Date: Sun 27 Aug 2017
Source: Bas News [in Kurdish, trans. ProMED Mod.NS, edited]

The Director General of Health in Sulaymaniyah revealed that 2000 cases of diarrhoea and vomiting were recorded in the hospitals in Sulaymaniyah city [Iraqi Kurdistan] in one week, and they have taken a number of measures to control the outbreak.

Dr Miran Mohammed, the Director General of Health in Sulaymaniyah, informed Bas News that "according to the data and information received from Sulaymaniyah city hospitals, 2000 cases of diarrhoea and vomiting were recorded during one week only. In comparison with the previous week, the cases have increased 4-fold."

Mohammed added that "to prevent an increase in the number of cases, we held a meeting with the concerned parties today [Sun 27 Aug 2017] and made a number of decisions, including having better monitoring of water sources and increasing the chlorine level in the water. We also decided to prohibit selling and distributing water in tankers that are not specified for drinking water and when the source of water is doubtful."

The Director General of Health in Sulaymaniyah stated that "hospitals are prepared to treat patients, and we will instruct the people to avoid eating outside and to avoid unclean food. It is also necessary to use clean water and wash vegetables and fruits with clean water before eating them."
[The aetiology or aetiologies of this prominent outbreak is unclear and could be viral, bacterial, or protozoan. No information is given regarding mortality. ProMED would appreciate more information about this outbreak. - ProMED Mod.LL]

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Date: Tue 25 Apr 2017 18:14
Source: Alsumaria News [in Arabic, trans. ProMED Mod.NS, edited]

A member of the local council of Al-Baghdadi sub-district in Al-Anbar governorate, Abdul-Jabbar Al-Obeidi, revealed on [Tue 25 Apr 2017] the spread of viral hepatitis in the sub-district and called on the Ministry of Health to intervene. Al-Obeidi said in an interview with Alsumaria News that "viral hepatitis has spread among more than 20 people in Al-Baghdadi sub-district (90 km or 56 miles west of Ramadi)." He called on the Ministry of Health to "intervene and send medical teams to Al-Baghdadi sub-district to detect the disease and treat the patients as there is fear that the disease will be spreading more widely among the people of the sub-district."

It is noteworthy that Al-Baghdadi sub-district is controlled by the security forces and the tribes after witnessing military operations and bombardment by the Islamic State (ISIS) during the past years. -- Communicated by: ProMED-MENA <> [Both the hepatitis A and E viruses are waterborne and can occur in outbreaks. In areas of poor public health infrastructure where waterborne infections are common if outbreaks of viral hepatitis occur in adults, it is likely that the culprit is the hepatitis E virus. This is the case since, in many countries, the seroprevalence rate of hepatitis A is close to 100% by the age of 10.

The following is part of a UN Eastern Mediterranean Regional Office (<>) report on viral hepatitis in Iraq:
"In Iraq, the number of hepatitis A cases has increased from 1802 in 2009 to 4473 in 2014 among nationals. The country is a low endemicity country for hepatitis B and C. The usual mode of transmission is blood transfusions or repeated exposure to blood and its derivatives (post-transfusion non-A non-B hepatitis).

For hepatitis B, 3674 cases were reported;
Hepatitis C 929 cases were reported and 199 cases were reported for hepatitis E.
This was due to expansion of diagnosis in district labs. In the past, diagnosis was in public health laboratory in governorates.

However, since 2013 diagnosis is conducted in district laboratories. Each district has an ELISA machine for hepatitis diagnostics. The major challenge for the program is availability of funds, security situation in the country, overcrowding in the areas of migrants and refugees. The program also suffers from lack of training and capacity-building and lack of availability of diagnostic kits.

The transmission of hepatitis type A and E is facilitated by poor infrastructure, poor quality of potable water, unsafe food and poor hygiene. A majority of health workers do not follow medical guidelines in dealing with blood and its derivatives, which has led to the spread of hepatitis B and C in communities.

