Cholera returns to Haiti after three years, affecting children


International efforts are coordinating a response to the waterborne pathogen

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Image by Kendra Helmer

By Shannon Reed

IN DECEMBER 2022, the World Health Organisation (WHO) announced that Haiti is experiencing a resurgence of cholera after declaring it cholera-free just ten months prior.

Cholera is an acute diarrhoeal illness, caused by infection with the bacterium Vibrio cholerae, that frequently contaminates food and water when sanitary conditions are substandard. As with many conditions, this has a disproportionate impact on the developing world.

The extremely virulent disease is endemic in many countries but caused an unforeseen humanitarian crisis in Haiti following a devastating earthquake in 2010. This displaced over one million people, further reinforcing the crisis as stress on sanitary facilities mounted.

The outbreak started in October 2010 and saw 820,000 confirmed cases and 10,000 deaths in Haiti alone, making it the largest cholera epidemic in a single country in recent history.

Despite being extremely virulent, a Vibrio cholerae infection can easily be treated through prompt administration with an Oral Rehydration Solution (ORS) and can be prevented with an oral vaccine, though without these measures, morbidity is high.

The most recent report from the WHO suggests that 86 percent of reported cases in Haiti have been hospitalised as of 13 December 2022, indicating a swift response by the Haitian public health authorities. This encouraging development may be due to the lessons learnt from the 2010 crisis.

Many patients infected with cholera do not experience symptoms; however, Vibrio cholerae will persist in human waste for up to ten days post-infection and potentially cause infection to others if the sanitation systems and hygiene of the affected population are inadequate.

Humanitarian crises such as natural disasters or political instability, both of which have affected Haiti in the last decade, can markedly increase the risk of cholera transmission. As such, the WHO has previously co-operated with national governments and Non-Governmental Organisations (NGOs) to provide a multi-sectoral approach. This is suspected to be the most effective strategy, with different groups specialising in different vectors of attacking the epidemic. Whilst the picture of the current outbreak is still developing, cases are being reported in major population centres Port-au-Prince and Cité Soleil. Both regions are experiencing extreme poverty and political chaos amidst a recent gang-fuelled blockade on its major port.

Evidently, the timing of this outbreak is poor. According to the WHO, the ongoing humanitarian crises affecting the region have contributed to the internal displacement of over 24,000 people. Haiti’s political and socio-economic insecurity will further complicate the response of the public health system and international aid charities that seek to import supplies (such as the 1.17 million cholera vaccines received in December 2022). More supplies are on the way, but logistical roadblocks take time to overcome.

The catastrophic earthquake that devastated Haiti in January 2010 caused around 220,000 deaths, according to United Nations (UN) figures, with the epicentre being just 25km away from Port-au-Prince. In the months that followed, millions of people were rendered homeless and vulnerable to looting and violence, and then to cholera following the contamination of the Artibonite river with faecal matter. An end to the previous outbreak was achieved through the comprehensive provision of water sanitation, education on good hygiene practices, vaccination of children, and decontamination of water sources.

Early data on the current outbreak (evaluating admissions to a cholera treatment centre in downtown Port-au-Prince) suggests that this resurgent strain may disproportionately affect young children, with a median patient age of 12 years in 2022 compared to 24 in 2010. This is due to their less well-developed immune systems and tendency to come into contact with contaminated water.

Emergency response activities have begun, involving a collaboration between the WHO, the Haiti Ministry of Public Health and humanitarian derivatives of the UN. As of December 2022, there are 70 cholera treatment centres (CTCs) throughout Haiti, with essential medical supplies such as ORS provided by WHO.

Surveillance of the outbreak and risk communication with the citizenry is also critical to its management. Thus, the WHO has provided training on rapid diagnosis in the CTCs, as well as safe transportation of samples to laboratories via the UN.

Nearby territories such as the Dominican Republic are expected to receive support from the aforementioned NGOs to strengthen their resources in case of cholera outbreaks within their own borders.

With the combination of a coordinated response from multiple organisations and knowledge acquired from the previous catastrophe, it is hoped that this outbreak can help avoid replicating the devastating loss of life of its predecessor.