Abstract
BackgroundIn 2010 and 2011, Haiti was heavily affected by a large cholera outbreak that spread throughout the country. Although national health structure-based cholera surveillance was rapidly initiated, a substantial number of community cases might have been missed, particularly in remote areas. We conducted a community-based survey in a large rural, mountainous area across four districts of the Nord department including areas with good versus poor accessibility by road, and rapid versus delayed response to the outbreak to document the true cholera burden and assess geographic distribution and risk factors for cholera mortality.Methodology/Principal FindingsA two-stage, household-based cluster survey was conducted in 138 clusters of 23 households in four districts of the Nord Department from April 22nd to May 13th 2011. A total of 3,187 households and 16,900 individuals were included in the survey, of whom 2,034 (12.0%) reported at least one episode of watery diarrhea since the beginning of the outbreak. The two more remote districts, Borgne and Pilate were most affected with attack rates up to 16.2%, and case fatality rates up to 15.2% as compared to the two more accessible districts. Care seeking was also less frequent in the more remote areas with as low as 61.6% of reported patients seeking care. Living in remote areas was found as a risk factor for mortality together with older age, greater severity of illness and not seeking care.Conclusions/SignificanceThese results highlight important geographical disparities and demonstrate that the epidemic caused the highest burden both in terms of cases and deaths in the most remote areas, where up to 5% of the population may have died during the first months of the epidemic. Adapted strategies are needed to rapidly provide treatment as well as prevention measures in remote communities.
Highlights
The cholera epidemic in Haiti, which began in 2010 spread rapidly in both urban and rural areas
Author Summary In October 2010, a large cholera outbreak was declared in Haiti and rapidly spread throughout the country, quickly overwhelming the existing health system
To gain insight into the true burden of the cholera outbreak in the community and on potential geographical differences due to accessibility, we conducted a survey in April–May 2011 in a large rural area across four mountainous districts in the Nord department
Summary
The cholera epidemic in Haiti, which began in 2010 spread rapidly in both urban and rural areas. A national training program for cholera management was developed to train clinical staff, most of whom were unfamiliar with the disease [4]. Despite these efforts, over 600,000 cases of cholera and 7,000 deaths were reported by the national health-structure based surveillance system within two years of the first case [5], and, at the time of writing this article, cases are still being reported (http://mspp.gouv.ht/). National health structure-based cholera surveillance was rapidly initiated, a substantial number of community cases might have been missed, in remote areas.
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