Yemen – Cholera – OCV
Editor’s Note:
   We have been monitoring the cholera outbreak in Yemen [currently the globe’s largest] for some time, with particular focus on the recent decision to allocate 1 million doses of OCV from the global stockpile for deployment in country. It has been unclear what the status of that deployment might be, and what review and decision processes might be underway as the volume of suspected cases and fatalities have continued to mount.
  We provide below a chronological sample of information and characterizations from WHO, other agencies, and the media on the status of the cholera epidemic and the OCV allocated to help address it. 
  We will continue to monitor this, noting the shifting narratives below, the absence of any posted information or announcement about the OCV decisions, and that no mention of the OCV intervention was included in the new WHO DG’s presentation on Yemen to the Security Council [see below].
10 July 2017
UN OCHA – L3 Emergencies Yemen
:: Key messages on cholera (10 July 2017)
Yemen, the world’s largest food security crisis, is now facing the world’s worst cholera outbreak which in the span of two months has spread to the entire country except for one governorate….
[No mention of OCV]
10 July 2017
WHO and partners, including UNICEF, scale up efforts to minimize spread of acute watery diarrhoea/cholera in the Eastern Mediterranean Region
10 July 2017 – With increasing numbers of people in some countries of the World Health Organization’s Eastern Mediterranean Region affected by acute watery diarrhoea and cholera, WHO in the Region is working with partners, including UNICEF, to save lives in areas where outbreaks are active, and reduce the risk of these diseases crossing into unaffected areas and neighbouring countries.
“The situation has reached a critical point. The number of people with acute watery diarrhoea/cholera in countries in the Region in 2017 alone is higher than the number of people affected worldwide in 2016. Infectious diseases know no borders, and can quickly spread if they are not effectively contained. As the numbers of cases grow day by day, it is imperative that we exert all efforts to make sure populations in cholera-endemic countries and neighbouring countries are protected,” said Dr Mahmoud Fikri, WHO Regional Director for the Eastern Mediterranean.
Population movement is increasing the risk of epidemic-prone diseases crossing into unaffected areas. In Somalia, the cholera outbreak has spread to the northern region, which had previously been cholera-free for more than 10 years. In Sudan, cases of acute watery diarrhoea have appeared for the first time in camps hosting internally displaced Sudanese in Darfur. Increasing numbers of people are expected to be affected during the current high season for transmission of waterborne disease due to deteriorating humanitarian conditions and lack of access to safe water and sanitation.  Acute watery diarrhoea/cholera are easily treatable, but can be life-threatening without immediate medical care. National health authorities in affected countries, supported by WHO and partners, are responding to the current outbreaks through disease surveillance for the early detection of cases, improving case management and infection control through the establishment of treatment centres, improving and monitoring water quality, providing medicines and supplies, introducing the oral cholera vaccine, and promoting safe hygiene practices in communities.
WHO and UNICEF co-hosted a sub-regional meeting region from 8 to 9 July 2017 in Beirut, Lebanon, on scaling up preparedness and response to acute watery diarrhoea/cholera in the Region. The meeting was attended by health officials from affected and neighbouring countries, as well as key partners involved in the health response.
A regional roadmap was developed during the meeting focusing on the areas of (a) strengthening coordination at sub-national level; (b) enhancing integrated, multi-sector rapid response teams in affected areas; (c) decentralising and expanding laboratory testing; (d) reinforcing guidelines for case management and infection prevention and control; (e) scaling up water and sanitation activities at household level; and
(f) enhancing risk communications at community level.

In line with the International Health Regulations (IHR 2005), WHO will also work closely with neighbouring countries to reinforce disease surveillance, laboratory and preparedness capacity, including at Points of Entry, to rapidly detect potential cases and ensure that all suspected acute watery diarrhoea/cholera cases are referred to appropriate health facilities.

11 July 2017
Geneva Press Briefing: UNHCR, OCHA, UNICEF, ITU, ILO, IOM, WHO,  TUESDAY, 11 JULY 2017
[Video: 01:09:01]
WHO – Christian Lindmeier [at approx.. 59:00 – 01:09; Editor’s excerpts as no transcript of the press briefing has been posted]
Reporter: Follow up on [OCV] vaccines for Yemen, what is status?
Response: Government still deciding…likelihood that OCV will not be used…OCV will likely be re-routed to other settings where they might be used more effectively…

