On October 19, 2010, MSPP was notified of a sudden increase in patients with acute watery diarrhea and dehydration in the Artibonite and Plateau Centrale Departments. The Laboratoire National de Sante Publique tested stool cultures collected that same day and confirmed V. cholerae
serogroup O1, biotype Ogawa, on October 21. The outbreak was publicly announced on October 22 (22
A joint MSPP-CDC investigation team visited 5 hospitals and interviewed 27 patients who resided in communities along the Artibonite River or who worked in nearby rice fields (23
). Many patients said they drank untreated river water before they became ill, and few had defecated in a latrine. Health authorities quickly advised community members to boil or chlorinate their drinking water and to bury human waste. Because the outbreak was spreading rapidly and the initial case-fatality rate (CFR) was high, MSPP and the USG initially focused on 5 immediate priorities: 1) prevent deaths in health facilities by distributing treatment supplies and providing clinical training; 2) prevent deaths in communities by supplying oral rehydration solution (ORS) sachets to homes and urging ill persons to seek care quickly; 3) prevent disease spread by promoting point-of-use water treatment and safe storage in the home, handwashing, and proper sewage disposal; 4) conduct field investigations to define risk factors and guide prevention strategies; and 5) establish a national cholera surveillance system to monitor spread of disease.
National Surveillance of Rapidly Spreading Epidemic
Health officials needed daily reports (which established reportable disease surveillance systems were not able to provide) to monitor the epidemic spread and to position cholera prevention and treatment resources across the country. In the first week of the outbreak, MSPP’s director general collected daily reports by telephone from health facilities and reported results to the press. On November 1, formal national cholera surveillance began, and MSPP began posting reports on its website (www.mspp.gouv.ht
). On November 5–6, Hurricane Tomas further complicated surveillance and response efforts, and many persons fled flood-prone areas. By November 19, cholera was laboratory confirmed in all 10 administrative departments and Port-au-Prince, as well as in the Dominican Republic and Florida (24
) (). Though recently affected departments in Haiti experienced high initial CFRs, by mid December, the CFR for hospitalized case-patients was decreasing in most departments, and fell to 1% in Artibonite Department (26
). Reported cases decreased substantially in January, and the national CFR of hospitalized case-patients fell below 1% (). As of July 31, 2011, a total of 419,511 cases, 222,359 hospitalized case-patients, and 5,968 deaths had been reported.
Administrative departments of Haiti affected by the earthquake of January 12, 2010; the path of Hurricane Tomas, November 5–6, 2010; and cumulative cholera incidence by department as of December 28, 2010.
Figure 2 Reported cases of cholera by day, and 14-day smoothed case-fatality rate (CFR) among hospitalized cases, by day, Haiti, October 22, 2010–July 25, 2011. UN, United Nations; CDC, Centers for Disease Control and Prevention; PAHO, Pan American Health (more ...)
Field Investigations and Laboratory Studies
To guide the public health response, officials needed to know how cholera was being transmitted, which interventions were most effective, and how well the population was protecting itself. Therefore, CDC collaborated with MSPP and other partners to conduct rapid field investigations and laboratory studies. Central early findings included the following.
First, identifying untreated drinking water as the primary source for cholera reinforced the need to provide water purification tablets and to teach the population how to use them. Although most of the population had heard messages about treating their drinking water, many lacked the means to do so.
In addition, in Artibonite Department, those with cholera-like illness died at home, after reaching hospitals, and after discharge home, which suggests that persons were unaware of how quickly cholera kills and that the overwhelmed health care system needed more capacity and training to deliver lifesaving care. Also, water and seafood from the harbors at St. Marc and Port-au-Prince were contaminated with V. cholerae, which affirmed the need to cook food thoroughly and advise shipmasters to exchange ballast water at sea to avoid contaminating other harbors.
The epidemic strain was resistant to many antimicrobial agents but susceptible to azithromycin and doxycycline. Guidelines were rapidly disseminated to ensure effective antimicrobial drug treatment.
Cholera affected inmates at the national penitentiary in Port-au-Prince in early November, causing ≈100 cases and 12 deaths in the first 4 days. The problem abated after the institution’s drinking water was disinfected and inmates were given prophylactic doxycycline.
