Cholera spike amidst a deteriorating humanitarian crisis in Afghanistan: a correspondence

According to the World Health Organization (WHO), cholera is a severe diarrheal infection caused by the bacterium Vibrio cholera and is a global health problem that has the potential to cause death within hours if left untreated1. The 2 serogroups that caused the most epidemic cholera were O1 and O1391. These organisms grow efficiently in warm water having low salinity and more organic nutrients in the active or nonculturable form2. The global burden of cholera is very high, with mortality and morbidity rates ranging from 20% to 50%, and it is the second highest cause of death among children under the age of five worldwide3. In endemic countries, researchers estimate that nearly 1.3 billion individuals are at risk of cholera. In 2021 and 2022, cholera outbreaks were reported in several African and Asian countries, including Afghanistan, Bangladesh, Ethiopia, Nigeria, and the Democratic Republic of the Congo. Since the last update on August 24, 2022, nearly 39,857 suspected cholera cases and 114 deaths have been reported worldwide4. Afghanistan has the highest cholera burden in Asia. According to the data, the most affected provinces are Kabul, Helman, Jawzjan, Kandahar, Baghlan, and Nangarhar. The most recent update was on August 24, 2022, when 31,441 suspected cholera cases and 18 deaths were reported, while as of September 12, 2022, a total of 150,278 suspicious cases and 55 deaths have been reported4. Poor sanitation, a lack of clean water, lack of awareness, overpopulation, inadequate health facilities, poverty, floods, and earthquakes are thought to be major challenges to the rising number of cholera outbreaks5,6. Cholera broke out in over 26 countries as of November 2022, as per WHO it is the highest number on record7. The complete eradication of cholera has been difficult due to constant new emerging resistant strains, lower immunity, lack of water sanitization and hygiene (WASH) infrastructure, water scarcity, poor economy, lack of awareness, and effects of climate change8. In Afghanistan, the cholera outbreak resulted in 18,000 cases and 12 deaths in the Jawzjan province in mid-June of 20229. The major contributors to the spike of cholera cases in Afghanistan have been the lack of surveillance and negligence. The prevention of cholera has become a challenge too as this virulent disease transmits via the fecal-oral route, so to avoid contamination Afghanistan must ensure that proper WASH is regulated in the country. Many areas have been reported to have poor quality water as water infrastructure has been neglected due to the country’s history of decade-long wars10. This leads to a surge in water contamination with infectious microbes, toxins, fecal waste, and microplastics, and consequently leads to waterborne and diarrheal diseases11. The vaccine for cholera has been highly demanded due to the surge in recent outbreaks resulting in a shortage of vaccines7. The treatment of cholera can be done easily, yet people are not aware of it according to WHO8. In Afghanistan, many people have died due to delays in providing any oral rehydration fluids or intravenous fluids in cases of severe dehydration. Cholera has also prevailed due to climate change, as the organism V. cholerae favors higher temperatures and specific pH/salinity in flooded regions to actively grow. Deforestation and drought have also been seen to induce cholera, as observed in a study on Africa, the main risk factor contributing to drought-related cholera outbreaks was 30% WASH risks12. This makes control and management of cholera further difficult in Afghanistan as both disasters, floods, and droughts, affected the country. Lastly, COVID-19 has indirect and direct roles in contributing to cholera in Afghanistan. COVID-19 has burdened healthcare facilities to the extent of extreme demands and a very insufficient supply of management. Afghanistan also faced a humanitarian crisis affecting the country’s well-being, leaving it dependent on financial aid, global support for control and management, and intense awareness for better overall health stability. To combat the current situation of cholera in Afghanistan, the provincial health directorate opened a 50-bedded hospital to treat cholera patients in the Kandahar, Helmand, and Zabul provinces of Afghanistan13. The WHO provided health care facilities with equipment including cholera kits to help Afghanistan deal with the cholera outbreak in the aftermath of a flood. Moreover, the WHO also conducted mass casualty management training in Paktika and Paktiya provinces for health care workers in triage, and pre and post health care facilities for making them fully prepared to deal with these situations14. The concerned authorities should respond to this situation promptly. Disease surveillance should be strengthened, and effective measures should be taken to rapidly detect and respond to the outbreak. Since the disease outbreak is due to unhygienic water and sanitation issues, it necessitates that proper hygiene practices, proper sanitation, and the availability of clean drinking water can prevent the spread of cholera15. Rapid access to treatment should be made possible. Oral rehydration should be available in communities as well as healthcare facilities to prevent massive casualties due to dehydration among cholera patients. According to WHO, it is advised that oral cholera vaccine should be available in areas undergoing cholera outbreaks, endemics, or major humanitarian crises. The international communities, UNICEF, and WHO should therefore help in providing treatment kits and cholera vaccines to highly vulnerable areas in Afghanistan. Apart from that, awareness campaigns should also be conducted among the general population to make them aware of the signs, and symptoms of cholera disease and encourage them to seek prompt healthcare if they develop those symptoms5. By adopting preventive strategies as described by WHO, there is a 90% chance of reducing the outbreak of cholera. These include enhancing the disease surveillance by epidemiologic and laboratory evidence, mapping the high-risk areas, improving the access to the adequate and timely provision of cholera treatment, and enhancing cross-border surveillance which can prevent widespread cholera epidemic in Afghanistan16. Ethical approval None. Consent for publication All authors agreed to the publication of this manuscript. Sources of funding None. Author contributions All authors contributed equally. Conflict of interest disclosures The authors declare that they have no financial conflict of interest with regard to the content of this report. Research registration unique identifying number (UIN) None. Guarantor None.