The priorities of the Ministry of Health are to establish an efficient hepatitis surveillance system, build the capacity of health personnel to manage patients, and provide medicines and diagnostic services at governorate level." Al Anbar Governorate, or Anbar Province, is the largest governorate in Iraq by area.

Encompassing much of the country's western territory, it shares borders with Syria, Jordan, and Saudi Arabia. The provincial capital is Ramadi; other important cities include Fallujah and Haditha. The name of the governorate in Persian language means "warehouse" or "silo", from the verb, anbâshtan (to store, to warehouse). This was the last stop/warehouses on the old Silk Road toward Syria.

The governorate can be found on a map at:
<>. - ProMED Mod.LL]
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20 March 2017, Erbil, Iraq

The World Health Organization with logistic support from the World Food Programme, airlifted 15 fully equipped ambulances to Iraq in order to strengthen the response to the increasing trauma and medical related emergencies in west Mosul. These ambulances will enhance trauma care at the frontlines and ensure timely referral to field hospitals.

At the urgent request of the Ministry of Health, the ambulances were appropriately designed, equipped and will be staffed with trained paramedics to offer care to patients while being transported to trauma stabilization points and field hospitals in Athba, Hamam Aleel and Bartalla.

“Early access to ambulance services is an important component of trauma care to ensure good patient outcomes in emergency situations. WHO’s priority is to prevent avoidable loss of life and further complications as a result of injury by providing rapid transport and medical treatment to ensure survival within the golden hour,” said Mr Altaf Musani, WHO Representative for Iraq.

“WHO in support of health authorities has established trauma stabilization points and field hospitals in Athba, Hamam Aleel and Bartalla close to the frontlines of the ongoing conflict,” added Musani.

An additional 15 ambulances are expected to arrive in the country next week to complete the planned shipment of 30 ambulances all meant to support the Ministry of Health and response of partners in Mosul.

To date, WHO has donated a total of 32 ambulances to the Directorate of Health in Ninewa to transport both emergency medical and trauma patients out of west Mosul. WHO will continue to support health authorities and partners to further strengthen the referral pathways by strengthening trauma stabilization points, field hospitals and operative and post-operative care points.

At the start of the west Mosul operations, the Government of Iraq immediately mobilized ambulances for trauma care. Other key partners such as the United Nations Population Fund (UNFPA) have also provided ambulances for trauma care.

Lessons identified from the operations in the eastern part of Mosul clearly demonstrate the vital role that ambulances played in ensuring patient transfers from east Mosul to Erbil. Both Directorates of Health of Erbil, Ninewa and Duhok ensured a well-coordinated referral pathway that saved lives of injured patients.

The procurement and management of these 30 ambulances has been made possible with generous funding from the European Commission’s Humanitarian Aid Office (ECHO), USAID/Office of Foreign Disaster (OFDA), the Government of Kuwait and Japan.
Date: Thu 26 Nov 2015
Source: WHO [edited]

WHO received notification from the National IHR Focal Point of Iraq of additional laboratory-confirmed cases of cholera. As of 22 Nov 2015, a total of 2810 laboratory-confirmed cases of _Vibrio cholerae_ O1 Inaba had been confirmed at the Central Public Health Laboratory in Baghdad, and only 2 deaths related to cholera were reported. These cases were reported from 17 Governorates of the country, namely Baghdad (940 cases), Babylon (675 cases), Qadisiyyah (442 cases), Muthanna (287 cases), Karbala (157 cases), Basra (102 cases), Wassit (68 cases), Najaf (46 cases), Thyqar (20 cases), Missan (21 cases), Dahuk (16 cases), Kirkuk (19 cases), Erbil (10 cases) Diyala (3 cases), Salaheddine (2 cases) Sulaimanneya (1 case) and Ninewa (1 case).

