Cholera in the Caribbean - PAHO

Cholera in the Caribbean

Dr. James Dobbins, PAHO/CPC/PED

PAHOPAHO

Major Perspectives on Cholera

• Description of cholera (with video)

• Background on cholera in the Caribbean

• Update on current cholera outbreak

• Prevention of cholera outbreaks

• Planning for cholera outbreaks

Additional Aspects of Cholera

• Detection of cholera – Priya Bagwandin

– Leslie Edwards

• Management of cholera outbreaks

– Community management – Sally Edwards– Emergency management – Robert Lee

• Planning for cholera – Terese Maitland

Description of Cholera

• Video of cholera patient

• Spectrum of disease

• Signs and symptoms

• Agent

• Transmission

• Treatment

Video of Cholera Patient

Caution!: this is an extremely graphic video of a cholera patient excreting large quantities of bodily fluid.

Spectrum of Disease

• Up to 90% of infections are asymptomatic

• Asymptomatic individuals still shed bacteria

• 20% of symptomatic patients have severe

disease

• Onset of severe disease can be < 6 hours

• Patients with severe disease can die within hours

if not rapidly rehydrated

• Type ‘O’ blood risk factor for severe illness

Spectrum of Disease

Signs and Symptoms of Cholera

• Abrupt onset of watery diarrhea

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

• Vomiting is common in severe cases• • Usually without fever

• Low blood pressure

Cholera Agent: Vibrio cholerae

• One of 70 species of Vibrio bacteria

• Only some strains of V. cholerae are toxigenic

• Disease caused by toxin when bacterium attaches to the wall of the small intestine

• Production of toxin requires presence of two plasmids, CTX and TCP

Cholera Agent: (continued)

• Classification of V. cholerae:

– Toxigenicity: Toxigenic and non-toxigenic– ‘O’ protein type: 1 and 139 (75)– Two biotypes: Classical and El Tor– Two serotypes: Inaba and Ogawa

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

• Can attach to zooplankton and move with water or shellfish (not killed by boiling shellfish)

• Very easy to kill with chlorine and by boiling water

Transmission of Cholera

• Fecal contamination of water and food– Primarily water-borne for lower-income

populations– Primarily food-borne for upper-income

populations

• Also from aquatic environment

• Infective dose is approximately 1 million organisms

Treatment of Cholera

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

• IV infusion with lactated ringer’s solution for severe cases [multiple lines if needed]

• Antibiotics in severe cases (depending on resistance)– Doxycycline– Azithromycin– Erythromycin– Ciprofloxacin

Treatment of Cholera

SEVERITY PERCENT LOCATION TREATMENT

Mild 13% Home ORS

Moderate 5% CTU/CTC ORS

Severe 2% CTU/CTCORS

IV LRSANTIBIOT

Initial Outbreak of Cholera in the Caribbean, 1849 - 1854

• Began in Cartegena, 1849

• Spread next to:– Jamaica (1850)– Nevis (1853)

• From Nevis, it spread to:– St. Kitts (1854)– Barbados (1854)– Trinidad (1854)

1854 Trinidad Cholera Outbreak

• Outbreak lasted for 19 weeks

• Out of a total population of 77,000:

– Approximately 20% were symptomatic

– Almost 100% infected

– 6% of the population died

– Case-fatality ratio of 30%

– More severe for African population

Trinidad Control Measures in 1854

• Prevention: burned barrels of pitch on all street corners

• Treatment: ingested oil of camphor that had been infused into lumps of sugar

• Result: 100% attack rate

30% case-fatality ratio

Update on Cholera in the Caribbean

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

• 2010 agent in Haiti and DOR: – toxigenic O1– El Tor– Ogawa

Update on the Caribbean

Countries Affected Confirmed Cases / Deaths• Haiti 285,931 / 4,870• Dom. Republic 918 / 12

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -• Venezuela 278 / 0• Canada 1 0• United States 10 0• Martinique 7 0• (Mexico) 1 0

Update on Haiti

• Overall, new cases per week are declining

• Haiti is divided into 10 Departments

• Each has its own outbreak depending the timing

of introduction and local conditions

• New cases are declining or stable in 8 depts.

