Rami Abi Ammar
Copyright © 2022 BUTEC.
Cholera is an acute diarrheal disease arising from the ingestion of the Vibrio cholerae bacterium through fecally-contaminated water or food. People infected with cholera may lose up to 25 liters of fluid per day due to vomiting and diarrhea. The loss of fluid and salts can cause severe dehydration and death within hours if patients are not treated promptly and adequately. Cholera outbreaks are often linked to poor water and sanitation infrastructure that facilitates the spread of the bacterium within water and food systems. As such, the risk of cholera epidemics is higher in humanitarian emergency settings, including settlements and crowded areas of displaced populations that lack adequate access to clean water, sanitation and health services. The incubation period of the Cholera bacterium is relatively short (between two hours and five days); therefore, the number of cases and fatalities can increase rapidly, creating serious public health concern.
Common Sources of Cholera Transmission
Cholera in Lebanon
Lebanon declared its first case of cholera in nearly three decades in October 2022. The World Health Organization (WHO) has graded the overall national risk of a cholera outbreak in Lebanon as very high, following high risk of outbreak on the regional level. The main circulating strain in Lebanon has been identified as serotype Vibrio cholerae O1 El-Tor Ogawa. The strain seemingly originated from a very recent outbreak in Syria, which has been traced to the Euphrates River, having already spread through Afghanistan, Pakistan, Iran and Iraq.
A total of 3,369 suspected and 536 laboratory-confirmed cholera cases have been reported by the Ministry of Public Health (MoPH) in Lebanon as of November 13. The case fatality ratio has been estimated at around 0.5%, with a total of 18 associated deaths. Around 45% of cases have been reported in individuals under 15 years of age, 26% of which are infants under 5 years of age. The second highest incidence of cholera is among individuals in the 25 - 44 age group, accounting for 22% of suspected and confirmed cases.
Cholera is spreading rapidly across Lebanon, with cases reported in 20 of the 26 districts. As seen in Figure 1, cases remain concentrated within the Akkar and the North Governorates, but have also spread across the Bekaa, Mount Lebanon and Baalbek-Hermel.
Bebnine in Akkar has recorded the highest number of cases, reaching 136 confirmed infections, Additionally, Rihaniyeh in Minniyeh-Danniyeh, Halba in Akkar and Aarsal in Baalbek-Hermel were among the first localities to report infections in early October 2022.Understanding the challenges in Bebnine can provide much-needed insight into the origin and mechanisms of the spread of cholera to other parts of the country.
Figure 1. Locality and number of laboratory-confirmed cases of cholera in Lebanon as reported by MoPH on November 13, 2022. (Source: MoPH)
Many patients being treated in the area are part of vulnerable communities, mainly Syrian refugees in informal settlements that lack adequate water supply and sanitation infrastructure. These communities rely on unsafe water from private tankers for household use, often with improper wastewater disposal that risks further contamination of surface and groundwater sources. Open defecation is sometimes reported in these settlements, increasing the risk of contamination with Cholera and other water-borne pathogens.
Even outside tented settlements, water security in the North is also considered poor. A 2018 IFI assessment considered that household and environmental water security (which reflect water quality) within the jurisdiction of the North Lebanon Water Establishment (NLWE) as relatively low. This is mainly attributed to intermittent public water provision, inadequate wastewater collection and treatment, and poor surface and groundwater quality. Electricity cuts and impacts of the economic crisis have further exacerbated the situation, forcing residents to rely even more on unregulated private supply tankers.
Figure 2. The towns of Bebnine in Akkar, Rihaniyeh in Minnieh-Danniyeh and their surroundings form the epicenter of the cholera outbreak in Lebanon. (Source: IFI).
Untreated or potentially contaminated wastewater discharged from households and informal settlements risks contaminating water sources used in irrigation. As seen in Figure 2, large areas in Bebnine and its surroundings are used for agriculture, including irrigated sheltered (greenhouse) fruit and vegetable products. The presence of irrigation water sources close to cholera epicenters pose a great risk to food systems, which can act as a medium for the spread of the bacterium beyond North Lebanon.
Water Sector Challenges at the Epicenter
The outbreak has come at a time when Lebanon is still struggling with a crippling economic crisis that has weakened its public health system and worsened already degraded and underinvested water and sanitation services. The rise in fuel prices and ensuing power outages have also greatly impacted the capacity of water establishments to supply and treat water.
Even before the crisis, water ecosystems in the North and Akkar Governorates were characterized by overall poor ecological integrity and health, primarily caused by anthropogenic stress. A major area of concern stems from the very low percentage of wastewater being treated, which constitutes a pervasive source of pollution to water bodies leading to a decrease in their overall health. Only around 21% of wastewater was treated annually by the NLWE pre-crisis.