The Government of Iraq, with the support of WHO and UNICEF, completed the 1st round of the oral cholera vaccination campaign. The campaign, which ended on the 2nd week of November 2015, led to the vaccination of 229 000 refugees and internally displaced people (93 percent of the target population) across 62 camps in 13 Governorates. The turnout was very high. No refusals or concerns were raised regarding the vaccine. The 2nd round of vaccinations will begin in the 1st week of December 2015 to complete the recommended dosing regimen and maximize clinical protection in the target population. Oral cholera vaccination should be part of a comprehensive and integrated package that also includes clean water supply, improved sanitation and hygiene to provide the greatest chance of protection against cholera and other diarrheal diseases.

On 2 Dec 2015, the pilgrimage of Arbaeen is going to take place in Karbala. A total of 10 million pilgrims are expected to attend. The National IHR Focal Point of Bahrain, the Islamic Republic of Iran, Jordan, Kuwait, Oman, Qatar and the United Arab Emirates have put in place preparedness measures for the early detection and management of any imported cholera case from Iraq. The measures include activating the public health preparedness and response plan; enhancing disease surveillance at all points of entry and at all health care facilities; ensuring the availability of sufficient supplies and kits at laboratories; enhancing water surveillance for cholera; enhancing food inspection measures at points of entry; training health care workers in the assessment and management of cholera cases, enhancing strict compliance of infection prevention and control measures at all health facilities, particularly those designated to receive cholera suspected cases, and conducting activities to promote awareness of travellers to Iraq and the public about the disease.

Between 16 and 17 Oct 2015, the WHO Office for the Eastern Mediterranean held a sub-regional meeting for Iraq and its neighboring countries. Another regional consultative cholera meeting was held in Amman, Jordan from 17 to 19 Nov 2015, and all cholera endemic countries in the region as well as other stakeholders participated in the meeting. The meetings provided a set of recommendations for enhancing disease surveillance, including laboratory confirmation; case management and infection control; water sanitation and hygiene practice; capacities at points of entry; and risk communication.

WHO does not recommend any travel or trade restrictions on any country affected by cholera outbreak.
[The previous WHO Iraq report said that the total cases were 4858, which seems to be an error, given reports before and now after that one.

The use of a cholera vaccine during an ongoing outbreak was 1st demonstrated to be effective during an outbreak in the African country of Guinea in 2012 and reported in 2014:

The publication with its citation and abstract is:
Luquero FJ, Grout L, Ciglenecki, I, et al: Use of _Vibrio cholerae_ Vaccine in an outbreak in Guinea. N Engl J Med 2014; 370: 2111-20; <>.

"The use of vaccines to prevent and control cholera is currently under debate. Shanchol is 1 of the 2 oral cholera vaccines prequalified by the World Health Organization; however, its effectiveness under field conditions and the protection it confers in the 1st months after administration remain unknown. The main objective of this study was to estimate the short-term effectiveness of 2 doses of Shanchol used as a part of the integrated response to a cholera outbreak in Africa.

We conducted a matched case-control study in Guinea between 20 May 2012 and 19 Oct 2012. Suspected cholera cases were confirmed by means of a rapid test, and controls were selected among neighbors of the same age and sex as the case patients. The odds of vaccination were compared between case patients and controls in bivariate and adjusted conditional logistic-regression models. Vaccine effectiveness was calculated as (1-odds ratio) X 100.

Between 8 Jun 2012 and 19 Oct 2012, we enrolled 40 case patients and 160 controls in the study for the primary analysis. After adjustment for potentially confounding variables, vaccination with 2 complete doses was associated with significant protection against cholera (effectiveness, 86.6 percent; 95 percent confidence interval, 56.7 to 95.8; P=0.001).

In this study, Shanchol was effective when used in response to a cholera outbreak in Guinea. This study provides evidence supporting the addition of vaccination as part of the response to an outbreak. It also supports the ongoing efforts to establish a cholera vaccine stockpile for emergency use, which would enhance outbreak prevention and control strategies."

Although these are small numbers, the investigators working in way less than ideal condition should be lauded for this study, which may be the "straw that broke the camel's back" regarding using a cholera vaccine during an ongoing outbreak of _V. cholerae_.

