Friday, October 29, 2010

ARTICLE - DEATH AND DIRTY WATER

DEATH AND DIRTY WATER: CHOLERA'S GRIM MARCH THROUGH HAITI
(Toronto Star) - By Jennifer Wells

DROUIN -At 6:15 on a weekday morning Lovely Avelus is not yet in her cherry red school attire, but rather the pale brown dress in which she slept.

An adolescent boy named Venecen — a shy recent addition to the family compound — carries her past the one-bunny rabbit cage to a semi-hidden patch of ground in order to provide some privacy for her morning toilet.

After a long, patient wait, Venecen tears a piece of frond from a plantain tree and hands it to Lovely so she may clean her bottom. Then off she scampers to continue playing peek-a-boo behind the curtain of her one-room home, which is dank and cold on this morning.

In the lone bed in this single room lies Lina, the 25-year-old daughter of Lovely’s uncle, Delius Elistin. Lina, who has a wet, rattling cough, gave birth to a baby boy two days before. She has not yet received any medical care.

It is simply too much.

Here in the land of earthquakes and here in the land of hurricanes and here in the land of abject poverty, Lovely’s family can now claim residence here in the land of cholera where, as of Friday, 330 have died and 4,714 cases have been confirmed.

Lovely’s extended family, none of whom has experienced an outbreak before, has some notion of what it means to play host to the latest disease to colonize Haiti. “We put two or three drops of bleach,” says Elistin, when asked what preventive treatments are applied to the water drawn from a nearby cistern. “We’re not putting much.”

Elistin says he has heard radio advisories recommending that the onset of diarrhea be treated by adding lemon juice to the water. It is true that lemon lowers the ph of water, thus making it an effective disinfectant against vibrio cholerae. If only it were so simple. “These days we cannot find lemons,” he says of his recent market searches. It’s hardly lemon weather.

Lovely’s mother, Rosemene, is cleaning out a small plastic container with a leaf. She is asked what special precautions she takes in preparing food, to which she responds that she washes the lettuce before consumption.

At Lovely’s home in Fermathe, at some remove from the squalor of the tent cities of Port-au-Prince, messages of prevention are half received and only partially executed. The U.S. Centers for Disease Control advises eight drops of bleach per gallon of water, which must be stored in clean, covered containers. Wash your hands after defecating is a steady reminder throughout the country. Lettuce? Verboten. “Boil it, cook it, peel it, or leave it,” is a simple CDC catchphrase which authorities here would do well to adopt.

It is as if the family lies in wait, just as the world lies in wait. Will the epidemic catch in the capital among the more than one million displaced in the fetid tent cities?

Cholera plays no obvious game. There are no stated rules.

It pops up one day in Drouin, and then Villard. And now there’s Petite Rivière and unconfirmed reports in Arcahaie. It is as if the epidemic were toying with the international and Haitian health communities, as if the bacteria too were playing a grim version of peek-a-boo.

It is unwise to think one has seen the worst of Haiti, or to imagine I had seen the worst of Haiti.

To observe the cholera outbreak in its full deathly flourish, one must travel to the Artibonite lowland, and so we chose the coastal route north from Port-au-Prince to Saint-Marc and from there northeast to Pont Sondé where the highway meets the Artibonite River. With luck, if the rains held, we would trace the river’s journey from Pont Sondé north again to Villard and then west to Drouin and on to Grande Saline where the Artibonite empties into the Gulf of Gonaives.

The coastal highway is often treacherous, not so much due to the state of the road, which is quite good, at least as far as Pont Sondé, but the quality of the driving. We observed four accidents on our way. The legless body of a trucker lies supine on the road, innards spilling outward, his head wrapped in a ragged bit of blue cloth, someone’s effort at a makeshift bandage.

At Pont Sondé it is market day and it is madness. Throngs of what must be thousands: farmers who have brought their haulage of sweet potatoes; women tending sacks of Haitian rice; split-open storage bags heaping with pyramids of rough salt brought from the coast. The fresh produce, agricultural bounty, is brought in by the tonnage and shipped out to larger cities: Gonaives to the north; Port-au-Prince to the south.

Across the span of the bridge, a serious line of women hustlers sells dry goods: ribbons and sparkly sandals and cosmetics. Below lies the river.

The river. The Artibonite is a historic irrigation artery for the country, albeit one that was dammed in the far east of the country by the U.S. in 1956, flooding part of the central plateau and displacing farmers there.

Here in the lowland — so rare in such a mountainous country — rice fields spread out square upon square, as if someone kicked a giant coil of sod and it rolled itself out to carpet the land.

The rains this season have been flooding and relentless. The area has been more or less under water since July, informs one aid worker. Women have come through deep water to get to market early.

The invasion of cheap, white American rice has economically devastated the rice farmers. Still, impoverished Haitian workers migrate here during the rice harvest, eager even for the 125 gourdes a day pay.

On Monday, as the death toll rose to 259 and the number of cases to 3,342, the United Nations Office for the Co-Ordination of Humanitarian Affairs echoed Haitian health ministry officials in citing cholera’s toll among the poorest of the poor. “Assessments show the majority of cases involve people from rural areas where rice growing is prevalent,” said the OCHA in a release.

Many deaths have been seasonal labourers. How ironic that doctors informing ill patients of the trademark characteristics of cholera describe the bacterial-ridden stool of victims as emerging “like rice water.”

Not all the victims are farm workers. Beyond Pont Sondé, just before the village of Villard, Maculèz Axelis dusts her aged feet though her small amount of un-hulled rice that she sells by the road. Her 14-year-old niece, Ti Madanm, died last night. She says the villagers have been asking that at least a clinic be built. If their requests had been heard, she says, the children would not have died. Simple rehydration salts often work wonders.

From the blacktop road at Villard, the journey turns to rougher stone and very quickly time evaporates. “Blanc!” cries a young boy outside a collection of the tin-roofed mud and straw huts that the rice farmers call home. That would be me, blanc. The outsider. Bonjour, blanc.

The villages spread either side of the Artibonite, which flows not more than 10 feet from the road. Great patches of drying rice trim the road: on one side the river, and on the other the rice.

Forty minutes later we arrive at the clinic at Drouin, serving the region of Grande Saline — with a population of about 45,000 — and the same named village that anchors it. The clinic was hit hard by the outbreak a week ago. “It was chaos. There were bodies everywhere,” says Dr. Rashid al Badi, who leads the clinical day shift.

Al Badi is wearing a red Humedica vest. The German aid agency is working in concert with a team of Cuban doctors. There are two tiny cholera victims hooked to IVs a few feet away. By midweek the clinic had recorded 40 deaths. I tell him I have heard that a patient passed away moments ago.

“He came alone,” al Badi says.

The patient was rehydrated. A single dose of the antibiotic Doxycycline was administered. “He was fully hydrated, we were trying really hard,” says al Badi. “Late morning he went into cardiac arrest.” Attempts at resuscitation failed.

He estimates the patient’s age at about 30, but who knows?

“The villagers didn’t recognize him.”

Perhaps he was a seasonal worker. “They are drinking water from the river directly,” al Badi informs. Of course they are. They have for centuries.

“Even after death we don’t know who to contact. We’re waiting for someone to come.”

On a narrow passageway between the clinic and a cement wall, the body of the unknown cholera victim has been placed. On this day, Wednesday, the death count will rise to 284.

The body has been covered with a blue tarp. Small thin pieces of wood have been placed on the edges of the tarp. The winds in the late afternoon can get quite spirited. I wonder if the wood will be blown away.

When the winds come up the rains cannot be far behind.

The village of Grande Saline cannot be reached, we are told. Access is flooded. Boats have been used to retrieve the ill. And a helicopter. And so, as they say in Creole, “nou fè bak.”

In doing so we trace the journey of the stricken seeking medical care to the road back to Villard where it meets the highway, returning via Saint-Marc and on to Port-au-Prince.

It’s a mistake to become oblivious to the noise and chaos and horn blaring. The Toyota pickup on our tail appeared to be any other impatient Haitian, the words “Merci Jesus” painted on the front of his truck. He was in a great hurry. Isn’t everyone? Until I noted a hand holding an IV bag rising from the back of the truck, and let the truck pass and studied the despairing look of a young man keeping the arm of a limp old man aloft, the old man’s lean form spread across two laps in the back of the pickup.

The truck pulled up to Saint Nicolas Hospital in Saint-Marc. Earlier in the day I had revisited the clinic, my third trip in. By Wednesday at the latest a cholera treatment centre was supposed to be in place, taking the victims out of the general hospital population.

“But they had to stop construction because people didn’t want them to build this centre near their homes,” says Dr. Mayette Yfto, the hospital’s chief administrator. He’s very polite, Dr. Yfto. The locals threatened to burn the thing down.

