Water supply in Muzafarrabad. There are still thousands of people living in displacement camps. Photo © Eddy Van Wessel

"When the first patients started coming in with symptoms like watery diarrhea and vomiting, we immediately suspected it was cholera. The rapid tests we did were positive and so we immediately set up a cholera treatment unit," says Luis Neira, medical coordinator for Doctors Without Borders/Médecins Sans Frontières (MSF) in Pakistan. Since mid-July, the disease emerged in various areas in Pakistan-administered Kashmir. Though the number of patients with cholera is decreasing in some areas, in other areas the numbers are still increasing.

The first patients with symptoms of cholera came to the MSF district hospital in Bagh in mid-July. On July 28, patients also started arriving at the MSF hospital in Hattian and in mid-August the first patients with similar symptoms were admitted to the MSF hospital in Muzafarrabad. In all locations, an isolation ward was quickly established within the hospital structure. In total, more than 2,300 people have been treated for cholera in the MSF medical facilities.

According to Luis Neira, there is a pattern of cholera outbreaks in the region during the monsoon season. "Cholera is transmitted by water that's infected with the cholera bacteria as well as through human carriers of the disease," he says. "People get water from natural resources like rivers and when people who have been infected travel around, they infect others."

Luis continues: "An additional problem in the earthquake-affected area is that roads are still in bad condition, and though most of the roads have been cleared, monsoons cause new landslides. It's still difficult for our teams to reach the villages and for the patients to travel to our medical facilities."

There are still thousands of people staying in displacement camps in the area. However, the majority of the people infected with the disease who have been arriving in Hattian and Muzafarrabad are from the areas around the towns itself. In Bagh district, 70 percent of the patients were coming from rural areas.

More than 2,000 patients have so far been treated in the Bagh District Hospital and in two cholera treatment units in Rerban and Mallot. In a special cholera treatment unit on the Hattian hospital grounds, 178 patients have been treated. MSF has set up a cholera treatment center on the Muzafarrabad hospital grounds where 110 patients have received medical care. In Muzafarrabad, the number of new patients is still rising, whereas in Bagh district and in Hattian, the amount of new admissions is decreasing.

"We now receive about 20 patients per day in our medical units, compared to close to 80 at the peak of the outbreak," says Fasil Tezera, coordinator for MSF programs in Pakistan. "Thanks to the involvement of key partners, including the Ministry of Health, World Health Organization and many other relief organizations, the case fatality rate of the current epidemic has remained low, and the outbreak could be scaled down drastically. We hope it will continue along that trend."

"It has been an impressive experience and a big challenge. We took the lead in providing treatment, coordinating with the Ministry of Health but also with other relief organizations and had to quickly reorganize the medical staff within the projects to assemble our cholera task teams," says Luis Neira.

More than 14 international staff and 158 national staff are providing medical care in response to the cholera outbreak in Pakistan-administered Kashmir.

About cholera
Cholera is an acute and frequently fatal infection of the small intestine that is caused by the bacterium vibrio cholerae. The incubation time differs from one to five days. The key symptoms are severe watery diarrhea and vomiting, leading to acute dehydration that can swiftly result in death when left untreated. The disease is caused by contaminated (drinking) water and unhygienic conditions.