Cholera in the Caribbean

PAHO/CPC/PED

September 2011

dd
 The Two Keys to Control Cholera

• Prevention
Ensure that there is safe water for those who are at
risk of becoming infected

• Treatment
Ensure that there is immediate, effective, safe,
treatment for those who are already infected
Cholera in the Caribbean

• Cholera background

• Epidemics in the Caribbean

• Outbreaks in Haiti and the
Dominican Republic
• Lessons learned from Haiti

•Preparing for Cholera here

 Video of Cholera Patient

Caution!: this is an extremely

graphic video of a cholera patient
excreting large quantities of
bodily fluid
 Spectrum of Disease

• 80% - 90% of infections are asymptomatic

• Asymptomatic individuals still shed bacteria
• 20% of symptomatic patients have severe disease (so only
2-4% of total infections)
• Onset of severe disease can be < 6 hours, usually 2-5 days
• Patients with severe disease can die within hours if not
rapidly rehydrated
 Signs and Symptoms of Cholera

• Abrupt onset of watery diarrhea

• Rapid loss of up to 10 to 20 liters of fluid

• Vomiting is common in severe cases

•
• Almost always without fever
 Cholera Agent: Vibrio cholerae

• One of 70 species of Vibrio bacteria

• Only some strains of V. cholerae are toxigenic

• Disease caused by toxin when bacterium attaches to the

wall of the small intestine

• Production of toxin requires presence of two plasmids,

CTX and TCP
 Cholera Agent: (continued)

• Classification of V. cholerae:

– Toxigenicity: Toxigenic and non-toxigenic

– ‘O’ protein type: 1 and 139
– Two biotypes: Classical and El Tor
– Two serotypes: Inaba and Ogawa

• Can survive, grow, and persist in both salt water and fresh water

• Can attach to zooplankton and move with water, shellfish (not

always killed by boiling shellfish)

• Very easy to kill with chlorine and by boiling water

 Transmission of Cholera

• Fecal contamination of water and food

– Primarily water-borne for lower-income populations
– Primarily food-borne for upper-income populations

• Also from aquatic environment

• Infective dose for severe disease is approximately

1 million organisms
 Risk Factors for Severe Illness

• Persons with type-O blood

• Malnourished individuals

• Immune-compromised individuals

• Size of infective dose

 Treatment of Cholera

• Oral rehydration salts (ORS) for all cases if tolerated

• IV infusion with lactated Ringer’s solution for severe

cases

• Antibiotics for severe cases (depending on resistance)

– Doxycycline
– Azithromycin
– Erythromycin
– Ciprofloxacin
Initial Outbreak of Cholera in the
Caribbean, 1849 - 1854
• Began in Cartegena, 1849
• Spread through Panama to:
– Jamaica (1850)
– Nevis (1853)
– St. Thomas (1853)
– St. John (1853)
– Tortola (1853)
– St. Kitts (1854)
– Barbados (1854)
– Trinidad (1854)
– Dominica (1854)
 1850-1851 Jamaica Outbreak

• Began in Port Royal on 08 October 1850

• Introduced by an American ship from Panama (?)
• Killed 30% of town’s population in just a few weeks
• Spread to Kingston where cholera killed 6,000 people in 6 weeks
(15% mortality)
• Then spread throughout the country
• Killed a total of approximately 40,000 people (10%)

Source: Thompson, Eulalee. Jamaica Gleaner, 03 November 2010.

1850-1851 Jamaica Outbreak

• Extremely high attack rates

– Probably 100% of population infected
– Approximately 20% were symptomatic
– 80,000 cases with 40,000 deaths
• Extremely high mortality
– 10% of the population died
– Case-fatality ratios of 50%
– More severe for black population
 Why Was Mortality So High?
• Prevention: Smoke from fires thought to keep cholera away

• Treatment: Induced diarrhea and used leaches; ingestion of

oil of camphor that had been infused into lumps of sugar

• Result: 100% attack rate

50% case-fatality ratio
 Cholera and the Black Population
• Blacks were living in extreme poverty
- Just 18 years after emancipation
- A time of great economic decline as sugar
prices fell throughout the Caribbean
- Plantation owners had been forcing former slaves off
their property and small farms

• Black population was 100% ‘O’ blood type

1991-1993 South American Cholera
Outbreak
The Americas
• 1,000,000 cases
• 9,000 deaths
The Caribbean
• 622 cases reported from Guyana
• 387 cases reported from Belize
• 12 cases reported from Suriname
1991-1993 South American Cholera
Outbreak

