Cholera 3 – Haiti

Cholera 2

October 29, 2010

I am writing from Petite Riviere near the epicenter of the cholera outbreak in Haiti in response to questions posed by a journalist from Agenzia Fides, a Catholic news service.

 

D. What news do you have about the situation in Haiti with regard to cholera?

Stando alle ultime informazioni dell’Oms, sono stati confermati un centinaio di casi di colera tra le popolazioni profughe del Pakistan ed Haiti. Quali notizie potete darci al riguardo?  

It is difficult to give exact details about this ever-changing cholera epidemic in Haiti, a country still suffering from the effects of the Jan. 12 earthquake that devastated a people that were already subject to a very underdeveloped social and healthcare infrastructure. In any case, the number of confirmed deaths from the cholera epidemic in Haiti as of 10/26 has surpassed 300. And these have been confined largely to the Artibonite region where the illness first appeared. There thousands of people have presented with watery diarrhea, fever and severe dehydration – signs of a possible cholera infection. The appearance of cholera was much unexpected in a country that had not seen an outbreak of the illness in more than half a century.

The death rate from the disease seems to be diminishing though. People are becoming more aware of the disease and health experts are providing treatment and emphasizing prevention through correct hygiene. This is taking place at a series of medical facilities in the Artibonite region. As of 10/27 the death rate was around 7.7 percent — well above the 1 percent or below that the WHO considers normal, but below the 10 percent seen when the outbreak appeared last week, according to Dr. Claire Lise Chaignat,  head of the WHO global task force on cholera control.

On October 27, Chaignat said “We have a serious cholera epidemic going on in Haiti,” Latest WHO figures show that 3,769 people have caught cholera in Haiti of whom 284 have died. The disease is spread by bacteria in contaminated water and food. And cholera can kill in 24 to 48 hours from dehydration and subsequent circulatory collapse. It is too soon to say when the outbreak will peak but the number of deaths and reported cases seems to be diminishing. The large number of medical staff and aid workers in Haiti since the earthquake mean there is a good chance of controlling the disease.

In all the people of Haiti seem to be facing this newest challenge, cholera, with their usual strength, and a full determination to plow ahead. The country is still suffering from the effects of the January 12 earthquake though. Recent figures indicate that there are some 1,300 camps for internally displaced persons that number around 1,500,000 – many living in and around the capital Port au Prince.  

Doctors Without Borders (MSF) reports on 10/28 that in St. Marc at St. Nicholas Hospital, near the epicenter of the outbreak, around 450 patients were treated each of the previous 2 days – including those who received oral rehydration solution (ORS) and intravenous treatment. An isolation unit was established for cholera patients, but of late, people have been arriving in less severe condition than in days past. It suggests that people are taking precautions and that there is a greater understanding in the community of the need to maintain strict hygiene and to seek medical assistance at the first sign of symptoms.

At Charles Colimon Hospital in Petite Riviere out of which CTF-SOS DRS is based and that MSF is coordinating, there have been  more than  500 cases of acute watery diarrhea that have been treated with IV or oral hydration. The number of cases arriving everyday is in the range of 60 and has been steady for several days now. The hospital is full of children and adults who are distributed in tents and receiving treatment as appropriate according to defined protocols. In all there are 8 cholera prevention/treatment centers in the Artibonite region. MSF is planning to construct a large 400-bed center in St. Marc that should be ready by now.

It is important to think about Port au Prince as well when thinking about the epidemic. Cholera is very contagious and can spread quickly, which could present a great threat to those living in the camps in and around Port au Prince if the illness arrives there.

On 10/23 it was reported that there were 5 cases of cholera in metropolitan Port au Prince. All of these cases represented people who had traveled from the Artibonite region. MSF reported on 10/27 that 34 people suffering from diarrhea presented at their facilities in Port au Prince. However, cases of watery diarrhea (AWD) that did not involve cholera have not been uncommon in Port-au-Prince since the January 12, 2010 earthquake.

MSF has a 20-bed cholera treatment center in place and is undertaking necessary measures and preparations at its Port-au-Prince facilities for any additional patients who present with cholera-like symptoms. Confirming cholera requires lab testing, but the treatment for cholera and AWD are the same, beginning with rehydration.

CTF-SOS DRS together with Doctors of the World, another NGO in Port au Prince, is looking to open up a 4-8 bed cholera prevention/treatment facility in Solino next to a camp containing 6,500 internally displaced persons (IDPs).

