The first US case associated with the epidemic in Hispaniola was laboratory confirmed on November 15, 2010, in a US resident who had traveled to Haiti and returned to Florida. The first case in a patient with history of travel to Dominican Republic was laboratory confirmed on January 29, 2011. As of April 4, 2011, a total of 23 cholera cases associated with the Hispaniola epidemic had been confirmed (). Patients resided in Florida (10), Massachusetts (4), New York City (4), Kansas (1), Michigan (1), North Carolina (1), Virginia (1), and Texas (1) (). Illness onset dates ranged from October 23, 2010, to February 2, 2011. Median age was 38 years (range 9–84 years), and 43% were female patients.
Confirmed cholera cases (n = 23), by onset date and travel history, United States, October 21, 2010–February 4, 2011.
Geographic distribution of cholera cases in the United States associated with Hispaniola, October 21, 2010–April 4, 2011.
All patients were treated with antimicrobial agents, rehydration, or both; 9 (39%) were hospitalized, 6 (30%) sought care at an emergency department, and none died. Six patients had illness onset before returning to the United States, 5 had illness onset on the day of return, and 12 had illness onset 1–11 days after return (typical incubation period for cholera is 18 hours–5 days) (5
Twenty cases were culture confirmed and 3 were confirmed by serologic testing. All 20 isolates matched the Haiti isolate outbreak pattern by pulsed-field gel electrophoresis. Susceptibility results for antimicrobial drug tested showed that all isolates were resistant to trimethoprim/sulfamethoxazole, furazolidone, nalidixic acid, sulfisoxazole, and streptomycin, and 18 isolates showed intermediate resistance to chloramphenicol, ampicillin, or amoxicillin/clavulanic acid.
Thirteen patients reported recent travel to Haiti (median length of stay 7 days, range 2–54 days) and 9 to Dominican Republic (median length of stay 4 days, range 2–9 days). One patient reported no recent travel but consumed cooked conch brought to the United States from Haiti by relatives. Travel was reported to the following departments in Haiti: Artibonite (2), Ouest (7), Centre (1), Nord (1), and Sud (1). One case-patient traveled to 2 departments, and 2 did not specify a destination. All case-patients associated with the Dominican Republic had attended a wedding in La Romana Province on January 22, 2010; an investigation conducted by the Dominican Republic Ministry of Health is ongoing. Aside from 2 case-patients who traveled to this wedding together, no other case-patients reported traveling together.
Visiting friends or relatives was the main reason for travel to Haiti (). Four patients traveled to Haiti to participate in relief activities, 2 as medical volunteers, 1 on a mission trip, and 1 to distribute canned foods. One patient immigrated to the United States from Haiti during the incubation period. A wide range of exposures was reported (); 5 patients were exposed to persons with cholera or cholera-like illness and to other risk factors for cholera acquisition. Medical volunteers participated in direct patient care. One volunteer reported no apparent lapses in safe water and food practices, although detailed information about food preparation was not available. No additional information was available for the other volunteer.
Reason for travel by destination for 22 cholera patients, United States, October 21, 2010–February 4, 2011*
Selected exposures during 4 d (7 d for body of water exposure) before illness onset in 23 cholera patients, United States, October 21, 2010–February 4, 2011*
Seven of 15 patients with information available reported receiving cholera prevention information before travel. Sources included newspaper articles (4), friends (4), CDC traveler’s hotline (1), and the World Health Organization website (1); 2 patients reported >1 source. None had ever received cholera vaccine. Two patients reported receiving a Travel Health Alert Notice upon arrival in the United States (M. Selent, unpub. data).