Cholera in Haiti: What You Need to Know

Cholera Confirmed in Haiti, October 21, 2010

UPDATE: This information is current as of October 22, 2010 at 11:30pm EDT

An outbreak of cholera was confirmed in Haiti on October 21, 2010.  Cholera had not been documented in Haiti for decades so cholera outbreaks were considered unlikely in Haiti immediately following the earthquake in January, 2010.  For a cholera outbreak to occur, two conditions have to be met: (1) there must be significant breaches in the water, sanitation, and hygiene infrastructure used by groups of people, permitting large-scale exposure to food or water contaminated with Vibrio cholerae organisms; and (2) cholera must be present in the population.  While it is unclear how cholera was re-introduced to Haiti, both of these conditions now exist.

Cholera infection is most often asymptomatic or causes a mild gastroenteritis. However, about 5% of infected persons develop severe, dehydrating, acute watery diarrhea.  The first line of treatment for cholera is rehydration. Administration of oral rehydration salts and, when necessary, intravenous fluids and electrolytes in a timely manner with adequate volumes will reduce case-fatality rates to <1%.  Severe cases of cholera should be treated with antimicrobial agents to which the circulating strain is susceptible.  Antimicrobial treatment is not recommended for mild cases of cholera and should never be used as “chemoprophylaxis” to prevent cholera on a mass scale.

As with other causes of acute watery diarrhea, the prevention and control of cholera require surveillance, heightened measures to ensure the safety of drinking water and food, and appropriate facilities and practices for disposal of feces and for handwashing. Although using vaccines to control an outbreak of cholera is complex, oral cholera vaccines are being considered for use among high-risk populations in Haiti.

Acute Watery Diarrhea and Cholera: Haiti Pre-decision Brief for Public Health Action

Key recommendations

The most effective measures to prevent transmission of acute watery diarrhea are provision of safe (chlorinated) water; safe water storage; appropriate disposal of feces; and handwashing with soap after caring for patients, toileting, cleaning other persons after toileting, or before preparing, serving, or eating food.  Because onset of the rainy season is likely to enhance transmission of acute watery diarrhea, these measures should be strengthened immediately, particularly in settlements for displaced persons.

Outbreaks of acute watery diarrhea are likely to occur.  Surveillance systems should be able to rapidly detect an increase in reported cases of acute watery diarrhea.  Such an increase should trigger efforts to determine the source of transmission, ensure implementation of control measures in the affected area, and determine the microbial etiology. 

Dehydration is the critical clinical issue.  Adequate supplies for oral and intravenous rehydration and training in clinical management of dehydration need to be in place throughout the affected regions before an outbreak occurs. 

Cholera is extremely unlikely to occur.  However, if adults present with acute watery diarrhea and severe dehydration, cholera testing should be performed.

1. What was the situation in Haiti prior to the earthquake?

National surveillance data for acute watery diarrhea in Haiti were not previously available.  Studies in Haiti have suggested that diarrhea is a common illness (approximately 4–6 episodes of diarrhea per child per year) and cause of death (5–16% of deaths) among children.1,2,3,4 Estimated diarrhea incidence in Haiti is several times higher than the expected annual incidence among young children in industrialized countries.

There have been no reports of cholera in Haiti since 1960 or earlier.  Cholera is absent from the Caribbean.

The National Public Health Laboratory (LNSP) was not routinely performing diagnostic tests for watery diarrhea before the earthquake.

2. What is the likelihood of cases/outbreaks of acute watery diarrhea developing in the near future?

Outbreaks of acute watery diarrhea are very likely to occur in the near future. More than 20,000 cases of acute watery diarrhea were reported after an earthquake in Pakistan in 2005,5 and there are many reported outbreaks of watery diarrhea following disasters involving flooding or in encampments for displaced persons.6,7,8 Transmission of acute watery diarrhea occurs through consumption of sewage-contaminated water or food, contact with contaminated environmental surfaces, or direct person-to-person spread in conditions of poor hygiene.  All of these routes of transmission exist in post-earthquake Haiti.  Current problems with water, sanitation, and hygiene infrastructure will be exacerbated during the rainy season, when contact with contaminated standing water and sewage run-off will be common.

An outbreak of cholera is very unlikely at this time.  For a cholera outbreak to occur, two conditions must be met: (1) there must be significant breeches in the water, sanitation, and hygiene infrastructure used by groups of people, permitting large-scale exposure to food or water contaminated with Vibrio cholera organisms; and (2) cholera must be present in the population.  While the current water, sanitation, and hygiene infrastructure in Haiti would certainly facilitate transmission of cholera (and many other illnesses), cholera is not circulating in Haiti, and the risk of cholera introduction to Haiti is low.  Most current travelers to Haiti are relief workers from countries without endemic cholera, and they are likely to have access to adequate sanitation and hygiene facilities within Haiti, such that any cholera organisms they import would be safely contained.  Similarly, importation of cholera through contaminated food has not been documented in Haiti in decades and is unlikely to become a problem during the relief efforts.

3. Should an outbreak occur, how would it be detected?

The Health Cluster has established sentinel site surveillance for acute watery diarrhea throughout Haiti.  An outbreak of acute watery diarrhea would be suggested by a rapid increase in the number of persons with three or more loose, non-bloody stools in a 24-hour period. 

The most likely etiologies of watery diarrhea in Haiti would be norovirus, rotavirus, enterotoxigenic Escherichia coli, Giardia, and cryptosporidia, which cause clinically indistinguishable disease at presentation.  Cholera testing should be performed if adults present with acute watery diarrhea and severe dehydration.

