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Cholera FAQ Haiti

A LOT of incomplete info leads some people to be placed at risk by


what’s missing. Also lots of speculation gets treated as fact.
No one person or organization has all needed info.
Alister William Macintyre research notes
Version 2011 May 17

Table of Contents
Introduction (1 Feb 23)....................................................................................................................... 2
Is the crisis about over? (1 May 10).......................................................................................... 3
Ways to catch (or not get) Cholera (1 Feb 22) ............................................................................ 4
Vaccination against Cholera (1 Feb 22) ................................................................................... 6
Why not Vaccinate? (1 Feb 23) ............................................................................................ 7
Q: How bad is this going to get? (1 Mar 20)........................................................................... 8
Death Rate cannot be computed due to unknown data (1 Mar 01) ............................... 9
Haiti Population Volume likely to get infected with Cholera ........................................10
What is Cholera? (1 Feb 22) ....................................................................................................11
Medical Professionals (1 Feb 26) ................................................................................................ 13
Cholera arrival in Haiti (1 May 11).............................................................................................. 16
UN independent investigation (1 May 05) ............................................................................18
Other nations beyond Haiti (1 May 16).................................................................................23

1 Cholera FAQ Haiti (date after file name is version edition)


Sanitation in developing nations (1 Apr 13) ..............................................................................24
Myths, Rumor, and Panic (2010 Perspectives)..........................................................................24
Fixing Water availability and Sanitation long term........................................................................26
National strategy planning includes: ...........................................................................................26

Introduction (1 Feb 23)


This information has been cut and pasted from a variety of sources which I believe to be
authoritative and credible. In a few cases the content is from my own common sense.
There’s aspects to this for which I do not yet have as good an understanding as I wish, but
continuously update my notes as I get improved info.
Most info sources say “people get this disease by …..” and then other people falsely assume
that is the ONLY way you can get this disease. The facts are that we have seen in Haiti that
there are MANY ways a person can get this disease, although some ways do dominate. In
this FAQ I will try to identify all the risks.
From time to time, some people ask me stuff for fact checking, which can lead to further
updates here, as I recheck various sources.
As I add to this, the most current edition on the web will be here,1 except when my updates
are coming directly from MPHISE sources, or widely reported news stories. Copies will also
be posted other places, for convenience of people who can then pick and choose which of
my research efforts they wish to download, where version #s or dates have been
incremented to help people identify latest new edition.
Topic sub-titles can end in a date signifying when that info last updated, so by viewing table
of contents, we see where most recent input to these research notes, especially aiding people
with copy of an earlier version. Digit 1 in front of month means 2011.
Users of this research hold Alister Wm. Macintyre harmless, and also the places I upload my
research to, and agree that my copyright is reserved and that the information is available for
the intended purpose of helping in the recovery of Haiti.

1
http://haiti.mphise.net/cholera-faq-development

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Is the crisis about over? (1 May 10)
Q: News reports periodically claim the crisis has peaked, rate of new cases declining. Then it
is another story a few weeks later. What is going on?

A: The crisis continues. Medical personnel are over-whelmed. They need more personnel,
funding,2 expertise. Mountain rural communities represent approximately 2/3 of Haiti by
land area and are extremely difficult to access. People in those communities, often die at
rate of 100% of getting the disease, before rest of Haiti learns they need help. The risk of
catching cholera is seasonal, due to lack of good sanitation, combined with rainy seasons. 3

1. Official data from Gov of Haiti, WHO, PAHO, international community, etc. is a
gross under-reporting … check out story from doctors on-the-ground such as:
http://biosurveillance.typepad.com/haiti_operational_biosurv/2010/12/heas-sitrep-
12810.html
2. Government offices are not open 24x7. There can be lags in data flow, reporting,
the data they choose to include in the official reports.
3. People die, and the official data does not know how come they died, unless there is
lab testing, whose facilities capacity lacking. There is more interest in getting medical
aid where needed, than figuring out statistics.
4. Cholera epidemics are usually multi-year phenomenon. In tropical zones like Haiti,
they have two wet season peaks per year. In colder and dryer periods, cholera cases
go down. Haiti will tend to have fall and spring peaks per year for the next three
years and then cholera will become an endemic disease in Haiti.
5. Immunity from the cholera vaccine tends to last about 2 years. The cholera vaccine
is expensive and sufficient units are not available. WHO has approved a vaccine that
is not particularly appropriate for Haiti.
6. Water and sanitation systems still need to be addressed, and cannot be solved rapidly.
7. Even though astronomical funds have been pledged for Haiti, there is a huge
mismatch between promised and needs, resulting in many NGOs running out of
money, and leaving the country.
8. OCHA is the UN agency with mandate for overall coordination of humanitarian aid
to Haiti. OCHA is an unwieldy monster bureaucracy, without the agility needed for
rapidly coping with disasters.4

For more info on the above dimensions and issues, see:

2 http://reliefweb.int/rw/rwb.nsf/db900sid/KKAA-8EB93P?OpenDocument&rc=2&cc=hti
(Sources: OCHA/Relief Net and Voice of America)
3 http://www.haiti.mphise.net/seasonal-rains-bring-rise-cholera-cases-haiti

http://www.haiti.mphise.net/haitians-rainy-season-looms-bringing-another-wave-cholera
http://www.haiti.mphise.net/fresh-outbreak-cholera-haiti-after-heavy-rains-0
http://haiti.mphise.net/node/1083
4 See my 1 year mini-reviews of how various efforts fared in their efforts to deliver what Haiti needed, for the

first year after the earthquake.

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http://haiti.mphise.net/heas

Ways to catch (or not get) Cholera (1 Feb 22)


Q. What are the different ways a person in Haiti can catch cholera?

Cholera – There are many ways for it to spread. There are a variety of good sanitation
practices to protect against all of these ways.5 The important thing is to be aware of the
different ways it can spread, or a person can catch it, then take preventative actions for all of
them.

You don’t catch it by breathing air of an infected person, or touching them while they are
alive, or touching same objects they touched, you catch it by the bacteria going into your
mouth, then down into your digestive system. However, the way you touch infected people,
and the risk that the objects can be moist for a while, can then mean the bacteria is on your
hands, which you can handle stuff which will later go in your mouth.

Human Carrier: Typically only 25% of the people, who carry the bacteria in their gut,
even show the symptoms, so someone in a region of the world, which has the epidemic,
might travel to a region of the world which does not yet have it. If there is poor sanitation
there, the human waste products (toilet # 2) can get into the food chain to other humans.

Contaminated Water: Food prepared, or washed, using water which has the cholera
bacteria, will deliver the bacteria to whoever eats that food. That water could have been
contaminated by a carrier or marine life. The water needs to be boiled, which may be
impractical in tent cities.

If you bathe in contaminated water, such as a polluted river, and some of it gets into your
mouth, you just caught cholera.

Many Haitians use sources of water which is contaminated, not because of any educational
deficiencies, but because fresh clean water is generally not available in Haiti, except for
people with lots of money.

Marine Life: Cholera bacteria is carried in a variety of plankton and sea food. It can
remain dormant for decades, then “bloom” in the appropriate climate conditions, like those
recently for Haiti. If you use that plankton in salad, and wash it, the washing process only
cleans the outside of the plankton, not the bacteria which is inside.

Animal Carrier: Farm Animals do not get this disease, but they carry the bacteria in their
gut, so if meat is not properly cooked, all sorts of problems can be communicated.

