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]

Notes on the Cholera Crisis in Haiti

As of 1800 last evening, according to the Pan-American Health Organization (PAHO), there have been 2,564 cases, and 194 deaths from cholera in Haiti in the past week. This represents a crude mortality of 7.6%. With prompt treatment, mortality from cholera is around 1-2%. This morning there are reports of more than 200 dead.

The latest PAHO situation report (PDF) seems to imply its initial emergency supplies are still in a warehouse near the Port-au-Prince airport.

There may have been cases of the disease as early as the week before last, which are unconfirmed by PAHO. The present outbreak is centred north of the capital, Port-au-Prince, in the Artibonite river watershed, and unconfirmed cases were reported yesterday in Port-au-Prince. It is not known how the disease came into Haiti, as the country has not had an outbreak of cholera for a century.

Map of the outbreak. Click to enlarge.

Initial primary treatment for cholera includes rehydration using oral rehydration salts. However, these need to be reconsitituted using potable water; this seems problematic where somewhere over 70% of Haitians had no access to clean water before the earthquake. The slow international response to the devastating earthquake is being blamed for the outbreak:

Melinda Miles, Director of Let Haiti Live, expressed her frustration to UN Dispatch today, “Considering that an outbreak of this nature was predicted nine months ago, it is absolutely stunning that so little was in place to prepare for it.”

A primer on cholera by Paul Jones: think massive diarrhea and dehydration.

Cholera has been known and feared for centuries due in large part to its tendency to occur as epidemics, which afflicts thousands and at one time had case-to fatality rates of nearly 50%. Today with improved treatment strategies case-to-fatality rates can be as less than 1%.

This infectious gastroenteritis is one of the most rapidly fatal illnesses in existence, threatening to propel its victims into hypovolemic shock within only 4 hours of its onset. Vibrio cholerae, the gram negative bacteria that produces the cholera toxin, takes a mere 24 -72 hours to incubate and once symptomatic, has begun its damaging work.

MSF Treatment guidelines. Click to enlarge.

A horrendous account of conditions at l’hôpital St-Nicholas in St-Marc:

We arrived at St Marc hospital to a horror scene. I had to fight my way through the gate as a huge crowd of worried relatives stood outside, while others screamed for access as they carried dying relatives into the compound. The courtyard was lined with patients hooked up to intravenous (IV) drips. It had just rained and there were people lying on the ground on soggy sheets, half-soaked with feces.

Media following the epidemic.

Another great resource: Haiti: Operational Biosurveillance. (Twitter)

On the ground, good sources of information and of course needing donations: Partners in Health (Twitter). Médicins sans frontières.

[Cross-posted at Sister Sage’s Musings]

[UPDATE: minor grammatical fixes. Added words “for the outbreak” at end of para 4 for clarity.)

[UPDATE 2: corrected mortality rate]