The cholera outbreak in Haiti has resulted in over 664,000 cases and 8,000 deaths since 2010. Cholera spreads rapidly in areas with contaminated water and poor sanitation. Factors exacerbating the outbreak in Haiti include a lack of immunity, poverty, damage from natural disasters, and an increased virulence in the cholera strain. NGOs like Oxfam have implemented water, sanitation, and hygiene programs to control transmission, including chlorine dispensers, wells, latrines, and health education. However, ongoing issues like flooding and funding gaps increase the risk of further cholera spread.

1. The Haiti Cholera Outbreak
Tom Mahin
July 16, 2013 Presentation

2. Current Status of the Outbreak
• As of July 6, 2013, there have been 664,921
cholera cases and 8,178 cholera deaths in Haiti.
From MSPP

3. Introduction to Cholera
“In its most severe form, cholera is one of the
swiftest lethal infectious diseases known,
characterized by an explosive outpouring
of fluid and electrolytes within hours of
infection that, if not treated
appropriately, can lead to death within
hours. In places where drinking water is
unprotected from fecal contamination,
cholera can spread with stunning speed
through entire populations. These two
characteristics of cholera have yielded a
reputation that evokes fear and often panic.
However, with prompt and appropriate
treatment, mortality can be kept low.” - UNICEF Cholera Manual

4. What is Cholera?
• Cholera is caused by Vibrio cholerae bacteria that act
by attaching to cells that line the intestine where it
produces a toxin that interferes with the normal
cellular processes of absorption and secretion of fluid
and electrolytes.
• Up to 50 per cent of infected people could develop
severe dehydration with high mortality risk if left
untreated.

6. Cholera Risk Factors
UNICEF Cholera
Manual 2013

7. Pregnancy and Cholera
• Cholera patients who are pregnant have additional risk
factors for more severe outcomes.
• The greatest potential impact of maternal cholera
infection affects the outcome of the newborn because
cholera infection in the third trimester poses a greater
risk of spontaneous abortion and premature delivery.
• Poor outcomes are due to dehydration and reduced
blood flow to the placenta.

8. From UNICEF Cholera Toolbox 2013
Survival Times for V. Cholerae Bacteria

9. Climate Change & Cholera
Climate change potentially increases the risk of
cholera in a number of ways:
• the growth of bacteria, like V. cholerae in the
environment substantially increases at higher
temperatures.
• severe natural disasters damage water and
sanitation infrastructure and create higher
transmission risk.

11. Haiti Overview

12. From the 2013 UN Humanitarian Action Plan
(Mid-year Review)
• “Following long periods of drought and the
destruction of harvests by Tropical Storm Isaac and
Hurricane Sandy in 2012, more than 15% of Haitians
face a significant risk of food shortages …”
• “As many as 81,600 children under five are acutely
malnourished; 20,000 of these suffer severe acute
malnutrition and are nine times more likely to die
than healthy children.”
• “The upcoming rainy and hurricane season is likely
to bring about an increase in cholera cases…while
funding gaps have led to a serious decrease in the
capacity to respond.”

13. “We had barely picked ourselves up”
• “We had barely picked ourselves up after the
earthquake when the cholera fell on us.”
- Jocelyne Pierre-Louis, a senior Haitian health official
• Haiti's outbreak "is one of the largest cholera
epidemics in modern history to affect a single
country."
- Jon Andrus, deputy director of the PAHO

14. Some Cholera Risk Factors in Haiti
• Low safe drinking water & improved sanitation coverage
• Hygiene – food handling & inadequate hand washing
• Natural disasters and rainy season(s)
• Topography is conducive to flooding
• Lack of pre-existing immunity at onset of outbreak
• Economic situation/poverty increases risk
• Household member with cholera increases risk of
cholera for whole family
• Children with malnutrition
• Remote areas have dramatically higher mortality risk
• Dramatically reduced number of cholera treatment
centers/units in 2013 increases mortality risks

16. Low Improved Sanitation Coverage

17. Sanitation/Hygiene at Markets
All photos by T. Mahin

18. Topography in Haiti is Conducive to Flooding

19. High Flood Risk Areas

20. Haiti: Recent Floods (as of June 30, 2013)
From OCHA

21. Hurricanes/Tropical Storms During the Outbreak

22. Non-Functioning Water Systems
(line reportedly inadvertently cut by road project)

23. Hygiene/Handwashing Issues

24. High Poverty/Unemployment Rates

25. The Epicenter of the Cholera Outbreak
From Piarrou et al. Understanding the Cholera Epidemic, Haiti July 2011 EID

26. Grande Saline
Desdunes

27. Haiti Cholera Strain Has Increased Virulence
• The current cholera pandemic caused by the “El Tor”
cholera strain has been spreading worldwide since 1960.
Subsequently studies revealed “altered El Tor” strains.
• Compared to the typical El Tor pandemic strain, the
“altered El Tor” strain in Haiti is linked to increased
production of cholera toxin and more severely
dehydrating diarrheal disease.
• In a CDC study in Haiti “Median time from illness onset
to death was ……12 hours (range 2 hours–8 days) for
community decedents”
– Routh et al. “Rapid assessment of cholera-related deaths,
Artibonite Department, Haiti, 2010” Emerg Infect Dis

