Widespread cholera outbreaks have forced health agencies to ration vaccines, raising questions about affected countries’ public health infrastructure. The disease has already infected hundreds of thousands of people this year, The New York Times reports. As a result, the International Coordinating Group (ICG), which manages the distribution of emergency vaccines and is made up of members of the World Health Organization (WHO) and humanitarian groups such as Doctors Without Borders and UNICEF, has recommended giving out just one vaccine dose per person instead of the full two-dose regimen, the WHO announced in a press release earlier this month (October 19).

Cholera is a bacterial infection typically spread through the ingestion of contaminated food or water. According to the Centers for Disease Control and Prevention (CDC), the main symptoms are profuse diarrhea and vomiting, resulting in severe dehydration. That dehydration leads to kidney failure, shock, and death in 3 percent of cases on average, but outbreaks from the past few years exhibited higher death rates, the Times reports.

According to the WHO press release, cholera cases have been reported in 29 countries this year, with particularly large outbreaks occurring in Haiti, Malawi, and Syria. This a sharp departure from the average of fewer than 20 afflicted countries per year over the past five years, the release adds, stating that flooding, drought, conflict, and human displacement have driven up the infection rate.

The increase in cases has worsened strain on public health infrastructure in the impacted areas, and officials are now figuring out how to distribute a limited supply of vaccines. Of the 36 million cholera vaccine doses slated for production this year, 24 million have already been distributed. Another eight million are approved for emergency vaccination in four of the affected countries, the press release continues. This leaves little room for emergency vaccination in the other affected countries and even less for preventative vaccination in vulnerable neighboring countries, the Times reports. The growing number of cases and “dire shortage” of the vaccine prompted the ICG recommendation for rationing, the WHO release states. While the vaccine’s protective capabilities and the duration of benefit are reduced without the second shot, the release argues that “the benefit of supplying one dose still outweighs no doses.”

“There is just not enough vaccine,” Daniela Garone, the international medical coordinator for the humanitarian organization Doctors Without Borders, tells the Times. “And it’s the chicken or the egg: Do you prevent or you react? At the moment we are only on the reacting, trying to prevent mortality, and we cannot prevent.”

As of today (October 31), France had begun distributing cholera vaccines in Lebanon, Reuters reports. Lebanon had been cholera-free since 1993 until its current outbreak, which likely reached the country from neighboring Syria and was exacerbated by ongoing economic crisis, Reuters adds.

“We have now dedicated 70% of our beds to cholera cases,” Mohamad Khodreen, director of Abdallah Elrassi public hospital in Akkar, Lebanon, tells the BBC. Reuters reports that French ambassador to Lebanon Anne Grillo told reporters that the outbreak was “a new and worrying illustration of the critical decline in public provision of access to water and sanitary services in Lebanon.”

Seth Berkley, the chief executive officer of GAVI, an organization that manages cholera vaccines globally, tells the Times he expects as many as 5 million doses could still be produced by the end of this year, and that as many as an additional 7 million could be made available from canceled requests. Despite growing case counts, the Times reports that cholera treatment can be simple and inexpensive, often requiring only rehydration salts and antibiotics. “Even countries that have not been exposed to cholera before, they can learn quickly,” Garone tells the publication.