cholera-hit Haiti

Pic. credit :BBC

Haiti cholera outbreak causes not clear, experts say

By Sigrun Rottmann. BBC News. 25 October 2010.

Until the current outbreak, cholera had not been documented in Haiti since 1960

The cholera outbreak in central Haiti that so far has killed more than 250 people and infected more than 3,000 is the worst health challenge the country faces since the earthquake in January.

There had been no documented outbreak of the disease in Haiti since 1960.

The US Centers for Disease Control and Prevention (CDC) said after the earthquake that while cholera testing should be carried out, the disease was "extremely unlikely to occur".

So why has the epidemic struck now?

It is not clear if the cause of the outbreak will ever be identified, but health experts agree that for cholera to occur, bad sanitation and hygiene have to coincide with people carrying the Vibrio Cholerae bacterium.

Sanitary conditions were poor in many parts of Haiti even before the earthquake, and Dr Brigitte Vasset from the international humanitarian organisation Medecins Sans Frontieres (MSF) in Paris is reluctant to link the outbreak directly with the quake.

"Central Haiti - where most people have been infected - was not the region most affected by the earthquake," she says.

While many displaced people might have sought refuge in the Artibonite region after the disaster, cholera bacteria could have been present in the Artibonite river or a stagnant water source even before the earthquake, Dr Vasset says.

She also points out that while no cases of cholera have been reported from rural areas, this does not mean that it has been completely absent.

Continue reading the main story

“Start Quote

As soon as people have been infected and excrete the bacteria, the epidemic spreads very quickly"”

End Quote Adam Kamradt-Scott London School for Hygiene

"In many African countries there are sporadic cases during the year, then the weather changes or other conditions change, and all of a sudden there is an outbreak," Dr Vasset says, adding that the disease is difficult to predict.

"I have worked in refugee camps where we expected a cholera outbreak - and it never came," she says.

Sarah Morgan, Senior Health Programme Adviser at aid agency World Vision, agrees that it is possible low-level cholera was present in Haiti all along.

"Surveillance data on cholera in Haiti are not available," she says. However, watery diarrhoea has been common in the country, causing 5% to 16% of the deaths among Haitian children, according to CDC data.

With diarrhoea so prevalent and no stringent monitoring by health authorities and 80% of those with symptoms showing only moderate signs of infection, sporadic cases of cholera might not have registered.

"While there might have been no significant outbreak of cholera, it is possible that there was a background level of the disease", Ms Morgan says.

That cholera has now been picked up so quickly after the outbreak in the Artibonite region is a great success for Haiti's health authorities and international organisations working the country, she adds.

On the rise

Cholera is widespread and on the rise, with three to five million cases worldwide, the World Health Organisation says.

More than 100,000 people die from the disease every year, with the majority of cases in Sub-Saharan Africa. Epidemics of Vibrio Cholerae are caused by one of two strains: 01, which has been identified as the cause of the current epidemic in Haiti, and the South-East Asian strain 0139.

It is difficult to get a complete picture of the global spread of the disease, because some countries are reluctant to report cholera for fear of travel sanctions, says Adam Kamradt-Scott from the London School of Hygiene and Tropical Medicine.

Mr Kamradt-Scott points out that around 75% of people infected with Vibrio Cholerae do not develop symptoms. But they excrete the bacterium with their faeces for up to 14 days - a potential source of infection for others.

With more people and aid coming to Haiti since the earthquake in January, there is a possibility that the bacterium was brought to the country from the outside, Mr Kamradt-Scott says.

"The bacteria can be resident in water for a quite a while," Mr Kamradt-Scott explains and points to a cholera outbreak in Peru in 1991.

There was speculation that that epidemic, which quickly spread across Latin America, came from bilge water and algae dumped by an Asian cargo ship, contaminating local shellfish.

In Haiti, the disease has more likely been spread because people used the Artibonite river for washing and drinking.

"As soon as people have been infected and excrete the bacteria, the epidemic spreads very quickly," Mr Kamradt-Scott says.

"It is then important to break the cycle of the disease", he adds.

