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Strengthening dengue control in Pakistan
Commentary
Maheen Saleem1, Ayesha Sheikh1, Hina Nawaz1 and Gati Ara2
1Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan. 2Department of Community Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan. (Correspondence to Gati Ara:
Keywords: dengue, vector-borne diseases, vector control, integrated vector management, Pakistan
Citation: Saleem M, Sheikh A, Nawaz H, Ara G. Strengthening dengue control in Pakistan. East Mediterr Health J. 2023;29(12):xxx–xxx. https://doi.org/10.26719/emhj.23.099
Received: 14/10/22; Accepted: 25/05/23
Copyright: © Authors; Licensee: World Health Organization. EMHJ is an open access journal. All papers published in EMHJ are available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo ).
Introduction
Climatic diversity is seriously impacting human health. Changes in climate, such as changes in rainfall patterns, flooding, catastrophic storms, severe fires, extreme precipitations, and intense droughts are exacerbating human pathogenic diseases and making the distribution of microbial species to surge drastically (1). Deficient water disposal facilities and poor flood control have increased the risks of water-borne diseases.
The dengue virus poses a serious threat globally, especially across the tropical countries. Dengue is caused by positive, single-stranded RNA viruses of the Flaviviridae family, and it is the most rapidly spreading arboviral disease. The virus is primarily transmitted by Aedes Aegypti mosquitoes and should be suspected when 2 of the following symptoms are accompanied by a high-grade fever of 40°C for 2–7 days: severe headache, retro-orbital pain, myalgia and arthralgia, vomiting, nausea, lymphadenopathy, or rash (2). Clinical presentation of infected patients is extensive and may differ from asymptomatic infection to alarming complications such as dengue haemorrhagic fever, dengue shock syndrome, marked bleeding, coagulopathy, encephalitis, and intracranial bleed (2).
Epidemiology of dengue worldwide and in Pakistan
Dengue primarily prevails in tropical and subtropical regions, in both urban and suburban areas. The infection is now endemic in around 129 countries worldwide and is currently the fastest growing mosquito-borne viral disease (2). The WHO estimates that Asia represents around 70% of the global burden of dengue, posing significant health and economic hazards to the South-East Asia Region (2).
In Pakistan, dengue fever is a year-round, nationwide hazard with most cases being reported between September and December. The National Institute of Health, Islamabad, reported 22 938 cases of dengue fever in 2017, around 3200 in 2018, 24 547 cases in 2019, 3442 cases in 2020, and a total of 48 906 cases with 183 deaths countrywide in 2021 (3). In the last 15 years, specific regions of Pakistan have seen 10 times increase in the reported cases of dengue (4).
Favourable breeding conditions for the disease vector
Dengue cases generally increase during the monsoon season, as the collective effects of rainfall, humidity and elevated temperatures provide the most convenient environment for mosquito breeding (4). Mosquitoes typically breed in water stored in containers like cement and plastic tanks, used tyres, flower pots, as well as stagnant water bodies and construction sites in neglected urban areas. Indoor water holding domestic containers, lavatory cisterns, laundry tanks, drums, and pet dishes are also breeding grounds.
Heightened dengue cases following the devastating flood
In 2022, Pakistan experienced the most severe flooding in recent years, triggered by the unusual torrential monsoon rains. The floods swept away entire villages and destroyed rural communities, displacing around 33 million people and exposing them to increased risks of drowning, malnutrition and water-borne diseases, especially dengue (5). Historic data reveal that increases in dengue cases significantly correlate with the amount of rainfall (6). Thus, the recent heavy flooding, followed by an enormous spike in dengue cases, has caused serious calamity in the country.
In the wake of these calamitous floods, reported dengue cases continued to increase throughout the country, including in Karachi where the public blames the government for the city’s poor sanitary conditions and for not carrying out timely fumigation campaigns (7). As of 15 September 2022, an estimated 3830 dengue cases had been reported in Sindh and at least 9 lives had succumbed to the virus (5).
Data from the tertiary care hospitals in Pakistan are often asserted by the health department, however, it is argued that the government’s system is inadequate to collect data across the provinces (8). A total of 350 new cases of dengue were reported across Northwest Khyber Pakhtunkhwa on 19 September 2022. There were 188 cases in Punjab Province and 96 in Islamabad within 24 hours (9). According to Pakistan’s climate minister, thousands of people were taking refuge in camps throughout the country with catastrophic healthcare consequences.