Instead the centre will be constructed in Pont Sondé.

The good news: the number of admissions at Saint Nicolas has slowed, says Patrick Almazor, the Partners in Health director for the Artibonite region. PIH has had a long-term working alliance at Saint Nicolas and its doctors and nurses have been key to handling the crisis. Sixty-five deaths have been recorded at the hospital. More than half of those victims died before being carried through the hospital gate.

On Tuesday, Almazor saw a body on the road to Petite Rivière. “After three or four days they dump them into the river,” he says. The nameless ones.

From Saint-Marc the medical geography of Haiti’s cholera epidemic splits in two.

On Thursday, there were reports of 174 cases further south along the coastal highway at Arcahaie. The name may mean little today but there was a time when the beach strip from, roughly, Montrouis to Arcahaie featured a Club Med and other Caribbean-style getaways and there was a time when a cholera epidemic in Haiti would have been measured in lost dollars in tourism and trade.

No more. The local news reports the small street vendors are suffering some.

On the northern side of the mountains that split the lowlands from the coast, cases have been reported at Verettes and Mirebalais.

For more than a week the mayor of Mirebalais has blamed the deaths in his community on a Nepalese-staffed United Nations base situated on the Meille River, a tributary of the Artibonite.

The UN has repeatedly insisted that none of the 700 on base has tested positive for cholera and that suggestions in some media reports that uncontained excrement has leeched from latrines are not true. The seepage, says UN spokesperson Vincenzo Pugliese, can be sourced to overflowing “soak pits” containing shower and kitchen waters.

“For sure it’s about migration. For sure,” says Mayette Yfto, meaning that the epidemic has been imported from lands abroad. It is as if Haiti is desperate to prove that this one horror, this one catastrophe, is not of its own making.

There may never be an absolute answer. Even genetic markers may ultimately fail to prove the epidemic’s source.

In a news conference Friday, Gabriel Timothee, director general of the ministry of health, said “patient zero” had yet to be identified. Eight deaths have been recorded in the Artibonite since Thursday.

As the media drifted away, Michel Thieren, head of the Pan American Health Organization in Haiti, offered the simplest assessment. “This is an epidemic that will settle over months,” he said gently.

What is clear is that cholera is now an endemic part of Lovely’s Haiti. And that the Artibonite River has proved a welcoming host.

ARTICLE - PROTESTS AT NEPAL BASE

PROTESTERS BLAME UN BASE FOR CHOLERA IN HAITI
(AP) - By Jonathan M. Katz

PORT-AU-PRINCE – Hundreds of protesters who blame U.N. peacekeepers from Nepal for Haiti's widening cholera epidemic marched on a rural military base Friday to demand the soldiers leave the country.

Demonstrators waving tree branches and carrying anti-U.N. banners walked from the central plateau city of Mirebalais several miles to the gates of the base perched above a tributary of the Artibonite River — a waterway identified by health officials as a conduit for the infection.

The protesters chanted "Like it or not, they must go" as the Nepalese soldiers and other U.N. peacekeepers remained inside.

Cholera has sparked widespread fear in Haiti, where it was unknown before the outbreak was first noticed by authorities Oct. 20. As of Friday morning, more than 4,700 people have been hospitalized and at least 330 have died, according to the U.N. Office for the Coordination of Humanitarian Affairs.

There has been no scientific conclusion on the origin of the epidemic, which became evident when dozens of patients began dying with high fevers and watery diarrhea at a hospital in the town of St. Marc a few miles from the last stretch of the river.

Experts say the disease was likely imported. Until this month there had not been a diagnosed case of cholera in Haiti as far back as records go in the mid-20th Century, said Claire-Lise Chaignat, head of the global task force on cholera control at the World Health Organization. The disease is pandemic in parts of Africa and Asia.

Speculation among Haitians is increasingly centered on the Nepalese peacekeeping base near Mirebalais, much of it being stoked by politicians including the town's mayor — a Senate candidate — ahead of the Nov. 28 national elections.

Cholera is endemic in Nepal and the country suffered outbreaks this summer. The current troop contingent arrived in shifts starting Oct. 9, after the outbreak in their home country and shortly before the disease broke out in Haiti. Cases have been concentrated downriver along the Artibonite.

The U.N. mission in Haiti responded to the rumors with a statement Tuesday saying that sanitation around the base was in line with the standards set by the U.S. Environmental Protection Agency and the United Nations.But when Associated Press journalists visited Wednesday, they found open and cracked pipes behind the base, with U.N. military investigators taking samples. There was an overpowering smell of human waste, and a pipe leading toward a septic tank was leaking foul-smelling black fluid toward the river.

The waste is dumped across the street in open pits that residents, who live a few yards away, said often overflow into the Artibonite tributary running below. The contractor, Sanco Enterprises SA, says the pits are sprayed with bleach. The U.N. mission says no cases of cholera have been found among the Nepalese soldiers, but it is not clear how or when testing was carried out. The U.S. Centers for Disease Control and Prevention says people are often infected with the disease without showing symptoms.

The spokesman for the U.N. mission did not immediately respond to requests for further comment.

On Friday, protesters called on the Haitian government to kick out the Nepalese soldiers.

"The Nepalese brought this disease to the center of Mirebalais," said Ernst Exilume, a 25-year-old student.

"We have no water to drink. We have no choice but to drink the water from the river."

International aid groups had made hygiene and the control of disease priorities after the Jan. 12 earthquake, especially as millions of Haitians found themselves homeless and living in tarp and tent settlements around the capital. Throughout the year banners imploring people to wash their hands have hung over streets and on walls.

Scientists from the CDC are retesting samples to determine the nature of the cholera strain at a molecular level, which could help pinpoint its origin. But the U.S. agency is not specifically investigating in the area of the base or taking environmental samples, CDC spokesman David Daigle said.

"For sure it is going to be important to know where the germ came from. I don't know if we are going to get an answer," Chaignat added.

ARTICLE - NEPAL BASE PROBED

MILITARY BASE BEING PROBED AS SOURCE OF HAITI CHOLERA OUTBREAK
(AP) - By Jonathan M. Katz

MIREBALAIS - U.N. investigators took samples of foul-smelling waste trickling behind a Nepalese peacekeeping base toward an infected river system on Wednesday, following persistent accusations that excrement from the newly arrived unit caused the cholera epidemic that has sickened more than 4,000 people in the earthquake-ravaged nation.

Associated Press journalists who were visiting the base unannounced happened upon the investigators. Mission spokesman Vincenzo Pugliese confirmed after the visit that the military team was testing for cholera - the first public acknowledgment that the 12,000-member force is directly investigating allegations its base played a role in the outbreak.

Meanwhile the epidemic continued to spread, with cases confirmed in two new departments in Haiti's north and northeast, said U.N. Office for the Coordination of Humanitarian Affairs spokeswoman Imogen Wall.

At least 303 people have died and 4,722 been hospitalized.International aid workers and the United Nations are focusing their efforts on stemming the spread of the outbreak, which was first noted on Oct. 20. But Haitians are increasingly turning their attention to its origins: How did a disease which has not been seen in Haiti since the early 20th century suddenly erupt in the countryside?

The mission strongly denies its base was a cause of the infection. Pugliese said civilian engineers collected samples from the base on Friday which tested negative for cholera and the mission's military force commander ordered the additional tests to confirm. He said no members of the Nepalese battalion, whose current members arrived in early October for a six-month rotation, have the disease.

The unit's commander declined to comment.Local politicians including a powerful senator and the mayor of Mirebalais are pointing the finger at the Nepalese peacekeeping base, which is perched above a source of the Meille River, a tributary to the Artibonite River on Haiti's central plateau. The Artibonite River has been the source of most infections, which remain concentrated in the rural area surrounding it - mostly down river from the mouth of the Meille.

"They are located exactly where the sickness started," Mirebalais Mayor Laguerre Lochard, who is also running for Senate, told the AP. Area residents are also blaming the base; a young man walked by its gate laughing and chanting, "Co-co-cholera. Cholera MINUSTAH" - referring to the peacekeeping mission by its French initials.

Cholera is pandemic in much of the world but almost unheard of in the Western Hemisphere. It is endemic to Nepal, which suffered outbreaks this summer. A recent article in the Japanese Journal of Infectious Diseases about outbreaks in 2008-09 said the strain found by researchers was "Vibrio cholerae O1 Ogawa biotype El Tor."

That is the same strain that has been identified in Haiti, epidemiologist Eric Mintz of the U.S. Centers for Disease Control and Prevention told the AP. But he cautioned that strain is common and description too general to be a "smoking gun" that would identify the strain's country of origin.

The CDC is not directly investigating the base, spokesman David Daigle said.

