Skip directly to site content Skip directly to page options Skip directly to A-Z link Skip directly to A-Z link Skip directly to A-Z link
Volume 14, Number 6—June 2008

Conflict and Emerging Infectious Diseases

Article Metrics
citations of this article
EID Journal Metrics on Scopus

Cite This Article

To the Editor

In the November 2007 issue of Emerging Infectious Diseases, Gayer et al. (1) describe how conflict leaves populations in dire poverty, internally displaced or seeking asylum, having poor access to essential services, and consequentially vulnerable to infectious diseases.

Cholera, caused by the bacterium Vibrio cholerae, is a disease that seems particularly sensitive to conflict and deserves more consideration. Major risk factors for cholera—poverty, overcrowding, poor hygiene, contaminated food, and lack of safe drinking water (2,3)—largely resemble the consequences of war and civil fighting. Yet little is known about the relationship between cholera and conflict. This lack of information may be because cholera tends to be epidemic, affecting hundreds to thousands of people across vast, war-torn regions, making it impossible for local governments, nongovernment organizations, and aid workers to control, let alone collect and analyze data.

Examination of data sources listed by Gayer et al. (1) and recent reviews (2,3) indicate that cholera occurs 1) in countries during war and civil unrest, as exemplified by the latest outbreaks among displaced populations across northern Iraq; 2) in neighboring countries, where temporary camps accommodate masses of political refugees under poor conditions, such as those in eastern Chad near Darfur, Sudan; and 3) during the postwar period when large numbers of repatriated persons return home and consequently place undue pressure on an eroded and fragile national infrastructure, as evident in Angola in recent years.

Appendix Figure

Thumbnail of Geographic distribution of recent emerging or reemerging infectious disease outbreaks and countries affected by conflict, 1990–2006. Countries in yellow were affected by conflict during this period (source: Office for the Coordination of Humanitarian Affairs, World Health Organization, Symbols indicate outbreaks of emerging or reemerging infectious diseases during this period (source: Epidemic and Pandemic Alert and Response, World Health Organization, Circles indicate diseases of viral origin, stars indicate diseases of bacterial origin, and triangles indicate diseases of parasitic origin. CCHF, Crimean-Congo hemorrhagic fever; SARS-CoV, severe acute respiratory syndrome coronavirus

Appendix Figure. Geographic distribution of recent emerging or reemerging infectious disease outbreaks and countries affected by conflict, 1990–2006. Countries in yellow were affected by conflict during this period (source: Office for the Coordination...

Moreover, all the countries affected by conflict shown in the Appendix Figure by Gayer et al. (1) have reported cholera outbreaks (24). They are also among the poorest countries in the world; the latest statistics on human development (5) indicate that compared with all developing countries, on average they have higher rates of undernourishment, refugees, child deaths, and less adequate water and sanitation facilities. Thus, more information is needed about conflict and cholera, especially in Africa.


Louise A. Kelly-Hope*Comments to Author 
Author affiliation: *Liverpool School of Tropical Medicine, Liverpool, UK



  1. Gayer  M, Legros  D, Formenty  P, Connolly  MA. Conflict and emerging infectious diseases. Emerg Infect Dis. 2007;13:162531.PubMedGoogle Scholar
  2. Gaffga  NH, Tauxe  RV, Mintz  ED. Cholera: a new homeland in Africa? Am J Trop Med Hyg. 2007;77:70513.PubMedGoogle Scholar
  3. Griffith  DC, Kelly-Hope  LA, Miller  MA. Review of reported cholera outbreaks worldwide, 1995–2005. Am J Trop Med Hyg. 2006;75:9737.PubMedGoogle Scholar
  4. World Health Organization. Cholera surveillance and number of cases. 2007 [cited 2007 Dec 10]. Available from
  5. United Nations Development Programme. Human development report 2007/2008. Fighting climate change: human solidarity in a divided world. 2007 [cited 2007 Dec 12]. Available from




Cite This Article

DOI: 10.3201/eid1406.080027

Related Links


Table of Contents – Volume 14, Number 6—June 2008

EID Search Options
presentation_01 Advanced Article Search – Search articles by author and/or keyword.
presentation_01 Articles by Country Search – Search articles by the topic country.
presentation_01 Article Type Search – Search articles by article type and issue.



Please use the form below to submit correspondence to the authors or contact them at the following address:

Louise A. Kelly-Hope, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK;

Send To

10000 character(s) remaining.


Page created: July 09, 2010
Page updated: July 09, 2010
Page reviewed: July 09, 2010
The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.