In addition to dengue, suspected malaria cases increased from 2.6 million in 2021 to 3.4 million in 2022. A sudden surge was observed following the devastating floods in Sindh and Baluchistan provinces in June 2022 (10). Confirmed malaria cases in Sindh Province reached 69 123 in August 2022, compared to 19 826 cases reported in August 2021. In Balochistan Province, 41 368 confirmed cases were reported in August 2022, compared to 22 032 cases in August 2021. These 2 provinces were severely affected by the floods and together accounted for 78% of all reported malaria cases in Pakistan in 2022. Reports from high-burden districts show that further 210 715 cases of malaria were reported in September 2022, compared to 178 657 cases reported in the same districts in August 2022 (10).
Suggested measures for tackling vector-borne diseases in Pakistan
Vector-borne diseases (VBDs) such as malaria, dengue and cutaneous leishmaniasis have serious consequences for Pakistan and the main method for tackling them and neglected tropical diseases (NTDs) is proper vector management. The 2022 historical malaria outbreaks in Pakistan indicate a need for comprehensive approach to integrated VBDs control in Pakistan with adequate resources for preparedness. Although emergency response is essential when there is an outbreak, it is not enough to contain dengue and other VBD outbreaks in the long-term. Isolated control programmes result in overlapping of measures and wastage of resources. A viable dengue prevention and control programme integrated with other vector control programmes is needed for greater efficiency and sustainability of control measures.
Integrated vector management (IVM) is a cost-effective, rational approach to sustainable vector control and it is promoted by WHO to curb vector population, destroy plausible breeding sites and minimize exposure to disease vectors (11). With adequate sanitation, improved drainage systems and environmental management, and mosquito-proofing of water storage repositories, there will be a reduction in the need for chemical control measures. Vector control measures should be implemented in all communities and especially in urban centres because of the dense population.
Personal prophylaxis includes the application of mosquito repellent lotions, use of mosquito coils, wearing protective clothing to minimise exposure, use of indoor residual sprays, and since Aedes mosquitoes are bite during the day with peak activity at dawn and dusk, it is recommended to stay indoors and use window screens or mosquito nets (2). However, with the low income and low literacy levels in the country personal prophylaxis may not be cost-effective and practical for the masses. Key public health messages on how to reduce the risk of dengue transmission among the population through personal protective measures, which depend on individual compliance, must be provided. Community-based health workers and the media should be sensitized to promote messages on reducing the risk of dengue transmission throughout the country.
In addition to IVM, vector and human case surveillance should be boosted in all affected areas and across the country. Many Pakistanis seek health care services from private practitioners who should be properly trained on dengue management, referral and notification. There is need for a robust and sustainable digital notification system that connects all health care providers in the country.
The Global Vector Control Response 2017–2030 provides a new approach to fortifying vector control worldwide through augmented capacity, enhanced surveillance, improved coordination, and integrated action across sectors and diseases. It calls on Member States to develop or adapt national vector control strategies and operational plans that align with this strategy (12).
Multisectoral collaborations for the control of vector-borne diseases is required as well as political will with adequate and sustained resource allocation for reinforced monitoring, increased technical capacity, improved infrastructure, and community mobilization.
Improved infrastructure and better drainage systems are needed, together with affordable diagnostic testing, training of health care providers for standard management of cases in out and in-patient settings, and easier access to platelets for needy patients. All these should be complemented with advocacy for better control of dengue in Pakistan.
References
1. Mora C, McKenzie T, Gaw IM, Dean JM, von Hammerstein H, Knudson TA, et al. Over half of known human pathogenic diseases can be aggravated by climate change. Nat Clim Chang 2022;12(9):869–875. https://doi.org/10.1038/s41558-022-01426-1.
2. World Health Organization. Dengue and severe dengue. Geneva: World Health Organization, 2022. https://www.who.int/news-room/fact-sheets/detail/dengue-and-severe-dengue.
3. International Federation of Red Cross and Red Crescent Societies. Operation Update Report Pakistan: Dengue Response. Geneva: IFRC, 2022. https://reliefweb.int/report/pakistan/pakistan-dengue-response-final-report-dref-operation-ndeg-mdrpk022.
4. Shabbir W, Pilz J, Naeem A. A spatial-temporal study for the spread of dengue depending on climate factors in Pakistan (2006–2017). BMC Public Health 2020;20(1):1–10. https://doi.org/10.1186/s12889-020-08846-8.
5. Pakistan floods: Dengue cases soaring after record monsoon. BBC News, 14 Sep. 2022. https://www.bbc.com/news/world-asia-62907449.