The U.N. issued a statement on Tuesday defending the base. It said the Nepalese unit there uses seven sealed septic tanks built to U.S. Environmental Protection Agency standards, emptied every week by a private company to a landfill site a safe 820 feet (250 meters) from the river.

But those are not the conditions AP found on Wednesday.

A buried septic tank inside the fence was overflowing and the stench of excrement wafted in the air. Broken pipes jutting out from the back spewed liquid. One, positioned directly behind latrines, poured out a reeking black flow from frayed plastic pipe which dribbled down to the river where people were bathing.

The landfill sites, across the street, are a series of open pits uphill from family homes. Ducks swim and pigs wallow in pools of runoff. The pits abut a steep slope which heads straight down to the river, with visible signs where water has flowed during recent heavy rains.

The people who live nearby said both the on-base septic tank and the pits constantly overflow into the babbling stream where they bathe, drink and wash clothes.

"The water is no good at all. You shouldn't wash in it," said Jean-Paul Chery, a sand miner who lives near the human-waste pits with his wife and five children.

Lochard, the mayor, said he had told Nepalese officers not to place the landfill sites in that location but never received feedback from peacekeeping headquarters in Port-au-Prince.

Pugliese denied that the reeking black flows from the base were human waste, saying that the only liquid investigators was testing came from kitchens and showers. He said the pipes had only been exposed for the tests, though he could not explain why the liquid inside them was allowed to flow toward the river.

The samples were collected in mid-morning by uniformed military personnel, who scooped black liquid into clear jars with U.N. sky-blue lids. About a half hour later, as AP and Al Jazeera journalists stood by, the Nepalese troops began hacking around the septic tank with pickaxes and covered the exposed pipe jutting from behind the fence, but did not plug it.

Then tanker trucks from the contractor, Sanco Enterprises S.A., arrived to drain the septic tank and dump their contents across the street in the waste pits. As the septic tank drained, the flows behind the base stopped.

The waste company's CEO, Marguerite Jean-Louis, declined to comment, citing her contract with the U.N.Source

Thursday, October 28, 2010

ARTICLE - CLEAN WATER

HAITI SCRAMBLES TO SECURE CLEAN WATER
(AP) - By Ingrid Arnesen and Mike Esterl

Cholera Epidemic Underscores Need to Overhaul Crumbling Sanitation Network; Helicopters Ferry in Supplies of Chlorine

U.N. investigators seeking the cause of the cholera epidemic gathered human waste this week from a peace-keeping base in Mirebalais, Haiti.

ST. MARC, Haiti—Haiti's cholera epidemic is adding fresh urgency to the need to upgrade the country's water and sanitation network, a pivotal step to containing the highly infectious and deadly disease that spreads through contaminated water.

The government and international aid groups are rushing emergency supplies to combat the illness, including enlisting helicopters to rapidly distribute tons of chlorine to disinfect municipal water supplies. But more permanent solutions will take years, they acknowledge.

The current outbreak could cause about 105,000 illnesses within the first year and last for several years, the U.S. Centers for Disease Control and Prevention said Thursday. That projection, however, is based on a number of factors including the spread of cholera in other countries in the Americas as well as refugee camps in Africa. So estimates range widely, from 30,000 to 950,000 possible illnesses in the first year, and are likely to be refined, cautioned Scott Dowell, head of the CDC's Haiti response.

A CDC spokesman said the projections represent a scenario that public-health officials use for emergency planning for the potential treatment of large numbers of people.

About half Haiti's population doesn't have access to filtered water and less than 10% has water piped into their homes—a situation that existed before a massive earthquake in January turned much of the Caribbean nation's capital to rubble.

Clean water is harder to secure in the country's rural areas, including the Artibonite valley, which largely escaped earthquake damage but is the epicenter of the outbreak that has killed more than 300 people and is spreading fast.

"Cholera is the latest reminder, that we didn't need, how urgent it is to revise many things," said Pierre Yves Rochat, rural sector representative of the national water agency Dinepa. "In 2010, the population of Artibonite is drinking only river water, like it did in 1804," when Haiti became independent, he noted.

The infrastructure is so poor that aid groups say more people in the capital, Port-au-Prince, have access to clean water today than they did before the earthquake. International organizations have been distributing water by truck to more than a million Haitians in hundreds of crowded refugee camps in and near the capital since January.

The Inter-American Development Bank estimates that Haiti needs to invest $850 million to ensure that just three-quarters of its population has access to clean water, up from 50% in cities and 30% in rural areas.

Funding for long-term water and sanitation projects remains a work in progress. The IDB and the Spanish government offered $115 million in support earlier this year, but the Haitian government is waiting for more commitments from other organizations.

"We get water delivered twice a day, but it is not enough. It barely allows us to wash, but there is not enough to drink," said Jatelin Daniel, a refugee in a camp in front of the collapsed presidential palace in Port-au-Prince.

Authorities aren't clear where the epidemic began. This week, U.N. investigators took samples of foul-smelling waste that was trickling behind a peacekeeping base in Haiti, toward an infected river system, the Associated Press reported. The investigation followed persistent accusations that excrement from the newly arrived unit caused the cholera epidemic.

Aid groups say they hope to end the emergency trucking of water supplies to camps by the end of the year. But there's no clear plan yet for replacing the stopgap service. Only about 10% of homes in the capital had water connections before the earthquake, which leveled tens of thousands of buildings.

Progress on longer-term projects has moved at a snail's pace in recent years. The IDB approved a $54 million loan in 1998 to bring clean water to several rural towns, including St. Marc. But the project was stalled for several years amid political instability and debt defaults. Ten years later, after being converted to grants, only a little over half of those funds have been disbursed.

In St. Marc, the local water utility now sends water through its pipes about 10 hours a day, up from a bit over an hour a day two years ago. But many residents still aren't hooked up and the water, while cleaner than river water, still requires treatment before drinking.

In some rural areas, the situation is worse than it was two years ago. The government estimates 250 water-supply networks in the countryside that were damaged by several hurricanes in 2008 still haven't been repaired.

In Cap Haitien, the country's second-largest city, Oxfam and other aid groups have laid more than 12 miles of water pipes and installed a pumping station and drainage canals since 2006. The $5 million project, mostly funded by the European Union, was supposed to be providing clean water to as many as 100,000 people by now. But Oxfam says no water is being distributed, and blames the delay on a dearth of local contractors.

The government also is struggling to professionalize its water-management ranks. Dinepa, or the National Water and Sanitation Directorate, was created last year in a bid to overhaul a bureaucracy that wasn't working.

"This is a problem that hasn't gotten the level of investment needed. But it's also an institutional problem," said Federico Basañes, chief of the IDB's water and sanitation division.

The regional lender and Spain announced in July they would provide $50 million in grants in part to "strengthen" Dinepa.

Some of that money will be directed to Port-au-Prince. "There are very few people who know where the network is, the magnitude of the network, and the conditions of pipes. It's a very difficult situation," said Mr. Basañes.

Port-au-Prince also doesn't have a sewage system—a critical shortcoming plaguing the rest of the country. Only 29% and 12% of urban and rural Haitians, respectively, had ready access to sanitation in 2008.

Dinepa began working on a detailed master plan for improving access to water and sanitation last year. "But the earthquake arrived and postponed that discussion," said Sergio Mazzucchelli, a senior Dinepa official. Mr. Mazzucchelli said authorities hope to cement plans next year, following national elections next month.

ARTICLE - FOLLOW THE MONEY, FOLLOW THE SEWAGE

Dear Readers:

I thank a reader for this link to video footage showing the proximity of MINUSTAH toilets to the river near Mirebalais. They look like portable toilets, the kind that have to be pumped for off-site disposal, but I'm not certain. Peacekeepers were digging in the ground between the few yards between the toilets and the river.

A U.N. senior official stated that water samples were negative for cholera. the narrator, Sebastian Walker, stated that U.N. headquarters confirmed that some of the peacekeepers came from Nepal in mid-October, a few weeks after the cholera outbreak in Nepal.

An independent, transparent, competent, comprehensive investigation of that base should be done, followed by a full sweep of all bases in the country, their sewage practices, designs, performance, contractors, money spent and to whom.

A recent map of MINUSTAH bases is at:

http://www.un.org/Depts/Cartographic/map/dpko/minustah.pdf

Thank you,
Stuart Leiderman

Al Jazeera visited the MINUSTAH base in Mirebalais today and stumbled upon a bunch of Nepalese troops digging beside their toilets:

Follow the video link to:

http://www.youtube.com/user/gaetanmariage#p/u/0/lKu7V7pDLyQ

ARTICLE - DEATHS RISE ABOVE 300

HAITI CHOLERA DEATHS RISE ABOVE 300
(AFP) - By Clarens Renois

PORT-AU-PRINCE (AFP) – Haiti's cholera toll rose Thursday above 300, as doctors sought desperately to contain the epidemic as victims overwhelmed the quake-hit nation's crumbling hospitals, spilling into its maternity wards.

