The first case was a Syrian refugee in Akkar, in northern Lebanon. It was reported on 5 October 2022, and it ended an absence of nearly 30 years for cholera in the country.
By 1 June 2023, Lebanon had recorded 671 confirmed and 7,993 suspected cases, according to a commentary by Zeina Bayram, Abdul Bizri and Umayya Musharrafieh of the American University of Beirut, published in the Eastern Mediterranean Health Journal. Culture tests identified the strain in the confirmed cases as Vibrio cholerae O1 El-Tor Ogawa.
From Syria to Lebanon
Syria had announced its own outbreak on 10 September 2022. The authors say the announcement caused panic in Lebanon, largely because the border is porous and Syrian refugees move between the two countries. Even so, they write, no measures were adopted to prevent cross-border transmission, and the disease spread rapidly.
The first infection in Lebanon was reported in Minieh-Dannieh District. Cases then rose in nearby Akkar and Baalbeck districts and spread to Beirut and Mount Lebanon. Vibrio cholerae was found in drinking water sources, irrigation channels and sewage.
One death was reported on 12 October 2022, a week after the outbreak began. By 14 March, deaths had reached 23.
Who fell ill
Surveillance data from the Lebanese Ministry of Public Health show the highest share of suspected and confirmed cases among children aged 0 to 4, at 31%. Children aged 5 to 14 made up 23%, and adults aged 25 to 44 made up 18%. Of the confirmed cases, 18% needed hospital admission, 47% were male and 53% were female.
The ministry designated a few laboratories to diagnose cases and named 9 referral hospitals as treatment centres. A vaccination campaign began on 12 November, and reports started to decline in December 2022. The ministry nonetheless said the outbreak was not yet over.
A system already under strain
The authors set the outbreak against Lebanon’s wider troubles. The country is in its worst economic depression to date and is now classed as lower-middle income. Health workers and medical supplies are in drastic shortage, and inflation, power cuts and water cuts have left health institutions fragile. The system had not recovered from COVID-19.
Lebanon hosts the largest number of refugees per capita in the world, mostly Syrians. Refugee camps and temporary settlements are typical sites of poor water quality and sanitation, and so of high cholera transmission. A UNICEF representative in Lebanon has said that millions of people are affected by limited access to clean, safe water. The authors call the rising case count “just a tip of the iceberg.”
They describe the outbreak as a manifestation of weak political and healthcare systems, and say no significant action is being taken to fix the situation amid high inflation, shortages of funds and dwindling international aid. Without improvements in the political and financial sectors, they warn, Lebanon may be edging toward a devastating epidemic.
