Cholera in Haiti: From control to elimination

Two years after a massive earthquake and subsequent cholera outbreak, Haitians are trying to improve public health.

Haiti Cholera outbreak [GALLO/GETTY]
More than 7,000 Haitians died from Cholera and experts worry deaths will spike in the rainy season [GALLO/GETTY]

Two years after a 7.0 magnitude earthquake devastated Haiti, reconstruction efforts are being hampered by an ongoing cholera outbreak which has killed thousands.

In an effort to eliminate the water borne disease, officials from the Pan American Health Organisation (PAHO), UNICEF and the US Centers for Disease Control and Prevention (CDC) announced a partnership with the governments of Haiti and the Dominican Republic on Wednesday, to try and improve sanitation and access to drinking water in the Western Hemisphere’s poorest country.

The goal is to extend proper sanitation facilities to at least two-thirds of the Haitian population by 2015, a daunting task which could cost $1.1bn.

“Of course we need to control [the epidemic], of course we need to reduce the mortality,” said Dr Mirta Roses, Director of PAHO, in her opening address at the international press conference in Washington, DC. “The call of action is for a cholera-free Hispaniola [the island containing Haiti and the Dominican Republic], which means not just prevention and control, but elimination.”

The cholera epidemic began in October 2010, ten months after the earthquake, causing at least 7,001 deaths and making more than half a million seriously ill. The disease spread like wildfire; the CDC calls it one of the largest cholera epidemics to affect a single region in modern history.

Cholera is a water-borne gastrointestinal illness caused by the bacteria Vibrio cholerae.  Patients experience uncontrollable diarrhea, rapidly leading to severe dehydration, electrolyte imbalances and sometimes death. Cholera can be easily treated with proper hydration and antibiotics. Even still, the latest figures from the World Health Organisation (WHO) show three to five million cases worldwide with 100,000-120,000 cholera-related deaths each year.

Poverty and infrastructure 

“Cholera is a disease that defines poverty; it has done so historically and continues to do so today,” said Dr Sanjay Wijesekera, Chief of Water and Sanitation at UNICEF. “In [some] rural areas, 99 per cent of people practice open defecation. This has huge public health implications.”

No end in sight for Haiti’s cholera epidemic

Haiti has the least developed water and sewage treatment facilities in the Western Hemisphere, ranking 145 out of 169 countries in the United Nations Human Development Index. Prior to the earthquake, 86 per cent of the people in Port au Prince, the capital, were living in slum conditions with 70 per cent subsisting on less than $2 per day. In 2008, only 17 per cent of Haitians had access to proper sanitation (flush toilets, septic tanks, ventilated pit latrines) and 63 per cent to clean drinking water.

“There is no effective public water system in Haiti,” said Dr Louise Ivers, Chief of Mission for Partners in Health, a Boston based non-profit organisation, living in Haiti. “The river is the place where bathing, drinking and defecation all occur.”

By contrast, 93 per cent of people living in the Dominican Republic have access to proper sanitation, which is comparable to the rest of Latin America and the Caribbean.

Dr Kevin De Cock, Director of the Centre for Global Health at the CDC, agrees. “It comes as no surprise that when cholera was introduced, it turned into one of the largest cholera epidemics in history.”

Origins of an epidemic

Haiti had not seen cholera in almost a century; the strain that started the epidemic was originally isolated from Bangladesh, according to a recent report in the New England Journal of Medicine.

The question of how this strain arrived in Haiti was the subject of a UN special report which concluded that the source of the epidemic was most likely a camp for UN peacekeepers from Nepal, whose human waste was dumped by independent contractors into an unsecured pit that was susceptible to flooding in heavy rainfall.

Haitians, who had suspected as much, were understandably upset. The US-based Institute for Justice and Democracy has filed claims against the UN on behalf of some 5,000 cholera victims, demanding hundreds of millions of dollars in compensation. They argue that the UN mission in Haiti failed to screen peacekeepers for cholera and allowed untreated waste from the base to be dumped into the main river.

