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Case Study: Haitian Cholera Outbreak

Emergency Manager Course

Skopje, Republic of North Macedonia
20-24 January 2020

Distribution Statement A
Approved for Public Release: Distribution is Unlimited
 Course Overview

• Pre-Incident Environment
• Incident Overview
• Medical Community
• Challenges of Initial Response
• Emergence and Response to Cholera Outbreak
• Long-term Impact on Haitian Health Services
• Lessons Learned

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 Objectives

• Provide summary and overview of real-world

incident resulting in large scale biological
contamination
• Review resulting response and mitigation
• Highlight lessons learned post contamination

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Socio-Economic Situation

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 12 January 2010

• 35-second 7.0 magnitude earthquake

• Hypocenter close to the Earth’s surface
• Epicenter 25 km southwest of Port-au-Prince

Yomangani
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 Immediate Effects

• 220,000 dead
• 300,000 injured
• 1.3 million in temporary shelters
• 600,000 seeking refuge

Benjamin Dal, Ph.D., M.P.H.

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 Immediate Effects

• 105,000 homes destroyed, 208,000 damaged

• 1,300+ educational establishments
• 50+ hospitals and health centers
• President’s palace, Parliament, Law Courts,
Ministry of Health destroyed

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 Immediate Response

• No external assistance available for 24 hours

• Health priorities
• Search and rescue
• Trauma care
• Disposal of bodies

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 Secondary Concerns

• Water
• Food
• Shelter
• Sanitation

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 Immediate Response – Health Care
Facilities

“At the time of the earthquake, there were nearly 600

patients in the hospital. Within 30 minutes of the
impact, approximately 800 persons entered the
premises; most were injured, and 95% were trauma
cases. All patients were on the grounds of the
hospital as instructions were given to immediately
evacuate the buildings. Fifteen hundred patients
initially required care. At 5 PM, only night duty staff
was present.”

- Dr. Alex Larsen (HUEH)

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 Beyond Trauma Care

Mass Communication Specialist 2nd

• Primary Needs
•

Class Laura A. Moore

Water and sanitation
• Food
• Shelter
• Access to primary health care
• Other Priorities
• Surveillance of communicable diseases
• Rehabilitation

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 Sanitation

“Sanitation continues to be a major challenge of

utmost concern. It is currently estimated that less
than 5% of the needs for latrines is being met (one
latrine per 50 people). This poses huge challenges
for public health in temporary settlement sites.” –
World Health Organization

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 Communicable Disease Control

• Epidemics risk factors include

• Displacement of populations
• Contamination of water
• Overcrowded settlements
• Deteriorating sanitation
• Defense
• Emergency surveillance
• Early warning systems

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 Post-Incident Surveillance

An emergency surveillance system must

• Start early
• Include sentinel stations
• Be simple
• Be complemented by an alert system

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 Cholera – What is it?

• Bacterial infection
• Symptoms include diarrhea and dehydration
• Spread through contaminated food or water

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 Emergence of Cholera in Haiti
(1 of 2)

• First appeared in October 2010 – 10 months after

earthquake
• Caused by contamination of the Artibonite River
with a pathogenic strain of current South Asian
type Vibrio cholerae

Kendra Helmer, USAID

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Emergence of Cholera in Haiti
(2 of 2)

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 Factors Contributing to Spread of
Disease

• Use of river for washing, bathing, drinking, and

recreation
• Salinity gradient in Artibonite River Delta
• Lack of immunity
• Poor sanitation

U.S. Fish and Wildlife Service Southeast

• Medical facility conditions

Region
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 Public Health Response Priorities
(1 of 2)

• Access to rehydration therapy

• Access to safe water, sanitation, and hygiene supplies
• Establish national surveillance system
• Laboratory testing of suspected
cholera cases
• Conducting environmental health
assessments

USAID
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 Public Health Response Priorities
(2 of 2)