Reporter: Wait…A number of agencies had been working on this…it was clear from you [WHO] and other agencies that these vaccines were going there…vaccines are staged…what has changed?
Response: Yemen a “complex situation” with regard to cholera…outbreak is at different stages in different districts…it’s a race against the clock…can’t plan a campaign like a normal country…security situation difficult…also, huge volume of vaccines…cold chain issues right to point of use…also now in middle of an outbreak…need to get ahead of the curve…makes no sense now…must get ahead of the situation to make best use of OCV…logistically a huge effort…

Reporter: Follow-up – We are talking about 300,000 cases…many deaths…what might you have done differently…
Response:  Too early to speculate…volatile situation…
11 July 2017
U.N. Suspending Plan for Cholera Vaccination in Yemen
New York Times, July 11, 2017 – By NICK CUMMING-BRUCE and RICK GLADSTONE
United Nations officials said a cholera vaccination campaign no longer made sense in Yemen because the war would make the effort difficult.
GENEVA — The United Nations said on Tuesday that it was suspending plans for a cholera vaccination campaign in Yemen — reversing a decision made a month ago — because the disease’s rampant spread and the ravages of war there would make such an effort ineffective.
Jamie McGoldrick, the United Nations aid coordinator in Yemen, said plans for preventive vaccination were being “set aside.” He attributed the change to obstacles in delivering vaccines in the middle of a conflict that has crippled the country’s health system and hampered access to some areas threatened by the contagious disease.
Christian Lindmeier, a spokesman for the World Health Organization, told reporters the vaccine doses originally designated for shipment to Yemen would probably be sent to other countries threatened by cholera, where they could be used more effectively.
The surprise disclosure, made at a regular news briefing at the United Nations headquarters in Geneva, came as the number of Yemenis afflicted with cholera reached 313,000 and the death toll exceeded 1,700
… A vaccination effort in Yemen, Mr. Lindmeier said, is a “difficult approach because you can’t plan a campaign like you would do in a normal country” where war and insecurity are absent…
12 July 2017
The situation in the Middle East (Yemen) – Security Council, 7999th meeting – 12 Jul 2017 – 
[Video: 1:09:43]
WHO DG Tedros Report [at approx. 24:00 – 30:00]
No mention of OCV

Under-Secretary-General for Humanitarian Affairs and Emergency Relief Coordinator, Stephen O’Brien: Statement to the Security Council on Yemen, 12 July 2017
… Nearly 16 million people do not have access to adequate water, sanitation and hygiene, and more than 320,000 suspected cholera cases have been reported in all of the country’s governorates bar one. At least 1,740 people already are known to have died from this entirely preventable disease – probably many more in the many very remote areas of Yemen we can’t reach….
…This cholera scandal is entirely manmade by the conflicting parties and those beyond Yemen’s borders who are leading, supplying, fighting and perpetuating the fear and fighting…
Just for the sake of reaching all the millions of Yemenis with cholera vaccines, so desperately needed, the people of Yemen need stability. Failure to do so renders their fate, and our – and your – ability to intervene useless and hopeless. We should all feel deeply guilty about that – and especially the conflicting parties in Yemen should do so and those who drive them from outside Yemen. Our joint – your –top common priority should be always to save civilian lives and protect them. The Yemeni people deserve this equally to any other citizen of the world – be it one of you around this table or someone cowering in fear somewhere in Sana’a or Taizz in Yemen…
14 July 2017
Geneva Press Briefing: WHO, OHCHR, UNHCR, IOM – 14 Jul 2017 
Biweekly Geneva Press Briefing Chaired by Alessandra Vellucci, Director of the United Nations Information Service in Geneva
[Video: 1:09:03]
Dominic LeGros, WHO focal point for cholera [at approx 04:40 to 22:00; Editor’s excerpts as no transcript of the press briefing has been posted]
:: Began by relating the status of a number of other cholera outbreaks underway globally.
:: Referenced October 2017 meeting as call for action to address recurring cholera outbreaks…notes that solution is not a technical issue…a matter of engagement/political will by countries and development donors.

Reporter: Could you elaborate on thinking behind not proceeding with selected OCV vaccinations?
Response: Decisions made by Yemeni authorities to delay. We understand that decision… outbreak is so mature in Yemen…difficult to find districts where OCV could make maximum contribution. 43 OCV campaigns since formation of stockpile. Also, need resources for classic response strategies [WASH]…

Reporter: Follow up…so, effectively, was the window of opportunity to use the vaccine [OCV] missed at some point in the past?
Response: Dealing with a country that so far did not choose the vaccine…[OCV] is a new strategy, new tool…we have seen this kind of delay in decision to use. The other fact is that epidemic is moving very fast there so difficult to project course…