6. Tahir MJ, Siddiqi AR, Ullah I, Ahmed A, Dujaili J, Saqlain M. Devastating urban flooding and dengue outbreak during the COVID-19 pandemic in Pakistan. Medical Journal of the Islamic Republic of Iran 2020;34:169. 10.47176/mjiri.34.169.
7. Siddiqui T. Dengue cases on the rise in Karachi as fumigation yet to yield required results. DAWN.COM. 2022. https://www.dawn.com/news/1711442/dengue-cases-on-the-rise-in-karachi-as-fumigation-yet-to-yield-required-results.
8. Ilyas F. Experts question official data after Sindh govt revises dengue death toll to 27. DAWN.COM. 2022. https://www.dawn.com/news/1711131
9. Agency X. Dengue surge rages in Pakistan. The Manila Times, 1 September 2022. https://www.manilatimes.net/2022/09/19/news/world/dengue-surge-rages-in-pakistan/1858946.
10. World Health Organization. Malaria – Pakistan. Geneva: World Health Organization, 2022. https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON413.
11. World Health Organization. Dengue fever – Pakistan. Geneva: World Health Organization, 2021. https://www.who.int/emergencies/disease-outbreak-news/item/dengue-fever-pakistan#:~:text=In%20Islamabad%2C%20multi-sectoral%20coordinated%20activities%20including%20vector%20surveillance%2C .
12. World Health Organization. Integrating vector management. Geneva: World Health Organization. https://www.who.int/westernpacific/activities/integrating-vector-management.
Oman eliminates mother-to-child transmission of HIV and syphilis
Ali Elgalib1, Richard Lau1, Zeyana Al-Habsi1, Samir Shah1, Bader Al-Rawahi1 and Seif Al-Abri1
1Directorate General for Disease Surveillance and Control, Muscat, Oman. (Correspondence to Dr Ali Elgalib:
Keywords: HIV/AIDS, mother-to-child transmission, syphilis, Oman
Citation: Elgalib A, Lau R, Al-Habsi Z, Shah S, Al-Rawahi B, Al-Abri S. Oman eliminates mother-to-child transmission of HIV and syphilis. East Mediterr Health J. 2023;30(01):xxx–xxx. https://doi.org/10.26719/emhj.23.100
Received: 16/01/23; Accepted: 25/05/23
Copyright: © Authors; Licensee: World Health Organization. EMHJ is an open access journal. All papers published in EMHJ are available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo ).
On 28 September 2022, WHO certified that Oman had eliminated mother-to-child transmission (MTCT) of HIV and syphilis, becoming the first country in the WHO Eastern Mediterranean Region (EMR) and the sixteenth country in the world to achieve this (1). Oman’s achievement serves as an example of how strong political leadership, long-term planning and investment in comprehensive maternal and child health services can contribute to programme success despite the socio-cultural sensitivities surrounding sexually transmitted infections. Other countries with similar health system and social context can now aspire to replicate Oman’s experience.
Oman has a low HIV prevalence (2), and the first case was reported in 1984. The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimated that there were 2500 people living with HIV in Oman in 2021 (3). The journey towards EMTCT of HIV and syphilis started in 1987 with the launch of the National AIDS Control Programme, which was subsequently incorporated into the Third Health Development Plan (1986–1990) and continued as one of the priority programmes in subsequent years. Sexually transmitted infections (STIs) was included in the programme during the fifth national 5-year Health Development Plan (1996–2000) in January 1997, when the WHO syndromic case management of sexually transmitted infections was adopted.
Oman has an extensive network of laboratories in the public (n = 260) and private (n = 212) sectors, which provide antenatal screening and other diagnostic services. Both sectors are ultimately regulated by the Ministry of Health (MOH) and are mandated to adhere to the national accreditation standards issued and enforced by the Directorate General for Quality Assurance Centre at MOH.
The programme to improve maternal and child health services was launched nationally in August 1987, same year with the HIV/AIDS programme, to provide comprehensive care to mothers and their babies, promote their health, reduce morbidity and mortality, and promote hospital deliveries. To achieve its objectives, the programme targeted improvements in antenatal care (ANC) coverage and good prenatal care by promoting early booking during the first trimester of pregnancy. ANC coverage increased to more than 99% in 2019, with ANC booking during the first trimester reaching 79.5% (4). About 73.9% of mothers delivered in 2019 had visited ANC clinics 4 or more times during their pregnancy, and 62% were assessed medically at least once during the last 4 weeks of their pregnancy (4).