The lack of treatment of most wastewater, and hence the rise of cholera cases, is directly linked to the absence of wastewater collection systems in many areas and/or non-operational
Figure 3. Towns at the epicenter of the cholera outbreak in Lebanon lack sewage collection infrastructure (under construction in Bebnine and not existing in Rihaniyeh). Two of three wastewater treatment plants in the area are non-operational and lack connection to water users. (Source: IFI)
wastewater treatment plants (WWTP). In the absence of these plants, raw sewage is discharged into water bodies (surface and subsurface) and diverted to agricultural land, leading to contamination of soil and surface and groundwater sources.
In Bebnine and its surroundings, wastewater infrastructure is virtually non-existent. As illustrated in Figure 3, two non-operational WWTPs are located in the vicinity of the cholera epicenter, and only one operational WWTP exists in nearby Hmaira. However, given the current lack of power supply by national utility Electricite du Liban and the high cost of fuel needed to operate electricity generators, even operational WWTPs cannot operate at full capacity, if at all. Furthermore, sewage networks do not exist outside Hmaira and Majdala, most being under construction or in the proposal stage (see Figure 2).
Water quality is therefore greatly compromised in these areas. Additionally, water establishments in Lebanon do not have a systematic approach to monitor water quality across their jurisdictions. Neither water establishments nor the Ministry of Energy and Water (MoEW) have local or national water safety plans or quality monitoring programs for drinking water. Water sources are often tested on an ad hoc basis, following complaints or reported incidents of contamination. Even then, water establishments and the MoEW lack the specialist capacity and facilities to regularly sample and test water at various stages of transmission and distribution, or to do so with sufficient coverage. These shortcomings greatly increase the risk of infection of subscribers and vulnerable communities alike.
Water Sector Emergency Response
Reducing the spread of the Cholera bacterium requires ensuring access to safe water to both affected and unaffected areas. This can be ensured by the chlorination of bulk water supplies, including municipal water and tanker trucks, while monitoring and maintaining an adequate chlorine residual at points of collection and at the household level.
In response to the current outbreak, international aid has provided the financing and materials to limit the spread of the bacterium. This includes over 216,000 liters of fuel provided to operate water pumping stations and wastewater lift stations across the country, including Tripoli’s WWTP, to ensure safe water supply to and in affected areas and their surroundings. In addition, 20 tonnes of chlorine powder have been provided to the four water establishments and for distribution to municipalities in Akkar (including Bebnine) to chlorinate private tanker water supplies. UNICEF has undertaken the rehabilitation of the water supply system in Bebnine. In Aarsal, ICRC has undertaken the rehabilitation of the solar energy system of the Wadi Sweid and Wadi Matlab Pumping Stations.
Beyond Emergency: Maintaining Water Quality and Managing Future Risks
While emergency response is vital for reducing the further transmission of cholera across the country and the region, long-term improvements in water supply and sanitation are necessary in preventing the occurrence and spread of cholera and other water-borne diseases. Water establishments should be empowered through investment in infrastructure and capacities to better prepare and respond to future shocks.
Rehabilitation of existing non-operational WWTPs and increasing the capacities and efficiency of operational plants is crucial in ensuring safe, sustainable household and agricultural water supply. Investments in solarization of WWTPs could allow water establishments to operate outside the constraints of rising fuel prices and optimize energy efficiency within their networks. All this must go hand in hand with increasing the coverage of sewage networks and ensuring existing wastewater collection infrastructure operates without leaks or risks of contaminating water, food or soil. Reuse of collected and treated wastewater also reduces the stress of over-abstraction of groundwater resources, further impacted by climate change in the long run.
Capacities of water establishments to monitor and manage their networks must be reinforced. This includes the systemization of water testing and quality monitoring. The development of national and regional water safety or quality monitoring plans would help establish coordinated control measures able to reduce the risk of future outbreaks. These plans must be supported with staffing, expertise, and facilities to optimize the monitoring and response process with the establishments.
Most of the cases are concentrated in the Governorates of Akkar and North Lebanon, in villages of the Akkar and Minnieh-Dannyieh districts. Many cases are also being reported in Aarsal in the Baalbek-Hermel Goveronorate, Zahle in the Bekaa Governorate, and to a lesser extent in Beirut and Mount Lebanon.
 Bebnine, Rihaniyeh and their respective surroundings have a concentration of informal settlements housing vulnerable communities that lack access to water and sanitation infrastructure. Land use in the area is predominantly agricultural, including irrigated sheltered agriculture, field crops, fruits, olives and citrus. Groundwater irrigation wells in these towns may be at risk of contamination with Cholera and in turn contaminate local agricultural produce that could reach other parts of the country
 As an example, the highest number of Cholera infections in Yemen were reported in localities where WWTPs are non-functional.
 Under USAID-funded project “Water Sanitation and Conservation,” IFI is developing Water Safety Plans for the four regional water establishments and the Litani River Authority to be implemented throughout 2023 and 2024.