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      Conflict and Emerging Infectious Diseases

      , *

      Emerging Infectious Diseases

      Centers for Disease Control and Prevention

      conflict, cholera, outbreak, letter

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          To the Editor In the November 2007 issue of Emerging Infectious Diseases, Gayer et al. ( 1 ) describe how conflict leaves populations in dire poverty, internally displaced or seeking asylum, having poor access to essential services, and consequentially vulnerable to infectious diseases. Cholera, caused by the bacterium Vibrio cholerae, is a disease that seems particularly sensitive to conflict and deserves more consideration. Major risk factors for cholera—poverty, overcrowding, poor hygiene, contaminated food, and lack of safe drinking water ( 2 , 3 )—largely resemble the consequences of war and civil fighting. Yet little is known about the relationship between cholera and conflict. This lack of information may be because cholera tends to be epidemic, affecting hundreds to thousands of people across vast, war-torn regions, making it impossible for local governments, nongovernment organizations, and aid workers to control, let alone collect and analyze data. Examination of data sources listed by Gayer et al. ( 1 ) and recent reviews ( 2 , 3 ) indicate that cholera occurs 1) in countries during war and civil unrest, as exemplified by the latest outbreaks among displaced populations across northern Iraq; 2) in neighboring countries, where temporary camps accommodate masses of political refugees under poor conditions, such as those in eastern Chad near Darfur, Sudan; and 3) during the postwar period when large numbers of repatriated persons return home and consequently place undue pressure on an eroded and fragile national infrastructure, as evident in Angola in recent years. Moreover, all the countries affected by conflict shown in the Appendix Figure by Gayer et al. ( 1 ) have reported cholera outbreaks ( 2 – 4 ). They are also among the poorest countries in the world; the latest statistics on human development ( 5 ) indicate that compared with all developing countries, on average they have higher rates of undernourishment, refugees, child deaths, and less adequate water and sanitation facilities. Thus, more information is needed about conflict and cholera, especially in Africa. Supplementary Material Appendix Figure Geographic distribution of recent emerging or reemerging infectious disease outbreaks and countries affected by conflict, 1990–2006. Countries in yellow were affected by conflict during this period (source: Office for the Coordination of Humanitarian Affairs, World Health Organization, Symbols indicate outbreaks of emerging or reemerging infectious diseases during this period (source: Epidemic and Pandemic Alert and Response, World Health Organization, Circles indicate diseases of viral origin, stars indicate diseases of bacterial origin, and triangles indicate diseases of parasitic origin. CCHF, Crimean-Congo hemorrhagic fever; SARS-CoV, severe acute respiratory syndrome coronavirus

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          Cholera: a new homeland in Africa?

          Cholera was largely eliminated from industrialized countries by water and sewage treatment over a century ago. Today it remains a significant cause of morbidity and mortality in developing countries, where it is a marker for inadequate drinking water and sanitation infrastructure. Death from cholera can be prevented through simple treatment-oral, or in severe cases, intravenous rehydration. The cholera case-fatality rate therefore reflects access to basic health care. We reviewed World Health Organization (WHO) data on cholera cases and deaths reported between 1960 and 2005. In the 1960s, at the beginning of the seventh and current cholera pandemic, cholera had an exclusively Asian focus. In 1970, the pandemic reached sub-Saharan Africa, where it has remained entrenched. In 1991, the seventh pandemic reached Latin America, resulting in nearly 1 million reported cases from the region within 3 years. In contrast to the persisting situation in Africa, cholera was largely eliminated from Latin America within a decade. In 2005, 31 (78%) of the 40 countries that reported indigenous cases of cholera to WHO were in sub-Saharan Africa. The reported incidence of indigenous cholera in sub-Saharan Africa in 2005 (166 cases/million population) was 95 times higher than the reported incidence in Asia (1.74 cases/million population) and 16,600 times higher than the reported incidence in Latin America (0.01 cases/million population). In that same year, the cholera case fatality rate in sub-Saharan Africa (1.8%) was 3 times higher than that in Asia (0.6%); no cholera deaths were reported in Latin America. The persistence or control of cholera in Africa will be a key indicator of global efforts to reach the Millennium Development Goals and of recent commitments by leaders of the G-8 countries to increase development aid to the region.
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            Cholera, 2006.


              Author and article information

              Emerg Infect Dis
              Emerging Infectious Diseases
              Centers for Disease Control and Prevention
              June 2008
              : 14
              : 6
              : 1004-1005
              [* ]Liverpool School of Tropical Medicine, Liverpool, UK
              [* ]World Health Organization, Geneva, Switzerland
              Author notes
              Address for correspondence: Louise A. Kelly-Hope, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK; email: l.kelly-hope@
              Address for correspondence: Michelle Gayer, Disease Control in Humanitarian Emergencies, Department of Epidemic and Pandemic Alert and Response, Health Security and Environment Cluster, World Health Organization, 20 Ave Appia, CH-1211, Geneva-27, Switzerland; email: gayerm@
              Letters to the Editor

              Infectious disease & Microbiology

              letter, conflict, cholera, outbreak


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