5 http://www.associatedcontent.com/article/6021120/how_to_prevent_and_control_an_outbreak.html?cat=5

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Insects may carry vibrio cholerae and deposit it on food, water or other surfaces that
humans come in contact with and subsequently contract cholera, when their living
conditions involve poor sanitation.

Dead Bodies which died of cholera: Someone who has died of cholera is covered
with the vibrio, and anyone touching the body without adequate knowledge about self
protection and good hygiene is at risk of infection!!!!!

During the last moments of life people in the advanced stages of this illness are losing bodily
fluids from intestinal reflux and diarrhea. These bodily fluids contain the vibrio and these
fluids, as well as any other moist surface upon which they are found including the body, are
infectious until that body is properly disinfected and all external orfices to the
gastrointestinal system 'plugged' with chlorine saturated rags/sponges. Any one touching or
otherwise handling that body is subject to contamination and infection.

The clothes, bedding, floors, and all surfaces upon which these bodily fluids are found are
sources of infection!!!

Investigation of several cases during this outbreak including the very first clinical cases in
Lafito, revealed that the victims had not traveled to or within an area where cholera was
being reported, their only connection was that they had attended a funeral ceremony for a
cholera victim, shortly before becoming infected, and had laid hands on the body.

Q: Is this a pandemic, an epidemic, or an outbreak?

A pandemic is when a disease is in multiple nations. The problem which exploded in Haiti
in middle of October 2010 is now also in patients in Dominican Republic, Venezuela, USA,
and other nations, so by definition it is a pandemic. It is not yet proven what relation the
Haiti problem has to cholera disasters in Nigeria, Zimbabwe, and other nations, but the fact
remains that several nations already have a problem with cholera, and there is high risk of it
spreading to more nations.

However, the authorities are still labeling this as an epidemic or outbreak, which means the
volume of people catching the thing is way in excess of what would normally be considered
reasonable.

Q: The patients in Dominican Republic and USA are under the care of doctors, so it is not
yet a problem there, right?

A: For every one person with the symptoms, there are three other people on average who
are carrying it, but show no symptoms.

Q: Can you catch cholera via kissing?

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A: Al not think so, unless the cholera was delivered to one person mouth very recently.
(How long does the bacteria remain in mouth after it gets delivered there?)

Q: Can you catch cholera by shaking hands?

A: If a person has recently handled moist bedding of a person who died of cholera, and not
disinfected self afterwards, then their hands carry the cholera bacteria, so shaking hands can
then have both persons have it, then if either puts their hand to their mouth, they got it.

Q: If a person has cholera bacteria on their hands, and they use a door knob, is the bacteria
still on the door knob ready to be transferred to another person?

A: Many bacteria can be communicated that way, such as SARS, but when the moisture goes
away, which is needed as a carrier for cholera bacteria, it also dies. As a general rule, all
surfaces which are often touched by multiple people, such as telephone handsets, door
knobs, cooking utensils, they all should be regularly either cleaned or disinfected or both.

Q: If a person visits toilet of a commercial airliner, who has cholera, then someone else uses
same toilet, can they catch cholera by sitting on the infected toilet seat?

A: Cholera is transmitted to a body through the mouth. With proper sanitation, hand
washing etc. you should be safe from this kind of threat.

Q: What should travelers to Haiti do, to protect themselves?

A: All travelers to areas where cholera has occurred should observe the following
recommendations:

 Drink only water that you have boiled or treated with chlorine or iodine. Other safe
beverages include tea and coffee made with boiled water and carbonated, bottled
beverages with no ice.
 Eat only foods that have been thoroughly cooked and are still hot, or fruit that you
have peeled yourself.
 Avoid undercooked or raw fish or shellfish, including ceviche.
 Make sure all vegetables are cooked, avoid salads.
 Avoid foods and beverages from street vendors.
 Do not bring perishable seafood back to the United States.

A simple rule of thumb is "Boil it, cook it, peel it, or forget it."

Vaccination against Cholera (1 Feb 22)

Q: Can we be Vaccinated to protect us from ever getting this?

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A: Yes, but for whatever reason the Haiti population is not yet getting this protection,
although there is some discussion, which could lead to a change in policy..6

There is stuff which can be put in the water supply to kill the bacteria, which has been used
successfully in other nations, if I am to believe everything I read. But this suffers from the
“not invented here” syndrome of the oligarchy of international interests in charge in Haiti.

There are people who want to test the “put in water” solutions, but they have been unable to
get funding or approval to do this in Haiti.

India has an oral vaccine, which Bangladesh is using in the largest cholera fighting
experiment in history, so far.7 The study includes 240,000 people from one of Dhaka’s
poorest suburbs, Mirpur, two-thirds of whom will receive two doses of the cheap, Indian-
made vaccine. The remaining 80,000 people will not be given the vaccine as the control
group. Both groups will be monitored for the next four years.

Russia has a vaccine which they have offered to Haiti, but apparently the offer is being
ignored.

Sweden markets Dukoral®


SBL Vaccin AB,
SE-105 21 Stockholm, Sweden
e-mail: info@sblvaccines.se
website: www.sblvaccines.se

Bio-surveillance checked rumors regarding some medicines being less effective than others.
Thanks to Haitian officials' rapid response to their inquiry, the National Laboratory
(LNSP) has officially confirmed the Haiti strain is not resistant to doxycycline. It
is sensitive to doxycycline, cipro, and cotrimoxizole but resistant to ampicillian
and bactrim.

Why not Vaccinate? (1 Feb 23)

Q: Are there good arguments against vaccinating Haitians?

A: Yes, vaccinations without other solutions might not be enough.

1) The effectiveness of the cholera vaccine has been debated. It is less effective with the
chronically malnourished. If those inoculated with the vaccine are not able to only drink

6 http://www.haiti.mphise.net/dennis-chao-model-cholera-vaccination-haiti
7 http://vaccinenewsdaily.com/news/233583-bangladesh-begins-worlds-largest-cholera-vaccine-trial

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clean water, they may still get cholera, and may get sick with other endemic water-borne
illnesses, as well.
2) The cholera vaccine is expensive, and there other mechanisms to acquire immunity.
Because cholera is dose dependent, if T-shirts are being used systematically to screen out
most of the Vibrio Cholerae bacteria, those using this screening technique will get an
immune response without getting cholera.
3) The cholera vaccine only creates an immune response for 2 years.
4) The use of a vaccine is often promoted as a "silver bullet" that is a miracle cure (panacea).
In reality, its effectiveness in circumstances like Haiti is much less effective than advertised.
5) If the vaccine is used as an excuse to not do community capacity building, it would be a
net negative.
6) Administering vaccine in the mountain communities will be difficult. Herd immunity is
unlikely be reached in Haiti as a whole through the vaccine alone.

Q: How bad is this going to get? (1 Mar 20)

A: No one knows.

Many people speculate. A study by the University of California, San Francisco (UCSF) and
the Harvard Medical School,8 released 2011 March 16, estimates the number of cases could
reach up to 779,000 between March and November of 2011..

Sanitation in Haiti has been a disaster area, since long before the 2010 January earthquake.
That is one of the primary causes, in Haiti, for the spread of this disease. Solving that could
take years.

