Cholera Treatment Centres Research Articles

Cholera Outbreak in Dadaab Refugee Camp, Kenya - November 2015-June 2016.

Dadaab Refugee camp in Garissa County, Kenya, hosts nearly 340,000 refugees in five subcamps (Dagahaley, Hagadera, Ifo, Ifo2, and Kambioos) (1). On November 18 and 19, 2015, during an ongoing national cholera outbreak (2), two camp residents were evaluated for acute watery diarrhea (three or more stools in ≤24 hours); Vibrio cholerae serogroup O1 serotype Ogawa was isolated from stool specimens collected from both patients. Within 1 week of the report of index cases, an additional 45 cases of acute watery diarrhea were reported. The United Nations High Commissioner for Refugees and their health-sector partners coordinated the cholera response, community outreach and water, sanitation, and hygiene (WASH) activities; Médecins Sans Frontiéres and the International Rescue Committee were involved in management of cholera treatment centers; CDC performed laboratory confirmation of cases and undertook GIS mapping and postoutbreak response assessment; and the Garissa County Government and the Kenya Ministry of Health conducted a case-control study. To prevent future cholera outbreaks, improvements to WASH and enhanced disease surveillance systems in Dadaab camp and the surrounding area are needed.

Long-term effectiveness of one and two doses of a killed, bivalent, whole-cell oral cholera vaccine in Haiti: an extended case-control study.

SummaryBackgroundNo study of long-term protection following killed oral cholera vaccination has been done outside of the historically cholera-endemic areas of south Asia, or has examined protection after a single-dose vaccination regimen. To address this, we examined the duration of protection of the standard two-dose regimen and an incomplete regimen of one dose up to 4 years after vaccination in Haiti.MethodsIn the setting of two-dose vaccination campaigns with a killed, bivalent, whole-cell oral cholera vaccination, we did a case-control study from October, 2012 through November, 2016. Eligible participants were required to be resident in the vaccine catchment area (Artibonite Department or Central Department) where they were recruited at the start of the study; and be eligible for the vaccination campaign (ie, aged ≥12 months, not pregnant, and living in the region at the time of the vaccine campaign). Patients with cholera had a positive stool culture and were recruited from cholera treatment centres. Community controls were matched to people with cholera by age group, time, and neighbourhood. We did adjusted matched regression analyses to calculate vaccine effectiveness and examine heterogeneity in effectiveness over time. The primary outcome was the effectiveness of one and two oral cholera doses as compared with zero doses from 2 months to 48 months after vaccination, measured by self reporting.FindingsAmong 178 people assigned to the case group and 706 people assigned to the control group, we found no evidence that two-dose effectiveness decreased during follow-up. In adjusted analyses, the average cumulative 4 year effectiveness for two doses was 76% (95% CI 59–86). In contrast, single-dose effectiveness decreased over time in a log-linear fashion, with a predicted vaccine effectiveness of 79% at the end of 12 months (95% CI 43–93), which declined to zero before the end of the second year.InterpretationIn a setting of epidemic and newly endemic cholera in Haiti, single-dose vaccination with killed, bivalent, whole-cell oral cholera vaccination provided short-term protection; however, vaccination with two doses was required for long-term protection, which lasted up to 4 years after vaccination. These results add to the evidence in support of the use of killed, bivalent, whole-cell oral cholera vaccination as part of comprehensive cholera control plans.FundingUS National Institute of Allergy and Infectious Diseases of the National Institutes of Health and the Bill & Melinda Gates Foundation.

The cost of responding to a waterborne cholera outbreak in a village in Uganda compared to a simple hypothetical intervention, 2016

Introduction: in September 2015, a cholera outbreak occurred in a village in Hoima District, western Uganda. The Ministry of Health assembled a rapid response team, with support by CDC, UNICEF and WHO, to investigate the outbreak, establish the Kaiso Cholera Treatment Center (KCTC), and implement control measures. The team identified 120 cholera cases (with 5 deaths) and determined that drinking contaminated water from the lakeshore caused this outbreak. We sought to determine the cost of investigating and controlling this outbreak, and compare it to a would-be simple preventive measure; constructing deep wells to provide cleaner water.

The Recurrence of Cholera in the City of Lubumbashi: Investigation of Risk Factors for an Effective Response and Health Education Perspective

Introduction: Cholera is one of the so-called dirty hand diseases. Its effective response saves lives. The city of Lubumbashi has recorded at least one cholera epidemic for almost ten years, each of which generates significant socio-economic costs. Method: We conducted a case-control study on cholera in the city of Lubumbashi in the Democratic Republic of Congo in 330 individuals, including 110 cases matched to 220 controls. The linear list of the cholera treatment center was used to identify the cases. Results: Half of the respondents were 50, 30% did not treat water before drinking, and the remaining 49.70% used the treatment of drinking water. The risk factors for the cholera outbreak that were found to be statistically significant include: poor food preservation (AOR = 3.32, 95% CI [1.85 - 5.96], and p value = 0.0001), contact with a cholera patient (AOR = 2.88, 95% CI [1.65 - 5.01], and p value = 0.0002) and stay outside Lubumbashi (AOR = 4.18, its 95% CI [1.83 - 9.55]). Conclusion: An urgent need for information on risk factors for cholera and a rapid organization of the response is the key to cope with this recurrent epidemic in the city of Lubumbashi.