One week after cholera was confirmed in Haiti for the first time in decades, the death rate is slowing but almost 5,000 people have now been infected and officials warn it could be years before it is eradicated. Clinics were beyond capacity with cholera patients on the floor of one radiology department and another five-bed maternity center, not well equipped to treat the virulent diarrheal disease, housing 300 patients.

The source of the outbreak is still unclear, although MINUSTAH, the UN peacekeeping force is probing claims its septic tanks leaked into the Artibonite river and contaminated it with fecal bacteria. The World Health Organization (WHO) warned the outbreak was far from over and Haiti should prepare for the disease to hit its capital Port-au-Prince, which is teeming with tent cities after January's catastrophic earthquake.

"We cannot say it is contained," WHO's cholera chief, Claire-Lise Chaignat, told journalists in Geneva.

"I think we haven't reached the peak," she said, recommending that Haitian authorities prepare for the "worst case scenario" -- cholera in the capital.

The acute intestinal infection is caused by ingesting food or water contaminated with the Vibrio cholerae bacteria.

The source of the infection is believed to have been the Artibonite river, a major artery that runs through Haiti to the coast near Saint Marc -- the outbreak's epicenter some 60 miles (100 kilometers) north of Port-au-Prince.

Although easily treated, cholera has a short incubation period -- sometimes just a few hours -- and causes acute watery diarrhea that can quickly lead to severe dehydration and death. Some 1.3 million people displaced by the 7.0 earthquake on January 12 are still crammed into thousands of makeshift camps. Aid agencies fear cholera could spread like wildfire in such conditions.

Fear of the disease is turning to anger, as Haitians begin to blame foreign aid workers and peacekeepers for the Caribbean nation's first ever outbreak of cholera.

The installation of a vital treatment center in Saint-Marc had to be halted on Wednesday after some 300 residents confronted doctors and aid workers. Fueled by fear the facility would spread cholera to two nearby schools, residents hurled stones at medical workers of the international medical agency Doctors Without Borders (MSF).

The specialized treatment center was being set up outside the overwhelmed Saint Nicolas hospital here, where some 800 patients are already being treated with hundreds of new cases arriving each day, officials said.

Argentine troops with MINUSTAH moved in, stopped the protest, and then oversaw the dismantling of the facility.

"It was a big misunderstanding," Haitian doctor Yfto Maquette told AFP in the hospital's chaotic courtyard overflowing with patients who were supposed to have been moved to the new facility.

"The fact that we don't have the center is stopping us from effectively treating people," said an MSF official who declined to be named.

"We need to get the message out that cholera is a disease that we are very experienced in treating," he said. Maquette pointed out there was still need for basic response tools for the crisis, saying the medical team "only has one ambulance to bring people into the hospital."

Meanwhile, the group's field coordinator in Saint-Marc was optimistic the epidemic was being controlled.

"The fact that we are seeing fewer severe cases is positive," said Federica Nogarotto, the MSF field coordinator in Saint-Marc. "It suggests that people are taking precautions and that there is a greater understanding in the community of the need to maintain strict hygiene and to seek medical assistance at the first sign of symptoms."

Among the young patients at Saint Nicholas was four-year-old Jules Djelickson, who lay motionless on a cot, staring vacantly into the distance, as his mother Pacius Celette waved a grubby rag to keep flies off his face. Asked about the MSF site being shut down, she said: "The community is scared, but they don't have a choice, we need it."

Wednesday, October 27, 2010

ARTICLE - CHOLERA AFFECTING ELECTION CAMPAIGNS

CHOLERA SPREADING, AFFECTING ELECTION CAMPAIGNS IN HAITI
(Miami Herald) - By Jacqueline Charles

PORT-AU-PRINCE -- First presidential hopeful Michel `Sweet Micky' Martelly asked for a days long campaign truce. Then, opponent Jude Célestin announced that he was temporarily suspending all radio and TV ads, and called on his opponents to follow.

Now, Leslie Voltaire is asking to postpone the Nov. 28 election.

A deadly outbreak of cholera in an already earthquake-wracked Haiti has become one more complication in a nation still grappling with the effects of the devastating Jan. 12 earthquake that left an estimated 300,000 Haitians dead and at least 1.5 million Haitians living underneath tents and tarps.

As campaign jingles continue to play on local radios and three presidential candidates taped a televised debate Wednesday morning, Haiti health officials reported that after days of successfully containing the epidemic to the rural valley where it first broke last week, cholera had finally spread.

Officials said 174 cases had been confirmed in the city of Arcahia, a small rural village 20 miles north of Port-au-Prince. There were also suspected cases in nearby Cabaret, and they were investigating reports in Cité Soleil, a slum in the capital not far from the main international airport.

The waterborne bacterial infection had killed 303 Haitians, including five in Arcahia, and hospitalized 4,722 Haitians, the government said late Wednesday.

``It's encroaching, and we are taking measures,'' said Dr. Ariel Henry, the chief of cabinet for the Ministry of Health. ``We are training people on the ground to give out oral rehydration salts. We are putting in place cholera treatment centers. We are also doing a big effort all over the country with 50,000 people. We are training them, and we are preparing to deploy them.''

The health ministry has not asked for a delay of the vote, but it has asked candidates to refrain from holding rallies in cholera-affected communities. For some like Voltaire, an urban planner who is among the 19 presidential candidates seeking to replace President René Préval, that is not good enough.

``The vote should happen when the World Health Organization says it is contained, or when the [Provisional Electoral Council] says this election will not use rallies,'' Voltaire said.

So far, neither the WHO, which is working alongside Haitian health officials to contain the epidemic, nor the electoral council charged with putting on the elections has called for a postponement out of public health concerns.

Gaillot Dorsinvil, president of the council, told The Miami Herald the fate of the elections is up to the government, and as far as the council was concern, the vote was moving ahead as scheduled.

That message was reiterated Wednesday in Washington when the diplomat leading a joint Organization of American States/Caribbean Community observation mission reported that ``the electoral process is progressing steadily toward 28 November.''

``The political environment is more reassuring with the increasing participation of parties, political platforms and candidates who initially intended to boycott the elections,'' said Colin Granderson, who is also the assistant secretary general of CARICOM.

Still, Granderson conceded that the evolution of the cholera outbreak and its potential impact on the process remain a concern.

Célestin, who participated in the televised debate Wednesday in which the question of cholera was raised but not possible postponement of the elections, said he's not seeking a delay.

Rather, he believes that Haitians should not have their attentions divided while the government and international humanitarian community scale up a massive prevention and public education campaign, alerting Haitians on how they can save themselves from a disease that kills within hours when not treated in time.

``The population should not have to listen to campaign jingles while people are dying,'' said Célestin, tapped by Préval to succeed him. ``To see candidates put posters in a hospital in Mirebalais where people are dying, it's sad.''

Martelly also complained about how some candidates are trying to politicize the epidemic to their benefit, wearing campaign T-shirts and vehicles as they visit the sick. He's disappointed, he said, that his request has fallen on deaf ears.

``We need to start working together even though we may be different candidates,'' he said. ``At the end of the day, Haiti must be the priority.''

Not everyone favors a pause. Lawyer Jean-Henry Céant, who debated Célestin, said the elections should continue as planned. Sen. Youri Latortue, whose coalition is supporting longtime opposition leader Mirlande Manigat, also wants to see the schedule maintain. Manigat had a slight lead over Célestin in a recent poll.

``We are entering into this election under difficult circumstances, but we cannot leave the country without a government,'' said Latortue, who on Tuesday summoned the health minister to a session to get a report on the government's efforts. ``We have a lot of problems to resolve.

We already do not have any money. Each time you postpone the date that is money.''

Observers say even if no decision is taken on the election, how the government handles the outbreak could influence the outcome of the vote in what is emerging as a competitive race.

Though Célestin is neck-and-neck with Manigat in the most recent poll, he is trailing in a number of quake-battered cities, including the capital where observers say he's being hurt by the government's often-criticized handling of the quake response.

``If the management of the outbreak is not well-handled, it may jeopardize the government's image or any one associated with the actual management and government,'' said Gregory Brandt, president of the Haiti-French Chamber of Commerce.

Rosny Desroche said he doesn't see how the government can escape unscathed.

"People are suffering. Either way, the government will be held responsible,'' he said.

But Reginald Boulos, the chairman of the Economic Forum of the Private Sector, which commissioned the poll, said cholera could also be a chance for the Préval government to redeem itself.

``The earthquake was a negative for the government because they didn't react appropriately,'' he said. ``It could turn out to be a positive thing if they manage it well; if they show leadership, and compassion in the people. Or it can be a downfall for them if again there is lack of coordination and waste of money, and people are dying.''

