Cholera – Lebanon

Outbreak at a glance

The Ministry of Public Health of Lebanon notified WHO on 6 October 2022 of two laboratory culture-confirmed cholera cases reported from the northern part of the country. As of 13 October, a total of 18 cases have been confirmed, including two probable deaths (CFR 11.1%). This represents the first cholera outbreak in Lebanon since 1993. Responding to the current cholera outbreak may overwhelm the already fragile health system in the country.

Outbreak overview

On 6 October 2022, the Ministry of Public Health (MoPH) of Lebanon, notified WHO of two laboratory-confirmed cholera cases, confirmed by bacteria culture test, reported from North and Akkar governorates, northern Lebanon. The index case, a 51-year-old Syrian man living in an informal settlement in Minieh-Danniyeh district (North governorate), was reported to the MoPH on 5 October 2022. The patient was admitted to the hospital on 1 October with rice water stool and dehydration. Following a possible healthcare-associated transmission, the second case, a 47-year-old health worker, was reported, representing the first nosocomial infection of this outbreak.

Immediately following the confirmation of the first two cases, active case finding in the informal settlement where the index case lived, identified 10 additional cases confirmed by bacteria culture test. In addition, Vibrio cholerae was found in potable water sources, irrigation, and sewage. These positive cultures were confirmed on 9 October.

In Halba (the capital of Akkar Governorate), an additional two cases were culture-confirmed among Lebanese nationals. On 10 October, an additional four cases were culture-confirmed among Syrian nationals living in an informal settlement in Aarsal town of the Baalbek district.

As of 13 October, a total of 18 confirmed cases have been reported. The most affected age group are children under 5 years (44.4%; n=8), followed by persons aged 45 to 64 years (22.2%; n=4), 25-44 years (16.7%; n=3) and 5-15 years (16.7%; n=3). Females are disproportionally affected in the outbreak (72%; n=13). Of the total cases, 11 (61.1%) were reported from the district of Minieh – Danniyeh, four cases (22.2%) from Baalbek district and three cases (16.7%) from Akkar district (Figure 1).

In parallel, sewage water testing conducted in Ain Mraisseh in Beirut, Ghadir station in Mount Lebanon, and Bourj Hammoud also in Mount Lebanon, confirmed the presence of V. cholerae in all three sources, indicating that cholera has spread to two other regions of the country (Beirut Area and Mount Lebanon) located far from the initial confirmed cases.

Figure 1. Map of confirmed cholera cases by district, Lebanon (n=18), as of 18 October 2022. 

This is the first outbreak of cholera in Lebanon since the last case was reported in 1993 with no local transmission documented since then.

At this stage of the outbreak, laboratory confirmation of cases is done by bacterial culture and MALDI-TOF spectrometry which is conducted at the Department of Experimental Pathology, Immunology, and Microbiology at the American University of Beirut, a WHO collaborating centre.

Epidemiology of cholera

Cholera is an acute enteric infection caused by ingesting the bacteria Vibrio cholerae present in contaminated water or food. Cholera transmission is closely linked to inadequate access to clean water and poor sanitation facilities or can be linked to the consumption of contaminated food items.  V. cholerae can spread rapidly, depending on the frequency of exposure, the exposed population and the setting. Cholera affects both children and adults, and can be fatal if untreated.

The incubation period is between 12 hours and five days after ingestion of contaminated food or water. Due to the short incubation period of cholera, outbreaks can develop rapidly.

Most people infected with V. cholerae do not develop any symptoms, although the bacteria are present in their faeces for 1-10 days after infection and are shed back into the environment, potentially infecting other people. Among people who develop symptoms, the majority have mild or moderate symptoms, while a minority develop acute watery diarrhoea with severe dehydration, which, if left untreated, can lead to death within hours.

Cholera is an easily treatable disease. Most people can be treated successfully through prompt administration of oral rehydration solution (ORS).

The consequences of a humanitarian crisis – such as disruption of water and sanitation systems, or the displacement of populations to overcrowded camps with inadequate access to clean water and sanitation – can increase the risk of cholera transmission, should the bacteria be present or introduced.

A multi-sectoral approach including a combination of surveillance, water, sanitation and hygiene, social mobilization, treatment, and oral cholera vaccines is essential to control cholera outbreaks and to reduce deaths.

The Ministry of Public Health has established a coordination mechanism with multi-sector partners including the Ministry of Energy and Water, WHO, UNICEF, and the International Committee of the Red Cross (ICRC).