Because Vibrio Cholerae produces toxins that lead to watery diarrhoea, patients need to be rehydrated by with liquids containing sugar and salt or with intravenous fluids.

Those infected need to receive treatment immediately, Mr Kamradt-Scott says. If not treated, the death-rate of cholera can rise up to 50%.

But the potentially deadly cholera cycle can only be broken when people also stay away from the contaminated water source until the bacteria have cleared, he adds.

The hospital courtyard in St Marc is full of families caring for their sick relatives

Learning to survive in cholera-hit Haiti

By Laura Trevelyan BBC News, St Marc, Haiti

The Artibonite river in Haiti has turned deadly. Once a source of water for the villagers that live along its banks, now it is thought to be the source of the cholera epidemic.

For those who used to bathe, play and do laundry in the river - or drink from it - life has changed drastically.

Aid agencies deliver bottled water daily and leaflets are being given out to the villagers.

"This is very good information," one man tells me, as he reads about how handwashing is important in combating the spread of the disease.

"If we had learned this before, lives could have been saved," he observes.

A mother and daughter who live in a small shed by the river tell me that they lost relatives to the cholera.

"We would never drink that water now," they tell me, looking askance at the river flowing by.

But how do you carry out your daily lives now, I ask.

"We boil the water," they say.

The public information campaign is well underway. Outside St Nicholas' hospital in St Marc, a song blares out from the sound system, encouraging people to use clean water and clean toilets.

There is plenty of bottled water, courtesy of the aid agencies, but clean toilets are another matter.

Human cost

At the hospital itself, there are urns of water on the way in, so people can wash their hands.

People are urged to wash their hands thoroughly as they visit the hospital

A sponge mat on the floor soaked with chlorine is meant to help disinfect the people who might be carrying cholera.

But so many people trample over it, the sponge is turning muddy.

The hospital director tells me he hopes Haitians will now understand just how important basic cleanliness is.

In the crowded hospital courtyard, families tend their sick relatives anxiously, watching the intravenous drips.

The father of eight-year-old Ritchee Camulus is so grateful to the doctors here.

He thought he might lose his son, who had severe dehydration. But now, Ritchee is recovering.

How are you, I ask. Ritchee smiles broadly and asks after me in return.

Cholera can kill within hours. At that back of the hospital I am shown the morgue.

A brand new child's coffin is a poignant reminder of how the most vulnerable are the worst affected by the disease.

I meet Marken in the morgue, searching for the body of his nephew Joseph, who died two days ago.

Haitian authorities hope the epidemic may now be stabilising, but the human cost continues to mount, in a country which has already seen so much suffering.

A cholera outbreak in Haiti has killed more than 200 people in northern and central Haiti. The BBC's Laura Trevelyan has visited the Saint Nicholas hospital in Saint-Marc, a port town in Artibonite department:

Every corner of this open air courtyard is filled with patients.

A woman weeps, her two children just confirmed as having cholera.

A father cradles his two-year-old, as the mother tries to get their unresponsive son to drink the rehydrating fluid which will help keep him alive.

An elderly woman lies motionless on a camp bed, covered with a blanket. She looks emaciated.

Everywhere I look, I see eyes which have sunk back into their sockets - the sign of advanced dehydration from diarrhoea.

Crowded households

A few hours on an intravenous drip can cure people in this state - or it may not be enough.

A young boy is sleeping, his breathing shallow - his mother watches intently.

Dr Koji Nakashima from Partners in Health, a group working with the Haitian health authorities throughout the country, has spent all day administering intravenous drips to patients.

"The terrifying thing about this disease is how quickly it can kill," he says.

"Patients come in and they're unresponsive. They don't have the resources to get here quickly - they come by donkey, on foot. It is a very challenging environment."

His colleague Dr Louise Ivers has been helping to manage admissions to the hospital.

People are coming in earlier on in the stages of cholera, she says, so there seem to be slightly fewer severe cases than there were. But the people keep coming.

