In late October of 2010 the unthinkable happened. Only 9 short months before, Haiti had undergone a devastating earthquake that destroyed much of the country’s infrastructure, and left many thousand dead and a million people homeless. Now cholera, which had not been seen in the country for many decades, swept through the countryside and the refugee camps. By the end of the year more than 170,000 cases had been reported, with 3600 deaths, and no end is in sight. The outbreak appears to have originated from a single source, possibly from a member of a Nepalese peacekeeping force, as the specific serotype is endemic to the same area of Asia.
Cholera is an acute bacterial infection of the intestines, caused by Vibrio cholerae. A toxin that the bacterium produces causes acute watery diarrhea and subsequent dehydration. The disease usually results from drinking water contaminated by human feces, less often from poorly cooked food. Person to person transmission is rare. For a cholera epidemic to occur there usually must be a significant breakdown in water supply, sanitation, and personal hygiene. Infection is most often inapparent or produces only mild symptoms. Only 5% have a severe disease with massive diarrhea and rapid dehydration, leading to death in 50% of cases if untreated. Mild to moderate infection can be treated with Oral Rehydration Therapy, (ORT). More severe infection, and/or the presence of intractable vomiting, usually requires the use of intravenous fluids. Ringer’s Lactate is preferred. Antibiotic therapy with doxycycline or azithromycin may shorten the course and prevent spread, and is recommended by WHO for moderate or severe infection. The CDC and WHO are not currently recommending the cholera vaccine, either for travelers to Haiti, health workers in epidemic or endemic countries, or in Haiti populations at risk during the epidemic.
In an article from Lancet, Partners in Health, who have worked extensively in Haiti for many years, and have provided exemplary care during both the earthquake and the cholera epidemic, propose five complementary interventions that may slow the current epidemic in Haiti:
1. Identify and treat all those with symptomatic cholera: consider all modes of therapy, including antibiotics. Antibiotics are currently being used only in severe infections. Wider use would shorten the duration of infection and the carriage of the bacterium.
2. Make oral cholera vaccines available in Haiti and elsewhere. Current recommendations from WHO do not recommend routine use during the current epidemic. This decision is based on cost and logistical considerations which, in Partners in Health estimation, are not insurmountable.
The widespread use of vaccines could save thousands of lives.
3. Remedy Haiti’s water insecurity and improve sanitation, emphasizing separation of the water supply from fecal contamination, a measure that has not been sufficiently emphasized by aid organizations This step will have an additional benefit by improving the overall health of communities.
4. All health projects must be dedicated to improving Haiti’s overall health system.
This important step has often been ignored by aid organizations
5. Cholera demands a global health policy, one not based on gross domestic product. “The goals of responding to cholera in Haiti should look the same as the goals of responding to cholera in the Dominican Republic or Florida. No epidemic of cholera is local for long. In this dire emergency we can accept nothing less than complementary prevention and care” 3
1. Haiti Cholera Outbreak: Information for Health Providers. cdc.gov. 2010
2. Frieden et al: Public Health in Haiti—Challenges and Progress. NEJM.org, 1056, 2010
3. Ivers, Farmer et al: Five Complementary Interventions to Slow Cholera in Haiti: Lancet 376, 2048-51, 2010
Submitted by Roger Boe MD