Response measures implemented, include the following:

1. Intensification of active surveillance and case finding in high-risk camps, informal settlements and hotspot areas, including water quality monitoring (free residual chlorine).
2. Training of trainers for the central and peripheral teams of the surveillance unit was held on 10 and 11 October, and will be followed by training of registered local physicians, hospitals, medical centers and public health centers (PHCs) at central and peripheral levels from 19 to 25 October.
3. Updating of surveillance protocols.
4. Designation of nine referral governmental hospitals to act as cholera treatment centers.
5. Development of a cholera preparedness and response plan, in collaboration with WHO and UNICEF and in agreement with all healthcare partners, that includes the following, but not limited to:

• Improving capacity for early detection and ensuring proper linkages with WASH response through the support of integrated multisectoral field mission in the Akkar region.
• Circulars have been issued to hospitals, health centres and health workers regarding the necessity of informing MoPH of any suspected case.
• Distribution of 1000 Bioline rapid diagnostic tests.
• Initial stock of medicines required to treat 400 cases was secured.
• MoPH is exploring a potential request to the International Coordinating Group (ICG) on Vaccine Provision for oral cholera vaccine (OCV) doses to cover 400 000 refugees and hosting communities including potential vaccination for prisons.
• The functionality of water testing laboratories is being assessed in eight hospital laboratories as a first stage to allow for quick, decentralized case identification in various Lebanese regions.
• A crisis cell was formed to coordinate the provision of clean water, water quality monitoring, and access to adequate sanitation, targeting vulnerable groups living in informal settlements.
• The associations of doctors and nurses and the Lebanese Society of Bacterial Diseases were contacted to develop training courses for healthcare workers on case management and methods of infection prevention and control, especially within health institutions.
• Collaboration with relevant ministries, especially energy and water, interior, municipalities, and the environment, to provide safe water and sanitation.

Lebanon’s health system has been hard-hit by a three-year financial crisis and an explosion at the port of Beirut in August 2020 that destroyed essential medical infrastructure in the capital. In this context, responding to a cholera outbreak may overwhelm the already fragile health system in the country.

According to The United Nations High Commissioner for Refugees (UNHCR), Lebanon hosts the largest number of refugees in the world per capita and square kilometre, with 1.5 million Syrian refugees and about 13 715 refugees of other nationalities. Additionally, there is a large population of Palestinian refugees that are particularly exposed due to unsafe WASH services in various camps (Beqaa, Trablos, Beirut, Saida, Sour), possibly with limited medical services provided.

Due to porous borders allowing free movement between Lebanon and neighbouring countries, the exportation of cholera cases is highly likely.

The current cholera outbreak in Lebanon was reported six weeks after a cholera outbreak was declared in neighbouring Syria. On 15 September 2022, WHO assessed the risk of the cholera outbreak in Syria and predicted that due to shortages of drinking water and a fragile and limited health system in Lebanon, there was a risk of a cholera outbreak should the disease be introduced into the country.

Power cuts, water shortages, and inflation have strained the already fragile health system in Lebanon. Poverty has also worsened for many Lebanese, with many families frequently rationing water, unable to afford private water tanks for consumption and domestic use.

Since the last cholera outbreak in Lebanon occurred in 1993, there is a need to update cholera surveillance and case management guidelines and re-train healthcare workers.

WHO recommends improving access to proper and timely case management of cholera cases, improving infection, prevention, and control in healthcare facilities, improving access to safe drinking water and sanitation infrastructure, as well as, improving hygiene practices and food safety in affected communities as the most effective means of controlling cholera.

Oral cholera vaccine should be used in conjunction with improvements in water and sanitation to control cholera outbreaks and for prevention in targeted areas known to be at high risk for cholera. Key public health communication messages should be provided to the population.

Surveillance for early case detection, confirmation and response in other provinces and regions of Lebanon should be reinforced especially at the district level while expanding community-based surveillance.

WHO does not recommend any restrictions on international travel or trade to or from Lebanon based on the currently available information.

• WHO factsheet on cholera
• UNCHR Lebanon
• Global Task Force on Cholera Control
• WHO Cholera, Health Topics
• Cholera vaccine stockpiles
• WHO EMRO, Cholera

Citable reference: World Health Organization (19 October 2022). Disease Outbreak News; Cholera – Lebanon. Available at: https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON416