Update: Outbreak of Cholera --- Haiti, 2010

Update: Outbreak of Cholera --- Haiti, 2010
Weekly
December 10, 2010 / 59(48);1586-1590



On December 8, 2010, this report was posted as an MMWR Dispatch on the MMWR website (http://www.cdc.gov/mmwr).

The first cholera outbreak in Haiti in at least a century was confirmed by the Haitian National Public Health Laboratory on October 21, 2010 (1). Surveillance data through December 3, provided by the Haitian Ministry of Public Health and Population (MSPP), indicated that the outbreak had spread nationwide and that cases of cholera and cholera-associated hospitalizations and deaths had climbed rapidly in November. As of December 3, MSPP reported 91,770 cases of cholera from all 10 departments and the capital city of Port-au-Prince; 43,243 (47.1%) patients had been hospitalized, and 2,071 (2.3%) had died. A rapid mortality assessment in Artibonite Department found that deaths occurred as rapidly as 2 hours after symptom onset and identified important gaps in access to life-saving treatments, including oral rehydration solution (ORS). Urgent activities are under way, and additional efforts are imperative to reduce cholera mortality by expanding access to cholera treatment and to reduce cholera transmission by improving access to safe water and adequate sanitation.

A nationwide cholera surveillance system has been established in Haiti. Hospitals and clinics send daily case counts to local MSPP officials; aggregate data are sent on to department-level officials and then to central government officials. A case of cholera is defined as profuse, acute, watery diarrhea in a resident of a department in which at least one case of cholera has been laboratory-confirmed by isolation of Vibrio cholerae from culture of a stool specimen. A hospitalized case occurs in a patient admitted to a health facility (i.e., a hospital or cholera treatment site) for at least one night. A cholera death is the death of a person with illness that meets the case definition for cholera. Any cholera death that occurs in a health facility, regardless of whether the decedent was admitted overnight, is considered a cholera hospital death. MSPP posts daily and cumulative tallies of cholera reports on a public website; tallies are stratified by department and age group (aged <5 years and all ages).* Since November 16, nonhospitalized cases have been posted in addition to hospitalized cases.

All 10 departments and the capital city of Port-au-Prince have reported laboratory-confirmed cases of cholera. As of December 3, a total of 91,770 cases had been reported nationwide, and 43,243 (47.1%) patients had been hospitalized (Figure 1). The largest number of cases (42,596 [46.4%]) were reported from Artibonite Department, which comprises approximately 16% of the Haiti population (2) and is the department where cases were first laboratory-confirmed (Figure 2). As of December 3, of 2,071 deaths, 1,437 (69.4%) had occurred in hospitals. A total of 82,599 (90.0%) cases, 39,435 (91.2%) hospitalizations, and 1,908 (92.1%) deaths had occurred among persons aged ≥5 years.

Nationwide, during November 27--December 3, the median daily number of deaths was 41 (range: 18--64). As of December 3, the overall case-fatality ratio (CFR) (cumulative deaths divided by cumulative cases) was 2.3%. The hospital CFR (cumulative hospital deaths divided by cumulative hospitalized cases) was 3.3%. The daily nationwide hospital CFR has varied; however, simple linear regression indicates decreases in the rolling 7-day hospital CFR in Artibonite (p<0.001) and in all other departments combined (p<0.001) (Figure 3). In Artibonite Department, the rolling 7-day hospital CFR decreased from a high of 4.2% on November 9 to a low of 1.4% on December 1 (Figure 3).

A rapid assessment of mortality from cholera among persons aged ≥5 years was conducted in Artibonite Department during November 12--16. Teams visited homes of 22 cholera decedents identified through records in two hospitals. Family members were interviewed about decedents' use of ORS and other health-care services. Family and community members were asked about other cholera deaths in the community, resulting in identification of an additional 65 decedents, whose families also were interviewed. Among the total of 87 cholera decedents identified, 58 (67%) were male; eight (9.2%) were aged 5--18 years, and 79 (90.8%) were aged 19--100 years. Of the 87 deaths, 48 (55%) occurred in a hospital or other health facility, and 39 (45%) occurred in the community. For those who died in the community, median time to death from onset of symptoms was 12 hours (range: 2 hours--8 days). Only nine (23%) of the 39 persons who died in the community received ORS. Sixteen (41%) of the 39 had sought health care; eight died en route to a health facility, and eight died after discharge. When asked to cite reasons for not seeking health care, family members in 10 cases did not think the ill person had cholera; family members in seven cases reported difficulty getting to a health facility (including transport at night), and family members in six cases did not see the need to seek care.

Reported by

Ministry of Public Health and Population, Haiti. Pan American Health Organization. CDC.

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Update: Outbreak of Cholera --- Haiti, 2010