ARTICLE - CHOLERA EPIDEMIC - WHO

HAITI CHOLERA EPIDEMIC YET TO PEAK: WHO
(AFP)

GENEVA – The World Health Organisation's cholera chief warned on Wednesday that the epidemic in Haiti, which has so far killed 284 people, had not been contained and had yet to pass its peak."I don't think that it is contained. We cannot say it is contained," Claire-Lise Chaignat, coordinator of the WHO's Global Task Force on Cholera Control, told journalists.

On Sunday, Haiti's Foreign Minister Marie Michele Rey expressed confidence about tackling the disease and said it appeared to be under control for the time being. Chaignat said the WHO was recommending that authorities in Haiti prepare for the "worst case scenario", the spread of the cholera bacteria to the capital Port-au-Prince.

Thousands of displaced people there have been living in insalubrious conditions in tightly-packed makeshift camps there since the devastating earthquake on January 12, which left 250,000 people dead.Chaignat also warned that it was "too early to speak about a peak. I think we haven't reached the peak."

The death rate from cholera has decreased, with a case fatality rate now of 7.7 percent compared to 10 percent at the beginning, according to the WHO. However, that remains well above the UN health agency's accepted threshold of one percent.

More than 3,600 people have been infected in the sudden cholera outbreak in the impoverished Caribbean nation since it was uncovered last week.

The WHO's cholera experts remain mystified by the origins of the epidemic in Haiti.

"We are very surprised to see the epidemic in Haiti. We have never found cholera there before," Chaignat said.

However, it was not the first time that the bacterial disease has appeared in a country without an explanation, she added. The acute intestinal infection is caused by ingestion of food or water contaminated with the Vibrio cholerae bacteria.

Although easily treated, it has a short incubation period of a few hours up to five days and causes acute watery diarrhoea that can quickly lead to severe dehydration and death without treatment.

In March, the WHO expressed concern about the "growing number and frequency of major cholera outbreaks," following protracted outbreaks in Angola, Ethiopia, Somalia, Sudan, northern Vietnam and Zimbabwe.

The UN health agency believes that the true global burden of the disease is much higher than the number of cases reported to it.

BIOSURVEILLANCE UPDATE - 7

OPERATIONAL BIOSURVEILLANCE

FLASH REPORT: CHOLERA IN CITE SOLEIL

As evidenced in multiple reports by the HEAS, a clear route of cholera transmission from Artibonite existed along the coastal highway from Arachaie to Lafito to, potentially, "Camp Obama" and (of greater concern) Cite Soleil. As feared, cholera has now been reported in Cite Soleil in a case without a travel history from Artibonite Valley:

The clinic in Cite Soleil treated a patient this morning that presented at the clinic with rice water diarrhea and vomiting. It is the considered diagnosis of the tropical medicine experienced physician at the clinic that this is cholera.

It was further determined that this individual had not traveled outside of Cite Soleil. It is of very great concern that the case history proved that this patient has not been away nor does she ever travel from her home in Cite Soleil. This transmission occurred in Cite Soleil.

Also of great concern, because of efforts to clear rubbish and garbage from the water courses the contaminated soil that lines these channels is being spilled onto the banks which serve as the paths leading into the heart of this overcrowded area of the city. The Cite Soleil is seeing a sharp rise in diarrheal illness most probably associated with the spillage of what constitutes raw sewage along the afore described paths.

While these later described patients that are presenting to the clinic with diarrhea do not have symptoms consistent with a diagnosis of cholera this trend, a rapid increase in cases of diarrheal illness, portends a disaster if cholera now in the area crosses the epidemic threshold!!! Two days of rain will make this almost inescapable.

Please remember that the first case reported above is separate. The symptoms of that patient matched word for word the WHO accepted case description for cholera.

The team considers this a priority alert for Port-au-Prince worthy of immediate investigation.

UPDATED CASE COUNTS AND IMPLICATIONS FOR SUSTAINED TRANSMISSION

From our perspective, we agree with PAHO's recent statement today about the epidemic and while we all would like to be hopeful, we are reminded of the recent 2008-2009 epidemic of cholera in Zimbabwe. Responders there were lulled into a false sense of security as the epidemic waned, only to be badly disappointed as the epidemic continued onward to produce 98,424 suspected cases and 4,276 deaths (Case Fatality Rate of 4.3%) from August 2008 to June 2009 that were officially reported. Fifty-five out of 62 districts in all 10 provinces had been affected, according to the World Health Organization.

Currently we are seeing 4,147 cases officially reported, with 292 deaths. We assume PAHO is reporting these as separate groups of people, where the total number of cases reported is actually 4,147+292= 4,439. If we generally assume that only 25% of cases display clinically apparent illness, we conservatively assume then there has been at least 17,756 infected people to-date. This is a truly alarming number of people, especially when considering 1) this is likely the result of under-reporting and 2) a large percentage of these infected individuals could be shedding pathogen into the environment for weeks post-infection.

There are a number of factors in play to explain the apparent high CFR:

1. CFRs are often inflated at the front-end of outbreaks and epidemics in general, especially when dealing with an area of limited infectious disease warning capability, because the social bias in reporting up to a national level is driven by fatalities or the most severe clinical outcomes.

2. Once the clinical entity (i.e. cholera) is recognized to be the etiological agent, extrapolations for the true infectious disease load in community may then be calculated for a truer estimate (such as we've proposed above).

3. Once social sensitization has been achieved through a warning process such as we have achieved, reminders for clinical diagnosis are also distributed which actually alters the probability of clinical diagnosis for milder cases. This means your reported case count may migrate a bit over time.

Bottom line, our team remains on maximum alert and are concerned about the potential for ecological establishment and introduction to other nations in the Caribbean.

EXPANSION OF CHOLERA AND THE TEMPERING OF HOPE

We, like the rest of the responder community, have dared to hope containment may be possible at various junctures of this crisis. We noted recent reporting of cases seen in Limbe and Plaisance, where Limbe is a 15 minute drive from Cap Hatien, and are reminded this situation is still very much in flux and unlikely to resolve soon. One of the HEAS partners who was close to the recent 2008 massive epidemic of cholera in Zimbabwe noted that responders there also had indication of a stabilizing or slowing down of transmission, only to be horribly disappointed as tens of thousands were infected. While we keep hoping Haiti will "get a break", we simply cannot allow ourselves to stand down for a moment. This remains an IDIS Category 5 event that is very much in-play. And the question of ecological establishment remains an open one as well.

CONTEXT: ANTI-CLINIC PROTEST IN ST. MARC

We previously noted a protest that erupted in St Marc over the creation of a cholera treatment facility, and we have been provided with several important points of context:

MINUSTAH was not directly involved in the creation of the treatment center but was providing security for MSF personnel by request.

The chosen site of the facility was across the street from a school; and
Was a community soccer field

The latter two points are crucial for the following reasons:

We have come to realize over the years that for communities coping with a high level of threat perception, especially during unexpected or non-routine infectious disease events, protection of children becomes an exquisitely sensitive nexus of concern that may lead to social outcry and even violence.

Communities under collective stress such as is readily observed in St Marc have a high demand for coping outlets such as recreation and access to religious services, for example. Compromised access to such outlets is actually a key indicator that prompts us to monitor for civil unrest.

If the community in question is already experiencing tension such as the negative MINUSTAH-Haitian public dynamic, then these issues become all the more important to monitor... and avoid.
At some point following conclusion of this disaster response effort it would be a prudent activity to review these kinds of observations to better inform response activities in the future.

ANTI-CLINIC PROTEST IN ST. MARC
Media reported on students protesting the activation of a cholera treatment center in St. Marc managed by MSF.

This is clearly a community education issue. Such community anxiety is very common when dealing with a pathogen previously unknown to a community or not in recent generational memory. We have seen the various manifestations of community anxiety for years in many different cultures under many different scenarios- from Ebola to the 2009 influenza pandemic. It relates to community coping mechanism when dealing with a non-routine, unexpected perceived threat, particularly one perceived difficult to control.

Tuesday, October 26, 2010

ARTICLE - CHOLERA PROTESTS

CHOLERA FEARS SPARK ANTI-CLINIC PROTEST IN HAITI
(AP) - David Barraza

PORT-AU-PRINCE — Protesters threw rocks at a cholera treatment center as it was preparing to open in the city of St. Marc on Tuesday, highlighting the fear surrounding a disease that was almost unknown in Haiti before it began spreading through the countryside, aid workers said.

Some of the roughly 300 students and other protesters said they feared the Doctors Without Borders-Spain clinic would bring more of the disease to their seaside town, which is one of the hardest hit in the week-old epidemic that has killed 284 people and infected 3,769, according to United Nations figures.

