Haiti Cholera Update #13

The last report of the MSPP (Ministère de la Santé Publique et de la Population) on 12 November 2010 reports 14,642 cases of cholera and 917 deaths. The hospital mortality rate is 3.8%. Cholera promptly treated has a mortality rate of 1-2%. It is probably worthwhile to bear in mind that in the view of James Wilson at Haiti: Operational Biosurveillance, the number of cases is likely enormously under-reported. He currently estimates approximately 100,000 people have been infected. If 75% of these cases are subclinical, and we accept a (conservative) 3.8% mortality rate, the estimated number of deaths would be 950 — a figure strikingly close to official reports. The United Nations is estimating 200,000 persons will be infected during the epidemic. According to Nigel Fisher, Deputy Special Representative and Resident and Humanitarian Coordinator, MINUSTAH,

The Cholera continues to, the number of cases continue to expand quite rapidly as foreseen. We do have cases now in every ‘Department’ as well as in Port Au Prince. The numbers of cases that we’ve had so far have been Ministry of  Health cases of hospitalized patients, we’re now trying to ramp up the collection of data from communities so that we can get a more realistic figure. We expect to have, once that data comes in, a significant increase in recorded cases so people should not be surprised at that.

The U.N. has launched a US$164 million appeal to combat the epidemic in Haiti.

The World Health Organization meanwhile has declared that finding a definitivre source of the epidemic is not a priority:

A WHO spokeswoman says controlling the outbreak and helping those infected is more important.

Fadela Chaib told reporters in Geneva on Tuesday that “at some time we will do further investigation but it’s not a priority right now.”

One protester was killed late Mondays as anti-U.N. riots spread to several Haitian cities in what WHO described as politically motivated unrest.

The U.N.’s spokeswoman in Geneva, Corinne Momal-Vanian, described the suspicion that Nepalese troops were to blame for the outbreak as “misinformation.”

Rioting has been reported in were reported in Cap-Haïtien, and The Guardian is reporting UN soldiers shot and killed one protester. Mediahacker is reporting two deaths, and other civil disturbances in Hinche and Gonaives. In Hinche, says Mediahacker, “protesters tried to leave the coffin of a man who died of cholera in front of the city’s UN peacekeeping base.” The violence has been variously attributed to the presence of MINUSTAH (United Nations Stabilization Mission in Haiti), who are widely suspected by the Haitian people and politicians of bringing cholera in to the country, the upcoming national elections on the 28th, or the establishment of cholera treatment centres in the community, which has been a point of contention in other places. One account:

The earthquake, the hurricane, and now the cholera. The manifestasyon which began this morning around 6:30 a.m. is strictly about Cholera and the UN, and people are serious about wanting them out. I asked a man on the street if he thinks this will go on into tomorrow: “Wi, demen sidyevle,” yes, God-willing, he says, “we won’t stop until Minustah quits the country. They brought cholera here and many many people died.” One woman told me that there are riots like this in Port-de-Paix and Hinche, but this is so far unconfirmed.

Spanish Minustah soldiers are coming from Ft. Liberte, but groups of protesters went out to Limonade to set up road blocks earlier today. Rt 1 leading into Cap from the south and out to the east are blocked. The picked-apart skeletons of trucks make quick barricades across the roads, sometimes within 100 yards of another. Groups have also set burning tires up to block paths. You have to identify yourself as NOT Minustah or else people will throw rocks. One man told me “Ameriken se Ameriken, Minustah se Minustah.”

We heard helicopters around 2:00 p.m., but haven’t seen them since. The airport is closed and the US Embassy has sent out a new warning on their site. Earlier this afternoon, protesters burned the police stations at Pont Neuf and Barriere Bouteille before heading to the one at l’Arsenal in downtown Cap. As of 3:00 p.m., one person has died and 26 others are hospitalized from the altercations. The man who died was shot by a Minustah soldier.

Médecins sans frontières on the present course of the outbreak:

The situation in the north of Haiti remains extremely serious. MSF teams working in the region are overwhelmed by the needs of the many new patients arriving at facilities in Cap Haitien, Port de Paix, Gonaives, and Gros Morne every day. Fears persist in the communities, including in Port-au-Prince, over the presence of cholera treatment centers (CTCs), in spite of their importance to immediate lifesaving measures against the epidemic.

[snip]

In the lower Artibonite region, where the outbreak started, MSF teams in Petite Rivière and St. Marc are still very busy. While there are some indications of the epidemic possibly stabilising, the CTCs in both places are at capacity. The caseload in Dessaline, however, is still increasing; 177 people were admitted on Friday and a 280-bed capacity facility is being built. In general, as in the north, it is still difficult to reach remote areas to offer treatment where it is needed. MSF has resorted, in some cases, to dropping materials from helicopters to support some local health centres.

