Cholera FAQ Haiti 2011 May 17

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

Cholera FAQ HaitiA LOT of incomplete info leads some people to be placed at risk by

what’s missing. Also lots of speculation gets treated as fact.No one person or organization has all needed info.

Alister William Macintyre research notesVersion 2011 May 17

Table of ContentsIntroduction (1 Feb 23)....................................................................................................................... 2

Is the crisis about over? (1 May 10).......................................................................................... 3

Ways to catch (or not get) Cholera (1 Feb 22) ............................................................................ 4

Vaccination against Cholera (1 Feb 22) ................................................................................... 6

Why not Vaccinate? (1 Feb 23) ............................................................................................ 7

Q: How bad is this going to get? (1 Mar 20)........................................................................... 8

Death Rate cannot be computed due to unknown data (1 Mar 01) ............................... 9

Haiti Population Volume likely to get infected with Cholera ........................................10

What is Cholera? (1 Feb 22) ....................................................................................................11

Medical Professionals (1 Feb 26) ................................................................................................ 13

Cholera arrival in Haiti (1 May 11).............................................................................................. 16

UN independent investigation (1 May 05) ............................................................................18

Other nations beyond Haiti (1 May 16).................................................................................23


Sanitation in developing nations (1 Apr 13) ..............................................................................24

Myths, Rumor, and Panic (2010 Perspectives)..........................................................................24

Fixing Water availability and Sanitation long term........................................................................26

National strategy planning includes: ...........................................................................................26

Introduction (1 Feb 23)This information has been cut and pasted from a variety of sources which I believe to beauthoritative and credible. In a few cases the content is from my own common sense.There’s aspects to this for which I do not yet have as good an understanding as I wish, butcontinuously update my notes as I get improved info.

Most info sources say “people get this disease by …..” and then other people falsely assumethat is the ONLY way you can get this disease. The facts are that we have seen in Haiti thatthere are MANY ways a person can get this disease, although some ways do dominate. Inthis FAQ I will try to identify all the risks.

From time to time, some people ask me stuff for fact checking, which can lead to furtherupdates here, as I recheck various sources.

As I add to this, the most current edition on the web will be here,1 except when my updatesare coming directly from MPHISE sources, or widely reported news stories. Copies will alsobe posted other places, for convenience of people who can then pick and choose which ofmy research efforts they wish to download, where version #s or dates have beenincremented to help people identify latest new edition.

Topic sub-titles can end in a date signifying when that info last updated, so by viewing tableof contents, we see where most recent input to these research notes, especially aiding peoplewith copy of an earlier version. Digit 1 in front of month means 2011.

Users of this research hold Alister Wm. Macintyre harmless, and also the places I upload myresearch to, and agree that my copyright is reserved and that the information is available forthe intended purpose of helping in the recovery of Haiti.

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


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

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

1. Official data from Gov of Haiti, WHO, PAHO, international community, etc. is agross under-reporting … check out story from doctors on-the-ground such as:http://biosurveillance.typepad.com/haiti_operational_biosurv/2010/12/heas-sitrep-12810.html

2. Government offices are not open 24x7. There can be lags in data flow, reporting,the data they choose to include in the official reports.

3. People die, and the official data does not know how come they died, unless there islab testing, whose facilities capacity lacking. There is more interest in getting medicalaid where needed, than figuring out statistics.

4. Cholera epidemics are usually multi-year phenomenon. In tropical zones like Haiti,they have two wet season peaks per year. In colder and dryer periods, cholera casesgo down. Haiti will tend to have fall and spring peaks per year for the next threeyears and then cholera will become an endemic disease in Haiti.

5. Immunity from the cholera vaccine tends to last about 2 years. The cholera vaccineis expensive and sufficient units are not available. WHO has approved a vaccine thatis not particularly appropriate for Haiti.

6. Water and sanitation systems still need to be addressed, and cannot be solved rapidly.7. Even though astronomical funds have been pledged for Haiti, there is a huge

mismatch between promised and needs, resulting in many NGOs running out ofmoney, and leaving the country.