U.N. peacekeepers from Argentina arrived with riot shields to reinforce police. Warning shots were heard; the U.N. said its soldiers fired blanks. There were no reports of injuries.

Haitian health officials assured the crowd the clinic would not open in that neighborhood. Doctors Without Borders-Spain country chief Francisco Otero said the medical aid group would try to reopen it in another part of St. Marc. The clinic is intended to rehydrate and treat people with the severe diarrheal disease.

"In the coming days we are going to start to work with this community, to explain that there is no risk for them to have such a facility," Otero told The Associated Press.

More than 420 new cholera cases were confirmed Tuesday, according to the U.N. Office for the Coordination of Humanitarian Affairs. Twenty-five new deaths were confirmed, bringing the total to 284.

OCHA spokeswoman Imogen Wall says the majority of cases occurred along the central Artibonite River with many new instances in Haiti's central plateau. St. Marc's main hospital was the first to widely alert the epidemic as it overflowed with the sick and dying.

U.N. staff have been told to avoid areas of heavy infection unless they are given special permission to go there. Guatemalan police manned a checkpoint Tuesday on the highway from Port-au-Prince to Mirebalais, a hard-hit city in central Haiti, to make sure unauthorized U.N. vehicles did not pass.

Aid workers, meanwhile, scrambled to contain the spread of the disease, which has not occurred in Haiti for generations.

Speaker trucks passed through neighborhoods in the capital, where a handful of cases have been confirmed in people who apparently contracted it in the countryside, advising the city's millions of residents to wash their hands.

The Dominican Republic, which borders the central plateau where many new cases are being found, announced that all people crossing the border must wash hands and complete a medical form. They also stepped up military surveillance and closed a twice-weekly binational market on Monday, sparking protests on the Haitian side of the border.

ARTICLE - CHOLERA BACTERIA

CHOLERA KILLS E. COLI, SALMONELLA
(CBC) - By Emily Chung

Cholera bacteria are deadly to other bacteria that cause gastrointestinal illness — a finding that may provide clues about how cholera survives between epidemics.

Cholera, a gastrointestinal disease transmitted through unclean water, often strikes in the wake of natural disasters.

An outbreak of cholera in Haiti had killed 259 people and sickened 3,342 people by Monday, according to the Haitian Health Ministry, although the situation appeared to be stabilizing.

Worldwide, the disease kills 120,000 a year, the World Health Organization reported in 2005.

But new research by University of Alberta microbiologists shows cholerae, the bacterium that causes cholera, doesn't just kill people — it is also an effective killer of E. coli (Escherichia coli, responsible for the Walkerton, Ont., tainted water deaths in 2000), Salmonella typhimurium (which affects mice, but is related to the bacteria that cause salmonella food poisoning), and other bacteria that cause symptoms such as diarrhea.

The findings published Monday in the Proceedings of the National Academy of Sciences, help explain how outbreaks of cholera may sometimes recur six months or a year after the last reported case of the disease.

Cholera bacteria usually need a human host. But by killing other bacteria that compete with it for resources such as food, cholera may have a better chance at surviving in the harsh world outside the human body, said Dana MacIntyre, lead author of a paper.

"In areas with limited nutrient supplies, it creates a niche for itself where it's the only bacteria."
MacIntyre made the discoveries about Vibrio cholerae in collaboration with Sarah Miyata, Maya Kitaoka and Stefan Pukatzki, a microbiology professor at the University of Alberta.

In the case of E. coli, its population fell up to 100,000-fold when it was grown with cholera bacteria, the study reported.

The researchers aren't sure exactly how cholera kills the other bacteria, but they found it necessary that cholera bacteria have a functioning "secretion system."

"Basically, you can compare it to a needle to the surface of the cell that would make contact with the target cell," said MacIntyre, who conducted the research for her undergraduate thesis project.

The researchers don't know if the bacteria injects a toxic protein or just kills through the act of puncturing another cell. But they do know it's not as simple as secreting a toxic substance into the environment — killing requires contact between the cholera bacteria and their prey.

Catheter cleaning?

About 80 other bacteria have similar secretion systems, including some that aren't harmful to humans, MacIntyre added.

In the future, humans might be able to make use of this bacteria-killing method by harnessing harmless bacteria to get rid of harmful bacteria such as E. coli on medical equipment, she said.
However, this possibility is still a long way off, she cautioned.

Pukatzki, the microbiology professor, and his lab are working on research to figure out the method used by Vibrio cholerae to kill other bacteria. Meanwhile, MacIntyre has graduated and is preparing to apply for medical school next year.

The researchers began looking into whether cholera could kill other bacteria after noting that its secretion system contained proteins similar to those found in bacteriophages, viruses that attack bacteria. Bacteriophages have a tail spike that punctures bacteria and injects viral genetic material. The proteins on the tip of the spike are similar to those found in V. cholerae's secretion system.

ARTICLE - MINUSTAH STATEMENT

Port-au-Prince - The UN Mission for the Stabilization of Haiti (MINUSTAH) denied Tuesday that it is at the origin of the ongoing outbreak of cholera in the Caribbean country.

"MINUSTAH is keen to shed light around rumours published by certain media that led to the belief that human refuse thrown into a river in Mirebalais by MINUSTAH would be at the origin of the cholera epidemic in Haiti," the mission said in a statement.

MINUSTAH said that it does have a Nepalese contingent in Mirebalais, which uses seven septic tanks. These tanks have, however, been built in accordance with the regulations of the Environmental Protection Agency (EPA), the mission said.

The septic tanks in question are emptied every week by a subcontractor's trucks, which then take their load to a site which has "the authorization of the municipality of Mirebalais," the statement stressed.

"It is 250 metres off the Meille river, which is more than 20 times the internationally required distance," MINUSTAH said.

Some 259 people have died and more than 3,000 infections have been confirmed since cholera broke out a week ago in central Haiti.

The government and aid organizations in the impoverished country are working frantically to stop the disease from spreading, amid fears that cholera could reach overcrowded refugee camps still housing around 1 million people since the January 12 earthquake.

Posted by Earth Times Staff

ARTICLE - 25 NEW CHOLERA DEATHS

HAITI REPORTS 25 NEW CHOLERA DEATHS
(AFP) - By Clarens Renois

Haiti reported 25 more cholera deaths on Tuesday as UN health officials warned the epidemic was not over yet amid lingering fears it could still infiltrate the capital's putrid refugee camps.

The cholera outbreak, the first in Haiti in more than 100 years, has stabilized in recent days but the number of new deaths announced on Tuesday was more than four times the six reported on Monday.

Overall infections have been increasing steadily and doctor Roc Magloire of the Haitian public health ministry said the number being treated in hospitals and clinics had risen over the past 24 hours by 270 to 3,612.

So far the poorest country in the western hemisphere has managed to avoid the nightmare scenario of the epidemic taking hold in the unsanitary tent cities that cling to the hilly slopes of Port-au-Prince.

Large parts of the capital and other nearby towns were flattened by January's 7.0-magnitude quake which killed a quarter of a million people and displaced 1.3 million.

"At the WHO we think more cases will be found. The most important thing is prevention," World Health Organization spokeswoman Fadela Chaib told reporters in Geneva.

As the toll built, Haiti's more prosperous neighbor, the Dominican Republic -- with which it shares the Caribbean island of Hispaniola -- tightened up border security to keep the disease at bay.

Officials in Santo Domingo said entry into the country from Haiti would be severely restricted, and border security increased to ensure new regulations are complied with.

"We will maintain strict supervision of our ports, airports and border crossings points to prevent the transmission of this disease to our country," public health minister Bautista Rojas was quoted as saying.

Chaib urged the Dominican Republic to keep the border open, but admitted there was no harm in making contingency plans.

"There is no need to close the borders or restrict travel or trade because a neighboring country has cholera. This is what we say for all cholera outbreaks worldwide."

Aid agencies, meanwhile, stepped up efforts to educate Haitians about the risks and treatment of the disease, using local radio stations and text-messages about hygiene precautions.

Haitian officials said Monday they believed the outbreak had been contained and was limited to central areas near its believed source on the Artibonite river. But a UN statement quickly tempered any optimism by warning that a nationwide outbreak infecting tens of thousands of people was still a distinct possibility.

"We are particularly concerned about Port-au-Prince and those in the slum areas as well as in the camps, but we are also preparing for outbreaks in the rest of the country," said Nigel Fisher, UN Humanitarian Coordinator in Haiti.

Living conditions in the camps, where pools of human waste lie in areas where people bathe, do laundry and share meals, are ideal for cholera to thrive. The disease, which is primarily transmitted through contaminated food and water, can fatally dehydrate a victim in a matter of hours.