600
Guyana

400

200

Belize
0 Suriname
90

91

92

93

94

95

96

97

98

99

00
19

19

19

19

19

19

19

19

19

19

20
Cholera Subtypes in the Caribbean

• 1991agent in Peru:
– Toxigenic O1
– El Tor
– Inaba

• 2010 agent in Haiti and DOR:

– toxigenic O1
– El Tor
– Ogawa
 Update on the Caribbean

Countries Affected Cases Deaths

• Haiti 438,365 6,260
• Dom. Republic 16,919 300
----------------------------------
• Venezuela 278 0
• United States 11 0
• Martinique 6 0
• Canada 1 0
• Puerto Rico 1 0

HAI: 26 August 2011; DOR: 31 August 2011

The Beginning of the Cholera Epidemic

“On October 18, the Cuban Medical Brigade reported

an increase of acute watery diarrhea (61 cases treated
in Mirebalais during the preceding week) to MSPP. On
October 18, the situation worsened, with 28 new
admissions and 2 deaths.”
“MSPP immediately sent a Haitian investigation team,
which found that the epidemic began October 14.”

Piarroux R, Barrais R, Faucher B, Haus R, Piarroux M, Gaudart J, et al. Understanding the

cholera epidemic, Haiti. Emerg Infect Dis. 2011 Jul
 The Epidemic Spreads

“The start of the cholera epidemic was explosive in

Lower Artibonite. It peaked within 2 days and then
decreased drastically until October 31.”
“On October 22, cholera cases were notified in 14
additional communes… In each case, cholera started
after the arrival of patients who fled from the ravaging
epidemic in the Artibonite delta.”
 Mirabalais

Lower Artibonite (7 communes)

The rest of Haiti

Cas vus 438 365
Cas hospitalisés 232 641
Décès 6 260
Létalité 1,4%
 Water and Sanitation Situation
Haiti, July 2011

“Water-trucking is now down to 20 percent of what it

was after the earthquake.”

“… about 1/3rd of the NGOs supporting camps in Port-

au-Prince will be closing down their water-trucking and
sewage removal activities over the next few months
because funds are running out.”

ProMED post: 02 July 2011:http://promedmail.oracle.com/pls/otn/pm?an=20110702.2016

 Update on Haiti

• Overall, new cases per week are declining

• Haiti is divided into 10 departments + PaP
• Each has its own outbreak depending the timing of
introduction and local conditions
• New cases are declining or stable in 5 depts
• New cases rising in 5 depts + capital area
 Update on the Dominican Republic

• New cholera cases per week rose sharply

• Cholera deaths also rose sharply
• The death rate due to cholera also rose
• Cases are occurring in isolated villages and
neighborhoods without water or sanitation
June JULY
July August
Lessons Learned from Haiti

• Planning for an outbreak

• Outbreak prevention
• Outbreak detection
• Outbreak response
• Emergency management of an
outbreak
 Lessons on Planning

• Haiti is an example of what can happen when a cholera

outbreak occurs completely unexpectedly, with no
advance planning

• If you don’t stay ahead of the disease you will have a

very difficult and lengthy time catching up
 Lessons on Disease Detection

• The epidemic began suddenly, going from 0 to over 7,000

cases per week in the original department, Artibonite
• A cluster of 60 cases of acute diarrheal disease was
detected
• Response began 5 days after the onset
• By then it was too late to control the epidemic
Lessons on Emergency Management

• When cholera reached the rice-growing area of the

Artibonite Valley, hundreds of people were infected
with many deaths
• People fled the area in panic, spreading the bacterium all
around the country
• The time for early management had come and gone
 Lessons on Epidemic Response

• Time will always be against us

• The costs of controlling cholera are large, so rapid control
is essential to being able to provide necessary medical
services to those in need while funding is still available
• Outside help is often necessary for controlling cholera,
but that help will not be provided for an indefinite period
of time
 Lessons on Sources of Infection

There are two sources of infection in a cholera

epidemic:

• The patients in the cholera treatment units

• Something in the environment in the communities

where the patients were infected
 Lessons on Disease Prevention

• We imagine that we can keep cholera out of our country,

but we can’t…it’s an illusion
• We focus on treatment, but to only do this means that the
epidemic will never end
• Intense community activities are needed to stop the
epidemic
• Secondary prevention should be the main focus of our
planning and our actions
 Lessons on Community Actions - 1

• Actions in the community after cases come to the

Cholera Treatment Unit are just as important as actions
taken within the CTU

• The addresses of cholera cases should be mapped to

identify specific communities where immediate
intervention is necessary
Investigation of source of infection
Map cases of
Cholera
Cholera in Jeremie

Rue
Camagnol
Lessons on Community Actions - 2

• Active search for additional cases

• Health education and communication
• Identification of potential sources of infection
- Water
- Food
- Food handlers
Lessons on Community Actions - 3

• Disinfection
- Water sources
- Houses of infected persons
- Vehicles used for transporting cases
- Bodies
 Preparing for Cholera

• No other Caribbean territory is even remotely similar

to Haiti in terms of water and sanitation problems,
population density, and poverty so no other territory
can expect to have a similar outbreak

• So what exactly are we preparing for?

