Monsoon and cholera outbreaks in Pakistan: a public health concern during a climate catastrophe : IJS Global Health

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Monsoon and cholera outbreaks in Pakistan: a public health concern during a climate catastrophe

Jamil, Hashaam MBBSa; Liaqat, Arslan MBBSb; Lareeb, Iqra MBBSc; Tariq, Waleed MBBSa; Jaykumar, Vadodariya MBBSd; Kumar, Lakshya MBBSd; Tahir, Muhammad J. MBBS, BSce; Anjlee, Fnu MBBSf; Naseem Shah, Syed MBBSg; Asghar, Muhammad S. MBBSh,*

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International Journal of Surgery: Global Health 6(1):p e105, January 2023. | DOI: 10.1097/GH9.0000000000000105
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The monsoon season affects several areas in Pakistan, resulting in floods, landslides, and severe weather-related diseases, having major humanitarian impact. According to the National Disaster Management Authority (NDMA), as of August 1, 2022, due to monsoon 478 people have died across Pakistan. The Ministry of Foreign Affairs had requested humanitarian assistance from the United Nations (UN) and the international community for persisting calamities caused by floods and heavy rainfall across the country1. The monsoon is the primary rain-producing system for South Asia and a significant contributor to overall rainfall. An average of 579,732 people are adversely affected each year, ranking Pakistan ninth among countries impacted by floods globally2. Flood-affected areas are excellent breeding grounds for pathogens, leading to the spread of waterborne diseases as diarrhea, hepatitis, cholera, typhoid, malaria, dysentery, and giardiasis.

Cholera is the leading water-borne endemic associated with monsoon rainfall caused by Vibrio cholera, a gram-negative, noninvasive bacterium causing severe watery diarrhea can result into severe dehydration and even death. V. cholera is responsible for severe epidemics of cholera and endemic diarrhea worldwide, especially in developing countries. Cholera, which can be epidemic, endemic, or even pandemic, is caused by the 2 toxic serogroups of V. cholera: O1, and O1393. Oral or intravenous rehydration is the main treatment modality for cholera. The antimicrobial administration is indicated only in severe cases, reducing the severity and length of disease. Tetracyclines (eg, doxycycline), fluoroquinolones (eg, ciprofloxacin), macrolides (eg, erythromycin), and trimethoprim/sulfamethoxazole have commonly been used to treat cholera4. Antimicrobial drug resistance, however, has the potential to compromise the efficacy of antibiotic therapy. The currently available oral cholera vaccines are live attenuated vaccines that require the administration of 2 subsequent doses with a gap of 2 weeks. It exhibits 83% effectiveness during the first year and effects lasting for as long as 5 years5.

Globally, it is estimated that 1.3–4 million cases and 21,000–143,000 deaths are attributable to cholera, annually6. Cholera is one of the seasonal endemic in Pakistan7. A cholera outbreak burst in Karachi in 2003 following monsoon rainfall. Between 2005 and 2009, the Disease Early Warning System (DEWS) teams responded to 261 alerts and 46 outbreaks of acute watery diarrhea/suspected cholera all over Pakistan8. A total of 4610 cases of suspected cholera were reported by the Ministry of Health (MOH) Pakistan in 2006. Similarly, in 2010, MOH reported 99 cases of V. cholera O17. An unprecedented rise in cholera has been reported in Pakistan since the beginning of 2022, making it a rising health threat. The Field Epidemiology and Disease Surveillance Division (FEDSD) of the National Institute of Health (NIH), as of April 17, 2022, have reported 6231 suspected cases of cholera9. In monsoon spell, 2022, 500 cases have been reported in District Zohb, Balochistan within 4 days, and an emergency has been declared10. The spread of illnesses is facilitated by the excellent breeding conditions provided by rain-affected areas. Stagnant pools of water serve as ideal breeding habitats for pathogens resulting in diarrhea and other waterborne diseases. Furthermore, the subpar standards of hygiene in flood relief camps contribute to disease transmission. Poor sanitation systems and inaccessibility to clean water are the common practices in the underdeveloped rural areas affected majorly by heavy rainfall and floods. The inability of the disaster control management to be prepared for seasonal calamity, poor surveillance systems, lack of public health control activities, and awareness about waterborne diseases are the leading factors contributing to seasonal cholera outbreaks.

Globally, health crisis due to natural disasters are common in developing regions. These adversities are a particular challenge for health care systems. The following immediate actions should be taken by the International and national health and disaster management authorities to combat the formidable threat of cholera in monsoon-affected areas: (i) there is an overwhelming need to develop nationwide cholera surveillance and reporting systems. Surveillance for early case detection, confirmation, and response should be reinforced. (ii) The government must launch cholera vaccination campaigns to control cholera outbreaks in high-risk areas and promote self-administration of the second oral cholera vaccines dose, which is a potential way to improve full vaccination coverage and reduce the vaccine implementation cost. (iii) Authorities must ensure nationwide access to clean water, sanitation, and hygiene (WASH) activities. Improving access to clean water, proper sanitation, awareness about hygiene practices and food safety are effective means to prevent cholera outbreak. Infection control and prevention activities should be promoted among health care workers and general public. (iv) The general public should be informed of the risks and encouraged to engage in community activities that promote cholera prevention, early care seeking, and treatment. (v) The treatment of infected patients should be ensured by the easy availability of medical supplies as oral and intravenous rehydration and antibiotics. The early effective management of cholera prevents from disease severity and reduces the morbidity and mortality and control epidemics. (vi) A centralized strategy should be implemented to conduct cholera control programs and raise awareness to incorporate behavioral changes and improve living standards at the community level.

Ethical approval


Sources of funding


Author contribution

H.J., M.J.T., and W.T.: conceived the idea. A.L., V.J., I.L., and L.K.: retrieved the data A., and S.N.S., write up of manuscript. M.S.A, W.T., and M.J.T.: reviewed and provided inputs. All authors approved the final version of the manuscript.

Conflict of interest disclosures

The authors declare that they have no financial conflict of interest with regard to the content of this report.

Research registration unique identifying number (UIN)



Muhammad S. Asghar.

Provenance and Peer Review

Externally peer reviewed, not commissioned.

Data statement

No datasets generated.




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