In Port-au-Prince, the picture remains chaotic and troubling. The Cite Soleil neighbourhood, a sprawling slum, is essentially the frontline of the outbreak in the capital. Efforts are underway to increase admissions to 250 per day at the MSF-supported, Ministry of Health, Choscal Hospital. People presenting with severe symptoms are transferred to CTCs in MSF facilities in the nearby Sarthe and Tabarre neighborhoods. Teams are also looking for another place to construct a cholera treatment unit (CTU) in the neighbourhood.

I missed this quote in the last update, but it’s worth going back to. From James Wilson, somewhat facetiously:

Direct quote from senior US government official:

…we think [the cholera epidemic] can be managed effectively, as the response has been good in Haiti, and the GOH with our help has gotten out ahead of the curve, and are working hard to stay there…This is not to say that 1,500-2,000 or so deaths from cholera a year in Haiti for the next several years is acceptable, and we hope to get the mortality rates down well below that. But this is not in the same league as the earthquake either, so I think you can turn off the alarm bells.

Cholera has spread to inside Haiti’s prison system:

After the death, last month, of 5 prisoners to the Civil prison of Hinche (of the cholera), it is the turn of the National Penitentiary to be affected by the cholera epidemic. In recent days, four prisoners died, reported a spokesperson for the Haitian National Police (PNH), indicating that more than ten others presented all the symptoms of the cholera.

The National Penitentiary, principal prison of the capital, houses 1.469 inmates (figure of October 2010) with sub human living conditions, compared to that, the life is good in the IDP camps. Danielle Boisvert, who heads the correctional unit of MINUSTAH since June 1st, 2010 was declared in September “On average, each prisoner has access to less than 1 m2 and in certain prisons such as the National Penitentiary, they have less than 0.5 m2. In less than one half-m2 a person cannot sleep wide nor even squatted” ideal conditions for the spread of cholera.

I will post thew next update Thursday or Friday, or sooner if events warrant. For more immediate updates, I highly recommend Crawford Killian at his blog H1N1.

More resources:

Haiti: Operational Biosurveillance (Twitter)

H5N1

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

Mediahacker: Independent multimedia reporting from Haiti (Twitter)

Ministère de la Santé Publique et de la Population (Homepage) (Cholera Updates) (in French)

PAHO’s Haiti Cholera page. (PAHO Situation Reports and other documentation.) (Blog.)

Praecipio International (HEAS)

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

Partners in Health (Twitter).

Médecins sans frontières

Haiti Cholera Update # 7

As of writing, MSPP (Ministère de la Santé Publique et de la Population) has not released updated information on cases/deaths. The latest figures were to be released at 1000 this morning, but I have been unable to find any information regarding them. The last report was on 30 October 2010 when 337 deaths and 4,764 were noted. According to HaitiLibre: “[T]he government has not issued (at the time this article was written) any new assessment since Saturday on the evolution of the cholera epidemic in the country because of public holidays [!], this is, despite the maximum health warning level (the holidays seem to take precedence over the government’s crisis and information to the population).”

Tropical Depression Tomas weakened significantly overnight, and is not now forecast to regain hurricane strength before making landfall on the southwest peninsula Friday morning. However, Jeff Masters writes the gravest danger is not from the winds, but the heavy rainfall, which may well be an event spread over several days:

It doesn’t take much rain to cause a flooding disaster in Haiti–ordinary seasonal heavy rains have killed 23 people in southern Haiti over the past month, including twelve people in Port-au-Prince this past weekend. According to the Associated Press, most of last weekend’s deaths occurred when surging rivers burst through houses built in ravines. With the soils already saturated from last weekend’s rains, the stage is set in Haiti for a significant flooding disaster capable of causing heavy loss of life.

[snip]

Crucially, the storm has waited too long to begin this process, and it now appears unlikely that Tomas will have time to grow beyond Category 1 hurricane strength before landfall in Haiti on Friday. NHC is giving Tomas a 5% chance of reaching Category 3+ strength, which is a reasonable forecast. With the atmosphere expected to be very moist, it is likely that Tomas will dump very heavy rains of 4 – 8 inches over much of Haiti, even if Tomas strikes as a tropical storm. Rains of this magnitude are capable of causing heavy loss of life due to extreme floods running down Haiti’s deforested mountain slopes.

In the context of the cholera epidemic, it is probably not necessary to add the much increased risk of exacerbation of contaminated water supplies. From the Pan-American Health Organization’s briefing yesterday:

We cannot overlook the vulnerable populations who do not live in these resettlement camps and may not have access to safe drinking water. The response must be comprehensive.

An emerging top priority now for all of us is preparing for Tropical Storm Tomas. We have received reports that the storm has already had a serious impact on St. Lucia, with mudslides and severe damage to the island’s water systems.

If the storm hits Haiti, it’s obvious that is will make a difficult situation even worse. Cholera is mainly being spread through contaminated water, and more water supply disruptions pose additional increased risks for cholera and other waterborne diarrheal diseases.