 The Most Likely Outbreak Scenario for
Caribbean Territories

• Small outbreaks scattered in time and place

• No more than 100 infected persons in each outbreak

• Each territory should prepare for this number of

infections
 Scenario for each Outbreak

• No more than 100 infected persons

• No more than 20 symptomatic cases

• No more than 5 hospitalized cases

• No more than 1 death

 Planning for Cholera Outbreaks

• One component of overall planning for disaster

management

• Part of the Health Emergency component

• Cholera-specific activities need to be addressed

 Cholera-Specific Activities

• Planning for a cholera outbreak

• Prevention of a cholera outbreak

• Detection of a cholera outbreak

• Response to a cholera outbreak

 Planning for a Cholera Outbreak -1

• Adapt national health disaster plan to accommodate cholera

• Review current treatment of patients with severe

dehydration

• Designate specific space for rehydration

• Train staff to safely treat patients with diarrhea

• Order supplies and equipment

 Planning for a Cholera Outbreak -2

• Communicate risk to public

• Increase coordination among all disaster management

partners

• Prepare for community intervention

- Emergency supplies of water
- Increased health education
- Intense search for additional cases
 Prevention of Cholera - 1

• Personal hygiene:
– Purify drinking and cooking water
– Wash all food
– Wash hands before cooking or eating
– Use sanitation facilities for defecation
 Prevention of Cholera - 2

• Environmental control:
– Provide clean water for the population
– Provide sanitary facilities for the population
– Increase food safety
• Social gatherings
• Market places
– Target high-risk populations
 Prevention of Cholera - 3

• Vaccination against Cholera

– There is an approved oral vaccine but it does not

produce long-lasting immunity

– A new oral vaccine performs better but has not yet

been approved by WHO

– Not a viable option for the Caribbean

 Detection of a Cholera Outbreak

• Distribute surveillance case definition

• Improve speed of surveillance and reporting
for severe diarrheal disease
• Improve capacity of national laboratories to
detect Vibrio cholerae
• Establish link with reference laboratory for
confirmation of cholera
 Response to a Cholera Outbreak

• Focus surveillance for early detection

• Follow up contacts of confirmed cases
• Ensure proper clinical management of patients
• Ensure proper environmental controls
– Disinfection of hospital waste
– Disinfection of dead bodies

• Prompt management of health emergency

• Communicate information to the public
 Risk Communication

• Arrival of cholera is possible – don’t panic

• How to avoid infection with cholera
• How to treat cholera at home
• When to seek medical care
• Where to seek medical care
Risk Factors for the Introduction of Cholera

• Legal and illegal immigrants living precariously

• Travelers passing through focal points for air and sea

transportation

• Importation of contaminated food or water

• Movement of ocean currents (?)

(Note that WHO does NOT recommend placing restrictions on travel or trade)
Ocean Currents in the Caribbean
 Risk Factors for Spread of Cholera

• Limited access to clean water and safe sanitation

• Poor hygiene behavior

• Long referral time to health facilities

• Overcrowding as in slums and institutions

• Under-supervised food markets

• Places recently affected by natural disasters

Risk of Introduction of Cholera

100% DOR

TCI

75%

BAH SLU DOM JAM

50% SXM ANU TRT ANG CUR

BAR CAY CRE MON SVG

BVI GUY SKN
25%
ARU BZE SUR

BON STE
BDA SAB
0%
Risk of Spread of Cholera

100% DOR

75%
TCI

GUY
SVG SUR BZE
50% SXM
SLU DOM
MON
JAM ANG
25% BAH ANU CRE SKN STE CUR

TRT BVI
ARU BAR BON
BDA CAY SAB
0%
 Risk of Cholera in the Caribbean

100
DOR

75
Risk of Spread of Cholera

GUY TCI

BZE

SUR SVG
50
SLU
SXM DOM
MON
ANG JAM
GRE
STE CUR
BAH
SKN ANU
25
TRT
BVI
BON
ARU BAR

BER
CAY
SAB
0
0 25 50 75 100
Risk of Introduction of Cholera
 The Two Keys to Control Cholera

• Prevention
Ensure that there is safe water for those who are at
risk of becoming infected

• Treatment
Ensure that there is immediate, effective, safe,
treatment for those who are already infected
Thank You