The biologic used, Shanchol (produced in India), contains killed different biotypes of bacilli of both O1 and O139 serotypes. In a large study in Kolkata, India, a cluster-randomized, double-blinded, placebo-controlled study revealed a cumulative efficacy of the product at 5 years of 65 percent (95 percent CI [confidence interval] 52-74), with significant protection at the p less than 0.0001 level (1). The other WHO prequalified vaccine, Dukoral, produced in Sweden, contained several biotypes of O1 only together with recombinant cholera toxin B subunit.

As a review, the cholera toxin, encoded by the ctxA and ctxB genes, is the principal toxin produced by _V. cholerae_ O1 and O139 and is responsible for the disease. The genes are encoded with a filamentous bacteriophage. The toxin has many immunological properties that include impressive adjuvant properties and action as an anti-inflammatory agent. Each toxin molecule contains a catalytic A subunit (the active toxin) and 5 B subunits that bind the holotoxin to its ganglioside GM1 receptor. After internalization, a subunit of A, A1, will catalyze the ribosylation of a GTP-binding protein which increases the activation of adenyl cyclase and a chloride channel CFTR (cystic fibrosis transmembrane conductance regulator) which produces increased chloride secretion, intestinal water accumulation and diarrhea. It is mutations in CFTR that produces cystic fibrosis, a disease that affects a number of organs related to difficulties in fluid secretion (2).

1. Bhattacharya SK, Sur D, Ali M, et al: 5 year efficacy of a bivalent killed whole-cell oral cholera vaccine in Kolkata, India: a cluster-randomised, double-blind, placebo-controlled trial. Lancet Infect Dis. 2013; 13(12): 1050-6; available at <>.
2. Lutwick LI, Preis J: Cholera. In, Tropical Pediatrics: A Public Health Concern of International Proportions. NovaBiomedical, New York, 2014 (in press). - ProMed Mod.LL]

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Date: Sun 22 Nov 2015
Source: WHO Surveillance, forecasting, and response [edited]

The cholera outbreak in Iraq has continued to decline over the past 3 weeks with a few cases being reported from the affected districts or governorates. A total of 4858 laboratory-confirmed cases tested at provincial laboratories have been reported from the country, with 2 related deaths as of 17 Nov 2015.

Currently, 17 out of the 19 governorates in Iraq have reported laboratory-confirmed cases. The central public health laboratory has identified that the causative strain of this outbreak is _Vibrio cholerae_ O1 Inaba. The strain has been found to be sensitive to commonly-used antimicrobials, including tetracycline, ciprofloxacin, and erythromycin. A total of 16 isolates have been sent to the Pasteur Institute in France for genotyping and other advanced testing.

Since the 1st laboratory-confirmed case of cholera in Iraq was notified officially to WHO on 15 Sep 2015 in Alshamiya district in Diwaniya governorate, the Ministry of Health has collected 119,983 stool samples for suspected cholera. The positive stool samples were re-tested at the central public health laboratory in Baghdad for quality purposes and only 2745 stools samples were found to be positive for _Vibrio cholerae_ O1 Inaba.

Nearly 10 districts within Baghdad, Babylon, Diwaniya, and Muthana governorates have reported over 89 percent of all laboratory-confirmed cholera cases, and most of these districts receive their water supply solely from the Euphrates river. Figure 1 [for figure, see source URL above. - ProMed Mod.LL] shows the declining trends in the number of laboratory-confirmed cholera cases reported daily in Iraq between 30 Aug 2015 and 17 Nov 2015.

The trends in cholera cases in the 4 most affected governorates and 5 most affected districts have been declining significantly in recent weeks. Likewise, district and governorate's specific attack rates have clearly shown a downward trend in the last few weeks.

Considering the available surveillance data, there is no evidence that cholera is spreading to new communities or districts. According to the Ministry of Health none of the internally displaced persons and refugee camps across Iraq reported any laboratory-confirmed cholera cases.
[There have been cases from the Iraqi outbreak in several of the other Middle Eastern countries. Unofficially, there have been cases of cholera in war-torn Syria, which could explode into a major outbreak. - ProMed Mod.LL]

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