statement from Doctors Without Borders (Médecins Sans Frontières, MSF) this week.

The organization is collaborating with the Health Ministry to implement a novel strategy to fight cholera in the Somali Regional State, which has been hit the hardest.

MSF is working with the regional health bureau to implement the ‘Case Area Targeted Intervention (CATI)’ method. It involves identifying cholera patients with the help of local officials and disinfecting their residences, as well as residences in the vicinity. Patients and people in the area are given a dose of the oral vaccine and an antibiotic (doxycycline) and provided with hygiene kits. The work also involves cholera awareness and educational programs.

CASI contrasts with more traditional responses to cholera outbreaks, which involve implementing interventions across much larger geographic areas in an attempt to reach as much of the population as possible in a short time. CASI is notably more resource efficient.

MSF has successfully implemented CATI in other cholera-endemic countries such as Haiti and Democratic Republic of Congo.

In addition to rigorous case triangulation and health promotion activities with local health authorities, MSF supported the set up and running of a Cholera Treatment Centre (CTC) at Ayerdega Health Center to provide comprehensive treatment and care for patients with severe illness.

A Cholera Treatment Unit (CTU) was built at Jigjiga Primary Hospital to provide initial care and treatment for moderately ill patients, and five oral rehydration points were also installed in various parts of the city. These rehydration points provide oral rehydration solutions, which is a powder dissolved in water to treat patients with mild cholera and dehydration symptoms, improving patient access to care, and decreasing the number of patients arriving to the CTC and CTUs.

“We have limited resources to fight the outbreak, including the provision of mass vaccination campaigns due to the shortage of vaccines. The introduction of CATI symbolizes a turning point in the region’s battle against cholera,” says Ermias Amare, a CATO coordinator and public health emergency officer at the Somali regional health bureau.

Between November 2023 and February 2024, MSF and the MoH treated more than 800 cholera patients, administered the limited number of oral cholera vaccines that were available to more than 8,000 people, and about 1,700 households have been provided with hygiene kits and health promotion information.

“The main challenge is ensuring that medicines are available in the right place, at the right time, in the right quantity and for free. Most important medicines are oral rehydration salts and zinc supplementation for less severe patients. IV fluids (like Ringers Lactate) for patients with dehydration and antibiotic treatment (doxycycline or azithromycin or ciprofloxacin),” said Alan Pereira (MD), a medical coordinator for MSF.

Implementers say despite it still being in the trial stage in Ethiopia, CATI’s initial results are promising. The health bureau reports case numbers have dropped in all of Jigjiga’s districts except one.

MSF and the Health Ministry are compiling an impact analysis of the approach in Jigjiga, and the organization says it anticipates further partnership to assist at-risk communities in other parts of the country.

MSF has already expanded its response to Kebridehar, the second-largest urban center in the Somali region, and is supporting response efforts in Lafaciise, a town 40 kilometers away from Jigjiga.

Cholera In Ethiopia

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