There is a public relations problem with many people seeking to nail down death rate and
other statistics, which detracts from the need to emphasize what is missing from support for
medical professionals, and other people, trying to mitigate this disaster. If that support was
superior, then the spread of the disease would not be as catastrophic as it has been. 9

Unfortunately a large number of medical researchers, outside of Haiti reality, are doing their
analysis based only on the official incomplete reports. 10

8 http://www.topnews.in/usa/cholera-epidemic-haiti-may-exceed-un-projections-study-28373
9 http://www.associatedcontent.com/article/6122776/cholera_epidemic_in_haiti_what_did.html?cat=5
10 Here is an example of a wonderful effort, using seriously incomplete data sets.

http://www.annals.org/content/early/2011/03/07/0003-4819-154-9-201105030-00334?aimhp

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Death Rate cannot be computed due to unknown data (1 Mar 01)

Several people have asked me to fact check some of my shared info, but Haiti does not do a
good job of keeping track how many people have died, what they died of, and this disease is
one where many people are carriers without showing the symptoms.

No one knows how many people have caught the disease, or how many have died, so there
can only be projections based on what is known.

Although the death rate is around 2% with what is in the official figures, it is largely known
that official figures are hugely under-reported.11 It is just not known how many people have
died from this, who never got into the official figures.

In the early stages of this epidemic, up to one in ten people with symptoms dies, in areas
with poor access to good medical care which is informed about cholera treatment and has
the appropriate medical supplies. More than half, who die, do so before they can get to a
hospital. This is one of the reasons that the death rate is much higher in rural and mountain
areas, than where it is more practical to get to medical facilities.12 There could be people
dead who no one knows they were trying to get to a hospital.

In Haiti villages where the disease first strikes, usually 100% of the initial victims die, until
quality medical care finds out they have the problem, and gets there. Then the death rate
drops to 20-40%, then drops more.

The historic case fatality for cholera case around the world (showing up mostly in
developing countries) has been around 2%. Good medical care systems can reduce the
case fatality rate to near 0. However, this current epidemic in Haiti is showing far worse
outcomes than most.

Officially, there have been over 4,000 deaths in the first three months of the epidemic in
Haiti. Unofficially, the numbers are probably over 7,000. Compare this to 1,500 deaths
in Ecuador over three years. This may be partly from the greater virulence of the 01
Ogawa strain. But that does not explain everything.

Poor nutrition. Poor water systems. Co-morbidities. High burden of illness and high
social burden are also factors.

11http://biosurveillance.typepad.com/haiti_operational_biosurv/2010/12/heas-sitrep-12810.html
12National mortality rates from cholera are down to 2 percent, from as high as 9 percent earlier, but in some
rural areas, more than one-in-ten people who contract the disease die.
In Haiti's Sud Est region, the mortality rate hit 10.7 percent as of 2011 Feb. 9, while in Nippes it was 6.7
percent and in the Grande Anse region, 5.9 percent.
http://www.google.com/hostednews/ap/article/ALeqM5iZdt_XRYLIGJXA-
nf0QEryGs40ew?docId=d5e68b358385450c8de8e6b2a67f623a

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The apparent case fatality rate may be 30%, 50%, or even 100% in the first contact
communities. The actual case fatality rates will be far lower. We may be dealing with
case fatality rates in the 4% level nation-wide so far. In Port-au-Prince, it may now be
down to 1% to 2%. However, in the remote areas without medical care and education, it
will be far higher. That is why MPHISE-HEAS needs to set up Health Capacity Zones in
700+ areas, including the more remote areas.

Haiti Population Volume likely to get infected with Cholera

In other nations with cholera epidemics, maybe 2% of the population got the disease. How
many people in Haiti? 9 million … 2% of that is 180 thousand.

But early in 2011, we are already above 200,000 known victims in the official statistics.

If you figure the 1 million plus people in the tent cities, and wooden shack towns, have very
bad sanitation, and the ¾ million who escaped Port au Prince early on to rural areas, but got
malnutritioned, the aftermath of earthquake made Haiti more vulnerable to this kind of
thing.

Comparison made on people infected with cholera:

Zimbabwe 36, 000 cases and 1,800 deaths in 10 years,

while Haiti has about 12, 000 cases and 796 deaths in less than a month (1/12 of a year).

These are official figures. Various other information sources indicate:

1. There is a lag in data getting to official records, such that the actual rate of sickness
and death is approx four times the official records. Thus, if official story says 1,000
people dead, the truth is closer to 4,000 people dead.
2. For every one person who shows symptoms, another three have the disease but are
not sick, so multiply by four again how many are infected. Thus if official story says
10,000 people got the disease, the truth is closer to 160,000.

Q: Are some people more susceptible to this than others?

A: Yes, first of all children and elderly are more vulnerable than middle aged.

Second, people who have been malnutritioned due to aftermath of prior disasters, are in a
weakened state, vs. any diseases.

Third the mean population with type O blood, the most susceptible to cholera, is about 4%.
With 1 and 1/2 one million people living in squalid conditions, that puts maybe 60,000

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people at high risk. With a disorganized government, a disorganized UN or constrained by
the GoH, and a huge number of NGO's trying to do great things but doing them
independently, we can estimate a minimum of 80,000 victims, of whom only 25% will show
the symptoms or 20,000, with 2,000 deaths..

Q. If that's a minimum estimate, what's the other end of the scale?

A. Check out what Senator Bill Frist, an MD has to say, based on the information he has
received so far.

Remember that the aftermath of the earthquake was made worse thanks to serious damage
to Haiti civil service killed in collapsed government buildings. What do you suppose will
happen to the quality of service to the people of Haiti when government officials start dying
of cholera?

What is Cholera? (1 Feb 22)

Q: What is cholera?

A: Lots of Internet sites answer this question. Check out some of the following:

http://renewal4haiti.org/Cholera

Google Health https://health.google.com/health/ref/Cholera

WHO World Health Organization http://www.who.int/cholera/en/ and


http://www.who.int/topics/cholera/en/

US Government sites http://www.cdc.gov/cholera/index.html and


http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001348

Wikipedia http://en.wikipedia.org/wiki/Cholera

The disease is caused by a bacterial infection of the intestine. It is usually transmitted by


drinking water or eating food contaminated with cholera bacteria.

Officials say transmission between people is rare. However, some deaths in Haiti have been
traced to the scenario of cholera infected persons being touched by persons who were
otherwise healthy before they did so. There have also been cases of a person, who died of
cholera, being touched at a funeral by people who were infected in the process. The issue is
a lack of education how to be around a sick person, without getting contaminated with their
disease.

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The initial infection is usually mild or without symptoms, but the illness can sometimes be
severe. In those cases, the person could experience profuse, watery diarrhea and vomiting
that leads to rapid loss of body fluids and eventual dehydration and shock. Death could
result in hours without treatment.

Q: What are the cholera symptoms?

A: Lots of Internet sites answer this question. Check out some of the following:

US CDC Centers for Disease Control and Prevention

http://www.cdc.gov/nczved/divisions/dfbmd/diseases/cholera/

Here is what everyone ought to know:

http://haiti.mphise.net/meet-dr-kesler-dalmacy-and-dr-marie-ange-d-tardieu

Q: If I refrain from getting close to anyone who has the cholera symptoms, will I be
safe?

A: Short answer ... No, because many people carry the bacteria without showing the
symptoms.

At the present time, most people who are “passing” the bacteria look just like anyone else.
Haiti sanitation is a disaster area. You can catch it many ways thanks to people who have
the bacteria but are not currently sick, and thanks to environmental issues.

Human victims do not show the symptoms for 1-4 days, after the bacteria in person’s food
or water consumed, but they are passing the disease on to other people. After symptoms
first appear, the victim could be dead in 1 hour to 2 days, so getting more liquids into
someone with the symptoms is absolutely critical to save them.

