Cholera Epidemic

Overview

The ongoing Haiti cholera outbreak is the worst epidemic of cholera in recent history, according to the U.S. Centers for Disease Control and Prevention. In little over two years, as of January 2013, it has killed more than 7,900 Haitians and hospitalized hundreds of thousands more while spreading to neighboring countries including the Dominican Republic, Cuba, Venezuela, and the United States. Since the outbreak began in October 2010, more than 6% of Haitians have had the disease.

The outbreak began in mid October 2010 in the rural Center Department of Haiti, about 100 kilometers (62 mi) north of the capital, Port-au-Prince, killing 4672 people by March 2011 and hospitalizing thousands more. The outbreak occurred ten months after a powerful earthquake which devastated the nation’s capital and southern towns on 12 January 2010. By the first 10 weeks of the epidemic, cholera spread to all of Haiti’s 10 departments or provinces.

As of 12 December 2012, hospitalizations (2,300 per week) and deaths (40 per week) are roughly triple since Hurricane Sandy struck the island in what was expected to be a quiet cholera season, causing more deaths than the cyclone took in all countries combined. In November 2010, the first cases of cholera were reported in the Dominican Republic and a single case in Florida, United States; in January 2011, a few cases were reported in Venezuela. The epidemic came back strongly in the 2012 rainy season, despite a localized delayed vaccine drive. In late June 2012, Cuba confirmed three deaths and 53 cases of cholera in Manzanillo, in 2013 with 51 cases in Havana.

Quick Facts: Quick Facts for the on-going Cholera outbreak. 8,300+ dead (all countries). Haiti: 7,912 dead (as of 7 Jan 2013).

Background

During the 20th century, six major cholera pandemics had spread around the world. At the time of this outbreak, the world was experiencing the seventh, caused by a new strain of the Vibrio cholerae bacterium, El Tor. Epidemics involving this strain started in 1961 in Indonesia, and spread rapidly elsewhere in eastern Asia and then to India and Bangladesh, the USSR, Iran and Iraq. This was the first outbreak in Haiti ever recorded. On 21 October, the US Centers for Disease Control and Prevention (CDC) confirmed that cases of diarrheal illness that hospitals in the Artibonite region had been receiving had been identified as cholera. Haiti has not had a cholera outbreak in recorded history, so it triggered panic and confusion in the populace, complicating relief efforts.

The spread was partially blamed on the poor distribution of health supplies due to logistical problems. The Pan American Health Organization said there was also a lack of access to untainted drinking water.

The suspected source for the epidemic was the Artibonite River, from which most of the affected people had drunk water. Suspicion among Haitians centered on a UN military base on a tributary of that river home to peacekeepers from Nepal. On October 26, MINUSTAH officials issued a press statement denying the possibility that the base could have caused the epidemic, citing stringent sanitation standards. The next day, October 27, reporters Jonathan M. Katz of the Associated Press and, later that day, Sebastian Walker of Al Jazeera English visited the base and found gross inconsistencies between the statement and the base’s actual conditions. Katz also happened upon UN military police taking samples of ground water to test for cholera, despite UN assertions that it was not concerned about a possible link between its soldiers and the disease. MINUSTAH spokesmen later contended that these samples proved negative for cholera. However, an AP investigation showed that the tests were improperly done at a laboratory in the Dominican Republic with no experience testing for cholera.

The U.S. Centers for Disease Control and Prevention said its tests of “DNA fingerprinting” showed various samples of cholera from Haitian patients were identified as Vibrio cholerae serogroup O1, serotype Ogawa, a strain found in South Asia.

For three months, UN officials, the CDC, and others argued against investigating the source of the outbreak. Gregory Hartl, a spokesman for the World Health Organization (WHO), said finding the cause of the outbreak was “not important”. “Right now, there is no active investigation. I cannot say one way or another [if there will be]. It is not something we are thinking about at the moment. What we are thinking about is the public health response in Haiti.” Jordan Tappero, the lead epidemiologist at the CDC, said the main task was to control the outbreak, not to look for the source of the bacteria and that “we may never know the actual origin of this cholera strain.” A CDC spokesperson, Kathryn Harben, added that “at some point in the future, when many different analyses of the strain are complete, it may be possible to identify the origin of the strain causing the outbreak in Haiti.”

Paul Farmer, a co-founder of the medical organisation Partners in Health and a UN official himself (as Bill Clinton’s No. 2 at the Office of the Special Envoy for Haiti, however, told AP on November 3 that there was no reason to wait. “The idea that we’d never know is not very likely. There’s got to be a way to know the truth without pointing fingers.” A cholera expert, John Mekalanos, supported the assertion that it was important to know where and how the disease emerged because the strain is a “novel, virulent strain previously unknown in the Western Hemisphere and health officials need to know how it spreads.” The Swedish ambassador to Haiti said the epidemic had strains originating in Nepal. However, Nepal’s representative to the United Nations “categorically refuted” the hypothesis that Nepali peacekeepers were the source of the outbreak.

Under intense pressure, the UN relented, and said it would appoint a panel to investigate the source of the cholera strain. That panel’s report, issued in May 2011, confirmed substantial evidence that the Nepalese troops had brought the disease to Haiti. However, in the report’s concluding remarks, the authors hedged to say that a “confluence of circumstances” was to blame. Even so, the report presented no alternate hypotheses about how the strain could have arrived in a remote river far outside the earthquake zone, where few foreigners visit or work.

Some US professors have disagreed with the contention that Nepalese soldiers caused the outbreak. Some said it was more likely dormant cholera bacteria had been aroused by various environmental incidents in Haiti. Before studying the case, they said a sequence of events, including changes in climate triggered by the La Niña climate pattern and unsanitary living conditions for those affected by the earthquake, triggered bacteria already present to multiply and infect humans. However, a study unveiled in December and conducted by French epidemiologist Renaud Piarroux contended that UN troops from Nepal had started the epidemic as waste from outhouses at their base flowed into and contaminated the Artibonite River.