Because Leogane, a city right near the heart of the epicenter of the January 12 seismic event, is also home to many camps with IDPs, an additional cholera treatment center will be constructed there with 800 beds.

D. What are the cases of cholera due primarily to: precarious sanitary conditions, a lack of drinking water, a shortage of medical assistance?

Le cause sono dovute prevalentemente alle precarie condizioni sanitarie nelle quali vertono, la mancanza di acqua potabile e di assistenza specifica?

Exactly why Haiti was struck by this cholera epidemic at this point and with such devastating results is not totally clear. There had been no documented outbreak of the disease in Haiti since 1960.  In fact, the US Centers for Disease Control and Prevention (CDC) said after the earthquake that while cholera testing should be carried out, the disease was “extremely unlikely to occur”.

So why has the epidemic struck now? It is not clear if the cause of the outbreak will ever be identified, but health experts agree that for cholera to occur, bad sanitation and hygiene have to coincide with people carrying the vibrio cholerae bacterium.

Sanitary conditions were poor in many parts of Haiti even before the earthquake, and it would be a stretch to link the outbreak directly with the quake.

Central Haiti [Artibonite] where most people have been infected was not the region most affected by the earthquake.  The cholera bacteria could have been present in the Artibonite River or a stagnant water source even before the earthquake. On the other hand, some are suggesting that the bacterium was imported and dumped into the river – maybe even by members of the United Nations. This last theory has not been substantiated though it is suggested in a paper of repute, Le Nouvelliste.  Surveillance data on cholera in Haiti are not available. However, watery diarrhea has been common in the country, causing 5% to 16% of the deaths among Haitian children according to Center for Disease Control data. With diarrhea so prevalent and no stringent monitoring by health authorities and 80% of those with symptoms showing only moderate signs of infection, sporadic cases of cholera might not have registered by the Ministry of Health. Presenting another challenge is the fact that around 75% of people infected with vibrio cholerae do not develop symptoms. But they excrete the bacterium with their feces for up to 14 days – a potential source of infection for others. Those that are infected need to receive treatment immediately, If not, the death-rate of cholera can rise up to 50%.

In the end, it is difficult to predict when, why and where a cholera outbreak will take place. And then controlling it once there is an epidemic is quite a challenge. It is a matter of breaking the cycle of the disease. And the potentially deadly cholera cycle can only be broken when people also stay away from the contaminated water source until the bacteria have cleared.  

The present epidemic Haiti is a perfect example of this. However, at a minimum one can say that the following contributed in one way or another to the outbreak and eventual spread of cholera: a source of water contaminated with the bacterium vibrio cholerae – most likely the Artibonite River [used for washing and drinking], a decreased immunity to the infectious agent, insufficient hygiene and sanitary conditions, a diminished awareness concerning the signs and symptoms of the illness in both the affected population and healthcare providers, and the varying availability of clean drinking water. Finally, and unfortunately, as soon as people have been infected with cholera and excrete the bacteria, the epidemic spreads very quickly. On the other hand, the health care workers in Haiti – here because of the post-earthquake relief effort, while not being able to prevent the beginning of the epidemic, nevertheless have been able to effectively limit its spread – through prevention and through providing rehydration to replace water and electrolytes and antibiotics. Among those helping in this regard are the Ministry of Health, MSF and teams from Our Little Brothers and Sisters Hospital in Port au Prince. CTF-SOS DRS is playing a significant role as well.     

D. What must be done to prevent the situation from getting worse?

Di cosa c’è bisogno per evitare che la situazione si aggravi?

From the previous answer it is clear that avoiding the contaminated source of water, practicing good hygiene, improving sanitary conditions, providing prompt medical assistance, drinking clean water, and heightening an awareness of the illness on the part of all will go a long way in preventing the situation from getting worse. Saying a prayer or two would help as well!

A major emphasis should also be placed on preventing the spread of the illness to the camps and elsewhere in Port au Prince, having an early warning system in place to detect new cases, and then have cholera prevention and treatment centers strategically located in and around Port au Prince should the epidemic spread to the city. Unfortunately, predicting when, where and why an epidemic will erupt is very difficult. So even if there is a lull in the number of cases in the Artibonite and no new cases in Port au Prince, there could be a recrudescence and a new epidemic. If that happens in Port au Prince the results could be devastating.

