Haitian Cholera Update #3

The Pan-American Health Organization (PAHO) reports as of yesterday, 27 October 2010, there have been 292 deaths from cholera and 4,147 confirmed cases. This represents a crude mortality rate of 7.04%. Cholera promptly treated has a mortality rate of 1-2%. There was no situation report issued yesterday, and these numbers are taken from the daily briefing, in which  PAHO deputy director Jon Kim Andrus  was careful to emphasize were compiled by the Haitian Ministry of Health and Population (Ministère de la santé publique et de la population  — MSPP).

Andrus also outlined the strategy for containing the outbreak, developed by MSPP in close collaboration with international partners, including PAHO, the UN and NGOs. This strategy is directed at mitigating the number of new cases of cholera and rapid treatment of those infected. It includes community-based messaging campaign on describing handwashing, water purification, and how to prepare oral rehydration salts. In addition, there will be considerable action on the ground:

The Ministry of Health is also sending community health aides into poor and densely populated areas, including temporary settlement areas that were created after the earthquake, to actively seek out and refer the sickest people to the Cholera Treatment Centers, while at the same time giving them a first dose of oral rehydration salts.

They will also supervise measures in the local communities and neighborhoods to ensure clean drinking water and that proper waste disposal and maintenance of latrines is being done.

More than 60 community health aides are in the process of being deployed to the temporary settlement camps that were set up after the earthquake.

The community health aides are intended to support and complement the many Red Cross community health aides that are already working in the country on the ground.

The Ministry also will be establishing a network of community health posts, with the idea of having 1 post for every 25 families, that will have the capacity to  treat diarrhea.

The overall strategy is aimed to strengthen primary health care centers across the country with 24/7 coverage, and to build new structures in addition to 33 designated hospitals nationwide that will serve as Cholera Treatment Centers for the most severe cases.

As noted yesterday, there is some optimism that these efforts are containing the outbreak. However, Haiti: Operational Biosurveillance (HOB) has this caveat:

From our perspective, we agree with PAHO’s recent statement today [i.e. yesterday — ed.] about the epidemic and while we all would like to be hopeful, we are reminded of the recent 2008-2009 epidemic of cholera in Zimbabwe.  Responders there were lulled into a false sense of security as the epidemic waned, only to be badly disappointed as the epidemic continued onward to produce 98,424 suspected cases and 4,276 deaths (Case Fatality Rate of 4.3%) from August 2008 to June 2009 that were officially reported. Fifty-five out of 62 districts in all 10 provinces had been affected, according to the World Health Organization.

Currently we are seeing 4,147 cases officially reported, with 292 deaths.  We assume PAHO is reporting these as separate groups of people, where the total number of cases reported is actually 4,147+292= 4,439.  If we generally assume that only 25% of cases display clinically apparent illness, we conservatively assume then there has been at least 17,756 infected people to-date.  This is a truly alarming number of people, especially when considering 1) this is likely the result of under-reporting and 2) a large percentage of these infected individuals could be shedding pathogen into the environment for weeks post-infection.

Additionally, they add, “[T]he question of ecological establishment remains an open one as well.” If on cue, HOB reported yesterday the first case of cholera in Cité Soleil without a travel history from the Artibonite region, that is to say, a case apparently transmitted within Cité Soleil.

A meeting between the health ministers of Haiti and Dominican Republic aimed to reopen by Friday the transnational markets between the two countries, which were closed Monday.

More on the protest Tuesday at the Médecins san frontieres (MSF) clinic in St-Marc. MSF’s account is here. BOH provides some context: the clinic was across the street from a school and took up a soccer field. They write:

1. We have come to realize over the years that for communities coping with a high level of threat perception, especially during unexpected or non-routine infectious disease events, protection of children becomes an exquisitely sensitive nexus of concern that may lead to social outcry and even violence.
2. Communities under collective stress such as is readily observed in St Marc have a high demand for coping outlets such as recreation and access to religious services, for example.  Compromised access to such outlets is actually a key indicator that prompts us to monitor for civil unrest.

HaitiLibre has a different take, and they pull no punches: “It is unfortunate, “they write, “that ignorance of the people, can exacerbate a situation already extreme, but it is even more deplorable that the lack of authority of a government incapable of enforcing its decisions in an area declared on ‘high alert’ and to contribute, while agreeing to yield to the population, to more endanger this same population, it is supposed to protect.” The new location for the treatment centre, which was supposed provide 400 beds to relieve pressure on l’hôpital St-Nicholas, has not yet been determined.

Media reports on the epidemic here.

More resources:

Haiti: Operational Biosurveillance. (Twitter)

H5N1 (And thanks for the kind comments.)

HaitiLibre (English) (français) (Twitter — English and French)

On the ground, good sources of information and of course needing donations:

Partners in Health (Twitter).

Médecins sans frontières

[UPDATE: corrected mortality rate]

Haiti Cholera Update #2

The Pan-American Health Organization (PAHO) reports (PDF) as of 1800 yesterday, 26 October 2010, there have been 284 deaths from cholera and 3,769 confirmed cases. This represents a crude mortality rate of  7.4%. Cholera treated promptly has a mortality rate of 1-2%. Deaths are about equally divided between hospitals and the community; 96% of the deaths are reported from the Artibonite region, where the outbreak began. However HaitiLibre reports actual figures are somewhat higher: 304 deaths and 4,774 cases. [Via]

The slowing of the death rate and the confirmed numbers of new cases has generated some optimism that the outbreak has been contained. However, this outbreak has larger implications, and vigilance will still be needed, as Haiti: Operational Biosurveillance points out:

This is the first documented cholera epidemic in the Caribbean in many years, since the last pandemic of the early 1990s.  WHO’s recent declaration that travel restrictions from Haiti will not be required raises serious questions of whether spread in the region is truly unlikely.

[snip]

This would imply this is an ordinary outbreak / epidemic of cholera.  It is not, and it represents a key epidemiological change for the Carribean region that should be monitored closely.

The Dominican Republic has closed its borders, however it is generally believed the border is highly porous.  Should the epidemic continue, we expect to see cases there eventually.  Jamaica is on high alert, as are other countries in the region.  While we do not want to cause further damage to Haiti’s economy, the question of international travel restrictions should be re-examined at frequent intervals given the volume of multi-national responders flying in to assist.

[snip]

Translocation of cholera to developing or undeveloped areas of the Caribbean, Mexico, Central or South America would likely present in a similar manner as seen in Haiti.

Noteworthy is the Dominican Republic’s decision to more closely regulate border traffic and, in at least one case, shut down a crossing altogether.

A report from the frontline in St-Marc.

Social unrest and a sense of dislocation and loss of power accompany societal crises like epidemics.  Haiti: Operational Biosurveillance documented a couple of instances of this yesterday. Protesters stoned a Médecins san frontières clinic in St-Marc intended to provide rehydration therapy for cholera victims. The local community feared the disease would be brought into their neighbourhood. The clinic was moved to another part of the city. Additionally, the UN Mission for the Stabilization of Haiti (MINUSTAH) was forced to respond to a “community outcry” and rumours that Nepalese troops had carried cholera into Haiti, based an a reported outbreak in Kathmandu on 23 September 2010.

Media reports on the epidemic here.

More resources:

Haiti: Operational Biosurveillance. (Twitter)

H5N1

HaitiLibre (English) (français) (Twitter — English and French)

On the ground, good sources of information and of course needing donations:

Partners in Health (Twitter).

Médecins sans frontières.

[UPDATE: corrected mortality rate]