Cost-of-illness of cholera to households and health facilities in rural Malawi.

Cholera remains an important public health problem in many low- and middle-income countries. Vaccination has been recommended as a possible intervention for the prevention and control of cholera. Evidence, especially data on disease burden, cost-of-illness, delivery costs and cost-effectiveness to support a wider use of vaccine is still weak. This study aims at estimating the cost-of-illness of cholera to households and health facilities in Machinga and Zomba Districts, Malawi. A cross-sectional study using retrospectively collected cost data was undertaken in this investigation. One hundred patients were purposefully selected for the assessment of the household cost-of-illness and four cholera treatment centres and one health facility were selected for the assessment conducted in health facilities. Data collected for the assessment in households included direct and indirect costs borne by cholera patients and their families while only direct costs were considered for the assessment conducted in health facilities. Whenever possible, descriptive and regression analysis were used to assess difference in mean costs between groups of patients. The average costs to patients’ households and health facilities for treating an episode of cholera amounted to US$65.6 and US$59.7 in 2016 for households and health facilities, respectively equivalent to international dollars (I$) 249.9 and 227.5 the same year. Costs incurred in treating a cholera episode were proportional to duration of hospital stay. Moreover, 52% of households used coping strategies to compensate for direct and indirect costs imposed by the disease. Both households and health facilities could avert significant treatment expenditures through a broader use of pre-emptive cholera vaccination. These findings have direct policy implications regarding priority investments for the prevention and control of cholera.

First Wave of the 2016-17 Cholera Outbreak in Hodeidah City, Yemen - ACF Experience and Lessons Learned.

Introduction:Although cases were reported only in 2010 and 2011, cholera is probably endemic in Yemen. In the context of a civil war, a cholera outbreak was declared in different parts of the country October 6th, 2016. This paper describes the ACF outbreak response in Hodeidah city from October 28th, 2016 to February 28th, 2017 in order to add knowledge to this large outbreak. Methods:The ACF outbreak response in Hodeidah city included a case management component and prevention measures in the community. In partnership with the Ministry of Public Health and Population of Yemen (MoPHP), the case management component included a Cholera Treatment Center (CTC) implemented in the Al Thoraw hospital, 11 Oral Rehydration Therapy Corners (ORTCs) and an active case finding system. In partnership with other stakeholders, prevention measures in the community, including access to safe water and hygiene promotion, were implemented in the most affected communities of the city.Results:From October 28th, 2016 until February 28th, 2017, ACF provided care to 8,270 Acute Watery Diarrhea (AWD) cases, of which 5,210 (63%) were suspected cholera cases, in the CTC and the 11 ORTCs implemented in Hodeidah city. The attack rate was higher among people living in Al Hali district, with a peak in November 2016. At the CTC, 8% of children under 5 years-old also presented with Severe Acute Malnutrition (SAM). The Case-Fatality Rate (CFR) was low (0.07%) but 15% of admitted cases defaulted for cultural and security reasons. Environmental management lacked the information to appropriately target affected areas. Financial resources did not allow complete coverage of the city.Conclusion:Response to the first wave of a large cholera outbreak in Hodeidah city was successful in maintaining a CFR <1% in the CTC. However, considering the actual context of Yemen and its water infrastructure, much more efforts are needed to control the current outbreak resurgence.

The cost of responding to a waterborne cholera outbreak in a village in Uganda compared to a simple hypothetical intervention

Purpose: In September 2015, a cholera outbreak occurred in a village in Hoima district, Uganda. The Ministry of Health assembled a rapid response team, with support byCDC, UNICEF and WHO, to investigate the outbreak, establish the Kaiso Cholera Treatment Center (KCTC), and implement control measures. The team identified 120 cholera cases (with 5 deaths) and determined that drinking contaminated water from the lakeshore caused this outbreak. We sought to determine the cost of investigating and controlling this outbreak, and compare it to a would-be simple preventive measure – constructing deep wells to provide cleaner water. Methods & Materials: We collected cost data,including personnel and material costs at KCTC, health facilities,Hoima district health office, Uganda Public Health Fellowship Program, UNICEF, CDC,and WHO. We defined direct cost of responding to this outbreak as expenditure on medications, medical equipment and supplies, utilities, and allowances and transport for responders; indirect cost included salary and other compensations for responders. We did not include difficult-to-measure costs such as vehicle depreciation, building maintenance, and loss of productivity to case-persons due to illness and deaths. The cost of constructing deep wells was quoted by a U.S.-based NGO. Results: The total cost incurred in investigating and controlling this outbreak was $71,769, including $21,059 in direct cost ($19,225 for allowances and transportation, $1,774 for medical equipment and supplies, and $60 for utilities), and $50,620 in indirect cost (74,484 person-hours of salary and other compensationsfor responders). Conversely, constructing a deep well to provide cleaner water would cost approximately $2500. Essentially, the total cost incurred in this outbreak would have been enough toconstruct 28 (=71769/2500) deep wells;even the direct cost only would have been enough to construct 8 (=21059/2500) deep wells. One such deep well would have prevented this outbreak and averted future waterborne outbreaks. Conclusion: A simple prevention measure such as constructing deep wells for village residents can be substantially cost-effective for preventing waterborne diseases such as cholera. We recommend that the government should proactively implement prevention measures for waterborne outbreaks whenever possible, instead of passively responding to these outbreaks.