8. OCHA is the UN agency with mandate for overall coordination of humanitarian aidto Haiti. OCHA is an unwieldy monster bureaucracy, without the agility needed forrapidly coping with disasters.4

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

2 http://reliefweb.int/rw/rwb.nsf/db900sid/KKAA-8EB93P?OpenDocument&rc=2&cc=hti(Sources: OCHA/Relief Net and Voice of America)3 http://www.haiti.mphise.net/seasonal-rains-bring-rise-cholera-cases-haitihttp://www.haiti.mphise.net/haitians-rainy-season-looms-bringing-another-wave-cholerahttp://www.haiti.mphise.net/fresh-outbreak-cholera-haiti-after-heavy-rains-0http://haiti.mphise.net/node/10834 See my 1 year mini-reviews of how various efforts fared in their efforts to deliver what Haiti needed, for thefirst year after the earthquake.


http://haiti.mphise.net/heas

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

Q: The patients in Dominican Republic and USA are under the care of doctors, so it is notyet a problem there, right?

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

Q: Can you catch cholera via kissing?


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

Q: Can you catch cholera by shaking hands?

A: If a person has recently handled moist bedding of a person who died of cholera, and notdisinfected self afterwards, then their hands carry the cholera bacteria, so shaking hands canthen have both persons have it, then if either puts their hand to their mouth, they got it.

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

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

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

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

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

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

Drink only water that you have boiled or treated with chlorine or iodine. Other safebeverages include tea and coffee made with boiled water and carbonated, bottledbeverages with no ice.

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

Avoid undercooked or raw fish or shellfish, including ceviche. Make sure all vegetables are cooked, avoid salads. Avoid foods and beverages from street vendors. Do not bring perishable seafood back to the United States.

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

Vaccination against Cholera (1 Feb 22)

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


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

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

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

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

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

Sweden markets Dukoral®SBL Vaccin AB,SE-105 21 Stockholm, Swedene-mail: [email protected]: www.sblvaccines.se

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

Why not Vaccinate? (1 Feb 23)

Q: Are there good arguments against vaccinating Haitians?

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

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

6 http://www.haiti.mphise.net/dennis-chao-model-cholera-vaccination-haiti7 http://vaccinenewsdaily.com/news/233583-bangladesh-begins-worlds-largest-cholera-vaccine-trial


clean water, they may still get cholera, and may get sick with other endemic water-borneillnesses, as well.2) The cholera vaccine is expensive, and there other mechanisms to acquire immunity.Because cholera is dose dependent, if T-shirts are being used systematically to screen out

most of the Vibrio Cholerae bacteria, those using this screening technique will get animmune response without getting cholera.3) The cholera vaccine only creates an immune response for 2 years.4) The use of a vaccine is often promoted as a "silver bullet" that is a miracle cure (panacea).In reality, its effectiveness in circumstances like Haiti is much less effective than advertised.

5) If the vaccine is used as an excuse to not do community capacity building, it would be anet negative.6) Administering vaccine in the mountain communities will be difficult. Herd immunity isunlikely be reached in Haiti as a whole through the vaccine alone.

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

A: No one knows.

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

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

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

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

8 http://www.topnews.in/usa/cholera-epidemic-haiti-may-exceed-un-projections-study-283739 http://www.associatedcontent.com/article/6122776/cholera_epidemic_in_haiti_what_did.html?cat=510 Here is an example of a wonderful effort, using seriously incomplete data sets.http://www.annals.org/content/early/2011/03/07/0003-4819-154-9-201105030-00334?aimhp


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

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

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

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

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

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

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

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

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

11 http://biosurveillance.typepad.com/haiti_operational_biosurv/2010/12/heas-sitrep-12810.html12National mortality rates from cholera are down to 2 percent, from as high as 9 percent earlier, but in somerural areas, more than one-in-ten people who contract the disease die.In Haiti's Sud Est region, the mortality rate hit 10.7 percent as of 2011 Feb. 9, while in Nippes it was 6.7percent and in the Grande Anse region, 5.9 percent.http://www.google.com/hostednews/ap/article/ALeqM5iZdt_XRYLIGJXA-nf0QEryGs40ew?docId=d5e68b358385450c8de8e6b2a67f623a


The apparent case fatality rate may be 30%, 50%, or even 100% in the first contactcommunities. The actual case fatality rates will be far lower. We may be dealing withcase fatality rates in the 4% level nation-wide so far. In Port-au-Prince, it may now bedown to 1% to 2%. However, in the remote areas without medical care and education, itwill be far higher. That is why MPHISE-HEAS needs to set up Health Capacity Zones in700+ areas, including the more remote areas.

