Analysis: Sharp Increase in Cholera Cases Fuels Fears of Disease Spread as Conflict Intensifies

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This content was originally published on RiskMonitor by our Intelligence and Analysis Services Team on 28/03/2019. Find out more about RiskMonitor now.


  • Medecins sans Frontieres (MSF) announce that cholera cases are once again increasing across Yemen.
  • Data shows a significant increase in cases in the governorates of Amran, Hajjah, Ibb and Taiz.
  • The intensification of conflict and failure to implement the Stockholm Agreement have increased the humanitarian crisis.
  • The disease is likely to spread in the immediate term, due to the upcoming rainy season and the deteriorating medical conditions.


Medecins sans Frontieres (MSF) released data on Tuesday, 26 March, revealing that the organisation has been treating an exponential rise in the number of cholera cases across four Yemeni governorates since the beginning of 2019: Amran, Hajjah, Ibb and Taiz.

Since the start of the year these governorates have witnessed conflict escalation between the Saudi-led coalition and Houthi forces as well as other national stakeholders. The latest outbreak of cholera is the result of the worsening conditions within these warzones, and highlights the challenge of improving disease detection, prevention and treatment amid the continuing instability.

Between 1 January and 26 March 2019, MSF admitted 7,938 suspected cholera cases to their health facilities in Amran, Hajjah, Ibb and Taiz governorates, with 50 percent of these cases coming from Ibb. This represents a large increase in the rate of new cases from 140 to 2,000 per week, and has fuelled fears of another large scale outbreak, several of which have plagued Yemen since September 2016.

In this three-month period, UNICEF also reported that 109,000 cases have been recorded nationwide, leading to 190 deaths, the majority of victims being infants under five-years-old.

The geographic distribution of the four aforementioned governorates demonstrates the nationwide threat. Ibb and Taiz are located in the south west of the country, and have witnessed a fierce escalation in fighting between multiple factions in recent weeks. Taiz’s location and isolation on the southern frontline has seen the major supply routes cut off, and the intense conflict has put a massive strain on public and health services.

Amran and Hajjah are located in the north of Yemen, deep within Houthi territory, and these two governorates have also witnessed a sharp escalation in fighting since January, as new pockets of conflict have opened up between local tribal groups and the Houthis, prompting further coalition airstrikes.

The deteriorating conditions on the ground are directly linked to the humanitarian crisis in Yemen, and they are both likely to continue in the immediate term whilst the political process remains stalled.

Root Causes

Cholera is an acute diarrhoeal disease caused by the ingestion of food or water that is contaminated with the bacterium Vibrio cholera. Although symptoms are not immediately apparent in sufferers, it can kill within hours or days if left untreated.

The World Health organisation (WHO) states that 80 percent of cases of cholera can be successfully treated with oral rehydration solution (ORS), whilst more severe cases can be treated with intravenous fluids and antibiotics.

The key to prevention is the provision of safe water and sanitation, alongside the use of integrated disease surveillance systems to pick up symptoms early. It is evident that Yemen lacks the capacity to provide the necessary early detection measures, and also lacks the multi-sectoral framework needed to deal with any outbreak.

The cholera epidemic in Yemen can be broadly divided into three phases: the first wave (Sept 28, 2016, to April 23, 2017), the increasing phase of the second wave (April 24, 2017, to July 2, 2017), and the decreasing phase of the second wave (July 3, 2017, to March 12, 2018). The most recent decreasing phase which took place before the current re-emergence of the disease was attributed to improved access to medical supplies and sanitary conditions.

However, the recent intensification of conflict, access restrictions and bureaucratic hurdles have seemingly reversed these gains, The upcoming rainy season, which runs from mid-April to mid-August, heightens the risk of the disease spreading significantly as agricultural land and water supplies become contaminated.

On 3 January 2019, researchers at the Wellcome Sanger Institute and Institut Pasteur concluded that the strain of cholera which caused the worst recorded epidemic in history originated from eastern Africa, and was brought to Yemen by migrants, after discovering the same strains of the disease had affected both regions.

Migrants from eastern Africa and other areas continue to use Yemen as a transit country, and this highlights the external threats and pressures the country continues to face.


The outlook in the medium term remains negative. The potential failure of the Stockholm Agreement, and the inability to implement any confidence-building measures in the key port of Hodeida, has meant that the proposed humanitarian corridors and supply routes which act as a lifeline to nearly 80 percent of Yemenis have remained closed, preventing foodstuffs and medical supplies from reaching the population.

The ongoing ceasefire violations and creation of new pockets of conflict decrease the likelihood of the humanitarian crisis easing. The implementation of the Stockholm Agreement remains unlikely in the short term, but it remains key to any humanitarian solution in the medium term.

The World Health Organisation (WHO) publicised a global roadmap to 2030, whereby it hopes to reduce cholera deaths by 90 percent and eliminate the disease in as many as 20 countries. MSF, the WHO and UNICEF have all stated their intent to scale up their response in Yemen so that the risk and spread of the disease is confronted as early as possible.

Humanitarian assistance, and water and sanitation activities must improve, and basic lifesaving networks and treatments are needed to treat the most vulnerable and affected populations. However, such measures remain a huge challenge and unlikely to be implemented in the immediate term, and any long term outcome is linked to the level of conflict on the ground and success of the political process.

This content was originally published on RiskMonitor by our Intelligence and Analysis Services Team on 06/02/2019. Find out more about RiskMonitor now.