Domestic reactions

Protesters have demanded that the Nepalese brigade of the UN leave the country. There were fears that following the discovery of 15 cases in the capital, the epidemic could spread further. The Pan-American Health Organisation predicted that 270,000 people would be infected within a year of the outbreak.

On 15 November, a riot broke out in Cap-Haïtien following the death of a young Haitien inside the Cap HAaitien U.N. base and rumours that the outbreak was caused by U.N. soldiers from Nepal. At least 5 people were killed in the riots, including 1 UN personnel. Riots then continued for a second day. Following the riots the UN said the outbreak was being staged for “political reasons because of forthcoming elections”, as the Haitian government sent its own forces to “protest” the UN peacekeepers. During a third day of riots UN personnel were blamed for shooting at least 5 protestors but denied responsibility. On the fourth day of demonstrations against the UN presence, police fired tear gas into an IDP camp in the capital.

Riots following the election were a cause for concern in the ability to contain the epidemic.

Initial Spread

By the end of October cholera had been confirmed in four of Haiti’s ten departments: Artibonite, Centre, Nord and Ouest, including the capital Port-au-Prince, and the capital’s Cité Soleil slum district, By 16 November it had spread throughout the country. In addition to those hospitalized  other people have been unable to receive treatment due to overcrowded hospitals. Health workers also feared the disease would spread after Hurricane Tomas hit the island causing more flooding.

There are fears that the disease could further spread, since many people still live in unsanitary camps as a result of the earthquake earlier in the year, after outbreak was reported in the camps. These concerns came despite claims that the outbreak had been contained in the north and central parts of the country. The first outbreak of cholera was reported in the Dominican Republic in mid-November 2010, following the Pan-America Health Organisation’s prediction. By January 2011, the Dominican Republic had reported 244 cases of cholera. The first man to die of it there died in the province of Altagracia on 23 January 2011. In the United States, a woman returning from Haiti to Florida was hospitalized for five days as a result of contracting cholera. She was expected to recover fully. The Florida Department of Health also investigated several other suspected cases of the disease.

On 15 November, Laura Dills, director of programming for Catholic Relief Services in Haiti, said, “Some people have been reporting that we’ve gotten in front of it and are in control of the spread of cholera. Actually WHO does not believe that. There’s such a severe under-reporting of cases that they’re not sure of all of the hot spots.”

The Haitian government estimated that there would be at least 400,000 cholera cases in the first 12 months of the epidemic—with half of those cases occurring by mid-January 2011.

In late January 2011, more than 20 Venezuelans were reported to have been taken to hospital after contracting cholera after visiting the Dominican Republic. 37 cases were reported in total. Contaminated food was blamed for the spread of the disease. Venezuelan health minister Eugenia Sader gave a news conference which was broadcast on VTV during which she described all 37 people as “doing well”. The minister had previously observed that the last time cholera was recorded in Venezuela was twenty years before this, in 1991.

On 15 March 2011, a report was issued by the University of California that predicted total infections would number up to 779,000 and total deaths up to 11,000 by November 2011, compared with earlier UN estimates that around 400,000 people would end up infected. The revised numbers were based on more factors than the UN’s estimates, which assumed a total infection rate of between two and four percent of the population. In a statement released at the same time, the WHO said total deaths thus far had reached 4,672, with 252,640 cases reported.

Casualties over the years

Some aid agencies have reported that the toll may be higher than the official figures because the government does not track deaths in rural areas where people never reached a hospital or emergency treatment center. In 2011, reports suggested over 6,700 people had been killed during the outbreak.

By March 2011, after the initial intense flare up, some 4,672 people died and as of March 2012, cholera has killed more than 7,050 Haitians and sickened more than 531,000, or 5 percent of the population.

The next years there was significant progress reduction of caseloads and deaths, with solid backing of international medical efforts and preventative measures, including latrines installed and changes in haitian behaviors, such as thoroughly cooking food and rigorous hand washing  Despite all these efforts, every rainy season or hurricane has caused a temporary spike in cases and deaths. Per the Haitian Health Ministry, as of August 2012, the outbreak had caused 7,490 deaths and caused 586,625 people to fall ill.

Political reactions

On 28 October, the head of Haiti’s health department, Gabriel Thimoté, said 4,147 people were being treated. WHO’s cholera chief, Claire-Lise Chaignat, said the epidemic was not contained and that she thought it had not yet “reached the peak”, so Haitian authorities should be prepared for a “worst case scenario” of cholera spreading in the capital, Port-au-Prince.

On 10 November, Gabriel Thimote, Haiti’s senior health official, said that the outbreak was “no longer a simple emergency, it’s now a matter of national security.”

The outbreak of cholera became an issue for candidates to answer in the 2010 general election. There were fears that the election could be postponed. The head of MINUSTAH Edmond Mulet said that it should not be delayed as that could lead to a political vacuum with untold potential problems.

On 12 November, the United Nations issued an appeal for around US$160 million to fight the spread of the disease, saying that “all our efforts can be outrun by the epidemic” and warned of a lack of space for patients in hospitals. It also denied that the Nepali contingent were responsible for the outbreak. In November 2011, the UN received a petition from 5,000 victims for hundreds of millions of dollars in reparations over the outbreak thought to have been caused by UN members of MINUSTAH.

In 2012, Bureau des Avocats Internationaux head Mario Joseph and Institute for Justice & Democracy in Haiti Director Brian Concannon filed suit against the United Nations, seeking reparations on behalf of victims of the outbreak.

 

Citation: wikipedia, 2010–2012 Haiti cholera outbreak