Achieving elimination of MTCT (EMTCT) of HIV and syphilis in Oman builds on a solid foundation of primary health care services that were established 4 decades earlier. Screening for syphilis (1990) and HIV (2009) were incorporated at ANC booking (5,6), with consistently good coverage over the past decade (4). And since 2018, HIV and syphilis testing coverage during ANC has been > 95% (4). The hospital-based specialised multidisciplinary teams care for pregnant women who test positive for HIV or syphilis and their exposed infants. The rate of MTCT of HIV has been < 2% since 2017, and the number of vertically infected HIV-positive children and children with congenital syphilis cases are below 50 per 100,000 livebirths (1). Indeed, the 2019 data submitted for WHO validation showed that HIV and syphilis testing coverage during ANC was 96% (89 141/92 897) and 99.9% (89 167/89 244), respectively. The HIV MTCT rate was 0% (0/39) and the rate of congenital syphilis per 100,000 livebirths was 1.18 (1/84 452) (1).
Training is an integral part of any successful healthcare programme and it should focus on developing the workforce to support programme priorities, implementation and outcomes. Since 2009, the MOH has conducted numerous capacity-building activities for ANC staff and HIV/STI service providers, to ensure high-quality EMTCT services. In January 2016, the Department of Communicable Diseases (DCD) introduced a package of interventions, including capacity building for HIV service providers and the development of clinical care pathways, to improve the quality of HIV services in the country (7,8). And despite the challenges of rolling out a national COVID-19 vaccination programme in 2021, DCD organised regional training workshops to support the use of national STI treatment guidelines, including the management of maternal and congenital syphilis.
Having achieved the validation for EMTCT of HIV and syphilis, Oman is now preparing for the validation of EMTCT of hepatitis B virus (HBV). Of note, the global community recently revitalised their commitment to triple EMTCT. Indeed, the global health sector strategies on HIV, viral hepatitis and sexually transmitted infections for the period 2022–2030 sets ambitious targets of 50 and 100 by 2025 and 2030, respectively, for the number of countries validated for EMTCT of HIV, HBV or syphilis (9). The WHO-defined core EMTCT services are: primary prevention of HIV, syphilis and HBV among women of childbearing age; ANC for HIV, syphilis and HBV; prompt linkage to care for pregnant women who test positive; safe delivery; treatment and follow-up of exposed infants; and optimal infant feeding (10). All these services are provided in Oman except ANC screening for HBV, due to high vaccination coverage; however, the MOH is planning to introduce ANC screening for HBV because it is a key requirement for the validation of EMTCT of HBV (10).
One of the most important concerns of any public health programme is its sustainability. The success of Oman in achieving EMTCT of HIV and syphilis should be seen more as the culmination of 3 decades of progress in implementing public health policies than as a targeted approach with a narrow objective. Systems and processes for collecting and monitoring epidemiological data and clinical case management are based on nationally agreed guidelines and protocols (11-13). Engagement with civil society and human rights organisations in Oman has contributed not only critical insight into developing key EMTCT policies and strategies but also to providing the necessary stakeholder support to implement and sustain these objectives. Continued strong political and public health leadership as well as multi-sectoral coordination are needed to ensure universal access to high-quality and decentralised EMTCT services as well as sustainability of the validation status.
References
1. Ministry of Health, Sultanate of Oman. Validation of elimination of mother-to-child transmission of HIV and syphilis, Oman 2018–2019 report. Muscat: Sultanate of Oman, 2022.
2. UNAIDS. UNAIDS Data 2020. Geneva: UNAIDS, 2020. https://www.unaids.org/sites/default/files/media_asset/2020_aids-data-book_en.pdf.
3. UNAIDS. UNAIDS Country Factsheets. Geneva: UNAIDS, 2022. https://www.unaids.org/en/regionscountries/countries/oman.
4. Ministry of Health, Sultanate of Oman. Annual health report 2019. Muscat: Sultanate of Oman, 2019. https://www.moh.gov.om/en/web/statistics/annual-reports.
5. Ministry of Health, Sultanate of Oman. HIV testing in pregnancy guidelines. Muscat: Sultanate of Oman, 2012. https://www.moh.gov.om/documents/272928/4017900/HIV+in+Pregnancy.pdf/88d30eb6-234a-d0c9-a1f1-531511ce41e4.
