Cholera in

Haiti

Katie Cicerchi

Background• Cholera

o Acute diarrheal infection caused by ingestion of food/water contaminated with the bacterium Vibrio cholerae

o Short incubation period: 2 hours to 5 days

o Extremely virulent—can kill within hours if untreated

Sources: WHO Cholera Factsheet updated February 2014; CDC

o Symptoms include profuse watery diarrhea and vomiting, and severe cases can lead to acute renal failure, severe electrolyte imbalances, coma, shock and death.

o Reservoirs are humans as well as brackish and marine water

Backgroundo About 75% of people

infected do not develop symptoms

o Among those with symptoms, about 20% develop acute watery diarrhea with severe dehydration

o Burden of disease estimated to be 3-5 million cases and 100,000-120,000 deaths annually

Sources: WHO Cholera Factsheet updated February 2014; CDC

Risk Factors• Lack of access to clean

water and sanitation• Closely linked to

inadequate environmental managemento At risk areas:

• Urban slums• Camps for internally

displaced persons

• MalnutritionSources: WHO Cholera Factsheet updated February 2014; CDC

Current State of Knowledge

• Treatment:o Easily treatableo Up to 80% can be treated with prompt

administration of rehydration saltso Severely dehydrated patients need IV

fluids and appropriate antibiotics to shorten the course of the disease and shedding of bacteria

o Mass administration of antibiotics is not recommended

• Prevention:o Water and sanitation infrastructureo WHO recently recommended

vaccination with oral cholera vaccine for endemic areas and areas at risk of outbreak

Sources: WHO Cholera Factsheet updated February 2014; CDC

Haiti• 2010: Population of 9.9

million• In 2008, just 63% had

access to improved drinking water source (19% piped and treated)

• 17% had access to adequate sanitation

• In 2010 more than 20% of children under five were stunted indicating high malnutrition

• As of 2010, no cholera reported in 100 yearsSources: WHO Haiti Fact Sheet, NEJM “Cholera Surveillance during the Haiti Epidemic: The First Two Years,” 2013

January 12, 20107.0 magnitude earthquake

230,000-316,000 killed300,000 injured

1.5 million displaced

Cholera Outbreak• October 19, 2010: Ministry of Health notified of

unusually high number of patients in two departments with watery diarrhea and dehydration

• October 21, 2010: Vibrio cholerae O1 confirmed by lab test

• October 28, 2010: Initiation of National Cholera Surveillance System with standardized reporting forms and case definition

• November 5, 2010: Hurricane Tomas passes over Haiti• November 19, 2010: Cholera present in 10/10 of Haiti’s

departments• November 21, 2014: 717,203 cases and 8,721

deaths

Sources: Haitian Ministry of Health and Population, NEJM “Cholera Surveillance during the Haiti Epidemic: The First Two Years,” 2013

Where did it come from?

• Inadequate sanitation at UN base in Mirebalais, Haiti

• Contaminated sewage dumped in the Meille river, a tributary of the Artibonite, Haiti’s longest and most important river

Public Health Response

• Short term:o Vaccinate o Biosand filter programo Ventilated improved pit latrine programo Education campaign

• Mid term:o Strengthen national surveillance

• Long term:o Water and sanitation infrastructureo Health care infrastructure

Short Term• Vaccination

o Shanchol• Whole cell killed vaccine• Longer term protection• Considerable herd

immunity• Two doses 1-7 weeks

apart• Use of OCV and cold

chain maintenance recently demonstrated in rural Haiti

o Vaccinate high risk populations including departments with high incidence and persons in slums/IDP camps

Source: Am. J. Trop. Med. Hyg. “Use of Cholera Vaccine in Haiti: A Rural Demonstration Project” 2013

Short Term• Biosand Water Filter (BSF)

Programo BSF removes up to 100% of helminths and

protozoa and up to 98.5% of bacteriao Contaminated water is poured into the top

of the filter where the biolayer outcompetes some pathogens. As water filters through sand and gravel, vast majority of remaining pathogens are trapped, absorbed or killed

o Set up network of biosand filter construction centers—employ Haitians to make BSFs

o Provide to schools and health centerso Sell at nominal cost to families

• Families can volunteer to get free filtero Sustainability:

• Train community health workers on BSF maintenance

• Set up system to track maintenance of filters and provide help line (2/3 of Haitians have access to a cell phone)

Source: Center for Affordable Water and Sanitation Technology

Short Term• Ventilated Improved Pit

Latrine Programo Separate excreta from surface and

ground water and flies; contains solid waste, destroys excreta by process of decomposition and die-off of pathogens

o Set up traveling teams of pit latrine construction workers

o Provide to schools and health centerso Provide at nominal cost to

neighborhoods• Communities can get free latrine if

they volunteer and help neighboring communities

o Sustainability:• Train community health workers on

maintenance• Set up system to track maintenance

and provide help lineSource: Center for Affordable Water and Sanitation Technology

Short Term• Social Marketing

Campaigno Once short term infrastructure is

in place, launch national social marketing campaign with five main messages:

1. Drink and use safe water2. Wash your hands often with soap and

safe water3. Use latrines or bury your feces; do not

defecate in any body of water4. Cook food well (especially seafood),

keep it covered, eat it hot, and peel fruits and vegetables

5. Clean up safely—in the kitchen and in places where the family bathes and washes clothesSource: CDC

Mid Term: Strengthening NCSS

• True burden of cholera is likely underestimated, particularly in rural areas

• Strengthening the National Cholera Surveillance System:o Stress timely and complete reportingo Invest in infrastructure improvement for health facilities in

rural areas (communications)o Require for-profit institutions to participate in surveillanceo Establish system for reporting community deaths (train

community health workers to help report?)o Set up regional networks of laboratories to identify cholera and

track changes in bacteria

Source: NEJM “Cholera Surveillance during the Haiti Epidemic: The First Two Years,” 2013

Long Term: Infrastructure• WASH infrastructure

o Estimated cost: $2.2 billion o Goal: Establish proper infrastructure within 10 years

• Improve access to health care

Evaluation• Vaccination

o Track vaccine coverage rates, cumulative doses delivered, uptake rate and completion of second dose as well as vaccine effectiveness (attack rate unvaccinated vs. attack rate vaccinated)

• Biosand Filters and Latrineso Routine field studies to evaluate use and performance

• Social Marketing Campaigno Pre-testing to determine culturally-appropriate messages that resonateo Pre-campaign, mid-campaign and post-campaign surveys to determine

effects and improve messaging

• National Cholera Surveillance Systemo Declining incidence across departmentso To ensure proper treatment, case fatality rate should remain below 1%

• WASH o Water quality monitoring (fecal coliforms)

Questions?

Photos• Partners In Health• http

://www.theguardian.com/world/2013/oct/09/un-sued-haiti-cholera-epidemic

• http://www.npr.org/blogs/health/2012/06/18/155311990/scientists-find-new-wrinkle-in-how-cholera-got-to-haiti

• http://www.who.int/bulletin/volumes/89/2/11-010211/en/

• http://www.unmultimedia.org/radio/english/2014/10/world-bank-pledges-50-million-dollars-for-water-and-sanitation-in-haiti/#.VH1TrGTF-Xw

• http://environment.nationalgeographic.com/environment/photos/drinking-water/