Haiti Population Volume likely to get infected with Cholera

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

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

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

Comparison made on people infected with cholera:

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

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

These are official figures. Various other information sources indicate:

1. There is a lag in data getting to official records, such that the actual rate of sicknessand death is approx four times the official records. Thus, if official story says 1,000people dead, the truth is closer to 4,000 people dead.

2. For every one person who shows symptoms, another three have the disease but arenot sick, so multiply by four again how many are infected. Thus if official story says10,000 people got the disease, the truth is closer to 160,000.

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

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

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

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


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

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

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

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

What is Cholera? (1 Feb 22)

Q: What is cholera?

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

http://renewal4haiti.org/Cholera

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

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

US Government sites http://www.cdc.gov/cholera/index.html andhttp://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001348

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

The disease is caused by a bacterial infection of the intestine. It is usually transmitted bydrinking water or eating food contaminated with cholera bacteria.

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


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

Q: What are the cholera symptoms?

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

US CDC Centers for Disease Control and Prevention

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

Here is what everyone ought to know:

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

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

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

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

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

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


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

Medical Professionals (1 Feb 26)

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

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

For urgent cases which do not have transport, partners should call

34827636 / 38515331.

If deaths occur in camps, partners should call 38799177.

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

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

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

A: Your people should already have a liason with HEAS. If not, join HEAS immediately,and communicate your needs to Jim Wilson, MD [email protected]

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

A. Contact Jim Wilson, MD [email protected].

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

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

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


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

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

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

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

Join Haiti Epidemic Advisory System. (HEAS) This group is getting traffic frommedical personnel on the ground all over Haiti … where specific help is needed –personnel, answers, supplies … and progress delivering it.

Setup your RSS news reader to subscribe to new posts as they arrive on the HaitiOperational Bio-Surveillance site.

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

Haiti Medical and Public Health Information Sharing Environment (MPHISE)http://haiti.mphise.net/

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

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

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

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

Humanitarian Road provides resources to help people in an emergency. Their website has links identifying hospitals, find shelter, treat wounds, learn about cholera, etc.

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

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


both the Haiti Cholera Outbreak of October 2010 and Haiti Earthquake info.Before using any of their data, check out map their permission page.13

o USA National Institutes of Health (NIH)’s Disaster Information ManagementResearch Center Health Resources for Haiti, Post-Earthquake.

o Citizen Action Team Databases http://www.citizencommandcenter.org/quick/startlist organizations and resources relevant to Haiti cholera outbreak.

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

Some official info, on fighting cholera, is incorrect, so medical personnelneed to consult with relevant medical professionals who can translatewhat are correct dosages.

November 15, MSPP (Haiti Medical Ministry) issued a sixty-page manual athttp://haiti.humanitarianresponse.info/LinkClick.aspx?link=Guide+du+formateur+de+bri

gade14++NOv.ppt&tabid=77&mid=757 for brigades fighting cholera. Page 60 has a posterwith directions for preparing oral rehydration solution. The text instructs "4 tikiyè" [Iunderstand "tikiyè" = small spoon] of salt and "12 tikiyè" of sugar per gallon of water, a salt-to-sugar ratio of 1:3. the illustration instructs one-half spoonful of salt and six heapingspoonfuls of sugar per gallon of water, a salt-to-sugar ratio of less than 1:12. thus, neitherthe ratios coincide, nor are the units of measurement standard, e.g. level vs. heaping spoons.

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

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

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

noted that the 1:3 ratio was incorrect and also that the make-up volume should be a liter, nota gallon. Experts advised that administering a too-dilute solution could cause hyponatremia.hyponatremia has been suggested as a possible cause of some recent cases of paralysis in

Haitian receiving treatment for cholera.