Finally, investigators found that epidemic V. cholerae
isolates all shared the same molecular markers, which suggests that a point introduction had occurred. The epidemic strain differed from Latin American epidemic strains and closely resembled a strain that first emerged in Orissa, India, in 2007 and spread throughout southern Asia and parts of Africa (27
). These hybrid Orissa strains have the biochemical features of an El Tor biotype but the toxin of a classical biotype; the later biotype causes more severe illness and produces more durable immunity (28
). A representative isolate was placed in the American Type Culture Collection, and 3 gene sequences were placed in GenBank (23
Training Clinical Caregivers and Community Health Workers
CDC developed training materials (in French and Creole) on cholera treatment and on November 15–16 held a training-of-trainers workshop in Port-au-Prince for locally employed clinical training staff working at PEPFAR sites across all 10 departments. These materials were also posted on the CDC website (www.cdc.gov/haiticholera/traning
). The training-of-trainers graduates subsequently led training sessions in their respective departments; 521 persons were trained by early December.
During the initial response ≈10,000 community health workers (CHWs), supported through the Haitian government and other organizations, staffed local first aid clinics, taught health education classes, and led prevention activities in their communities. Training materials for CHWs developed by CDC were distributed at departmental training sessions, shared with other nongovernmental organization (NGO) agencies, and used in a follow-up session for CHWs held on March 1–3, 2011 (see pages 2162–5). The CHW materials discussed treating drinking water by using several water disinfection products; how to triage persons coming to a primary clinic with diarrhea and vomiting; making and using ORS; and disinfecting homes, clothing, and cadavers with chlorine bleach solutions. Materials were posted on the CDC website as well.
Working with Partners to Increase Capacity for Cholera Treatment
Supply logistics were daunting as cholera spread rapidly across Haiti. Sudden, unexpected surges in cases could easily deplete local stocks of intravenous rehydration fluids and ORS sachets, and resupplying them could be slow. The national supply chain, called Program on Essential Medicine and Supplies, was managed by MSPP, with technical assistance from the Pan American Health Organization, and received shipments of donated materials and distributed them to clinics.
Early in November the USG provided essential cholera treatment supplies through the US Agency for International Development’s Office of Foreign Disaster Assistance (OFDA) to the national warehouse and IDP camps. CDC staff also distributed limited supplies to places with acute needs. To complement efforts by MSPP and aid organizations to establish preventive and treatment services, OFDA provided emergency funding to NGO partners with clinical capacity.
When surveillance and modeling suggested that the spread of cholera across Haiti could outpace the public health response, the USG reached out to additional partners to expand cholera preventive services and treatment capacity. PEPFAR clinicians were authorized to assist with clinical management of cholera patients and participated in clinical training across the country. In December, CDC received additional USG emergency funds and awarded MSPP and 6 additional PEPFAR partners $14 million to further expand cholera treatment and prevention efforts through 4,000 CHWs and workers at 500 community oral rehydration points. Funds were also used to expand cholera treatment sites at 55 health facilities. In addition, CDC established the distribution of essential cholera supplies to PEPFAR partners through an existing HIV commodities supply chain management system.
Improvements in Water, Sanitation, and Hygiene
To increase access to treated water and raise awareness of ways to prevent cholera, a consortium of involved NGOs and agencies, called the water, sanitation, and hygiene cluster, met weekly. Led by Haiti’s National Department of Drinking Water and Sanitation and the United Nation’s Children’s Fund, the members of this cluster targeted all piped water supplies for chlorination, and began distributing water purifying tablets for use in homes throughout Haiti. CDC helped the National Department of Drinking Water and Sanitation monitor these early efforts with qualitative and quantitative assessments of knowledge, attitudes, and practices. Emergency measures, especially enhanced chlorination of central water supplies, were expanded in the IDP camps because of the perceived high risk. OFDA and CDC provided water storage vessels, soap, and large quantities of emergency water treatment supplies for households and piped water systems. Distributing water purifying tablet supplies to difficult-to-reach locations remained a challenge.
Educating the Public
Beginning October 22, MSPP broadcast mass media messages, displayed banners, and sent text messages encouraging the population to boil drinking water and seek care quickly if they became ill. Early investigations affirmed the public’s need for 5 basic messages:1) drink only treated water; 2) cook food thoroughly (especially seafood); 3) wash hands; 4) seek care immediately for diarrheal illness; 4) and give ORS to anyone with diarrhea. In mid November, focus group studies in Artibonite indicated that residents were confused about how cholera was spreading and how to best prevent it, but they understood the need to treat diarrheal illness with ORS, how to prepare ORS, and how to disinfect water with water purification tablets (30
). Posters provided graphic messages for those who could not read (). On November 14, Haitian President René Préval led a 4-hour televised public conference to promote prevention, stressing home water treatment and handwashing, and comedian Tonton Bichat showed how to mix ORS.
Figure 3 Educational poster (in Haitian Creole) used by the Haitian Ministère de la Santé Publique et de la Population (MSPP) to graphically present the ways of preventing cholera. DINEPA, Direction Nationale de l’Eau Potable et d’ (more ...)