28. Dr. Sacks of John Hopkins:
"Cholera is an environmental bacterium. It can
persist in the environment for many, many years
without any human infection. ...”
From UCLA http://www.ph.ucla.edu/epi/snow/cholera_haiti.html

29. Cholera & IDP Camps in Port au Prince
• The earthquake of January 12, 2010, destroyed homes,
schools, government buildings, and roads around Port-
au-Prince; killing 230,000 persons and injured 300,000
and one and a half million residents sought shelter in
internally displaced person (IDP) camps.
• Drinking water systems - portable tanks filled by
trucked in water from deep boreholes and then
chlorinated in the camps - were installed by a number
of NGOs including Oxfam.
• When the outbreak arrived on Port au Prince, cholera
attack rates in the IDP camps were much lower than in
Artibonite and other areas (source – The CDC journal
Emerging Infectious Diseases).

31. Preparing Chlorine Solution for Tanks & Chlorine
Residual Testing - IDP Camps (after the earthquake)

32. Hurricane Tomas (Nov. 5, 2010)

33. From Tapero and Tauxe Emerging Infectious Diseases Vol. 17, No. 11, November 2011

35. Original Graph from MSPP/DINEPA
Impact of the Rainy Season(s) and Hurricane Sandy
on the Number of Cholera Cases

36. Comparison of Cholera Cases by Year
From MSPP

37. New Cholera Cases (per month) 2013
From OCHA

38. Cholera Treatment Units (CTU/UTC)

39. Water Sources
During the Cholera Outbreak

40. “ Sous” – Water Source - Hole in Ground Near River/Stream

41. Sous after Hurricane Sandy

42. Unprotected Dug Wells

43. Direct Use of Surface Water

44. Highly Contaminated Source after Rain Events

45. Highly Contaminated Source after Rain Events

46. Using Canal Water (Desdunes, Artibonite)
Turbidity 259 NTU

47. Examples of Oxfam’s Cholera-WASH Approach
• Repaired gravity flow water systems (GFSs) in Artibonite
• E. coli (m. ColiBlue 24) & turbidity testing of water sources
to confirm appropriate locations for chlorine dispensers
• Installed hand drilled wells & hand pumps in Artibonite
• Distribution of large numbers of Aquatabs & soap
• Installed and monitored chlorine dispensers at
community water sources in Nippes

48. Oxfam Cholera-WASH Activities (continued)
• Installed in-line tablet chlorination systems in Nippes
• Installed latrines at schools and homes
• Trained & worked closely with local water committees
• WASH cholera prevention messaging (e.g. radio)
• Provided WASH supplies to cholera treatment centers
• Installed rainwater collection systems at CTUs
• Installed protected dug wells with “rope pumps” in
Artibonite that are easy to maintain and repair

49. • Oxfam installed chlorine dispensers in Nippes (1 of 10
“Departments” in Haiti) because of high CFRs there &
because of the scarcity of other NGOs working on WASH

50. Chlorine Dispensers at Springs

52. Chlorine Dispensers at Hand Pumps

54. Partnered with International Action for In-Line
Chlorination of Gravity Water Systems with “Tablets”

56. Delivering Chlorine (“HTH”)
to a Water Committee Member

57. Hand Drilling Wells

58. Repairing Broken Water Pipes Using
Compression Couplings

59. New Rope Pump and Protected Well

60. E. Coli Testing (with m. ColiBlue 24)

61. E. Coli/Total Coliform Bacteria - 10:1 Dilution

62. E. Coli Results (Water Source)

63. Free Chlorine Testing
of Treated Water

64. Comparing
Chlorine
Testing
Equipment

65. Community Meeting in a Remote Mountain
Village Prior to Chlorine Dispenser Installation

66. Distribution of Aquatabs & Soap

67. Street Side Water Treatment Messaging
for Cholera Prevention

68. Oral Rehydration Therapy “ORT Corners”
in Communities

69. Four-Cabin Latrine Construction at Schools & Homes

70. Repair of Gravity Flow Water Systems

71. Support to National Water Supply
& Sanitation Agency (DINEPA)

72. Logistical Issues

74. Acknowledgements
• Bill and Melinda Gates Foundation
• Innovations for Poverty Action (IPA)
• International Action – Haiti
• ECHO
• Hach
• MSPP & DINEPA
• UNICEF