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

13 http://www.reliefweb.int/rw/hlp.nsf/db900ByKey/map_permission?OpenDocument include this text:(Source: OCHA/Relief Web) where appropriate.


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

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

A: Multiple areas.

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

Funding support for HEAS and related efforts.

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

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

Cholera arrival in Haiti (1 May 11)

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

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

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

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

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

16 http://oysterradio.blogspot.com/2011/05/vibrio-cholera-traced-back-to.html Thanks to Stuart Leidermanfor locating these links.Space image: http://earth.jsc.nasa.gov/sseop/EFS/printinfo.pl?PHOTO=STS083-749-28map: http://www.baynavigator.com/Apalachicola_National_Estuarine_Research_Reserve.cfmnational research reserve:http://www.eoearth.org/article/Apalachicola_National_Estuarine_Research_Reserve,_FloridaScientific analysis of this issue http://ufdc.ufl.edu/UF00089927/00048/4jhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC201907/pdf/aem00027-0427.pdfhttp://aem.asm.org/cgi/reprint/65/7/3142.pdf More coveragehttp://www.opednews.com/articles/Letter-Hand-Delivered-to-G-by-Anita-Stewart-110504-330.html


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

from the Gulf of Mexico due to tectonic shifts resulting from the earthquake; evolved into disease-causing strains from non-pathogenic strains naturally present in

Haiti; or originated from a human host who inadvertently introduced the strain into the

Haitian environment.

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

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

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

Q. What kind of credible scientific evidence is needed?

A. Samples need to be taken of where cholera bacteria is believed to exist, in quantitiesappropriate for proper laboratory testing. A process of legal chain of evidence must befollowed, so it can be proven who took what samples at what locations. The samples mustbe transported in accordance to international laws regarding the movement of biohazardousmaterials, then delivered to labs which have the qualifications to examine the DNA of thebacteria to compare it with other cholera bacteria from other places, such as Nigeria andZimbabwe. It may turn out that the source is neither the Estuary Theory nor the NepalTheory, but one of many other theories.

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

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

17 http://www.haiti.mphise.net/node/105518 http://www.cidrap.umn.edu/cidrap/content/other/news/may0911cholera-br.html


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

Q: Have there been efforts to collect scientific evidence?

A: Several efforts have been reported thru MPHISE.20

A pre-print of a French-conducted investigation into the origins of the Haitian choleraepidemic is available at http://www.cdc.gov/eid/content/17/7/pdfs/11-0059.pdf inEnglish translation. The numbers of cases, the speed spread and proximity to suspectedorigins were statistically analyzed.

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

Of significance is that the investigators, appearing on the scene within days of the outbreak -the exact dates and locations were not given in the report - did not find cholera in the river.Their inference is that there may have been only a single incidence of infectious sewage

overflow or dumping from the peacekeeping base and, from that point, the river flow greatlydiluted the concentration of organisms below Meille, i.e. after a few miles.

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

UN independent investigation (1 May 05)

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

19 See my 1 year reviews, UN, and NGO cooperation NOT.20 http://www.haiti.mphise.net/Video = Why Cholera hit Haiti so hard:http://www.haiti.mphise.net/video-haiti-grassroots-watch-4-why-has-cholera-hit-haiti-so-hard


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

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

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

Much of my grievances are due to the fact that the UN delayed this investigationuntil a lot of evidence no longer available. This is like the police waiting until a yearafter a bank robbery to investigate it, when all the security tapes are gone, thefingerprints gone, different employees now working at the bank, memories faded.

In the aftermath of the Cholera epidemic, there was a dramatic shift in Haitian eatinghabits. For example, since it was believed the Arbonite river was contaminated, andsince it overflowed its banks during flooding, many Haitians no longer wantedagricultural products from that area. For UN investigators to determine whatHaitians are eating, six months later, and then say that since they not eating foodfrom the Arbonite river now, they never did so, that is a misleading conclusion.

MPHISE-HEAS has shared reports from hospitals which treated Cholera cases, withwhat info was known about the first patients seen by those hospitals, showing firstcases before dates in this UN report. Maybe the UN investigators did not speak withthe people who developed those reports, or had access to those records.