Amid the makeshift homes in the overflowing Champs de Mars camp, across the street from Haiti's crushed national palace, the dread of cholera is palpable. "We know what to do to protect ourselves, but children are left to their own devices," said 24-year-old Elvia. "They don't wash themselves correctly and, look, the toilets are right in front of the tents where we live."

Five cholera cases were confirmed at the weekend in the capital, but UN officials said those people traveled in from outside and were quickly diagnosed and isolated.

Most of those infected have been admitted to hospitals and clinics around Saint-Marc, a major town northwest of the capital. Five cholera treatment centers have been set up in the Artibonite region and six more are planned in the capital as a precaution. Doctors Without Borders has installed a field hospital in Saint-Marc to treat patients and aid groups have sent emergency specialists to the Artibonite region to set up water, sanitation and hygiene facilities.

BIOSURVEILLANCE UPDATE - 6

OPERATIONAL BIOSURVEILLANCE

UPDATE: COMMUNITY OUTCRY BLAMING NEPALESE MINUSTAH DEPLOYMENT IN MIREBALAIS FOR CHOLERA EPIDEMIC

We've received word of community outcry and rumor transmission regarding sewage from a Nepalese MINUSTAH deployment contaminating the Artibonite River. We do not know if the UN has evaluated this complaint, but as is often the case in unusual epidemics, ostracism has appeared in a few places now as locals attempt to explain the unusual and place blame. Very common phenomenon in our operational experience.

We did a cross-check on Nepal and cholera activity and discovered that Kathmandu issued a cholera outbreak alert on Sept 23rd. They reported an abrupt increase of 25 cases, which obviously represents a small outbreak but officials were concerned enough to mount an organized response. Cholera is endemic in Nepal.

The only way to know for sure is to conduct a site investigation and compare samples from Nepal and the MINUSTAH Nepalese troops.

Cross-check of the peer-reviewed literature indicates the sole serotype of cholera in Nepal reported to the Nepal National Laboratory from 2008-2009 was 01 Ogawa El Tor (see attached).
Download Ogawa El Tor in Nepal

ARTICLE - TRYING TO FEND OFF CHOLERA

HAITI TRIES TO FEND OFF CHOLERA OUTBREAK IN CAPITAL
(AP) - By Jacob Kushner

Efforts focused on conditions in tent cities

PORT-AU-PRINCE, Haiti — Health authorities and international aid workers scrambled yesterday to keep a cholera outbreak in Haiti from spreading to the squalid camps in Port-au-Prince, where 1.3 million earthquake survivors live.The outbreak has already killed 250 people and made more than 3,000 sick. Five cholera patients have been reported in Haiti’s capital, heightening worries that the disease could reach the sprawling tent slums where abysmal hygiene, poor sanitation, and widespread poverty could rapidly spread it.

Government officials said yesterday that all five apparently got cholera outside Port-au-Prince, and they voiced hope that the deadly bacterial disease could be confined to the rural areas where the outbreak originated last week. Health Ministry director Gabriel Timothee said tightly limiting movement of patients and careful disposal of bodies can stave off a major medical disaster.

If efforts to keep cholera out of the camps fail, “the worst case would be that we have hundreds of thousands of people getting sick at the same time,’’ said Claude Surena, president of the Haiti Medical Association. Cholera can cause vomiting and diarrhea so severe it can kill from dehydration in hours. Doctors Without Borders issued a statement saying some Port-au-Prince residents were suffering from watery diarrhea and were being treated at facilities in the capital.

Cholera infection among the patients had not been confirmed, however, and aid workers stressed that diarrhea has been common in Port-au-Prince since the Jan. 12 earthquake. Aid workers say the risk is magnified by the extreme poverty faced by people displaced by the earthquake, which killed as many as 300,000 people and destroyed much of the capital city.

Haitians living in the camps risk disease by failing to wash their hands, or scooping up standing water to wash fruits and vegetables.

“There are limited ways you can wash your hands . . . in slums like we have here,’’ said Michel Thieren, an official with the Pan-American Health Organization in Haiti. “The conditions for transmission are much higher.’’

Aid workers are coaching thousands of impoverished families on how best to avoid cholera.

Various aid groups are providing soap and water-purification tablets and educating people in Port-au-Prince’s camps about the importance of washing their hands. Aid groups also began training more staff about cholera and where to direct people with symptoms. The disease had not been seen in Haiti for decades, and many people don’t know about it.

Members of one grass-roots Haitian organization traveled around Port-au-Prince’s camps booming warnings about cholera from speakers in the bed of a pickup truck.

“Many people have become sick,’’ announced Etant Dupain, in front of the Champs de Mars camp by Haiti’s broken national palace. “If you have a family member that has diarrhea, bring them to the hospital immediately. Have them use separate latrines.’’

Relief workers said additional supplies were being flown in, in anticipation that the number of cases would increase sharply. In a promising development, aid group Partners in Health said hospital management was improving in the city at the center of the initial outbreak, St. Marc, which is about a 60-mile drive northwest of the capital. Just 300 patients were hospitalized on Saturday, a number that has decreased by the end of each day.

A cholera treatment center in St. Marc is expected to be functional within the week, and efforts were ongoing to make clean water available in rural communities, especially those where rivers were the only source of water.

Some health specialists were hopeful that they will be able to control the outbreak of cholera in impoverished Haiti.

“In a way, it couldn’t have happened at a better moment than now because everyone is on the field — lots of [non-governmental organizations], lots of money. We haven’t had any hurricanes so far this fall but people are here, and people are prepared,’’ said Marc Paquette, Haiti director for the Canadian branch of Medecins du Monde.

Cholera is an acute bacterial infection that results in a severe form of diarrhea that quickly dehydrates and causes death unless victims are treated, primarily with plenty of water and antibiotics, at the onset. Medical officials said it is possible that some people suspected of having cholera have diarrhea caused by less dangerous germs.

Officials have prepared for months for waterborne diseases in Haiti, which has long-standing sanitation problems. But they were not specifically ready for cholera, which last appeared in Haiti 50 years ago. There are an estimated 3 million to 5 million cholera cases and 100,000 to 120,000 deaths every year worldwide, according to the World Health Organization. Outbreaks have been reported this year in Cameroon, Chad, Niger, Nigeria, Pakistan, Papua New Guinea, and Zambia.

Monday, October 25, 2010

ARTICLE - CHOLERA CAUSES NOT CLEAR

HAITI CHOLERA OUTBREAK CAUSES NOT CLEAR, EXPERTS SAY
(BBC) - By Sigrun Rottmann

Until the current outbreak, cholera had not been documented in Haiti since 1960 The cholera outbreak in central Haiti that so far has killed more than 250 people and infected more than 3,000 is the worst health challenge the country faces since the earthquake in January.

There had been no documented outbreak of the disease in Haiti since 1960. The US Centers for Disease Control and Prevention (CDC) said after the earthquake that while cholera testing should be carried out, the disease was "extremely unlikely to occur".

So why has the epidemic struck now?

It is not clear if the cause of the outbreak will ever be identified, but health experts agree that for cholera to occur, bad sanitation and hygiene have to coincide with people carrying the Vibrio Cholerae bacterium.

Sanitary conditions were poor in many parts of Haiti even before the earthquake, and Dr Brigitte Vasset from the international humanitarian organisation Medecins Sans Frontieres (MSF) in Paris is reluctant to link the outbreak directly with the quake.

"Central Haiti - where most people have been infected - was not the region most affected by the earthquake," she says.

While many displaced people might have sought refuge in the Artibonite region after the disaster, cholera bacteria could have been present in the Artibonite river or a stagnant water source even before the earthquake, Dr Vasset says.

She also points out that while no cases of cholera have been reported from rural areas, this does not mean that it has been completely absent.

"In many African countries there are sporadic cases during the year, then the weather changes or other conditions change, and all of a sudden there is an outbreak," Dr Vasset says, adding that the disease is difficult to predict.

"I have worked in refugee camps where we expected a cholera outbreak - and it never came," she says.

Sarah Morgan, Senior Health Programme Adviser at aid agency World Vision, agrees that it is possible low-level cholera was present in Haiti all along.

"Surveillance data on cholera in Haiti are not available," she says.

However, watery diarrhoea has been common in the country, causing 5% to 16% of the deaths among Haitian children, according to CDC data.

With diarrhoea so prevalent and no stringent monitoring by health authorities and 80% of those with symptoms showing only moderate signs of infection, sporadic cases of cholera might not have registered.

"While there might have been no significant outbreak of cholera, it is possible that there was a background level of the disease", Ms Morgan says.

That cholera has now been picked up so quickly after the outbreak in the Artibonite region is a great success for Haiti's health authorities and international organisations working the country, she adds.

On the rise
Cholera is widespread and on the rise, with three to five million cases worldwide, the World Health Organisation says.

