The insidious return of Cholera in the Eastern Mediterranean Region, Lebanon and Syria: a worrying signal! Past, present, and future forthcoming


history of public health
Eastern Mediterranean Region
infectious diseases
history of hygiene



War, hunger, and disease continue to decimate the populations of many countries in the world. Owing to conflicts, environmental instability and natural disasters, many people, especially the poorest, fall victim to epidemic diseases. One such disease, cholera, began to spread again in 2022, striking Lebanon and Syria, countries that have experienced serious social troubles for years. The return of cholera immediately alarmed the scientific community, which is now making every effort, most notably by implementing a major vaccination campaign, to prevent this disease from becoming endemic in these two countries, thus making them a reservoir for its potential spread in the Eastern Mediterranean Region.


Cholera is a disease that draws its strength from poor hygiene, primitive sanitation and the consumption of contaminated water and food. From the 19th century onwards, its spread was facilitated by overcrowded housing and lack of hygiene, which became commonplace features of urban life.


In outlining the spread of cholera in Lebanon and Syria, the authors raise the question of the possible resurgence of epidemic cholera, especially in the light of the consequences of the devastating earthquake that hit the border area between Turkey and Syria last February.


These events have had a devastating effect on the population, destroying, among other things, the few existing health facilities and aggravating the already difficult living conditions of millions of people who, owing to the ongoing war, have been living for years in makeshift settlements, bereft of water, sanitation and any form of health care.


Al Mandhari A, Hajjeh R, Abubakar A, Buliva E, Brennan R. Mitigating the resurgence of cholera in the Eastern Mediterranean Region. East Mediterr Health J. 2023 Jan 19;29(1):3-5. doi: 10.26719/2023.29.1.3.

Reda A, Sah R, Abdelaal A, Shrestha S, Rodriguez-Morales AJ. The emergence of cholera in multiple countries amidst current COVID-19 pandemic: Situation and implications for public health and travel medicine. Travel Med Infect Dis. 2022 Sep-Oct;49:102423. doi: 10.1016/j.tmaid.2022.102423.

Devi S. War driving cholera in Syria. Lancet. 2022 Sep 24;400(10357):986. doi: 10.1016/S0140-6736(22)01836-0.

World Health Organization. Cholera - global situation. Disease Outbreak News, 2022. Available at: (Accessed on: 31/03/2023).

Istituto Superiore di Sanità EpiCentro - L’epidemiologia per la sanità pubblica. Colera. Available at: (Accessed on: 31/03/2023).

Hempel S. The atlas of Disease. White Lion Publishing, London. 2018, pp.94-95.

Tognotti E. Storia dell’arrivo del colera negli anni Trenta dell’Ottocento. Lo shock e la cesura tra il “prima” e il “dopo”. Storicamente 2021; 7. doi: 10.52056/9788833138732/15.

Rosselli R, Martini M; Bragazzi NL, Watad A. The Public Health Impact of the So-Called "Fluad Effect" on the 2014/2015 Influenza Vaccination Campaign in Italy: Ethical Implications for Health-Care Workers and Health Communication Practitioners. Adv Exp Med Biol. 2017;973:125-134. doi: 10.1007/5584_2017_39.

Orsini D., Bianucci R, Galassi FM, Lippi D, Martini M. Vaccine hesitancy, misinformation in the era of Covid-19: Lessons from the past. Ethics, Medicine and Public Health 2022, 24, 100812

Martini M, Simonetti O, Orsini D, Armocida E, Zimmermann AP. The avid eaters of lives. New and old infectious diseases in Italy at the time of World War I: a historical overview of military medicine and public health. J Prev Med Hyg. 2022 Jan 31;62(4):E972-E980. doi: 10.15167/2421-4248/jpmh2021.62.4.2240.

Martini M, Orsini D. Achille Sclavo (1861-1930) and His Innovative Contributions to Italian Preventive Medicine and Healthcare Policy. Adv Exp Med Biol. 2022;1369:107-116. doi: 10.1007/5584_2021_673. Erratum in: Adv Exp Med Biol. 2022;1369:131-133. PMID: 34822143.

Orsini D, Martini M. The history of vaccinology and hygiene through Achille Sclavo and the cultural patrimony conserved in the archives and museums: the key role of medical museology. J Prev Med Hyg. 2022 Oct 27;63(3):E476-E481. doi: 10.15167/2421-4248/jpmh2022.63.3.2622.

Bartolozzi G. Vaccini e vaccinazioni. III ed. Milano: Elsevier; 2012, pp.209-300.

Albert MJ. Vibrio cholerae O139 Bengal. J Clin Microbiol. 1994 Oct;32(10):2345-9. doi: 10.1128/jcm.32.10.2345-2349.1994.

Faruque SM, Chowdhury N, Kamruzzaman M, Ahmad QS, Faruque AS, Salam MA, Ramamurthy T, Nair GB, Weintraub A, Sack DA. Reemergence of epidemic Vibrio cholerae O139, Bangladesh. Emerg Infect Dis. 2003 Sep;9(9):1116-22. doi: 10.3201/eid0909.020443.

Steinberg EB, Greene KD, Bopp CA, Cameron DN, Wells JG, Mintz ED. Cholera in the United States, 1995-2000: trends at the end of the twentieth century. J Infect Dis. 2001 Sep 15;184(6):799-802. doi: 10.1086/322989.

Khan HA, Masood W, Siddiqui A, Ahmad S, Salman Y, Essar MY. The Cholera outbreak in Karachi, Pakistan: Challenges, efforts and recommendations. Ann Med Surg (Lond). 2022 Jun;78:103873. doi: 10.1016/j.amsu.2022.103873.

Global Task Force on Cholera Control - GTFCC. Ending Cholera: A Global Roadmap to 2030. Geneva: World Health Organization. Available at: (Accessed on: 31/03/2023).

Cfr. Malaeb D, Sallam M, Younes S, Mourad N, Sarray El Dine A, Obeid S, Hallit S, Hallit R. Knowledge, Attitude, and Practice in a Sample of the Lebanese Population Regarding Cholera. Int J Environ Res Public Health. 2022 Dec 4;19(23):16243. doi: 10.3390/ijerph192316243.

Brennan R, Hajjeh R, Al-Mandhari A. Responding to health emergencies in the Eastern Mediterranean region in times of conflict. Lancet 2022 Apr 2;399(10332):e20-e22. doi: 10.1016/S0140-6736(20)30069-6.

Martini M, Orsini D. Armed conflict in the world threatens the eradication of Poliomyelitis: risks of humanitarian crises. Pathog Glob Health. 2022 Jul;116(5):267-268. doi: 10.1080/20477724.2022.2081785.

OCHA Office for the Coordination of Humanitarian Affairs. Syrian Arab Republic: Earthquakes - Situation Report No. 4, as of 16 March 2023. 19 March 2023. Available at: (Accessed on: 31/03/2023).

OCHA Office for the Coordination of Humanitarian Affairs. Syrian Arab Republic: Earthquakes - Syria Situational Updates - As of 1 March 2023. 1 March 2023. Available at: (Accessed on: 31/03/2023).

OCHA Office for the Coordination of Humanitarian Affairs. Syrian Arab Republic: NORTH-WEST SYRIA Situation Report. Last updated: 31 Mar 2023. Available at: file:///C:/Users/user/Downloads/Situation%20Report%20-%20North-west%20Syria%20-%2031%20Mar%202023.pdf (Accessed 02/04/2023).