When epidemiologists trace the spread of a disease, finding the first carrier, or the ‘index case’ is important. After numerous reports and speculation, a recent study published this week in the American Journal of Tropical Medicine and Hygiene uncovers what is believed to be the first case of Haiti’s cholera epidemic.

Researchers believe the first man to contract the disease was a 28-year-old from the rural town of Mirebalais, with a history of untreated psychiatric disease.  

Blaming this particular individual, however, misses the structural problem of contaminated water. “If it wasn’t him, it would have been someone else,” Ivers told Al Jazeera. “The problem of exposure through the river still would have been there.”

Cholera is a disease that defines poverty; it has done so historically and continues to do so today

Dr Sanjay Wijesekera, Chief of Water and Sanitation at UNICEF

Roses is quick to point out that it doesn’t really matter where it came from. “There has been a lot of questions on ‘who brought it’ ‘how it was spread’ that are relevant for research but not for halting the spread.”

After the outbreak began in Haiti, cases of cholera were reported as far as Miami and Boston. “One of the key learning points is that the interconnectedness of both rich and poor countries can lead to a global spread,” Ivers told Al Jazeera.

In another recent paper, researchers were able to track the spread of the disease through social media. News of the cholera outbreak hit Twitter and Facebook two weeks before traditional data was available to Haiti’s Ministry of Health, according to this week’s piece in the American Journal of Tropical Medicine and Hygiene.

“We used global data from people with relatives in Haiti, friends, aid workers, even celebrities who visited,” Dr Rumi Chunara, the study’s lead researcher, told Al Jaeera. “This method has a lot of potential for places where the infrastructure has been disrupted, like post-disaster areas.”

Relief efforts

In the wake of the epidemic, countless governmental organisations, charities, medical relief groups and individual practitioners rallied to the country.

Souad Lakhdim has been the PAHO Regional Manager in Haiti since the earthquake. “Our strategy [for cholera] had two objectives. One was to save lives, the other, to prevent the spread of disease,” she said.

For the first, numerous Cholera Treatment Centers or CTCs were set up around the country, and local medical staff were trained in cholera treatment guidelines. Additionally, oral rehydration centers were set up in smaller communities for patients who did not necessarily require intensive medical care.

To prevent the spread, health promotion initiatives were launched in the form of door-to-door programmes teaching proper personal hygiene, hand washing and defecation practices. Aid groups taught water chlorination and supplied chlorine tabs as well as attempted to secure clean water.

After the interventions, mortality decreased from 10 per cent of cholera victims at the start of the epidemic to a stable rate of less than one per cent from January 2011 onwards.

Steps forward

Haiti two years after the earthquake 

Although mortality due to cholera has decreased and stablised since the onset of the epidemic, Haiti continues to see 200 new cases cholera of a day. This is expected to increase to 1000 cases per day in April 2012, when the rainy season begins.

As foreign aid groups pull out of Haiti from December 2011 onwards, the Ministry of Health has plans to incorporate the cholera relief effort into the country’s existing health care system. In the long term, however, elimination will require major structural changes.

Building an infrastructure to fulfill the goals of the Call to Action will require $1.1bn, and a lot of patience. Based on similar cholera outbreaks in Africa and more recently in Central America after Hurricane Mitch, experts expect it will take around 10 years to fully control the disease.

In the meantime, Wijasekera said that many short term solutions are available. “Simple behavioral changes, such as washing hands at critical times, can have a huge impact. Low cost, huge impact. Of course, meant to be in conjunction with long term infrastructure changes, but these are immediate, inexpensive things we can do.”

In what could be a sign of brighter days to come, Haitian kids recently set a Guinness World Record for hand washing after 7000 school children soaped-up for National Hand-Washing Day.

Michel Martelly, Haiti’s President, encouraged the international community to get involved during Wednesday’s international call to action. “Decades of neglect and the failure to invest have led to many illnesses associated with the consumption of contaminated water, lack… of good hygiene, and poor excreta management,” he said. “More than ever before, now is the time to address these deficiencies.”

Follow Meera Dalal on twitter @MeeraDalal

Source: Al Jazeera