The bad sanitary conditions in many areas, combined with what the hurricane poses as huge amounts of rain and possibly flooding, are very likely to accelerate the spread of infection, making the overall caseload increase earlier and faster.

MINUSTAH (La Mission des Nations Unies pour la Stabilisation en Haïti — United Nations Mission for the Stabilization in Haiti) issued a statement revealing test results absolving peacekeeping troop of any role in the transmission of cholera:

La Mission des Nations Unies pour la Stabilisation en Haïti (MINUSTAH) se félicite de la contribution scientifique du Laboratoire National de Santé Publique (LNSP), en Haïti, et des Centres de Prévention et de Contrôle des maladies (CDC), à Atlanta, qui apportent des éléments de compréhension de l’épidémie de choléra en Haïti.

Selon leurs conclusions, la souche de choléra responsable de l’épidémie est identique à une souche trouvée en Asie du Sud. Toutefois, en raison de la rapidité des mouvements des souches de choléra à travers le monde – transmises par des aliments, des eaux contaminées ou par des personnes infectées – des spécialistes de la santé ont souligné la difficulté, voire l’impossibilité de déterminer, avec précision, la manière dont le choléra est arrivé en Haïti.

La MINUSTAH continuera à prendre les mesures préventives nécessaires dans le but de protéger le peuple haïtien et son propre personnel. Des tests des échantillons d’eaux prélevés à l’intérieur de la base militaire à Mirebalais et à l’extérieur, aux abords de la rivière, ont été conduits le vendredi 22 octobre et le mardi 26 octobre, et les résultats se sont tous révélés négatifs. Des tests supplémentaires ont été effectués le mercredi 27 octobre, à la demande du Commandant de la Force, à l’intérieur du camp et entre le camp et la rivière. Ces tests ont été analysés par un laboratoire indépendant et se sont aussi révélés négatifs.

(The UN Mission for Stabilization in Haiti (MINUSTAH) welcomed the scientific contribution of the National Laboratory of Public Health (LNSP), Haiti, and the Centers for Disease Control (CDC) in Atlanta, all of which provided basic understanding of the cholera epidemic in Haiti.

According to their findings, the strain of the cholera responsible for the epidemic is the same as the strain found in South Asia. However, because of the rapidity of movement of cholera strains around the world — transmitted by food, contaminated water or by infected persons — health specialists have pointed out the difficulty or impossibility of determining precisely the means by which cholera came to Haiti.

MINUSTAH will continue to take preventive measures necessary in the end to protect the Haitian people and its own personnel. Tests of water samples taken from inside of the military base at Mirabalais and exterior to it on the banks of the river were conducted on Friday 22 October and Tuesday 26 October, and results were shown to be all negative. Supplementary tests were done on Wednesday on the order of the Commandant of the Force, in the interior of the camp and outside the camp and river. These tests were analysed by an independent laboratory and again were found negative. [My translation.])

Finally, a few excerpts from an interview with Laurie A. Garrett, Senior Fellow for Global Health, Council on Foreign Relations:

But it’s inexcusable that we cannot control cholera today. We fully understand the disease. It is generally treatable with a combination of appropriate antibiotics. But most important is heavy-duty hydration with consistently safe water. The main thing with cholera is that you dehydrate. And death is associated with massive dehydration. If the water is the source of the cholera and you rehydrate with that water, you’re simply redosing yourself with the microbe, and you subsequently die. If you have safe water, you can slow down the pace of dehydration. Then you can slam with the appropriate antibiotics.

*****     *****     *****     *****     *****

[Question.]There’s aid money flowing into Haiti, and people have known about the deplorable sanitation and water systems in Haiti for a long time.

Actually, money isn’t flowing in. Senator Tom Coburn (R-OK) has held up more than $1 billion dollars for Haiti because he is unhappy with the State Department appointment for an individual who will play a key role in relief operations. So while dollars have been committed, they’ve not flowed at a rate that would allow us to feel comfortable that there is sufficient funding. Bulldozers and heavy lifting equipment to deal with the debris and to destroy shattered buildings only started moving really in the last couple of weeks on a major scale.

It’s shocking how far down the road we are without doing what you would do in any American city in a similar situation–mow down anything that would have been declared unsuitable for habitation and then start rebuilding. But most of Port-au-Prince is still debris, and it’s hard to build plumbing systems, sewer systems, water treatment systems when the debris is sitting in the way. However, I have to say that it’s my understanding that most of the water being distributed in the form of drinking water in Port-au-Prince is actually coming from specifically pumped water stations. That may actually protect Port-au-Prince from a serious outbreak.

More resources:

Haiti: Operational Biosurveillance (Twitter)

H5N1

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

Mediahacker: Independent multimedia reporting from Haiti (Twitter)

PAHO’s Haiti Cholera page. (PAHO Situation Reports and other documentation.) (Blog.)

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

Partners in Health (Twitter).

Médecins sans frontières