It has been reported that once a person is infected by this vibrio that they may shed it back
into their environment for four to six weeks. So the hospital makes the symptoms go away,
and once again they are infecting their community.

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Only 25% of the people who get this infection, will actually show symptoms, so quarantining
only the people who show the symptoms, will not stop travel of people who are infected and
will never show the symptoms, or the people who are infected, and have not yet shown the
symptoms. The 25% is an estimate based on situation in other nations, which may not be
precise match for Haiti disease spread.

Medical Professionals (1 Feb 26)


Q: When we have suspected cases of cholera in Haiti, where should they be reported?

A: All suspected cases of cholera anywhere in Haiti must be immediately reported to the
following surveillance numbers:
37019136, 37019135.

For urgent cases which do not have transport, partners should call
34827636 / 38515331.
If deaths occur in camps, partners should call 38799177.

If you are a medical worker in Haiti, and you treat a suspected case of Cholera, many medical
authorities want to be informed PDQ by you. You can report it to HEAS using this form.

If you are working to help victims of cholera, with medical services or water sanitation,
your organization is URGENTLY requested to contact the relevant GoH
ministry and UN cluster, so that your efforts can be coordinated with other NGOs working
this crisis. Your failure, to make contact with them, to help them coordinate NGOs into a
team effort, could cost lives. Their failure to make use of your services is also a risk.

Q: When we have a developing crisis with more patients needs for medical personnel or
medical supplies than our clinic has available, where do we go for help?

A: Your people should already have a liason with HEAS. If not, join HEAS immediately,
and communicate your needs to Jim Wilson, MD iceaxe5@gmail.com

Q. I am a medical professional who wants to go to Haiti to help.

A. Contact Jim Wilson, MD iceaxe5@gmail.com.

If you are in USA, also contact IMAT which sends medical teams to Haiti on a regular basis.

If you are in CANADA, contact CMAT which regularly sends medical teams to Haiti.

Q: How or where can medical professionals (and other people) learn latest health and
sanitation needs with Haiti cholera epidemic?

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A: Visit MPHISE / Forums / General Discussion / and download a copy of Al Mac
research notes document: Guide to Navigating Haiti Aid UN Clusters Info

http://haiti.mphise.net/guide-navigating-haiti-aid-un-clusters

This document is also available on Scribd under account of AlMac99, and other places.
Revised editions will also get periodically uploaded.

From there, add to your bookmarks: (As you visit each site, note many have links to other
relevant places which you may wish to bookmark also.)

 Join Haiti Epidemic Advisory System. (HEAS) This group is getting traffic from
medical personnel on the ground all over Haiti … where specific help is needed –
personnel, answers, supplies … and progress delivering it.
 Setup your RSS news reader to subscribe to new posts as they arrive on the Haiti
Operational Bio-Surveillance site.

Humanitarian Haiti has this tab just for Cholera Response. When you get to
Humanitarian Haiti, also check the other tabs, particularly the list of clusters. You
want to visit, and bookmark the ones on Health-Medical, and WASH (Water
Sanitation Hygiene).

 Haiti Medical and Public Health Information Sharing Environment (MPHISE)


http://haiti.mphise.net/
 Haiti MPHISE User-defined Operating Picture (UDOP) http://haiti.youdop.org/

Haiti Resilience System http://www.haitiresiliencesystem.org/

Pan American Health Organization (PAHO) multiple pages on situations in Haiti, such
as http://new.paho.org/disasters/?lang=en

Check Government of Haiti relevant sites like Cholera statistics by section communal
available on the medical ministry MSPP websites http://www.mspp.gouv.ht and
http://www.mspp.gouv.ht/site/index.php French

 Humanitarian Road provides resources to help people in an emergency. Their web


site has links identifying hospitals, find shelter, treat wounds, learn about cholera, etc.

 World Health Organization (WHO) Global Task Force on Cholera Control.


 On Relief Web, explore different kinds of emergencies presented there, and how you
can subscribe to links to new posts, as they come out. You may be interested in

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both the Haiti Cholera Outbreak of October 2010 and Haiti Earthquake info.
Before using any of their data, check out map their permission page.13
o USA National Institutes of Health (NIH)’s Disaster Information Management
Research Center Health Resources for Haiti, Post-Earthquake.

o Citizen Action Team Databases http://www.citizencommandcenter.org/quick/start


list organizations and resources relevant to Haiti cholera outbreak.

Also review the text (if any) surrounding my mention of those sites, and what you see when
you visit, to determine which of them will be most critical for you to follow.

Some official info, on fighting cholera, is incorrect, so medical personnel


need to consult with relevant medical professionals who can translate
what are correct dosages.

November 15, MSPP (Haiti Medical Ministry) issued a sixty-page manual at


http://haiti.humanitarianresponse.info/LinkClick.aspx?link=Guide+du+formateur+de+bri
gade14++NOv.ppt&tabid=77&mid=757 for brigades fighting cholera. Page 60 has a poster
with directions for preparing oral rehydration solution. The text instructs "4 tikiyè" [I
understand "tikiyè" = small spoon] of salt and "12 tikiyè" of sugar per gallon of water, a salt-
to-sugar ratio of 1:3. the illustration instructs one-half spoonful of salt and six heaping
spoonfuls of sugar per gallon of water, a salt-to-sugar ratio of less than 1:12. thus, neither
the ratios coincide, nor are the units of measurement standard, e.g. level vs. heaping spoons.

November 23, USAID reported that WHO and PAHO massively disseminated their oral
rehydration posters, throughout November HEAS

[for example, http://haiti.mphise.net/feedback-request-creole-ors-poster, ] and others

[for example, http://216.38.63.186/pipermail/haiti_ccih.org/2010/000068.html, ]

noted that the 1:3 ratio was incorrect and also that the make-up volume should be a liter, not
a gallon. Experts advised that administering a too-dilute solution could cause hyponatremia.
hyponatremia has been suggested as a possible cause of some recent cases of paralysis in
Haitian receiving treatment for cholera.

January 19, CCCM's [Cluster for Camp Coordination Management] situation Report at
http://www.cccmhaiti.info/page.php?id=41 stated "CCCM partners are raising their
concern regarding the coming "carnival" season [March 6-8], due to the expected movement
of population, which could cause a major spread of the disease," and recommended for
Leogane and Gressier, "...Provide some sensitization flyers (poster and flyers from
WHO/PAHO)...."

13http://www.reliefweb.int/rw/hlp.nsf/db900ByKey/map_permission?OpenDocument include this text:


(Source: OCHA/Relief Web) where appropriate.

15 Cholera FAQ Haiti (date after file name is version edition)


In Al Mac MPHISE blog, I provided a guide to two score (estimated) different places which
have maps of the medical problems in Haiti, a few of which are already in my document
guide to UN info about Haiti Aid. I since merged map links into one shareable directory of
Map resources.

Q: What do the medical professionals working the Haiti cholera crisis most need which they
do not already have access to?

A: Multiple areas.

Welcome at Haiti ports of entry, to make sure new additions to the overall work force are
aware of HEAS and related resources, officialdom registration requirements.

Funding support for HEAS and related efforts.

Gov of Haiti to relax border crossing taxation and other hold-ups for products intended to
save Haitian lives.

Different organizations which have collected medical data base info on NGOs working the
crisis, to share their info.

