An alarming outbreak of  meningitis has been gripping the Kurdistan Region of Iraq (KRI) since mid-April. Reminiscent of the early stages of the COVID-19 pandemic, however, the lack of information and transparency surrounding the disease has hindered efforts to understand its causes and the affected population. Informal reports suggest that the number of patients is approaching a thousand, with a potentially climbing death toll. While the World Health Organization (WHO) has identified enterovirus and streptococcus as the (probable) main pathological causes, wider determinants such as water scarcity, tourism, inadequate school water supply, the climate crisis, political instability, and a struggling health system all contribute to the emergence of these outbreaks and the severity of their consequences.

One potential determinant of the outbreak is certainly the scarcity of water resources in the region. Contaminated drinking water is a likely medium of transmission of the main causative agent (enterovirus) which spreads commonly through faecal transmission. Halabja City, the epicenter of the outbreak, lacks a water treatment plant and heavily relies on springs and underground water sources, resulting in insufficient and contaminated water supply. Moreover, the deterioration of distribution facilities across the Kurdistan Region has led to increased leakage rates. Previous cholera outbreaks in the region have been attributed to the deterioration of water pipes and the contamination of distribution pipelines due to open sewage channels and old sewage pipes.

Furthermore, the outbreak might be related to the influx of tourists (mostly from central and southern Iraq) over the last few months prior to the outbreak. The peak tourist season in the Kurdistan region from April to October attracts a significant number of visitors. In 2022, for example, over 6 million tourists visited the region, doubling its population. The influx of tourists places further strain on the already stretched water infrastructure. Particularly, the proximity of tourists to the River Diayla raises concerns about potential water contamination.

Inadequate school water supply is another factor that is likely contributing to the high rate of meningitis among school children. UNICEF reports indicate that only 50% of schools in Iraq lack basic water, sanitation and hygiene services. This lack of access to clean water is posing a risk of waterborne diseases to students including meningitis.

Iraq and its Kurdistan region have also been grappling with recurrent droughts, desertification, and other manifestations of the climate crisis. Reduced rainfall and snowfall have caused a rapid decline in water levels, affecting springs and shallow wells in the Erbil and Dohuk governorates. Groundwater levels have dropped by about 30-40 meters over the past decade, highlighting the vulnerability of the Kurdistan Region to environmental challenges.

Then there’s “(geo-)politics and governance”. The impact of conflict, political instability, mismanagement, including misallocation and neglect, have also put the region at increased risk of such outbreaks. Insufficient environmental regulation, poorly maintained distribution networks, inadequate sanitation infrastructure, and limited ecological awareness, … are just some of the examples through which the impact of politics & governance is felt. The ongoing political crisis, with a divided regional administration, also threatens the fragile stability achieved after the defeat of ISIS.

Finally, the health system in Kurdistan faces major challenges due to a critical shortage of staff, essential medicines, and supplies. Years of poor investment and rampant corruption have resulted in a strained health system. Lack of employment of new health workers, salary cuts, delays, and rising inflation further compound the situation.

To effectively tackle the meningitis outbreak, a multisectoral approach is thus required, with a particular focus on water, sanitation, and hygiene (WASH) measures. While enhanced surveillance and laboratory capacities are crucial, a WASH-centered strategy should be implemented to curb the spread of the disease. Transparency and data sharing by health authorities is also crucial in guiding policies and interventions. Iraq’s country office of WHO is in an excellent position to coordinate a multisectoral WASH-centered approach to tackle this crisis, by the way.

Finally, WHO should also apply on behalf of Kurdistan for the International Coordinating Group meningitis vaccine stocks and encourage Iraq to include meningitis vaccination as part of the country’s routine vaccination programme.