Informing humanitarians worldwide 24/7 — a service provided by UN OCHA

Iraq

Situation report on cholera outbreak in northern Iraq, 03 Sep 2007

Attachments

1. OVERVIEW

Since 23 August 2007, a three to four fold increase of acute watery diarrhea cases were being reported from one of the teaching hospitals of Sulaymaniyah province in Northern Iraq. Laboratory test performed on stool specimens confirmed Vibrio cholerae serogroup 01 Inaba as the causative pathogen for these reported acute watery diarrhea cases.

So far between 23 August and 02 September 2007, the cumulative number of cases of acute watery diarrhoea reported from four out of eleven districts of Sulaymaniyah province stands at 2,930 including 9 deaths with an overall case fatality rate of 0.30%. Of these reported cases, Vibrio cholerae has been laboratory confirmed in 187 stool samples.

On the other hand, Vibrio cholerae serogroup 01 Inaba was isolated from a stool specimen for the first time ever on 19 August 2007 from Kirkuk province of Northern Iraq where stool specimens are routinely collected and tested for detecting enteric pathogens as part of routine surveillance for diarrhoeal diseases which is in place in all hospitals of the province. Despite the fact that no discernible increase in case load of acute diarrhea have been observed between two comparable periods of 2007 and 2006, a total of 2,968 cases of acute diarrhoeal syndrome including 1 death (CFR: 0.033%) were reported from Kirkuk province between 29 July and 26 August 2007. Of these reported cases, Vibrio cholerae has been isolated from stool specimens of 101 cases.

2. PATTERN OF TRANSMISSION IN SULAYMANIYAH PROVINCE

As of 1st of September, the outbreak, since reported on 23 August, has spread to four out of eleven districts in the province (Please see the map below) exposing over 1,502,009 people at great public health risk. No surveillance system for diarrhoeal diseases existed in the province before the outbreak started on 23 August. Only recently with support from WHO Office of Iraq, the provincial health authority has started collecting surveillance data on cases reported to the health centres and hospitals. Therefore, due to inadequacy of reporting and other limitations of the surveillance system, the cumulative number of cases of cholera reported so far from the province may be grossly underreported and may not represent the true burden of the disease.

The available report suggests that the outbreak first started in Sulaymaniyah district and then spread to other three districts (Rania, Halabja and Chamchamal). Apart from these four districts, no laboratory confirmed case of Vibrio cholerae has, so far, been reported from any of the remaining six districts of the province. It is unclear at this stage what has been the source of infection for this current wave of cholera in the province.

The daily progression of cases as shown in figure-1 does not reflect any particular cyclical trend. The several spikes that are shown in the epi curve may be due to incomplete reporting as well as inadequacy of reporting. As the surveillance system improves and better quality data are available form the field, better understanding on the trends as well as on the progression of the outbreak over time would be possible. Recent information received from the field suggests that number of severe cases with symptoms and signs of cholera/acute watery diarrhea reporting to health centres and hospitals might have been dropping as compared to previous week, but cumulative numbers are, probably, increasing since the surveillance coverage is expanding with more and more health centres reporting on a daily basis and due to increased public awareness, more and more cases with mild symptoms and signs synonymous with symptoms of cholera are reporting to health centres. Nevertheless, given the data that are available, it clearly shows that the transmission is still continuing and likely to spread to other adjoining districts and the risk of exposure would prevail unless the control measures can specifically target areas which remains within the epicenter of this current outbreak.

As the information flow improves over the next couple of days, public health risk assessment of the current situation could possibly be done through a more comprehensive analysis of the current epidemiological situation.