More than 100,000 people die from the disease every year, with the majority of cases in Sub-Saharan Africa. Epidemics of Vibrio Cholerae are caused by one of two strains: 01, which has been identified as the cause of the current epidemic in Haiti, and the South-East Asian strain 0139.

It is difficult to get a complete picture of the global spread of the disease, because some countries are reluctant to report cholera for fear of travel sanctions, says Adam Kamradt-Scott from the London School of Hygiene and Tropical Medicine.

Mr Kamradt-Scott points out that around 75% of people infected with Vibrio Cholerae do not develop symptoms. But they excrete the bacterium with their faeces for up to 14 days - a potential source of infection for others.

With more people and aid coming to Haiti since the earthquake in January, there is a possibility that the bacterium was brought to the country from the outside, Mr Kamradt-Scott says.

"The bacteria can be resident in water for a quite a while," Mr Kamradt-Scott explains and points to a cholera outbreak in Peru in 1991.

There was speculation that that epidemic, which quickly spread across Latin America, came from bilge water and algae dumped by an Asian cargo ship, contaminating local shellfish.

In Haiti, the disease has more likely been spread because people used the Artibonite river for washing and drinking.

"As soon as people have been infected and excrete the bacteria, the epidemic spreads very quickly," Mr Kamradt-Scott says.

"It is then important to break the cycle of the disease", he adds.

Because Vibrio Cholerae produces toxins that lead to watery diarrhoea, patients need to be rehydrated by with liquids containing sugar and salt or with intravenous fluids.

Those infected need to receive treatment immediately, Mr Kamradt-Scott says. If not treated, the death-rate of cholera can rise up to 50%.

But the potentially deadly cholera cycle can only be broken when people also stay away from the contaminated water source until the bacteria have cleared, he adds.

ARTICLE - BAHAMAS SETS UP SCREENING

BAHAMAS SETS UP CHOLERA SCREENING
(The Tribune) - By Noelle Nicolls

BAHAMIAN emergency agencies have been put on high alert following the outbreak of cholera in Haiti.

Local health services have started emergency medical screening at Bahamian airports and seaports to respond to the outbreak of the deadly disease that has so far claimed more than 250 lives in Haiti.

Passengers travelling to and from Haiti and the Dominican Republic may be subject to airport screenings or medical surveys.

International travellers who have been to either destinations are being advised to contact a health centre if they experience symptoms such as stomach aches or diarrhea.

After being alerted by the Pan American Health Organisation on Friday that it received laboratory confirmation of cases of Cholera in Haiti, local emergency response services assembled a team to create a preventative strategy for the Bahamas.

There is no "immediate threat" to the Bahamas at this time, according to Dr Hubert Minnis, Minister of Health.

"There are no cases of cholera or suspected cases of cholera in The Bahamas at this time," he said.

However, the authorities have developed response plans in the event that the disease is imported into the Bahamas.

"The Water and Sewerage Corporation confirms that the government has adequate supplies of safe clean water. Its Water Quality Laboratory conducts routine sampling and analyses of water following well established protocols. The public is advised that tap water is safe to drink," said Dr Minnis.

"The Ministry of Health currently has medicines and supplies in stock to cover initial treatment needs. Educational materials are being developed to promote good hygiene and safe food handling practices. These messages will be in English and Creole," he said.

Cholera is a disease caused by ingesting food or water contaminated with faeces or infective material.

The symptoms include "the abrupt onset of profuse, painless watery diarrhea (rice water stools), with nausea and vomiting early in the disease." Untreated, it can result in severe dehydration or death within hours.

Efforts in the Ministry of Health are currently focused on preventing the introduction of the disease.

The public is advised to use clean water and maintain good hygiene practices.

When preparing food either wash, peel, shell and/or cook thoroughly.

ARTICLE - DOMINICAN REPUBLIC RESTRICTS ENTRY

DOMINICAN REPUBLIC RESTRICTS ENTRY FROM CHOLERA-STRICKEN HAITI

DAJABON, Dominican Republic – Dominican authorities barred Monday the entry of thousands of Haitian merchants and buyers on their way to take part in the traditional binational market that was suspended because of the cholera epidemic affecting Haiti.

The provincial director of the Public Health Ministry, Rafael Salas, told the press that this is an official government measure adopted to protect the population from the outbreak of cholera detected last week in Haiti that has already taken 253 lives.

Migration authorities said that it will only allow entry into the country for students and Haitians with Dominican visas, who have previously observed such hygienic measures as washing their hands, at points established by the Public Health Ministry on the border.

The suspension of the traditional binational market in Dajabon sparked complaints from Haitian merchants, many of whom came to the border from Port-au-Prince and remote areas.

The Dominican Republic also blocked Sunday the entrance to its territory to Haitian clergy who were going to take part in a meeting for peace in both countries, religious sources said.

Dominican authorities had announced a series of measures on the Haitian border due to the outbreak of cholera.

Among the measures was a ban on sales of food cooked in Haiti at the binational market.

While no suspected cases of cholera have been reported up to now in the Dominican Republic, Health Minister Bautista Rojas Gomez said that a unit has been set up in the national laboratory to diagnose the deadly disease, the press said Monday.

ARTICLE - RUSH TO STEM SPREAD

IN HAITI, RUSH TO STEM THE SPREAD OF CHOLERA
(New York Times) - By Denise Grady

The cholera epidemic in Haiti is likely to grow and persist, and will probably reach the Dominican Republic, health officials said on Monday, as they rushed to distribute medical supplies in hopes of keeping ahead of the disease’s spread.

“Now that cholera has established itself with a strong foothold in Haiti, it is clear to us that it will not go away for several years,” said Dr. John Andrus of the Pan American Health Organization at a news briefing Monday in Washington.

Efforts at prevention — mainly, providing clean water, soap and better sanitation — will bring the number of cases down but will not eradicate the bacteria, he said. Once the bacteria find their way into the right environment, like the brackish water of an estuary, cholera-causing microbes — Vibrio cholerae — can live on for a long time.

As of Sunday, there were 3,015 known cases and 253 deaths in Haiti. But the actual number of cases could be much higher, Dr. Andrus said, because about 75 percent of infected people have no symptoms. They can carry the bacteria for two weeks and shed them back into the environment, where they can infect others, which is most likely to occur when sanitation is poor and clean drinking water not available.

By far the most common way the disease is spread is through contaminated water. Person-to-person spread is far less of a risk because people need to swallow a large dose of bacteria to get sick. Dr. Robert Quick, a medical epidemiologist at the Centers for Disease Control and Prevention in Atlanta, said that water could be easily disinfected just by boiling it or using chlorine products made for that purpose.

Why the disease has suddenly appeared in Haiti is a mystery, experts say. It has not been there in decades, not even when an epidemic that started in Peru in 1991 affected much of Latin America. An infected person could have brought the bacteria in from another country, or it could have arrived in food or even on board a ship that discharged infected wastes into a local waterway. Once it landed, the squalid conditions were ideal for its spread.

Dr. John Mekalanos, chairman of microbiology and molecular genetics at Harvard Medical School, said he expected to receive samples of the bacteria from colleagues in Haiti and to sequence its genome. Comparing the results with other samples from past outbreaks in different locations should give researchers some clue about where this strain came from, he said.

Dr. Quick said that the disease usually began with watery diarrhea, and that people might not feel very sick at first. If they start taking oral rehydration solutions at that early stage, they can replace the lost fluid and recover within a few days. But if the treatment is delayed, the risk rises sharply. As the disease progresses, more fluid and electrolytes are lost, and vomiting starts. Then a person may not be able to keep the oral solutions down, and may need intravenous treatment. Without fluids, the end can come quickly.

“Basically, with severe cholera you go into shock, and without rehydration you develop kidney failure and other organ failure,” Dr. Quick said.

But even people with severe cases have been saved by rehydration, Dr. Quick emphasized. “People appear to be on death’s doorstep, but then they get fluids and their eyes open and they do fine,” he said.

One question that has been debated is whether people in Haiti’s refugee camps and slums should have been given cholera vaccine, or should be given it now. In the early aftermath of the earthquake, the more likely threats were epidemics of measles and diphtheria, so the focus was on vaccines against those diseases, said Donna Eberwine-Villagrán, a spokeswoman for the Pan American Health Organization.

She and Dr. Quick said that vaccine experts were still discussing whether to use cholera vaccine now, in areas that have not yet been affected. Once an epidemic has taken hold, it is usually too late to start vaccinating.

Dr. Quick said: “You need to mobilize people for a vaccination campaign. You need to have vaccine there, in optimal conditions, and you need to be able to provide two doses 7 to 14 days apart. You get protective immunity seven days after the second dose.”

And cholera vaccine is relatively expensive — $10 for two doses. Right now, health workers are scrambling to make sure rehydration solution is widely available. It costs pennies.