Cholera arrival in Haiti (1 May 11)

Q: How on earth did Cholera get into Haiti in the first place, and what can be done
about that?

A: In the absence of credible scientific evidence, there is only speculation and inference how
it got there.14 For example, here is the Estuary Theory:15

Cholera in Florida in 2011 was traced to Apalachicola Bay oysters, where tropical storms can
help distribute the problem over a wider area.16

14Is cholera caused just as much by environment, hydrology and weather patterns as by poor sanitation?
http://www.circleofblue.org/waternews/2011/the-stream/the-stream-february-22-cholera-and-climate/

15
http://haiti.mphise.net/estuary-theory

16http://oysterradio.blogspot.com/2011/05/vibrio-cholera-traced-back-to.html Thanks to Stuart Leiderman


for locating these links.
Space image: http://earth.jsc.nasa.gov/sseop/EFS/printinfo.pl?PHOTO=STS083-749-28
map: http://www.baynavigator.com/Apalachicola_National_Estuarine_Research_Reserve.cfm
national research reserve:
http://www.eoearth.org/article/Apalachicola_National_Estuarine_Research_Reserve,_Florida
Scientific analysis of this issue http://ufdc.ufl.edu/UF00089927/00048/4j
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC201907/pdf/aem00027-0427.pdf
http://aem.asm.org/cgi/reprint/65/7/3142.pdf More coverage
http://www.opednews.com/articles/Letter-Hand-Delivered-to-G-by-Anita-Stewart-110504-330.html

16 Cholera FAQ Haiti (date after file name is version edition)


The source of the cholera into Haiti has been controversial, with hypotheses that the
pathogen that causes cholera (Vibrio cholerae) arrived into Haiti:17

 from the Gulf of Mexico due to tectonic shifts resulting from the earthquake;
 evolved into disease-causing strains from non-pathogenic strains naturally present in
Haiti;
 or originated from a human host who inadvertently introduced the strain into the
Haitian environment.

Q: But didn’t the Nepal peacekeepers bring cholera with them from Nepal, then conduct
their sanitation in a criminally reckless manner?

A: That is an accusation theory which may not yet been proven in either a scientifically
credible manner,18 or in a way which would stand up in a court of law, assuming there is any
court which has relevant jurisdiction. The circumstantial evidence published in the news
media so far, could just as easily be interpreted to say that the Nepal peacekeepers who went
home from Haiti, caught it in Haiti, then returned it to their native land. If I was on the jury
of a trial of either accusation, I would have to rule that the investigators have so far failed to
prove their theories. For example, I see a news photo of a truck driver doing inappropriate
dumping. Nowhere in that media is there any proof that this was ordered by UN, by Nepal,
by Gov of Haiti, by anyone else. The truck and the driver are effectively anonymous
individuals.

Various officials, who ought to know what they are talking about, have made various
statements on various sides of these allegations. According to Monsters and Critics,
Sweden's ambassador to Haiti, Claes Hammar, was reported Wednesday Nov-17 to have
confirmed that the cholera came from Nepal.

Q. What kind of credible scientific evidence is needed?

A. Samples need to be taken of where cholera bacteria is believed to exist, in quantities


appropriate for proper laboratory testing. A process of legal chain of evidence must be
followed, so it can be proven who took what samples at what locations. The samples must
be transported in accordance to international laws regarding the movement of biohazardous
materials, then delivered to labs which have the qualifications to examine the DNA of the
bacteria to compare it with other cholera bacteria from other places, such as Nigeria and
Zimbabwe. It may turn out that the source is neither the Estuary Theory nor the Nepal
Theory, but one of many other theories.

Q. Will this evidence stand up in a court of law?

A. In my opinion, there is no court of jurisdiction.

17 http://www.haiti.mphise.net/node/1055
18 http://www.cidrap.umn.edu/cidrap/content/other/news/may0911cholera-br.html

17 Cholera FAQ Haiti (date after file name is version edition)


Unfortunately, the UN is incapable of multi-tasking, or doing cooperation between different
interests.19 Every time there is a cholera epidemic some place in the world, the priority is to
help the patients, not preserve evidence that might show how the nation got it. Then only
after the international medical community is doing what it can to deal with the crisis, does
the humanitarian community permit epidemiologists and environmental professionals do
analysis to try to figure out how it happened, by which time key evidence may be lost.

Q: Have there been efforts to collect scientific evidence?

A: Several efforts have been reported thru MPHISE.20

A pre-print of a French-conducted investigation into the origins of the Haitian cholera


epidemic is available at http://www.cdc.gov/eid/content/17/7/pdfs/11-0059.pdf in
English translation. The numbers of cases, the speed spread and proximity to suspected
origins were statistically analyzed.

The strongest conclusion was that the origin was highly-infectious human wastes going into
a tributary of the Artibonite river, near Meille, upstream of Mirebalais, from one or more
Nepalese soldiers at a peacekeeping base there. By deduction, the soldier(s) must have had
full-blown cholera to have excreted enough organisms to have so highly-contaminated the
river that serious and almost immediate infection was transmitted to Haitians who happened
to drink that water just at the time that the slug of microorganisms were passing by in the
river.

Of significance is that the investigators, appearing on the scene within days of the outbreak -
the exact dates and locations were not given in the report - did not find cholera in the river.
Their inference is that there may have been only a single incidence of infectious sewage
overflow or dumping from the peacekeeping base and, from that point, the river flow greatly
diluted the concentration of organisms below Meille, i.e. after a few miles.

Thus, they conclude, the cholera spread first from humans into the river, then into a few
residents who drank the water - in the wrong place, at the wrong time - and got sick, then
from some of them to others, then throughout the country as Haitians fled from the area,
and as their own contaminated diarrhea spread through the environment, to be ingested
from cholera-contaminated food, water and excreta and further spread by subsequently-
infected people.

UN independent investigation (1 May 05)

In one of them, the Secretary-General of the United Nations formed an Independent Panel
of four international experts (the “Independent Panel”), with a mandate to “investigate and
seek to determine the source of the 2010 cholera outbreak in Haiti.” 21

19See my 1 year reviews, UN, and NGO cooperation NOT.


20http://www.haiti.mphise.net/
Video = Why Cholera hit Haiti so hard:
http://www.haiti.mphise.net/video-haiti-grassroots-watch-4-why-has-cholera-hit-haiti-so-hard

18 Cholera FAQ Haiti (date after file name is version edition)


I advise people to use links to get at the ACTUAL report of this panel,22 which was
published May-04, since many people have posted their interpretations, and there are varying
versions, or interpretations of what the report is actually saying.23 Reports at UN sites have a
bad habit of getting lost after a few months,24 so I downloaded a copy, and can e-mail it by
request, if someone needs, and cannot get at it from official sites. 25

Warning, the UN also has a bad habit of perpetually copying incorrect information. At
the front of the report is a graphic regarding Cholera treatment, which is famous thanks to
the astronomical number of times medical people have brought to authorities attention the
fact that the dosages are incorrect, due to translation errors, the authorities have said thank
you, then continued using the bad information.26 In a few cases, top management of
authorities, treat reports of mistakes by authorities not as reason to fix the mistakes, but to
punish the whistle blowers who tried to help the authorities fix the mistakes.

I personally have some problems with the quality of this UN report.