14 July 2017
Vaccine deployment for cholera suspended in Yemen
By Daniella Emanuel, CNN
Updated 9:29 AM ET, Fri July 14, 2017
(CNN)The cholera outbreak in Yemen is spreading so quickly that plans have been suspended to deploy one million doses of vaccines to the country, according to the World Health Organization.
The number of suspected cases affected by the outbreak is now more than 325,000. Cholera is an acute diarrheal illness which kills thousands of people worldwide each year.
“The situation has evolved so rapidly that vaccines are not the priority tool to use right now,” Tarik Jasarevic, WHO spokesperson, said in an email.
“Now that cholera has spread to 91% of Yemen’s governorates, the focus will instead be on scaling up other interventions that will have a greater effect on the evolution of the outbreak and save lives.”
Those interventions include scaling up access to clean water and sanitation, treatment to people affected and working with communities to promote hygiene, sanitation and cholera prevention, explained Jasarevic.
The one million doses of vaccine were initially approved by the International Coordinating Group, an organization established in 1997 with the purpose of managing and coordinating the use of emergency vaccine supplies and antibiotics to countries in the midst of major outbreaks, according to WHO.
The one million doses of vaccine were initially approved by the International Coordinating Group, an organization established in 1997 with the purpose of managing and coordinating the use of emergency vaccine supplies and antibiotics to countries in the midst of major outbreaks, according to WHO.
Five hundred thousand doses were shipped to Djibouti in East Africa because of the country’s close proximity to Yemen, Jasarevic said. The country is across the Bab al-Mandab Strait from Yemen.
The vaccines are still there, and they may be shipped to another country for use, he said.
“The decision to suspend was taken by the Yemeni authorities in consultation with the technical teams that are working on cholera from the United Nations side,” said George Khoury, Head of Office at the UN Office for the Coordination of Humanitarian Affairs in Yemen.
WHO confirmed that they and other partners were consulted on the decision. They serve as advisers to the Yemen health authorities on vaccines and other interventions related to the ongoing cholera outbreak in the country, Jasarevic said.
“It was decided by the professionals that all the risks and the potential problems may outweigh the benefits of administering the vaccine,” Khoury said. “Given the limited number of vaccines, administering the vaccines in some areas and not others may create disputes on who gets and who doesn’t get the vaccine…

Public Health Emergency of International Concern (PHEIC)

Polio this week as of 12 July 2017 [GPEI]
:: At the G20 Head of State Summit in Hamburg, Germany, last weekend, leaders acknowledged the efforts to eradicate and committed to completing the job of polio eradication.  More.

:: Journal of Infectious Diseases publishes supplement of articles on polio endgame and legacy implementation lessons learned and best practices. [see below]

:: The Global Certification Commission for the Eradication of Poliomyelitis (GCC) met on 4-5 July in Paris, France.  This was the 16th meeting of the GCC, and the first under the group’s new Chair, Professor David Salisbury from the UK, following the retirement of the previous Chair Professor Tony Adams from Australia.  The meeting was attended by all six Regional Certification Committee (RCC) Chairs, along with partners of the Global Polio Eradication Initiative (GPEI).

:: In Syria, one of the previously-reported cases from Raqua, on re-testing, has been confirmed as negative for circulating vaccine-derived poliovirus type 2 (cVDPV2), and has been removed from the list of cases.  The total number of cVDPV2 cases is now 23 (22 from Deir-Al-Zour and one from Raqua).

:: The Pakistan and Afghanistan National Emergency Operation Centre teams convened a coordination meeting in Amman, Jordan, on 10–11 July.  A joint response plan was put together for new wild poliovirus type 1 (WPV1) cases / isolates in the southern corridor (comprising Quetta Block / Greater Kandahar). The teams also reviewed the situation in the greater Peshawar / Nangarhar and South East Afghanistan / Southern KP-FATA Corridors and agreed on further actions to improve the quality of immunization activities and surveillance with special focus on high-risk mobile populations.

:: Summary of newly-reported viruses this week:  Pakistan – one new wild poliovirus type 1 (WPV1) isolated from an acute flaccid paralysis case; Afghanistan – one new WPV1-positive environmental sample.  See country-specific section below, for more details.

