Cholera in Haiti: A Look at Recurring Outbreaks

July 2017

Brittany Thorp, Grand Valley State University

Introduction
Cholera is an enteric infection caused by the bacterium Vibrio cholerae. It is characterized by

watery diarrhea, but symptoms may also include abdominal cramping, nausea, vomiting, and

dehydration. Mortality is often a result of severe dehydration. Many individuals have mild to no

symptoms and do not experience severe illness. Cholera is spread through fecal-oral

transmission and can be found in contaminated food and water. John Snow noticed the first

case of cholera in 1848 in London, when it was transported from Germany to England by the

infected seaman infecting the local environment (Grad & Waldor, 2013). The bacterium attaches

to tiny crustaceans called copepods and travel worldwide with the host as they feed on algae

and plankton (Mayoclinic.org). Approximately one million cholera bacteria need to be ingested

to cause illness (Mayoclinic.org). Standing water and certain types of food (seafood, raw fruits

and vegetables, and grains), are the most common sources of cholera infection (Mayoclinic.org).

There is an increased threat in developing countries where safe water and sanitation facilities

are inadequately available (Jutla et al., 2013). Since the bacterium is a natural inhabitant of an

aquatic environment, countries such as Haiti, that have limited access to clean water are at

higher risk of inhabitants becoming infected. According to the Pan American Health

Organization / World Health Organization (2017), (in 2017, up to epidemiology week 5), Haiti
had a total of 1,897 cholera cases, including 28 related deaths (case fatality rate: 1.5%). The

prevalence rates of cholera in Haiti can be seen in Figure 1. Figure 2 gives the number of cases

of cholera in Haiti from 2015 to 2017. You can see in this graph the indication of a natural

disaster, Hurricane Matthew, which occurred in epidemiology week 40 of 2016. There was an

immediate increase in number of cases after the hurricane occurred.

Figure 1: Cases of Cholera in the Dominican Republic and Haiti, 2010-2017 ( Pan American
Health Organization / World Health Organization).
Figure 2: Number of Cases of Cholera by Epidemiology Week, 2015-2017 (Pan American Health
Organization / World Health Organization).

Outbreak
Cholera can be either endemic or epidemic. Before the outbreak of 20102011, cholera had not

been reported in Haiti for at least 100 years (Blackburn et al., 2014). Unfortunately, the first

outbreak occurred after 2010 when an earthquake severely damaged the Haitian public

sanitation system and displaced 1.5 million persons (Blackburn et al., 2014). The cholera

epidemic was one of the largest worldwide in recent history and is currently still occurring.

According to an npr article, a peacekeeping camp through the United Nations may have played

some role in the outbreak due to traveling peacekeepers spreading the disease to areas in Haiti

that had no previous immunity (Domonoske, 2016).

The estimated incubation period of toxigenic cholera is 1.4 days and cholera investigations

should use a recall period of at least five days to capture relevant exposures (Azman, Rudolph,

Cummings & Lessler, 2013). Travel to and from areas of an outbreak should be minimized and

monitoring of symptoms should occur during the recall period.

Surveillance
A public database of cholera is maintained by The World Health Organization (WHO) and gives

summaries, outbreak updates and an annual summary of aggregate national data in the Weekly

Epidemiological Record (Mohammad et al., 2012). However, due to inadequate laboratory and

epidemiological surveillance systems and economic, social and political disincentives, many

cases go unreported (Mohammad et al., 2012). The WHO estimates that the officially reported

cases represent only 510% of the actual number occurring annually worldwide (Mohammad

et al., 2012). Especially in a country such as Haiti, reporting may come second to fighting the

outbreak itself and fixing the failed sanitation system.

Individuals who present with symptoms of cholera are monitored for disease. In areas where

diagnostic testing is available, rapid tests can be used to identify cases. The WHO has these tests

available in cholera kits (WHO, 2017).

Prevention
In response to the outbreak in Haiti, the Haitian Ministry of Health and Population developed

the National Plan for the Elimination of Cholera, 20132022, with the intention to work toward

building better health coverage, improving sanitary and hygiene facilities, and increasing access

to potable water as long-term solutions to eliminate cholera (Childs et al., 2016). Short term

interventions include vaccinations for the populations that are living in areas with poor

sanitation and lack of access to potable water and administration of oral rehydration

solutions. Approximately 600,000 people should be targeted for cholera vaccination according

to the Haitian government (Childs et al., 2016). The United Nations can purchase the oral
cholera vaccine through the World Health Organization (WHO) (Childs et al., 2016). The WHO

also recommends including other prevention and control strategies, in endemic areas, and

perhaps in areas at risk for cholera outbreaks, with the oral cholera vaccines (Mohammad et al.,

2012).

A multifaceted approach using the above-mentioned strategies must be implemented to help

drastically lower the cholera cases in Haiti. International aide is needed for vaccination and

rebuilding resources. Other developing countries face the same issues and can use similar

techniques to stop the spread of cholera.

References
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http://dx.doi.org/10.3201/eid1704.101973
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http://doi.org/10.1016/j.jinf.2012.11.013
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