There is enormous turnover of medical personnel working different places in Haiti,due to the Republic of NGOs dropping medical support when funds run out, andhaving volunteers come and go all the time. It may be impossible to identify allrelevant medical staff, but limiting interviews to whoever is there 7 months after theincidents is a guarantee of not getting a good picture.

21 http://www.haiti.mphise.net/node/105522 http://www.un.org/News/dh/infocus/haiti/UN-cholera-report-final.pdf23 http://www.haitianinternet.com/articles.php/836http://www.haitilibre.com/en/news-2875-haiti-cholera-report-of-the-experts-on-the-origin-of-the-epidemic.html24 There is also risk that higher up UN authorities could scrap this report, if they do not like some of itscontent.25 I named my copy “Cholera Source 2011 May 04 UN”26 http://haiti.mphise.net/leiderman-heas-department-perpetual-errorshttp://haiti.mphise.net/feedback-request-creole-ors-poster


Cholera is a medical condition in which many people can carry the bacteria withoutshowing the symptoms. The fact that Nepal soldiers did not need treatment is notproof that they do not carry the bacteria. HEAS has estimated that for every oneperson who needs medical treatment, there are three who carry the infection, but donot show the symptoms.

Nepal has censorship regarding this situation. If any Nepal troops were unable tocome to Haiti, because they did show the symptoms, this is one of the pieces ofevidence conveniently hidden. Any report, which does not mention this dimension,is potentially misleading.

This latest UN report concludes the first cases were approx Oct 20. According tomy raw notes,27 there were approx 40-50 people dead by Oct 20, who had got to thehospitals. Oct 20 was when officialdom lab reports confirmed the problem wasCholera. Prior to that, officialdom was in denial, and even afterwards, manyhospitals unable to capture the samples needed for official testing, they toooverwhelmed to deal with the patients volume. Anecdotal evidence was that manymore had died in transit to medical aid. According to PAHO situation report # 3 onthe Cholera epidemic, issued Oct 23, this was the fourth day of confirmed choleraepidemic (Oct 21 was the first) but eighth day of people known to the hospitals to besick with this problem (Oct 17 was when hospitals first noticed flood of patientswith the dangerous symptoms).28 We can then use what is known about rate ofperson getting sick from first consuming the bacteria to back-calculate when firstcase actually was. If you have a copy of my raw notes, check “Law and DisorderTime Line.” I also downloaded some of those early reports.

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

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

27 My research notes “Haiti Cholera 2010 Oct” has raw info as it came out, about the epidemic whichapparently started Oct 2010 in Haiti, rather repetitive as each day bits of new info added to a repository ofknown so far.28 I might not have a copy of that precise report, but I have downloaded multiple reports right around that datefrom PAHO ECO, OCHA, WASH, and many of them repeat same info with latest day’s updates. See “Aldocs” directory in the Sitrep section, dated around then.29 MINUSTAH = UN peacekeepers in Haiti.


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

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

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

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

This contamination initiated an explosive cholera outbreak downstream in the ArtiboniteRiver Delta, and eventually throughout Haiti.

This explosive spread was due to several factors, including:

the widespread use of river water for washing, bathing, drinking, and recreation;regular exposure of agricultural workers to irrigation water from the ArtiboniteRiver;

the salinity gradient in the Artibonite River Delta, which provided optimalenvironmental conditions for rapid proliferation of Vibrio cholerae;

the lack of immunity of the Haitian population to cholera; the poor water and sanitation conditions in Haiti; the migration of infected individuals to home communities and treatment centers; the fact that the South Asian type Vibrio cholerae strain that caused the outbreak

causes a more severe diarrhea due to the larger production of the more potentclassical type of cholera toxin;

and, the conditions in which cholera patients were initially treated in medicalfacilities did not prevent the spread of the disease to other patients or to the healthworkers.

The introduction of this cholera strain as a result of environmental contamination withfeces could not have been the source of such an outbreak without simultaneous water andsanitation and health care system deficiencies. These deficiencies, coupled withconducive environmental and epidemiological conditions, allowed the spread of theVibrio cholerae organism in the environment, from which a large number of peoplebecame infected.