Should an outbreak be detected, stool specimens should be collected from a limited number of cases (10–20) and tested in the LNSP or, if needed, in another reference lab.  Microscopy and culture should be performed to determine etiology.  Rotavirus, Cryptosporidium, and Giardia typically cause more severe disease in children than in adults; enzyme immunoassays for these agents would be useful if outbreaks are seen primarily among children.  Rapid diagnostic tests for cholera are sensitive and specific for outbreak detection; cholera rapid tests are now available at the LNSP.

4. What options for public health action should be considered in the event of an outbreak?

Chlorination of piped and tankered water supplies and/or point-of-use water treatment and safe water storage, and access to improved sanitation facilities, handwashing stations, and soap are the most important outbreak mitigation strategies.  These should be strengthened before onset of the rainy season, particularly in settlements for displaced persons.  During an outbreak of cryptosporidiosis or giardiasis, boiling of water is preferred; chlorination is marginally effective against Giardia and is not effective against Cryptosporidium.

Dehydration is the critical clinical issue for all types of acute watery diarrhea.  The cornerstone of treatment is prompt provision of adequate low-osmolarity oral rehydration and/or isotonic intravenous solutions.  Because death due to dehydration from watery diarrhea can occur within hours, hydration supplies and clinician training on hydration management should be in place before an outbreak occurs.

Because most episodes of watery diarrhea are self-limited, antibiotics are primarily used to treat patients with clinical sepsis.  However, during an outbreak of giardiasis, metronidazole could be used to limit transmission.

For children with acute watery diarrhea, continued breastfeeding, nutritional support, and supplemental zinc (20 mg/day by mouth for 10–14 days for children 6–59 months of age; 10 mg/day by mouth for 10–14 days for infants younger than 6 months of age) can decrease duration and severity of diarrheal illness.

While not generally used to mitigate outbreaks, cholera and rotavirus vaccines are commercially available and could be considered in the event of a confirmed outbreak.  Vaccines are not available for other agents of watery diarrhea.

Traveler's Health

Cholera in Haiti

This information is current as of today, October 26, 2010 at 08:15 EDT

Updated: October 23, 2010

An epidemic cholera strain has been confirmed in Haiti, causing the first cholera outbreak in Haiti in many years. Cholera is a potentially fatal bacterial infection that causes severe diarrhea and dehydration.

The disease is most often spread through the ingestion of contaminated food or drinking water. Water may be contaminated by the feces of an infected person or by untreated sewage. Food is often contaminated by water containing cholera bacteria or because it was handled by a person ill with cholera.

The majority of cases have been reported in the Artibonite Departmente, approximately 50 miles north of Port-au-Prince. Affected hospitals are being strained by the large number of people who are ill.

This outbreak is of particular concern given the current conditions in Haiti, including poor water and sanitation, a strained public health infrastructure, and large numbers of people displaced by the January earthquake and more recent flooding.

The World Health Organization, along with a number of international agencies, is mobilizing to assist local and national response efforts.

Advice for Travelers

At this time, CDC and the U.S. Department of State maintain travel warnings for Haiti. These warnings recommend that U.S. citizens avoid all nonessential travel to Haiti. For more information, see Travel Health Warning: Major Earthquake in Port-au-Prince, Haiti on the CDC website.

Most travelers are not at high risk for getting cholera, but people who are traveling to Haiti should still take steps to prevent getting sick. Although no cholera vaccine is available in the United States, travelers can greatly reduce their risk for cholera by following CDC’s safe food and water advice:

Before departing for Haiti, talk to your doctor about getting a prescription for an antibiotic to treat travelers’ diarrhea.

Drink water that you have boiled for at least one minute or treated with chlorine or iodine (2 drops of household bleach or ½ an iodine tablet per liter of water). Other safe beverages include tea and coffee made with boiled or treated water, as well as drinks that have been bottled and sealed (such as bottled water, carbonated drinks, and sports drinks).

Do not put ice in drinks, unless the ice is made from boiled or treated water.

Eat only foods that have been thoroughly cooked and are still hot, or fruit that you have peeled yourself.

Do not eat undercooked or raw fish or shellfish, including ceviche.

Make sure all vegetables are cooked. Do not eat salads or other raw vegetables.

Do not eat foods or drink beverages from street vendors.

Do not bring perishable seafood back to the United States.

A simple rule of thumb for safe food and water is "Boil it, cook it, peel it, or forget it."

If you are traveling in Haiti and have severe watery diarrhea, seek medical care right away.  It is important to remember to drink fluids and use oral rehydration salts (ORS) to prevent dehydration.

Medical care facilities are strained with the high number of people who are ill. If you will be traveling to Haiti, CDC recommends that you purchase medical evacuation insurance in the event that you become ill while in Haiti. (See the U.S. Department of State list of U.S.-Based Air Ambulance or Medical Evacuation Companies.) If you are in Haiti and need medical care and you do not have access to medical evacuation, you can contact the Embassy of the United States in Port-au-Prince, Haiti, (American Citizens Services Unit office hours are 7:00 a.m. to 3:30 p.m., Monday through Friday. The Consular Section is closed on U.S. and local holidays.):

Boulevard du 15 October, Tabarre 41, Tabarre, Haiti

Telephone: (509) (2) 229-8000

Facsimile: (509) (2) 229-8027

Email: acspap@state.gov

from the Centers for Disease Control and Prevention