Journal of Infectious Disease
Volume 216, Issue suppl_1  1 July 2017
Polio Endgame & Legacy-Implementation, Best Practices, and Lessons Learned
49 articles focused on themes including:
Addressing the Challenges and Opportunities of the Polio Endgame: Lessons for the Future
Manish Patel; Stephen Cochi
The Global Commission for the Certification of the Eradication of Poliomyelitis certified the eradication of type 2 poliovirus in September 2015, making type 2 poliovirus the first human pathogen to be eradicated since smallpox. The eradication of type 2 poliovirus, the absence of detection of type 3 poliovirus worldwide since November 2012, and cornering type 1 poliovirus to only a few geographic areas of 3 countries has enabled implementation of the endgame of polio eradication which calls for a phased withdrawal of oral polio vaccine beginning with the type 2 component, introduction of inactivated poliovirus vaccine, strengthening of routine immunization in countries with extensive polio resources, and initiating activities to transition polio resources, program experience, and lessons learned to other global health initiatives. This supplement focuses on efforts by global partners to successfully launch polio endgame activities to permanently secure and sustain the enormous gains of polio eradication forever.

WHO Grade 3 Emergencies  [to 15 July 2017]
::  YEMEN: cholera outbreak – Daily epidemiology update: 15 July 2017
From 27 April to 14 July 2017, 338 969 suspected cholera cases and 1 770 deaths (CFR: 0.5%)
have been reported in 91.3% (21/23) of Yemen governorates, and 87.7% (292/333) of the

Iraq  – No new announcements identified.
NigeriaNo new announcements identified.
South SudanNo new announcements identified.
The Syrian Arab Republic – No new announcements identified.
WHO Grade 2 Emergencies  [to 15 July 2017]
Cameroon  No new announcements identified
Central African Republic  – No new announcements identified. 
Democratic Republic of the CongoNo new announcements identified
EthiopiaNo new announcements identified.
LibyaNo new announcements identified.
MyanmarNo new announcements identified.
Niger  – No new announcements identified.
Ukraine  – No new announcements identified
UN OCHA – L3 Emergencies
The UN and its humanitarian partners are currently responding to three ‘L3’ emergencies. This is the global humanitarian system’s classification for the response to the most severe, large-scale humanitarian crises. 
:: Iraq: Mosul Humanitarian Response Situation Report No. 39 (29 June to 11 July 2017)
:: Humanitarian funding is urgently required to assist 700,000 civilians displaced from Mosul [EN/AR/KU]
(Baghdad, 9 July 2017) – Since the military campaign to retake Mosul began on 17 October 2016, 920,000 civilians have fled their homes. Close to 700,000 people are still displaced, nearly half of whom are living in 19 emergency camps.
“It’s a relief to know that the military campaign in Mosul is ending. The fighting may be over, but the humanitarian crisis is not,” said the Humanitarian Coordinator for Iraq, Ms. Lise Grande.
“Many of the people who have fled have lost everything. They need shelter, food, health care, water, sanitation and emergency kits. The levels of trauma we are seeing are some of the highest anywhere. What people have experienced is nearly unimaginable,” said Ms. Grande.
“We’ve been working around the clock for months. Enormous efforts have been made by the Government and front-line partners to stay one step ahead of the crisis. We’ve done our best to protect and assist the people who need it the most.”
“There’s a lot to do in the weeks and months ahead. Of the 54 residential neighborhoods in western Mosul, 15 are heavily damaged and at least 23 are moderately damaged.”
“The civilians who are trapped in the areas where fighting is likely to occur, including Tel Afar, Hawija and western Anbar, will be at extreme risk. We have to make sure we are ready to help them,” said Ms. Grande.
Only 43 percent of the USD 985 million Humanitarian Response Plan for Iraq has been received. Partners urgently require US$562 million to meet the needs of millions of Iraqis who need help.

Syrian Arab Republic
:: 14 Jul 2017  Syrian Arab Republic: CCCM Whole of Syria Ar-Raqqa Displacement Map as of July 5, 2017

:: Key messages on cholera (10 July 2017)
Current situation
Yemen, the world’s largest food security crisis, is now facing the world’s worst cholera outbreak which in the span of two months has spread to the entire country except for one governorate (Socotra island)….

UN OCHA – Corporate Emergencies
When the USG/ERC declares a Corporate Emergency Response, all OCHA offices, branches and sections provide their full support to response activities both at HQ and in the field.
:: 10 Jul 2017 Ethiopia Weekly Humanitarian Bulletin, 10 July 2017

:: DRC: Number of internally displaced people rises to 3.8 million – the highest in Africa
7 July, 2017  The Democratic Republic of the Congo (DRC) is experiencing a significant change in conflict patterns, with growing intercommunal tensions and violence affecting new parts of the country. DRC is now one of the world’s most complex humanitarian crises, in which 7.3 million people need humanitarian assistance.
The relentlessly acute nature of the crisis, the lack of basic social services throughout the country and the persistent armed conflict have led to the internal displacement of 3.8 million people. This is the highest number of displaced people in the African continent…