 Much of my grievances are due to the fact that the UN delayed this investigation
until a lot of evidence no longer available. This is like the police waiting until a year
after a bank robbery to investigate it, when all the security tapes are gone, the
fingerprints gone, different employees now working at the bank, memories faded.
 In the aftermath of the Cholera epidemic, there was a dramatic shift in Haitian eating
habits. For example, since it was believed the Arbonite river was contaminated, and
since it overflowed its banks during flooding, many Haitians no longer wanted
agricultural products from that area. For UN investigators to determine what
Haitians are eating, six months later, and then say that since they not eating food
from the Arbonite river now, they never did so, that is a misleading conclusion.
 MPHISE-HEAS has shared reports from hospitals which treated Cholera cases, with
what info was known about the first patients seen by those hospitals, showing first
cases before dates in this UN report. Maybe the UN investigators did not speak with
the people who developed those reports, or had access to those records.
 There is enormous turnover of medical personnel working different places in Haiti,
due to the Republic of NGOs dropping medical support when funds run out, and
having volunteers come and go all the time. It may be impossible to identify all
relevant medical staff, but limiting interviews to whoever is there 7 months after the
incidents is a guarantee of not getting a good picture.

21 http://www.haiti.mphise.net/node/1055
22 http://www.un.org/News/dh/infocus/haiti/UN-cholera-report-final.pdf
23 http://www.haitianinternet.com/articles.php/836

http://www.haitilibre.com/en/news-2875-haiti-cholera-report-of-the-experts-on-the-origin-of-the-
epidemic.html
24 There is also risk that higher up UN authorities could scrap this report, if they do not like some of its

content.
25 I named my copy “Cholera Source 2011 May 04 UN ”
26 http://haiti.mphise.net/leiderman-heas-department-perpetual-errors

http://haiti.mphise.net/feedback-request-creole-ors-poster

19 Cholera FAQ Haiti (date after file name is version edition)


 Cholera is a medical condition in which many people can carry the bacteria without
showing the symptoms. The fact that Nepal soldiers did not need treatment is not
proof that they do not carry the bacteria. HEAS has estimated that for every one
person who needs medical treatment, there are three who carry the infection, but do
not show the symptoms.
 Nepal has censorship regarding this situation. If any Nepal troops were unable to
come to Haiti, because they did show the symptoms, this is one of the pieces of
evidence conveniently hidden. Any report, which does not mention this dimension,
is potentially misleading.
 This latest UN report concludes the first cases were approx Oct 20. According to
my raw notes,27 there were approx 40-50 people dead by Oct 20, who had got to the
hospitals. Oct 20 was when officialdom lab reports confirmed the problem was
Cholera. Prior to that, officialdom was in denial, and even afterwards, many
hospitals unable to capture the samples needed for official testing, they too
overwhelmed to deal with the patients volume. Anecdotal evidence was that many
more had died in transit to medical aid. According to PAHO situation report # 3 on
the Cholera epidemic, issued Oct 23, this was the fourth day of confirmed cholera
epidemic (Oct 21 was the first) but eighth day of people known to the hospitals to be
sick with this problem (Oct 17 was when hospitals first noticed flood of patients
with the dangerous symptoms). 28 We can then use what is known about rate of
person getting sick from first consuming the bacteria to back-calculate when first
case actually was. If you have a copy of my raw notes, check “Law and Disorder
Time Line.” I also downloaded some of those early reports.

What this May-04 UN report has to say for itself: The timeline suggests that the outbreak
spread along the Artibonite River, with first cases in Mirebalais.

After establishing that the cases began in the upper reaches of the Artibonite River, potential
sources of contamination that could have initiated the outbreak were investigated.
MINUSTAH29 contracts with an outside contractor to handle human fecal waste. The
sanitation conditions at the Mirebalais MINUSTAH camp were not sufficient to prevent
fecal contamination of the Meye Tributary System of the Artibonite River. Water in the
Meye Tributary System reaches the Artibonite River junction in less than 8 hours, and flows
downstream in another 1-2 days to a dam and canal system widely used for irrigation
throughout the Artibonite River Delta.

27 My research notes “Haiti Cholera 2010 Oct” has raw info as it came out, about the epidemic which
apparently started Oct 2010 in Haiti, rather repetitive as each day bits of new info added to a repository of
known so far.
28 I might not have a copy of that precise report, but I have downloaded multiple reports right around that date

from PAHO ECO, OCHA, WASH, and many of them repeat same info with latest day’s updates. See “Al
docs” directory in the Sitrep section, dated around then.
29 MINUSTAH = UN peacekeepers in Haiti.

20 Cholera FAQ Haiti (date after file name is version edition)


Several independent researchers studying genetic material from the bacteria responsible for
the outbreak of cholera in Haiti graciously provided their results. They used a variety of
molecular analysis techniques to examine multiple samples of the bacteria. Their results
uniformly indicate that:

1) the outbreak strains in Haiti are genetically identical, indicating a single source for the
Haiti outbreak; and,

2) the bacteria is very similar, but not identical, to the South Asian strains of cholera
currently circulating in Asia, confirming that the Haitian cholera bacteria did not originate
from the native environs of Haiti.

These research findings indicate that the 2010 Haiti cholera outbreak was caused by bacteria
introduced into Haiti as a result of human activity; more specifically by the contamination of
the Meye Tributary System of the Artibonite River with a pathogenic strain of the current
South Asian type Vibrio cholerae.

This contamination initiated an explosive cholera outbreak downstream in the Artibonite


River Delta, and eventually throughout Haiti.

This explosive spread was due to several factors, including:

 the widespread use of river water for washing, bathing, drinking, and recreation;
regular exposure of agricultural workers to irrigation water from the Artibonite
River;
 the salinity gradient in the Artibonite River Delta, which provided optimal
environmental conditions for rapid proliferation of Vibrio cholerae;
 the lack of immunity of the Haitian population to cholera;
 the poor water and sanitation conditions in Haiti;
 the migration of infected individuals to home communities and treatment centers;
 the fact that the South Asian type Vibrio cholerae strain that caused the outbreak
causes a more severe diarrhea due to the larger production of the more potent
classical type of cholera toxin;
 and, the conditions in which cholera patients were initially treated in medical
facilities did not prevent the spread of the disease to other patients or to the health
workers.

The introduction of this cholera strain as a result of environmental contamination with


feces could not have been the source of such an outbreak without simultaneous water and
sanitation and health care system deficiencies. These deficiencies, coupled with
conducive environmental and epidemiological conditions, allowed the spread of the
Vibrio cholerae organism in the environment, from which a large number of people
became infected.

The Independent Panel concludes that the Haiti cholera outbreak was caused by the
confluence of circumstances as described above, and was not the fault of, or deliberate

21 Cholera FAQ Haiti (date after file name is version edition)


action of, a group or individual. The following recommendations to the United Nations, to
the Government of Haiti, and to the international community are intended to help in
preventing the future introduction and spread of cholera:

1) The Haiti cholera outbreak highlights the risk of transmitting cholera during mobilization
of population for emergency response. To prevent introduction of cholera into non-endemic
countries, United Nations personnel and emergency responders traveling from cholera
endemic areas should either receive a prophylactic dose of appropriate antibiotics before
departure or be screened with a sensitive method to confirm absence of asymptomatic
carriage of Vibrio cholerae, or both.

2) United Nations missions commonly operate in emergencies with concurrent cholera


epidemics. All United Nations personnel and emergency responders traveling to emergencies
should receive prophylactic antibiotics, be immunized against cholera with currently available
oral vaccines, or both, in order to protect their own health and to protect the health of
others.