The doctors say cholera can kill very quickly if patients are is not treated properly

Although the Artibonite river has not been officially confirmed as the source of the outbreak, she says that when the first patients started arriving on Tuesday, staff noticed a pattern: all those infected had used the Artibonite river, whether for play or washing.

This central region of Haiti was not directly affected by the earthquake in January which killed about 300,000 people. But many who lost their homes came here to live.

Dr Ivers says that meant already-crowded households have been taking on even more people, leading to stressful conditions.

The earthquake did not cause the cholera epidemic - but it certainly contributed to the conditions which have allowed it to spread.

The question now is how to contain the disease.

I have brought hand sanitiser and baby wipes - thinking that might help. The doctors explain that as the disease is transmitted by faeces, made watery by the diarrhoea, I must try to ensure that my boots are clean.

Haiti has not seen a cholera outbreak in 100 years, and that is partly why this one is spreading so fast: there is no immunity.

The country has been disproportionately affected by political clashes, natural disasters from tropical storms to earthquakes - and now this.

All eyes now are on the migration of the disease, as it moves towards the capital Port-au-Prince.

~~~~~~~~~~~~~~~~~~~~~~~from Washington Post~~~~~~~~~~~

Cholera outbreak threatens Haiti's capital

Sunday, October 24, 2010;

PORT-AU-PRINCE, HAITI -- A cholera outbreak that already has left 250 people dead and more than 3,000 sickened is at the doorstep of an enormous potential breeding ground: the squalid camps in Port-au-Prince where 1.3 million earthquake survivors live. Health authorities and aid workers are scrambling to keep the tragedies from merging and the deaths from multiplying.

Five cholera patients have been reported in Haiti's capital, heightening worries that the disease could reach the sprawling tent slums where abysmal hygiene, poor sanitation and widespread poverty could rapidly spread it. But government officials said Sunday that all five apparently got cholera outside Port-au-Prince, and they voiced hope that the deadly bacterial disease could be confined to the rural areas where the outbreak originated last week.

"It's not difficult to prevent the spread to Port-au-Prince. We can prevent it," said Health Ministry director Gabriel Timothee. He said tightly limiting movement of patients and careful disposal of bodies can stave off a major medical disaster.

If efforts to keep cholera out of the camps fail, "the worst case would be that we have hundreds of thousands of people getting sick at the same time," said Claude Surena, president of the Haiti Medical Association.

Cholera can cause vomiting and diarrhea so severe that it can kill from dehydration in hours.

Doctors Without Borders issued a statement saying that some Port-au-Prince residents were suffering from watery diarrhea and were being treated at facilities in the capital. Cholera infection among the patients had not been confirmed, however, and aid workers stressed that diarrhea has not been uncommon in Port-au-Prince since the earthquake.

"Medical teams have treated many people with watery diarrhea over the last several months," Doctors Without Borders said.

Aid workers in the impoverished nation say the risk is magnified by the extreme poverty faced by people displaced by the Jan. 12 earthquake, which killed as many as 300,000 Haitians and destroyed much of the capital. Haitians living in the camps risk disease by failing to wash their hands, or scooping up standing water and then proceeding to wash fruits and vegetables.

"There are limited ways you can wash your hands and keep your hands washed with water in slums like we have here," said Michel Thieren, an official with the Pan-American Health Organization in Haiti. "The conditions for transmission are much higher."

Aid workers are coaching thousands of impoverished families how best to avoid cholera. Various aid groups are providing soap and water purification tablets and educating people in Port-au-Prince's camps about the importance of hand-washing.

Aid groups also began training more staff about cholera and where to direct people with symptoms. The disease had not been seen in Haiti for decades, and many people don't know about it.

Members of one grass-roots Haitian organization traveled around Port-au-Prince's camps booming warnings about cholera from speakers in the bed of a pickup.

"In a way, it couldn't have happened at a better moment than now because everyone is on the field - lots of [nongovernmental organizations], lots of money. We haven't had any hurricanes so far this fall but people are here, and people are prepared," said Marc Paquette, Haiti director for the Canadian branch of Medecins du Monde.

- Associated Press