• New cases rising only in South and Southeast

departments

Map of Cholera Outbreak in Haiti

Epidemic Curves by Department

Artibonite

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

08/1

1/10

15/1

1/10

22/1

1/10

29/1

1/10

06/1

2/10

13/1

2/10

20/1

2/10

27/1

2/10

03/0

1/11

10/0

1/11

17/01/1

1

24/0

1/11

31/0

1/11

07/0

2/11

14/0

2/11

21/02/1

1

28/0

2/11

07/0

3/11

14/0

3/11

21/0

3/11

28/0

3/11

04/0

4/11

Week of reporting

Nb

ho

spit

aliz

atio

ns

Port au Prince

0

1,000

2,000

3,000

4,000

5,000

6,000

08/11/

2010

15/11/

2010

22/11/

2010

29/11/

2010

06/12/

2010

13/12/

2010

20/12/

2010

27/12/

2010

03/01/

2011

10/01/

2011

17/01/

2011

24/01/

2011

31/01/

2011

07/02/

2011

14/02/

2011

21/02/

2011

28/02/

2011

07/03/

2011

14/03/

2011

21/03/

2011

28/03/

2011

04/04/

2011

Week of reporting

Nb ho

spita

lizat

ions

South East

0

100

200

300

400

500

08/1

1/20

10

15/1

1/20

10

22/1

1/20

10

29/1

1/20

10

06/1

2/20

10

13/1

2/20

10

20/1

2/20

10

27/1

2/20

10

03/0

1/20

11

10/0

1/20

11

17/0

1/20

11

24/0

1/20

11

31/0

1/20

11

07/0

2/20

11

14/0

2/20

11

21/0

2/20

11

28/0

2/20

11

07/0

3/20

11

14/0

3/20

11

21/0

3/20

11

28/0

3/20

11

04/0

4/20

11

Week of reporting

Nb

hosp

ital

izat

ions

Grande Anse

0

500

1,000

1,500

2,000

2,500

08/1

1/20

10

15/1

1/20

10

22/1

1/20

10

29/1

1/20

10

06/1

2/20

10

13/1

2/20

10

20/1

2/20

10

27/1

2/20

10

03/0

1/20

11

10/0

1/20

11

17/0

1/20

11

24/0

1/20

11

31/0

1/20

11

07/0

2/20

11

14/0

2/20

11

21/0

2/20

11

28/0

2/20

11

07/0

3/20

11

14/0

3/20

11

21/0

3/20

11

28/0

3/20

11

04/0

4/20

11

Week of reporting

Nb

hosp

ital

izat

ions

Update on the Dominican Republic

1 0 1 2 11 13 13

58 50 4019

35 35

7153

2955 46 43

6288

3918 27 19 110 5 5 6

66

92 95

73102

104

61

7189

131

108

104

111101

9179

80

61

4751

4646

2

32

0

50

100

150

200

250

42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Confirmados Sospechosos

República Dominicana: Distribución de casos sospechosos y confirmados por SE

Acumulado al 23 abril 2011 (SE 16)

Sala de situación de cólera. Dirección General de Epidemiología (DIGEPI). Ministerio de Salud Pública. República Dominicana

Map of Cholera Outbreak in the Dominican Republic

Tasa de incidencia de cólera, actualizado al SE 15-2011

Dirección General de Epidemiología. DIGEPI, MSP. 2011

Prevention of Cholera - 1

• Personal hygiene:

– Purify drinking and cooking water

– Wash all food

– Wash hands before cooking or eating

– Use sanitation facilities for defecation


• Environmental control:

– Provide clean water for populations

– Provide sanitary facilities for populations

– Food safety

• Social gatherings

• Market places

– Target high-risk populations


• Vaccination against Cholera

– There is an approved vaccine but it is not very efficacious

– A new vaccine performs somewhat better but has not been approved by WHO

– Not a viable option for the Caribbean


• Prophylactic use of antibiotics

– Clearly defined population

– High risk of infection

– Used successfully during a cholera outbreak in a prison in DOR

Planning for Cholera Outbreaks

• One component of overall planning for disaster management

• Part of the Health Emergency component

• Cholera-specific activities need to be addressed

Planning for a Cholera Outbreak

• Adapt national health disaster plan to accommodate cholera

• Designate specific rehydration centers

• Order supplies and equipment for centers

• Train hospital staff in clinical management

• Communicate risk to public• Increase coordination among all disaster

management partners

Remaining Steps for Planning

• Complete identifying and supplying main rehydration centers in all countries

• Complete training of hospital staff for the rehydration centers

• Evaluate completeness of national health disaster plans through needs assessment and simulation exercises

Response to a Cholera Outbreak

• Enhance surveillance for early detection

• Follow up contacts of confirmed cases

• Ensure proper clinical management of patients

• Ensure proper environmental controls

– Disinfection of hospital waste

– Disinfection of dead bodies

• Promptly manage the health emergency

• Communicate information to the public

Risk Factors for Introduction and Spread of Cholera

• Legal and illegal immigrants living precariously

• Focal points for air and sea transportation

• Limited access to clean water and safe sanitation

• Long referral time to health facilities

• Overcrowding as in slums and institutions

• Under-supervised food markets

• Places recently affected by natural disasters

• Remote indigenous and rural populations

0%

100% DOR

TCI

BAH SLU DOM JAM

SXM ANU TRT ANG CUR

BAR CAY GRE MON SVG

BVI GUY SKN

ARU BZE SUR

BON STE

BDA SAB

75%

50%

25%

Risk of Introduction of Cholera

0%

100% DOR

TCI

GUY

SVG SUR

SXM

SLU DOM

MON

JAM ANG

BAH ANU CRE SKN STE CUR

TRT BZE BVI

ARU BAR BON

BDA CAY SAB

75%

50%

25%

Risk of Spread of Cholera

Risk of Cholera in the Caribbean

0

25

50

75

100

0 25 50 75 100


Ris

k o

f S

pre

ad

of

Ch

ole

ra

Risk of Cholera in the Caribbean

0

25

50

75

100

0 25 50 75 100


Ris

k o

f S

pre

ad

of

Ch

ole

raDOR

TCI

JAM

BAH

SLUSXM

ANU

TRT

GUY

SUR SVG

MON

ANG

SKN

GRECUR

CAY

BAR

BVI

STE

BER

BONARU

BZE

DOM

SAB

Cholera Outbreak Vulnerability

Most vulnerable groups

PAHO & CAREC active preparations

PAHO outbreak response

Thank You

Cholera in the Caribbean - PAHO

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