Similarly, there is a need to work with the neighboring Dominican Republic in case cholera spreads there. The World health Organization (WHO) is doing that. The Pan American Health Organization, the regional office of the WHO, has said there is a “high risk” of the cholera spreading across the border of the island of Hispaniola to Dominican Republic. The border has not been formally closed but last Monday Dominican Republic authorities canceled the regular farm market normally held in the northern frontier town of Dajabon, and prevented hundreds of Haitians from crossing to attend it.

The main thing now is to contain the infection. The Ministry of Health and foreign organizations working in public health are trying to contain the spread of cholera by having people treated in centers in the Artibonite valley, as opposed to going to Port-au-Prince or other centers away from the Artibonite River, the source of contamination. There are also vigorous instructions on the radio as to the importance of thorough hand washing and proper food preparation.

The U.N., the government, and its foreign aid partners are expecting the disease to spread further in its epidemic phase. They have launched a combined treatment, containment and prevention strategy for the whole country, monitoring especially for new outbreak pockets in Port au Prince and elsewhere: The U.N. has said a nationwide outbreak with tens of thousands of cases is still “a real possibility”. So Health Minister Alex Larsen announced the government would train 30,000 health workers to join the anti-cholera campaign across the nation in the coming months.

D. What are the risks for the future in this population already so gravely affected?

Quali gli eventuali rischi per il futuro, già così incerto per questa popolazione così gravemente colpita?

The question pertains to Haiti and the rest of the world as well as concerns cholera. According to the WHO cholera is widespread and on the rise, with three to five million cases worldwide, More than 100,000 people die from the disease every year, with the majority of cases in Sub-Saharan Africa. Epidemics of vibrio cholerae are caused by one of two strains: 01, which has been identified as the cause of the current epidemic in Haiti, and the South-East Asian strain 0139.

Haiti is seeing its first cholera epidemic ion more than 50 years. More than nine months after the Caribbean country suffered a catastrophic quake that killed hundreds of thousands and left 1.3 million homeless, Haiti has been rocked by another emergency that killed 259 people in the first week.

In fact, Haiti will likely remain a humanitarian crisis well into 2011. The recovery and reconstruction effort in post-earthquake Haiti is going very slowly for all sorts of reasons. One of the biggest lessons to learn is to reduce the risk of disasters before they happen — a growing concern as climate change and urbanization mean natural disasters will become even harder to tackle in the future. Here enters Haiti, again, a country prone to natural disasters and one could argue an “ongoing man-made disaster.”

 The management of the earthquake, especially in the camps – although good in many respects – is still faltering. There are issues to address including protection – especially of women and girls from sexual violence – sanitation, and assessment of survivors’ needs. Shelter, potable water and medicines are badly needed at this time as well. Many houses are destroyed and some are beyond repair. Many people live in tents or makeshifts which make them vulnerable to various diseases. The winter period will be in November and people are in need of a winter package. Many don’t even have toilets.

In the villages they need a potable water supply which can be remedied by building purification and filtration stations. This will minimize waterborne diseases and other infections. This could help prevent a reoccurrence of the illness in the Artibonite region where the vibrio cholerae bacterium has not taken a hold and will likely remain indefinitely – becoming endemic, joining illnesses like malaria, tuberculosis and HIV AIDS which have been afflicting impoverished Haitians for years,.

It remains to be seen how the upcoming Nov 28 elections will affect or be affected by the outbreak. Despite the disease outbreak, the polls are still set to go ahead as scheduled.

D. What appeal would you like to make to the international community?

Qual’è l’appello che volete rivolgere alla Comunità Internazionale?

First of all, don’t forget Haiti and her people. And have compassion on them. Their suffering is both recent and longstanding: recently, because of the January 12 earthquake and now the cholera epidemic. But many Haitians were already in a situation of chronic poverty and underdevelopment. As a priest and a doctor I recognize that man is a composite of body and soul. To treat one to the neglect of the other is to do a disservice to our fellow man. And the Haitians are deserving of our help and compassion as much as anyone – even more in a certain sense given their difficult circumstances. So have compassion on them. Say a prayer, offer a hand, find an organization you can trust and support it in some way – financially or otherwise. Be in solidarity with the Haitians in any way you can. Thanks.

Fr. Scott Binet MD, MI

Family Physician

International Coordinator – Camillian Task Force

President SOS Doctors – www.sosdrs.org

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One thought on “Cholera 3 – Haiti

  1. This article is well phrased and informative for a new comer like me! Keep up the fantastic work and sure we continue to pray as well!

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