6. Ministry of Health, Sultanate of Oman. Pregnancy and childbirth management guidelines. Muscat: Sultanate of Oman, 2016. https://www.moh.gov.om/documents/272928/4017900/ANC+Level+1+2nd+edition.pdf/ 2faec81b-46b3-7071-5d5f-3a4a676089aa.
7. Elgalib A, Shah S, Al-Habsi Z, Al-Fouri M, Lau R, Al-Kindi H, et al. The cascade of HIV care in Oman, 2015-2018: A population-based study from the Middle East. Int J Infect Dis. 2020;90:28-34. 10.1016/j.ijid.2019.09.017.
8. Elgalib A, Al-Hinai F, Al-Abri J, Shah S, Al-Habsi Z, Al-Fouri M et al. Elimination of mother-to-child transmission of HIV in Oman: a success story from the Middle East. East Mediterr Health J. 2021; 27(4):381–389. https://doi.org/10.26719/2021.27.4.381.
9. World Health Organization. Global health sector strategies on, respectively, HIV, viral hepatitis and sexually transmitted infections for the period 2022-2030. Geneva: World Health Organization, 2022. https://cdn.who.int/media/docs/default-source/hq-hiv-hepatitis-and-stis-library/full-final-who-ghss-hiv-vh-sti_1-june2022.pdf?sfvrsn=7c074b36_13.
10. World Health Organization. Global guidance on criteria and processes for validation: elimination of mother-to-child transmission of HIV, syphilis and hepatitis B virus. Geneva: WHO, 2022. https://www.who.int/publications/i/item/9789240039360.
11. Ministry of Health, Sultanate of Oman. HIV in primary health care manual, 1st Edition. Muscat: Sultanate of Oman, 2019 https://www.moh.gov.om/en/home.
12. Ministry of Health, Sultanate of Oman. HIV Management in Oman – A guide for health care workers. Muscat: Sultanate of Oman, 2015 https://www.moh.gov.om/documents/236878/0/A+guide+for+health+care+workers/2ef88339-1211-43b3-ad4a-8b326bc3c9a3.
13. Ministry of Health, Sultanate of Oman. Management of sexually transmitted infections. A quick reference guide for Primary Care. Muscat: Sultanate of Oman, 2019.
Resurgence of cholera in Lebanon
Commentary
Zeina Bayram1, Abdul Bizri2 and Umayya Musharrafieh2,3
1American University of Beirut, Beirut, Lebanon. 2Department of Internal Medicine, Division of Infectious Diseases, American University of Beirut Medical Center, Beirut, Lebanon. 3Department of Family Medicine, American University of Beirut Medical Center, Beirut, Lebanon. (Correspondence to Umayya Musharrafieh:
Keywords: cholera, public health, infection prevention, Lebanon
Citation: Bayram Z, Bizri A, Musharrafieh U. Resurgence of cholera in Lebanon. East Mediterr Health J. 2023;29(x):xxx–xxx. DOI: https://doi.org/10.26719/emhj/23.111
Received: 19/12/22, Accepted: 28/04/23
Copyright: © Authors; Licensee: World Health Organization. EMHJ is an open access journal. All papers published in EMHJ are available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).
On 5 October 2022, following a cholera outbreak in Syria on 10 September 2022, there was a resurgence of cholera in Lebanon after nearly 30 years of its absence. The first case was reported in the northern region of Akkar and in a Syrian refugee (1). There was panic when the outbreak in Syria was announced, mainly because of the porous borders between Syria and Lebanon and the mobility of the Syrian refugees between the 2 countries. Despite this, no measures were adopted to prevent cross-border transmission. Consequently, the disease spread rapidly between the 2 countries in a very short time, placing Lebanon on the brink of a new catastrophe (2).
The number of cholera cases in Lebanon is increased at an exponential rate. As of 1 June, 2023, a total of 671 confirmed and 7993 suspected cases had been reported. The confirmed cases were of Vibrio cholerae O1 El-Tor Ogawa, confirmed by culture (3). One death was reported in Lebanon on 12 October 2022, 1 week after the start of the outbreak. By 14 March, the number of deaths had increased to 23. Surveillance data form the Lebanese Ministry of Public Health (LMoPH) showed that the number of suspected and confirmed cases was highest among children of aged 0–4 years (31%), followed by children of aged 5–14 years (23%), and adults aged 25–44 (18%). Eighteen percent of the confirmed cases required hospital admission and 47% were males while 53% were females.
