Yemen: Diphtheria Spreads as War and Blockade Leave Health System in Tatters

YEMEN 2017 © Malak Shaher/MSF

Hundreds of suspected cases of the disease not seen in Yemen in decades 

SANA'A, YEMEN/NEW YORK, DECEMBER 12, 2017—Doctors Without Borders/Médecins Sans Frontières (MSF) is responding to a suspected outbreak of diphtheria in Yemen, where the disease has reemerged as the country's health system is weakened by ongoing war and a blockade on essential goods.

According to the World Health Organization (WHO), 318 suspected cases of diphtheria and 28 deaths have been reported from mid-August to early December in 15 of Yemen's 20 governorates. Half of the suspected cases are children between the ages of 5 and 14, and nearly 95 percent of the deaths are children under 15. Most of Yemen's suspected diphtheria cases are in Ibb governorate.

Diphtheria is a contagious and potentially fatal bacterial infection characterized by a thick grey membrane at the back of the throat or nose, a sore throat and fever. It can be prevented through vaccination, but it can be challenging to treat—in part because it is often unfamiliar to health workers. Before this year, the last diphtheria case in Yemen was recorded in 1992, and the last outbreak was in 1982.

"Globally, diphtheria has been eradicated from most countries after systematic childhood vaccination campaigns, and it's become something of a neglected and forgotten disease," said Marc Poncin, MSF emergency coordinator in Ibb. "There has been a concrete loss of knowledge regarding its treatment, and this is making it much more difficult for health workers to quickly and correctly identify, isolate, and treat cases."

At the same time, the conflict and blockade are making it difficult for patients to reach health facilities, and for humanitarian organizations to bring specialized staff and supplies where they are most needed.

"After two and a half years of violence and a blockade on supplies including medicines and vaccines, the health care infrastructure is in tatters," Poncin said. "This is sending the Yemeni health system decades back in time. The blockade on fuel has meant that patients cannot afford to travel to the very few health centers still operating across the country. This is crucial, because if people infected are unable to access treatment regularly, diphtheria can spread in the body and be fatal in up to 40 percent of the cases."

The outbreak in Yemen is referred to as a "suspected" diphtheria outbreak because confirmation requires having a sample validated by a laboratory, and it has not been possible to perform these tests in Yemen.

The Yemeni health system has also struggled to respond to a massive cholera outbreak this year, which has declined but is not yet over. The response to diphtheria requires more specialized treatment than what has been available in Yemen until recently, as well as efforts to prevent its spread.

"To treat diphtheria, patients need to be isolated and receive antibiotics and anti-toxins," Poncin said. "But the global supply of the anti-toxin, which is the single most important aspect of treatment, is very limited, and no anti-toxins were available in Yemen prior to a few weeks ago."

To tackle the outbreak, MSF, together with the WHO, is acquiring most of the antitoxin that is still available worldwide, and ordering more antibiotics. MSF has also put together a rapid response team to survey and identify suspected cases in communities, and provide prophylaxis to those in contact with a diphtheria patient.

On December 11, MSF opened a Diphtheria Treatment Unit in Nasser Hospital in Ibb city, and is in the process of supporting two other treatment units in Yarim and Jiblah hospitals—the latter with intensive care unit capacities. An ambulance referral system will also be set up to transport suspected cases to hospital. MSF will additionally support transportation of samples to a laboratory to better confirm cases, and carry out health promotion activities to alert communities to diphtheria. MSF is also setting up an intensive care unit in Sadaqa hospital, Aden, where 14 cases were recorded, resulting in four deaths.

"We have been visiting houses where six or more displaced people are living in very cramped conditions," Poncin said. "In such settings there are no ways to properly isolate cases, and it creates the perfect conditions for diphtheria to spread. Isolating and treating patients, offering preventive care for affected communities and raising public awareness are therefore crucial to halt the spread of diphtheria. Yemen's health care system cannot afford another outbreak."

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