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


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

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

2) United Nations missions commonly operate in emergencies with concurrent choleraepidemics. All United Nations personnel and emergency responders traveling to emergenciesshould receive prophylactic antibiotics, be immunized against cholera with currently availableoral vaccines, or both, in order to protect their own health and to protect the health ofothers.

3) To prevent introduction of contamination into the local environment, United Nationsinstallations worldwide should treat fecal waste using on-site systems that inactivatepathogens before disposal. These systems should be operated and maintained by trained,qualified United Nations staff or by local providers with adequate United Nations oversight.

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

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

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

7) Recent advances in molecular microbial techniques contributed significantly to theinvestigative capabilities of this report. Through its agencies, the United Nations shouldpromote the use of molecular microbial techniques to improve surveillance, detection, and


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

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

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

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

A. This is important at two levels.

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

2. It feeds into conspiracy theories how the disease just appeared in Haiti seeminglyout of no-where. Many people believe there must be a patient zero, someone whoknowingly, or unknowingly, delivered the deadly disease to Haiti. But the science ofinvestigations with other nations cholera outbreaks is such that we usually cannotfigure out definitively how it happened. There are suspects, there is evidence, but noabsolute proof.

Other nations beyond Haiti (1 May 16)

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

A. Yes to both questions

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

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

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

30 http://www.associatedcontent.com/article/7749440/haitian_cholera_epidemic_slows_spreads.html31 http://online.wsj.com/article/BT-CO-20110209-720304.html


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

14 dead 16 currently hospitalized 750 cases so far

Sanitation in developing nations (1 Apr 13)See this video.33 What alternatives are there without good sanitation infrastructure?

Myths, Rumor, and Panic (2010 Perspectives)

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

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

A. Give all relevant vaccinations to the aid workers.B. Require that persons entering a nation, when they were recently at another

nation which has some horrible disease, they show proof of vaccination, ormedical test to show they are not infected.

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

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

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

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

32 http://www.defend.ht/world/articles/caribbean/996-dominican-government-declares-cholera-state-of-alerthttp://www.google.com/hostednews/canadianpress/article/ALeqM5jDM0jPI-CYEnvIe8E8QX8Uc039Yg?docId=6867566http://www.bbc.co.uk/news/world-latin-america-1342494133 http://www.youtube.com/watch?v=SsjsMFx_4NU&sns=tw


Q. Why demonstrations against Cholera treatment facilities?

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

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

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

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

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

This is a common mentality.

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

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

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

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

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

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


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

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

Fixing Water availability andSanitation long termQ: What is being done to fix the infrastructure risks long term?

A: Not much yet. This is part and parcel of the “rebuild Haiti back better” when the fundsare available, and the recovery plans approved, which is a complex topic better addressed inseparate documents.34

Work to support the medium and probably long term, should focus on improving livingconditions related to water, sanitation, hygiene and access to information services and health.

Downward trend of the epidemic is accelerated by:

early identification of cases and implementation of appropriate treatment; an information campaign and prevention measures at Community level, water supply and sanitation facilities and cholera treatment units; a regular supply of inputs in the oral rehydration centers, Centres and Units of

Treatment of Cholera. and improved access to health care, especially mountain villages far from good

roads.

National strategy planning includes:A problem with some of this planning is what I call “Mountain Management.”

There is so much that needs to be done, that it can boggle the mind, paralyze people.

That was the consequence of the earthquake for many people. It is the consequence of howsome lessons-learned solution documents are drafted. I address this issue sharing howmodern business solutions can be applied to disaster relief, in my research document = 1year UN (mini-review).

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


1. Integration of data collection on cholera in the national epidemiologicalsurveillance system and county.To do this, the following interventions will be implemented:

a. 1.1: Community involvement through participation. In terms of publichealth services: training of epidemiologists in the county collecting qualitydata, analysis and transmission of data at national level.1.2. At institutions of primary health centers: training of medical

personnel in the collection of epidemiological data and the timeliness ofthe transmission of data at the departmental level.1.3. Community-level councils and assemblies of communal sections

with special brigades

2. Warning and immediate response.

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

The system has demonstrated its ability to detect not only early warning ofcholera but also for other situations of risk to public health requiring rapidresponse. For example, the system detected in various Departments ofaggregates of suspected cases of acute flaccid paralysis, and poisoning bymethanol.