Vibrio cholerae was found in potable water sources, irrigation channels and sewage. The first infection was reported in Minieh-Dannieh District, from where it spread to nearby northern regions with a significant increase in the number of cases in nearby Akkar and Baalbeck districts. The infection spread to other locations in Beirut and Mount Lebanon (1). Few laboratories were designated and approved by LMoPH for the diagnosis and detection of cases and 9 referral hospitals were appointed as treatment centres (4). Cholera vaccination campaigns were launched on 12 November 2023, following which case report started to decline in December 2022. However, despite this decrease, the LMoPH said the cholera outbreak was not yet over.
Lebanon is currently experiencing a combination of other crises, including its worst economic depression until date, which has made the country to be labelled a low-middle-income country (5). The healthcare system in Lebanon is struggling with drastic shortages of healthcare professionals and medical utilities. The inflation, along with the power and water cuts, has rendered health institutions severely fragile. The healthcare system is still unsettled and has not recovered from the impact of the COVID-19 pandemic.
Several factors were expected to accelerate transmission and increase the impact of the outbreak. Lebanon hosts the largest number of refugees per capita in the world, mostly Syrian refugees. The Syrian refugees are a mobile population with tendency to move between their country of origin and country of residence. Conflicts and human migration are major contributors to the spread of infectious diseases such as cholera (6). Displacement can cause morbidities, and the rising cholera cases are just a tip of the iceberg.
Cholera is transmitted through contaminated drinking water and food, and the water supply infrastructure in Lebanon is poor. The UNICEF representative in Lebanon had indicated in a statement recently that millions of people in Lebanon are affected by the limited availability of clean and safe water [8] Refugee camps and temporary settlements are typical areas at risk of poor water quality and sanitation and, therefore, linked to high cholera transmission rates. Poor water infrastructure also affects households, schools, hospitals, and healthcare centres, thus aggravating the already existing humanitarian crisis in Lebanon (7).
The recent cholera outbreak is a manifestation of the weak political and healthcare systems in Lebanon. Lebanon has become vulnerable to preventable infectious diseases that the nation had not experienced in the past. Despite the threats to the health system and the health of populations living in Lebanon, no significant action is being taken to remedy the situation, especially considering the high inflation rate, shortage of funds, and the dwindling international aid.
Despite the very short period of exposure, the threat imposed by this outbreak in Lebanon is obvious. If no reasonable improvements are made to the political and financial sectors, solutions to the emerging health challenges seem far-fetched and Lebanon may be edging towards a devastating epidemic.
Funding: None.
Conflict of interest: None declared.
References
1. Health, L.M.o.P. Cholera Surveillance in Lebanon. 2022 March 15, 2023]; Available from: https://www.moph.gov.lb/en/Pages/127/64744/cholera-surveillance-in-lebanon.
2. reliefweb. Cholera Emergency Response in Syria and Lebanon. 2022 October 24, 2022]; Available from: https://reliefweb.int/report/syrian-arab-republic/cholera-emergency-response-syria-and-lebanon.
3. Organization, W.H. The global task force on cholera control. 2010; Available from: https://www.gtfcc.org/about-gtfcc/.
4. reliefweb. Disease Outbreak News: Cholera – Lebanon (19 October 2022). Available from: https://reliefweb.int/report/lebanon/disease-outbreak-news-cholera-lebanon-19-october-2022.
5. BANK, B. After Being an Upper-Middle Income Country for 25 years, Lebanon is now a Lower-Middle Income Country with a GNI Per-Capita of $3,450 in 2021. 2022; Available from: https://blog.blominvestbank.com/44410/wb-after-being-an-upper-middle-income-country-for-25-years-lebanon-is-now-a-lower-middle-income-country-with-a-gni-per-capita-of-3450-in-2021/.
6. Bizri, A.R., et al., COVID-19 pandemic: an insult over injury for Lebanon. Journal of Community Health, 2021. 46(3): p. 487-493.
7. Mari, L., et al. On the role of human mobility in the spread of cholera epidemics: towards an epidemiological movement ecology. Ecohydrology 2012 [cited 5 5]; 531-540]. Available from: https://onlinelibrary.wiley.com/doi/full/10.1002/eco.262.
8. WHO. Water supply systems on the verge of collapse in Lebanon: over 71 per cent of people risk losing access to water. Available from: https://www.unicef.org/press-releases/water-supply-systems-verge-collapse-lebanon-over-71-cent-people-risk-losing-access#:~:text=%E2%80%9CAt%20the%20height%20of%20the,Lebanon%2C%20Yukie%20Mokuo%2C%20said.