3) To prevent introduction of contamination into the local environment, United Nations


installations worldwide should treat fecal waste using on-site systems that inactivate
pathogens before disposal. These systems should be operated and maintained by trained,
qualified United Nations staff or by local providers with adequate United Nations oversight.

4) To improve case management and decrease the cholera case fatality rate, United Nations
agencies should take stewardship in:
a) Training health workers, especially at the treatment center level;
b) Scaling-up the availability and use of oral rehydration salts at the household and
community level in order to prevent deaths before arrival at treatment centers; and,
c) Implementing appropriate measures (including the use of cholera cots) to reduce the risk
of intra-facility transmission of cholera to health staff, relatives, and other patients.

5) To prevent the spread of cholera, the United Nations and the Government of Haiti
should prioritize investment in piped, treated drinking water supplies and improved
sanitation throughout Haiti. Until such time as water supply and sanitation infrastructure is
established:
a) Programs to treat water at the household or community level with chlorine or other
effective systems, handwashing with soap, and safe disposal of fecal waste should be
developed and/or expanded; and,
b) Safe drinking water supplies should continue to be delivered and fecal waste should be
collected and safely disposed of in areas of high population density, such as the spontaneous
settlement camps.

6) The international community should investigate the potential for using vaccines reactively
after the onset of an outbreak to reduce cholera caseload and spread of the disease.

7) Recent advances in molecular microbial techniques contributed significantly to the


investigative capabilities of this report. Through its agencies, the United Nations should
promote the use of molecular microbial techniques to improve surveillance, detection, and

22 Cholera FAQ Haiti (date after file name is version edition)


tracking of Vibrio cholerae, as well as other disease-causing organisms that have the
potential to spread internationally.

(click on the link below for the full 32 page report - PDF file)

http://www.un.org/News/dh/infocus/haiti/UN-cholera-report-final.pdf

Q: What is significance of whether Haiti had cholera 50 years ago or 100 years ago?

A. This is important at two levels.

1. Because cholera has not been in Haiti for several generations, there are no local
immunities to the disease. Vulnerabilities are maximized.

2. It feeds into conspiracy theories how the disease just appeared in Haiti seemingly
out of no-where. Many people believe there must be a patient zero, someone who
knowingly, or unknowingly, delivered the deadly disease to Haiti. But the science of
investigations with other nations cholera outbreaks is such that we usually cannot
figure out definitively how it happened. There are suspects, there is evidence, but no
absolute proof.

Other nations beyond Haiti (1 May 16)

Q. Has Cholera spread to other nations, where Haiti is being blamed?

A. Yes to both questions

Haiti Libre reports suspected cases in Dominican Republic Nov-9, then a week later
officialdom reports confirmed case.

A woman returning to Florida from Haiti has been diagnosed with Cholera, according to
multiple US news media - Al Mac first saw these stories Nov 18. There have been scattered
reports of other returnees from Haiti, bringing back infections.30

There has been a lot of news media coverage of a wedding party in the Dominican Republic
which served poorly cooked lobster from Haiti, which sickened dozens of people, and then
they carried cholera to Venezuela, USA, and other nations, whose good sanitation mitigated
risk of much more spread, but did not stop it entirely.31

30 http://www.associatedcontent.com/article/7749440/haitian_cholera_epidemic_slows_spreads.html
31 http://online.wsj.com/article/BT-CO-20110209-720304.html

23 Cholera FAQ Haiti (date after file name is version edition)


Then later the capital city was placed on alert.32 By mid May 2011, Dominican Republic is
up to:

 14 dead
 16 currently hospitalized
 750 cases so far

Sanitation in developing nations (1 Apr 13)


See this video.33 What alternatives are there without good sanitation infrastructure?

Myths, Rumor, and Panic (2010 Perspectives)


When people do not know the facts, or they disbelieve their government, all sorts of bogus
info can lead to rumors in need of being dispelled.

Q: Let’s suppose for the sake of argument that humanitarian workers go to one nation that
has some horrible disease, they catch it but do not show the symptoms, travel to another
nation, and now both nations have the disease. How do we prevent this?

A. Give all relevant vaccinations to the aid workers.


B. Require that persons entering a nation, when they were recently at another
nation which has some horrible disease, they show proof of vaccination, or
medical test to show they are not infected.

Q: Fighting cholera is very serious business, so why are some people apparently
behaving irrationally?

A: In history, we know that certain diseases have caused humongous deaths, and high death
rates among victims, so certain words like "Cholera, Ebola, Plague, Typhoid" tend to incite
extreme fear and panic, irrespective of advances in medical and other sciences.

In Haiti, there are some other words, and actors, which incite similar emotions.

For whatever reasons, many poor people in Haiti have come to distrust the UN military, and
international community, so many believe the conspiracy theory that cholera was deliberately
introduced into their nation as a form of biowar.

32 http://www.defend.ht/world/articles/caribbean/996-dominican-government-declares-cholera-state-of-alert
http://www.google.com/hostednews/canadianpress/article/ALeqM5jDM0jPI-
CYEnvIe8E8QX8Uc039Yg?docId=6867566
http://www.bbc.co.uk/news/world-latin-america-13424941
33 http://www.youtube.com/watch?v=SsjsMFx_4NU&sns=tw

24 Cholera FAQ Haiti (date after file name is version edition)


Q. Why demonstrations against Cholera treatment facilities?

A. The one in St Marc went in open air tents in a soccer field across the street from a school,
without first consulting or educating the local community, because time was of the essence
to save lives of patients. Parents in panic, think their children could catch it. Community
loss of recreational facilities. UN military provides security. Many obvious reasons when
you realize lots of general public do not have good understanding of how people catch
cholera.

Elsewhere in Haiti, people who do not know how cholera is communicated to other people,
they fear infection from these treatment facilities getting into local communities, so they do
not want one in their community.

No one wants a prison in their back yard – the criminals might escape.

No one wants a serious disease facility in their community – the disease might get out.

No one wants a heavily polluting industry near where they live – the pollution could hurt
them.

This is a common mentality.

Q: Could the hydro-electric oil leak into Arbonite river be the source of the cholera?

A. No. Pollution is not a cause of cholera. It comes from a bacteria.

Q: Various government officials around the world have been stating where the Cholera came
from to Haiti, at the same time as people involved with relevant labs have been asking for
relevant samples so they can figure this out. Where do the government officials
get their info, if the labs do not yet have the evidence?

A: The government has a responsibility to reassure the people, even if they do not yet have
credible info to provide good facts. This is one reason why, when they do have credible
info, some people do not believe what they have to say.

Even though SOME labs ask for cooperation through HEAS, that does not mean that ALL
labs have failed to get what they need. Some conduct their info with confidentiality. It is
possible that the government gets its info from secret labs.

Q: What people ought to be panicking over is not solving the mystery of where the Cholera
came from, but how to protect the mass of poor people in the tent city camps from a variety
of threats, including hurricanes. UN leadership has said that most of these people must

25 Cholera FAQ Haiti (date after file name is version edition)


remain in the tent cities for over a year from now, thru the 2011 hurricane season, or
beyond. Haiti tropical storm seasons are such that they inevitably will be facing multiple
hurricanes in a year. How do we know the transitional shelters are good
enough to protect against severe weather?

A: We do not know. We are stuck with the builders saying “Trust us, we know what we are
doing, you do not need any certification whatsoever from experts in building safety.”