The alert system is an essential component of epidemiological surveillancesystem. At the national level, the warning system provides a more complete viewof existing risks and prioritize actions. At departmental level alert system allowsto have information on the situation in remote areas and organize and theresponse.

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

2.1. The warning system and immediate response from PAHO / WHO shouldbe maintained, while adjusting to changing circumstances.2.2. Cuban brigades active research should continue their work by integrating, asexpected, health personnel Haitien.2.3. Staff and Community brigades CASEC ASEC should continue to play a role

in the alert of cases and deaths in their demographic and geographic areas.


3. Information by messages of prevention and diagnosis and early managementCommunity strategies to fight against cholera designed to respond to thesituation expected in the aftermath of the acute phase of the epidemic, are thefollowing:• The continued operation of the coordinating bodies in terms of disseminatingmessages to the population, involving all sectors involved (Health, Education,Youth and Sports, Interior, Women's Studies), local authorities, representativesof the company Civil (representing faiths; grassroots, local NGOs andinternational print media and talking.• Intensification of production and distribution of appropriate materials inCreole, validated in the field (if possible). Further dissemination, diversifying thechannels, messages of prevention and oral rehydration, making sure to cover thecommunities not yet affected, and conducting assessment surveys to identify theneeds of other communications activities through appropriate channels.• Collaboration with the Ministry of Education and its partners (organizationsrepresenting private schools, teachers and parents) to strengthen the activities ofhealth education in schools with a target, not only students but also their familiesthrough a child's approach to the child and family• The development, led by DINEPA, a permanent network of support staff inpublic health (water, sanitation and hygiene markets) of local (ASEC, CASEC)• The development, led by the Ministry, a permanent network of communityworkers (Rangers) from and living in the community, linked to health facilities inFirst Tier (EPA) with the following functions:1. initiate oral rehydration cases and refer them to the health institution nearestand most appropriate for their symptomatic state;2. provide home visits for active case finding and disinfecting homes;3. disseminate messages on MSPP cholera prevention and management of casesand4. to the institutions of health epidemiological information (CBM) and onrumors and popular reactions to stigma. Beyond the cholera, the network ofcrossing is intended to serve as a relay between EPA and the public for thereconciliation of supply and demand of the minimum package of communitycare and for the detection and response at all, emergencies Epidemiologic andnatural disasters.• Development and implementation by the departments plan to implement theabove strategies, and by the central level, plan to support the development andmonitoring of departmental plans.

4. Supply of drinking water to communities and promoting respect for basichygiene rulesSupport for projects DINEPA, MSPP and many partners of drinking water andsanitation community must continue. Management associated with choleraexcreta is the largest current threat to the spread of Vibrio and could prevent thesuccessful long-term answer. The implementation of sanitation systems in healthcenters, including CTC / CTU is reduced to the construction, in the best cases,septic tanks. However, in most cases the disadvantages medium and long-term


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

5. ANSWER health institutionsMaintaining the capacity of health services to care for cholera patients,

continuously or occasionally, in response to new outbreaks. Each health centershould be at least one post of oral rehydration, each hospital must be a CTU. Forthis it is necessary to ensure the following actions:• Enabling all health institutions (1st and 2nd level) to handle cases of cholera,with permanent staff form, and a free and permanent staffing of essential inputs(ORS, antibiotics and Ringer Lactate)• Knowledge and compliance with treatment protocols (whether for the generalpopulation or vulnerable populations: pregnant women, children, malnourishedor immuno compromised) would be needed within each institution• The same knowledge and the same protocol compliance will be required also inthe field of hospital hygiene, respect for the circuit, the waste managementactivities, care, management of liquid waste (excreta and vomit), the waterquality, preparation of disinfecting solutions, management bodies and control ofvectors.• These protocols will be taught, as many multiplies, maintain and update, ifnecessary;• The regular assessment of the quality of care must be provided by the healthauthority whose role is to ensure continuity of supply of inputs at the nationallevel and county-level centers and the possibility of placing has availableinventory as needed.

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

Cholera FAQ Haiti 2011 May 17

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