• Assess hospitals and clinics

• Epidemiologic surveys and
studies
• Cholera training for clinical staff
and community health workers
• Guidelines for household
infection control

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 Lessons Learned (1 of 2)

• Outbreak highlights risk of transmitting cholera

during mobilization of population for emergency
response
• Emergency responders should receive prophylactic
antibiotics, be immunized
against cholera

Tech. Sgt. Prentice Colter, USAF

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 Lessons Learned (2 of 2)

• Need to train health workers

• Scale-up availability and use of oral rehydration salts
• Implement appropriate measures to reduce the risk of
intra-facility transmission of cholera to health staff,
relatives, and other patients

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 Lessons from International Response (1 of
2)

• Medical care demands exceeded care available

• Medical international non-governmental
organizations responded rapidly
• Support arrived quickly due
to proximity

Kendra Helmer/USAID
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 Lessons from International Response (2 of
2)

• Large medical diaspora abroad responded as individuals

• Lack of Haitian military assets, but massive U.S. military
and United Nations peacekeeping intervention presence
• Strong and sustained health
initiatives

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 United Nations Stabilization Mission in
Haiti

• Brazilian and Chilean engineers level land for

Cholera Treatment Centers
• Bolivian installed tents and latrines
• Uruguayans transported fresh water, soaps,
water purification tablets, and rehydration
materials
• Additional support from Mission included
• Transportation of and security for personnel and supplies
• Education to prevent the spread of disease

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 Haitian Characteristics Affecting
Disaster Response

Advantages for Response Disadvantages for Response

• Easy access by land and • Small and poor country,

water
• Presence of peacekeeping
forces, United Nations
agencies, and humanitarian
Non-Governmental
Organizations
• Limited response capacity
• Weak institutions with little
control over Non-Governmental
Organizations
• Lack of governance and high-
level corruption
• Absence of armed forces

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 Health Characteristics

Positive Aspects Negative Aspects

• Strong internationally • Lack of reliable baseline health statistics
administered • High level of communicable diseases
pharmaceutical and • Only 50% of population has access to
supply system quality health services, water, or sanitation
• On-site presence of • 75% of health services delivered by Non-
external medical Governmental Organizations and faith
organizations groups, most unwilling to follow Ministry of
Health guidelines

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 Post-Incident Reportable Conditions (1 of
3)

Day of Actions
Emergency
Day 1 Evacuation of Pan American Health Organization of the
(6 pm) World Health Organization offices, and recovery of key
materials and communications equipment

Day 2 No information, confirm welfare of staff (personnel, food,

shelter), decision to move Pan American Health
Organization of the World Health Organization office to
Program on Essential Medicine and Supplies warehouse

Day 3 All staff accounted for; Attempted visit to National

Laboratory, roads blocked
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 Post-Incident Reportable Conditions (2 of
3)

Day of Actions
Emergency
Day 4 Contact public health authorities at Program on Essential
Medicine and Supplies; Visit National Laboratory,
building intact but vacant

Day 5 National Laboratory premise occupied by two foreign

field offices; Meeting with National Laboratory
Directory and U.S. Centers for Disease Control and
Prevention

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 Post-Incident Reportable Conditions (3 of
3)

Day of Actions
Emergency
Day 7 Formal start of ad hoc working group to plan a surveillance
system, including Ministry of Health, Pan American Health
Organization of the World Health Organization, U.S.
Centers for Disease Control and Prevention, Médecins Sans
Frontières (Epicenter), Cuban, Chinese, and Taiwanese
epidemiologists, etc.

Day 12 Formal launch of National Surveillance System

Day 13 Set up National Surveillance working group within the

Health Services cluster

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 Summary

• Pre-incident events and considerations

• Incident overview
• Impacts on the medical community
• Challenges of initial response
• Emergence and response to cholera outbreak
• Long-term impact on Haitian health services
• Lessons learned

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Questions?

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