Thursday, November 18, 2010

The Cholera Epidemic: how did it begin, and when will it end?

Since the January 12 earthquake, the dread of another catastrophe has hovered over Haiti. The effects of the earthquake were devastating: 250,000 people killed, 300,000 injured, and 1.3 million residents of Port-au-Prince (PAP) living in camps in tents and under tarps. The situation in PAP’s infamous slums is even worse than in the tent cities where there is some access to potable water and modest sanitation facilities. The conditions were ripe for an outbreak of an epidemic of infectious disease: improper disposal of human waste, overcrowding, and flooding, now that we are in the midst of the rainy season.

Artibonite: the epicenter of the outbreak

On October 19, the first confirmed cases of cholera were reported, not from PAP, but the town of Saint-Marc in the rural Artibonite department 30 miles north of the capital. The cases were reported along the contaminated Artibonite River where it is suspected that a broken septic tank leaked into the river. The disease took hold in Artibonite, and over the next month spread to six of the ten departments. As of November 16, there were 16,799 hospitalized cases and 1,039 deaths reported. We have been hard hit in Gros Morne, 20 miles north of Saint-Marc where close to 1,000 patients have been admitted to hospital and 36 deaths have been reported. The number of cases in the national statistics is underreported since we know of many patients who die at home and are unable to get to hospital. The Alma Mater Hospital only has a fifty-bed capacity; the area surrounding the hospital is dotted with cholera tents where patients are cared for either by oral rehydration salts or intravenous fluid replacement therapy.

Based on experience with cholera epidemics in other countries, recently in Zimbabwe, and in 1991 in Peru, this epidemic is likely to affect more than 250,000 Haitians. The epidemic in Peru dragged on for six years. The Haitian epidemic is further complicated by the fact that Haiti has not seen cholera in a century, and the habitants of the island have no immunity to the disease.

Containment Efforts

Cholera is an intestinal disease caused by the exposure to and ingestion of food or water contaminated by the highly contagious bacterium, Vibrio cholera. Approximately 20% of infections cause violent diarrhea and vomiting, and death from dehydration can occur in a few hours if the disease is not treated promptly by fluid replacement. Cholera is a preventable, containable and treatable infectious disease.

The response to the epidemic has included large scale hygiene promotion: improving sanitation, distribution of clean water, decontamination of human waste, and prompt treatment of affected individuals. There is a massive education campaign in the camps, on radio and in the community focused on hand washing technique, purifying water, and disposal and decontamination of human excreta. Soap, chlorine, disinfectant tablets, and jerry cans to properly clean water, are being distributed country-wide.

Cholera treatment centers have sprung up across the country; some are stand- alone units for the treatment of mild cases with oral rehydration salts, other centers are in close proximity to hospitals, such as the Alma Mater Hospital in Gros Morne, where serious cases are treated with intravenous fluids. Rural communities such as ours, are short of cholera beds (cots with a hole in the bottom to collect excrement in a bucket), and lack adequate stores of disinfectant and intravenous replacement fluids.