One million doses of an emergency oral cholera vaccine from a global stockpile have been approved for urgent use in Yemen, IRIN has learnt. It is the largest quantity ever deployed at once and is intended to help combat a deadly outbreak sweeping across the war-torn country.
At the latest count, there were 167,000 cases and 1,146 deaths in Yemen, equating to a death every hour by the Vibrio cholerae bacteria, which causes severe dehydration and diarrhoea. In just two months, Yemen's death toll from the outbreak already accounts for 1.2 percent of the global average of estimated annual deaths from cholera.
The speed of the spread of the disease is unprecedented, Doctor Nevio Zagaria, the World Health Organization's representative in Yemen, told IRIN.
The International Coordinating Group, a body established in 2013 to manage to the global stockpile of emergency cholera vaccines, made the decision to deploy the vaccine in Yemen last week, although no official announcement has yet been made.
Zagaria's team submitted the request to the ICG for access to the stockpile, and he said the first doses are expected to arrive on the ground early next month.
We are discussing with health authorities the targeting and planning of the campaign tentatively for the first days of July, he added.
Why the vaccine?
International health officials say the emergency vaccinations are necessary to contain the burgeoning epidemic in Yemen, which, after over two years of war, is suffering an acute lack of infrastructure to deal with diseases like cholera.
As the conflict continues, it continuously erodes the existing basic social services. It has affected the healthcare, water and sanitation systems, which have been damaged or run out of fuel to operate, explained Bismarck Swangin, a UNICEF spokesman based in the capital, Sana'a.
Less than half of Yemen's health facilities remain operational. The rest have been bombed and destroyed, and those hospitals still standing face dire shortages in power, supplies, and staff.
Doctors, nurses, and other healthcare workers in the public sector have not been paid in some nine months because of a schism in the central bank, and Swangin said many other health workers have fled areas they formerly worked in because of the danger. Those still working subsist on day-to-day support from humanitarian organisations.
These conditions have left some places in Yemen without any healthcare facilities or personnel to provide the IV fluids and oral rehydration tablets that quickly save lives.
Enter the vaccine, which is really a temporary solution to combat the disease's spread to uninfected individuals. The vaccine can only be administered to those who do not have cholera. It is a preventive measure, said Swangin.
And although one million doses were approved, challenges remain.
Identifying priority areas for vaccination is usually done through vulnerability mapping, which looks at factors like population density, sanitation systems, etc. to determine where vaccines would be most effective.
In Yemen however, identified hotspots may fall unevenly on various sides of the conflict. Any deemed unfairness in distribution could exacerbate animosities between the warring factions, requiring deft and delicate political manoeuvring in proposing target areas.
An uneasy alliance between Houthi rebels and forces loyal to former President Ali Abdullah Saleh control Sana'a, while President Abd Rabbu Mansour Hadi and his ministers � referred to by the international community as the legitimate government of Yemen � have decamped to the southern city of Aden.
With the country divided, actors on the ground will have to be careful the vaccination campaign - namely who gets the drug and where - does not generate new tensions. Discussions are in progress [about target areas for vaccination], but the needs of the whole of Yemen need to be met," said Zagaria.
How will it be deployed?
Any delays caused by protracted dialogue between the parties will be at the cost of human lives.
The airport in Sana'a has been shuttered to commercial flights by the pro-Hadi, Saudi Arabian-led coalition. Along with seriously diminished capacity at Yemen's ports plus a lengthy UN and Saudi vetting process, this is causing a bottleneck in humanitarian aid.
Nonetheless, the WHO coordinated the delivery of other vaccines as recently as May, using UN chartered flights that are still running (albeit with human rights workers and journalists barred). Zagaria seemed confident in their ability to do so again.
Once the vaccines arrive, the WHO representative said there is already a network and system in place to distribute them immediately on a door-to-door basis in priority areas to everyone above the age of one, and to allay the concerns of those who may be suspicious of the vaccine, or of health workers in general.
An education campaign will also be a key part of the rollout, especially following reports from Aden of people falsely claiming to be from the Ministry of Health and providing cholera vaccination.
In Sana'a, 42-year-old Yaseen al-Aswadi exemplifies the sort of challenges health workers may face. He told IRIN that in recent months health workers had come knocking on his door as part of a polio vaccination campaign. He refused. I don't trust any vaccination whatsoever from the UN and its agencies, he said. Al-Aswadi blamed the UN for an aggression, a war which internationally banned bombs are hitting children and women, youth and elderly." Before the war, he said he had no problem with immunisation, but now " trust [in the UN] has been lost.. the concern [about vaccination] is that they want to kill our kids.
According to UNICEF, there are 16,000 volunteers trained from earlier immunisation campaigns ready to help create public awareness. There are also solar panels and cold boxes still in the country to keep the doses chilled for up to a day in the absence of electricity.
Cholera expert Doctor David Sack, a professor at the Department of International Health at John Hopkins Bloomberg School of Public Health, told IRIN he has confidence in the effectiveness of the oral cholera vaccine in emergency outbreaks, explaining that it provides about 65 percent protection [for individuals], but also a significant amount of 'herd protection'. So in terms of effectiveness, it is actually higher than [65 percent].
Doctor Anna Lopez, an associate professor at the University of Philippines Manila National Institutes of Health who is also an expert in cholera outbreaks and vaccines, agreed. If you achieve high enough vaccine coverage for the community, people who do not get the vaccine also end up protected, she said.
However, she did add that one study suggested at least a 50 percent vaccination rate is needed to confer this herd protection to the majority of a population.
Will it be enough?
This begs the question as to whether one million doses will be enough to contain the outbreak, as eight million people in Yemen are already considered at risk of contracting cholera.
WHO requested up to 3.4 million doses from the ICG, but the size of the global stockpile and rate of production are both limited. Meanwhile, concurrent outbreaks of cholera in Somalia, Malawi, and Mozambique are creating competition for the existing vaccines.
And even if the outbreak is brought under control with the help of the emergency vaccines, in the face of prolonged war, Yemen faces the bleak prospect of being unable to stave off future waves.
At the moment, this is just 'firefighting'. Humanitarian aid cannot replace the needs of 27 million people, said Swangin, referring to both the vaccine and Yemen's larger humanitarian crisis.
Sack, from John Hopkins Bloomberg School of Public Health, put it even more starkly: This is one of the casualties that happens when you have war � things break down. You may not die of a bullet, but you'll die of a disease.