Fixing Water availability and


Sanitation long term
Q: What is being done to fix the infrastructure risks long term?
A: Not much yet. This is part and parcel of the “rebuild Haiti back better” when the funds
are available, and the recovery plans approved, which is a complex topic better addressed in
separate documents.34
Work to support the medium and probably long term, should focus on improving living
conditions related to water, sanitation, hygiene and access to information services and health.
Downward trend of the epidemic is accelerated by:
 early identification of cases and implementation of appropriate treatment;
 an information campaign and prevention measures at Community level,
 water supply and sanitation facilities and cholera treatment units;
 a regular supply of inputs in the oral rehydration centers, Centres and Units of
Treatment of Cholera.
 and improved access to health care, especially mountain villages far from good
roads.

National strategy planning includes :


A problem with some of this planning is what I call “Mountain Management.”
There is so much that needs to be done, that it can boggle the mind, paralyze people.
That was the consequence of the earthquake for many people. It is the consequence of how
some lessons-learned solution documents are drafted. I address this issue sharing how
modern business solutions can be applied to disaster relief, in my research document = 1
year UN (mini-review).

34 For example, check out my document = “Glossary of Housing Challenges in Haiti.”

26 Cholera FAQ Haiti (date after file name is version edition)


1. Integration of data collection on cholera in the national epidemiological
surveillance system and county.
To do this, the following interventions will be implemented:
a. 1.1: Community involvement through participation. In terms of public
health services: training of epidemiologists in the county collecting quality
data, analysis and transmission of data at national level.
1.2. At institutions of primary health centers: training of medical
personnel in the collection of epidemiological data and the timeliness of
the transmission of data at the departmental level.
1.3. Community-level councils and assemblies of communal sections
with special brigades

2. Warning and immediate response.

The alert system was introduced in November in support of the MSPP in the
collection, verification and response to urgent warnings of cholera in Haiti. The
alert system has provided additional data from national epidemiological
surveillance system by providing qualitative information allowing a better analysis
of data and thus better guide the required response.

The system has demonstrated its ability to detect not only early warning of
cholera but also for other situations of risk to public health requiring rapid
response. For example, the system detected in various Departments of
aggregates of suspected cases of acute flaccid paralysis, and poisoning by
methanol.

The alert system is an essential component of epidemiological surveillance


system. At the national level, the warning system provides a more complete view
of existing risks and prioritize actions. At departmental level alert system allows
to have information on the situation in remote areas and organize and the
response.

It is important and a priority to strengthen the system and integrate it into the
surveillance system at both national and departmental levels. Developing a
warning system with the involvement of all partners on the ground allow early
detection of situations that pose a potential risk to public health. The
mechanisms for transmitting information at municipal level and county will be
defined in terms of existing resources in each department (health workers,
community brigades, CASEC, etc.).

2.1. The warning system and immediate response from PAHO / WHO should
be maintained, while adjusting to changing circumstances.
2.2. Cuban brigades active research should continue their work by integrating, as
expected, health personnel Haitien.
2.3. Staff and Community brigades CASEC ASEC should continue to play a role
in the alert of cases and deaths in their demographic and geographic areas.

27 Cholera FAQ Haiti (date after file name is version edition)


3. Information by messages of prevention and diagnosis and early management
Community strategies to fight against cholera designed to respond to the
situation expected in the aftermath of the acute phase of the epidemic, are the
following:
• The continued operation of the coordinating bodies in terms of disseminating
messages to the population, involving all sectors involved (Health, Education,
Youth and Sports, Interior, Women's Studies), local authorities, representatives
of the company Civil (representing faiths; grassroots, local NGOs and
international print media and talking.
• Intensification of production and distribution of appropriate materials in
Creole, validated in the field (if possible). Further dissemination, diversifying the
channels, messages of prevention and oral rehydration, making sure to cover the
communities not yet affected, and conducting assessment surveys to identify the
needs of other communications activities through appropriate channels.
• Collaboration with the Ministry of Education and its partners (organizations
representing private schools, teachers and parents) to strengthen the activities of
health education in schools with a target, not only students but also their families
through a child's approach to the child and family
• The development, led by DINEPA, a permanent network of support staff in
public health (water, sanitation and hygiene markets) of local (ASEC, CASEC)
• The development, led by the Ministry, a permanent network of community
workers (Rangers) from and living in the community, linked to health facilities in
First Tier (EPA) with the following functions:
1. initiate oral rehydration cases and refer them to the health institution nearest
and most appropriate for their symptomatic state;
2. provide home visits for active case finding and disinfecting homes;
3. disseminate messages on MSPP cholera prevention and management of cases
and
4. to the institutions of health epidemiological information (CBM) and on
rumors and popular reactions to stigma. Beyond the cholera, the network of
crossing is intended to serve as a relay between EPA and the public for the
reconciliation of supply and demand of the minimum package of community
care and for the detection and response at all, emergencies Epidemiologic and
natural disasters.
• Development and implementation by the departments plan to implement the
above strategies, and by the central level, plan to support the development and
monitoring of departmental plans.

4. Supply of drinking water to communities and promoting respect for basic


hygiene rules
Support for projects DINEPA, MSPP and many partners of drinking water and
sanitation community must continue. Management associated with cholera
excreta is the largest current threat to the spread of Vibrio and could prevent the
successful long-term answer. The implementation of sanitation systems in health
centers, including CTC / CTU is reduced to the construction, in the best cases,
septic tanks. However, in most cases the disadvantages medium and long-term

28 Cholera FAQ Haiti (date after file name is version edition)


environmental monitoring and Vibrio, still is. À.dire:
• Contamination of aquifers;
• The risk that septic tanks are overflowing, given the low level of sanitation
activities. This problem becomes acute during the rainy season when the rivers
and water sources are contaminated with Vibrio.
• The risk of destruction of the reception system of excreta from septic vacuum
trucks, because there are not many tanks arranged for the reception and
treatment of excreta. Currently there is only a great pit where we did the spill,
Control measures of excreta on a larger scale must be selected. The chlorinating
potential of CTC and CTU is not enough and it becomes an urgent need to
establish the treatment of liquid waste, para.
• The creation of collection centers and processing of excreta at the departmental
level with the most simple, economical and sustainable - the stabilization ponds
of wastewater.
the establishment of ponds for the biological treatment of wastewater until the
final effluent quality is such that we can pour water in rivers or in infiltration
systems safe

5. ANSWER health institutions


Maintaining the capacity of health services to care for cholera patients,
continuously or occasionally, in response to new outbreaks. Each health center
should be at least one post of oral rehydration, each hospital must be a CTU. For
this it is necessary to ensure the following actions:
• Enabling all health institutions (1st and 2nd level) to handle cases of cholera,
with permanent staff form, and a free and permanent staffing of essential inputs
(ORS, antibiotics and Ringer Lactate)
• Knowledge and compliance with treatment protocols (whether for the general
population or vulnerable populations: pregnant women, children, malnourished
or immuno compromised) would be needed within each institution
• The same knowledge and the same protocol compliance will be required also in
the field of hospital hygiene, respect for the circuit, the waste management
activities, care, management of liquid waste (excreta and vomit), the water
quality, preparation of disinfecting solutions, management bodies and control of
vectors.
• These protocols will be taught, as many multiplies, maintain and update, if
necessary;
• The regular assessment of the quality of care must be provided by the health
authority whose role is to ensure continuity of supply of inputs at the national
level and county-level centers and the possibility of placing has available
inventory as needed.

6. Proceed with the implementation of the program of social protection and access
to basic health services, including the management of cholera with a system of
resource allocation based on the activities demonstrated

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