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BMJ Glob Health. 2019 Jul 15;4(4):e001709. doi: 10.1136/bmjgh-2019-001709. eCollection 2019.

Responding to epidemics in large-scale humanitarian crises: a case study of the cholera response in Yemen, 2016-2018.

Author information

Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
Department of Pediatrics, Stanford University School of Medicine, Stanford University, Stanford, California, USA.
Freeman Spogli Institute for International Studies, Stanford University, Stanford, California, USA.
Department of Civil and Environmental Engineering, Tufts University, Medford, Massachusetts, USA.



Large epidemics frequently emerge in conflict-affected states. We examined the cholera response during the humanitarian crisis in Yemen to inform control strategies.


We conducted interviews with practitioners and advisors on preparedness; surveillance; laboratory; case management; malnutrition; water, sanitation and hygiene (WASH); vaccination; coordination and insecurity. We undertook a literature review of global and Yemen-specific cholera guidance, examined surveillance data from the first and second waves (28 September 2016-12 March 2018) and reviewed reports on airstrikes on water systems and health facilities (April 2015-December 2017). We used the Global Task Force on Cholera Control's framework to examine intervention strategies and thematic analysis to understand decision making.


Yemen is water scarce, and repeated airstrikes damaged water systems, risking widespread infection. Since a cholera preparedness and response plan was absent, on detection, the humanitarian cluster system rapidly developed response plans. The initial plans did not prioritise key actions including community-directed WASH to reduce transmission, epidemiological analysis and laboratory monitoring. Coordination was not harmonised across the crisis-focused clusters and epidemic-focused incident management system. The health strategy was crisis focused and was centralised on functional health facilities, underemphasising less accessible areas. As vaccination was not incorporated into preparedness, consensus on its use remained slow. At the second wave peak, key actions including data management, community-directed WASH and oral rehydration and vaccination were scaled-up.


Despite endemicity and conflict, Yemen was not prepared for the epidemic. To contain outbreaks, conflict-affected states, humanitarian agencies, and donors must emphasise preparedness planning and community-directed responses.


armed conflicts; cholera; communicable disease control; emergencies; epidemics

Conflict of interest statement

Competing interests: RR and DL declare personal fees from the Johns Hopkins Bloomberg School of Public Health for conducting the study.

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