Effectiveness of one dose of oral cholera vaccine in response to an outbreak: a case-cohort study.

Oral cholera vaccines represent a new effective tool to fight cholera and are licensed as two-dose regimens with 2-4 weeks between doses. Evidence from previous studies suggests that a single dose of oral cholera vaccine might provide substantial direct protection against cholera. During a cholera outbreak in May, 2015, in Juba, South Sudan, the Ministry of Health, Médecins Sans Frontières, and partners engaged in the first field deployment of a single dose of oral cholera vaccine to enhance the outbreak response. We did a vaccine effectiveness study in conjunction with this large public health intervention. We did a case-cohort study, combining information on the vaccination status and disease outcomes from a random cohort recruited from throughout the city of Juba with that from all the cases detected. Eligible cases were those aged 1 year or older on the first day of the vaccination campaign who sought care for diarrhoea at all three cholera treatment centres and seven rehydration posts throughout Juba. Confirmed cases were suspected cases who tested positive to PCR for Vibrio cholerae O1. We estimated the short-term protection (direct and indirect) conferred by one dose of cholera vaccine (Shanchol, Shantha Biotechnics, Hyderabad, India). Between Aug 9, 2015, and Sept 29, 2015, we enrolled 87 individuals with suspected cholera, and an 898-person cohort from throughout Juba. Of the 87 individuals with suspected cholera, 34 were classified as cholera positive, 52 as cholera negative, and one had indeterminate results. Of the 858 cohort members who completed a follow-up visit, none developed clinical cholera during follow-up. The unadjusted single-dose vaccine effectiveness was 80·2% (95% CI 61·5-100·0) and after adjusting for potential confounders was 87·3% (70·2-100·0). One dose of Shanchol was effective in preventing medically attended cholera in this study. These results support the use of a single-dose strategy in outbreaks in similar epidemiological settings. Médecins Sans Frontières.

Factors Associated with Fatal Outcomes Following Cholera-Like Syndrome in Far North Region of Cameroon: A Community-Based Survey.

This study demonstrates that most cholera deaths in this region of Cameroon occur out of hospital. This is a region which is prone to cholera, and interventions are needed to improve access to emergency medical care, especially during cholera outbreaks. Cameroon has experienced 14 cholera epidemics during the last 20 years, and these have had high case fatality rates. This study attempted to assess the effect of delays in seeking care and the locations of care as possible risk factors for cholera mortality. The study used data from a community-based survey regarding the circumstances of 97 fatal cases and 197 control (nonfatal) cases following a cholera-like syndrome in villages with cholera-like diseases during cholera outbreaks in Cameroon during 2009-2011. Deaths occurred in one of four environments: the community, in a temporary community treatment center (TCTC), in transit to a treatment center, or in a hospital (39%, 32%, 5%, and 24%, respectively). Using a case-control analysis, factors associated with deaths included the nonuse of a cholera treatment center, receiving health care in a TCTC instead of a hospital, and greater than 4 hours delay between the onset of symptoms and the decision to go to a treatment center (odds ratios of 17.1 [confidence interval (CI): 7.0-41.8], 2.5 [CI: 1.2-5.0], and 2.2 [CI: 1.0-4.6], respectively). During cholera epidemics, a higher proportion of deaths are still occurring in communities. The nonuse and delays in deciding to go a treatment center, and treatment at TCTC rather than a hospital were risk factors for death among patients with cholera-like syndrome in Cameroon. Informing people on community management of cholera-like syndrome and improving care in all health facilities are needed to reduce deaths during cholera epidemics.

Successful multi-partner response to a cholera outbreak in Lusaka, Zambia 2016: a case control study

Background: A Cholera outbreak was reported in Lusaka District between February and May 2016, with 1,079 cases and 20 deaths recorded in the per-urban areas. Bauleni catchment area alone reported 441 (40.9%) case patients with case fatality rate of 4 (0.9%). Bauleni clinic was one of the three established cholera treatment centres (CTC) and other two being Kanyama and Matero Health Centres. Ministry of Health engaged partners that conducted a multi-intervention response to the outbreak. This study is aimed at identifying factors associated with the outbreak.&#x0D; Materials and methods: We conducted a case-control study, at the ratio 1:3, to identify risk factors associated with cholera outbreak. We identified cases of cholera through the cholera register at Bauleni health centre and randomly selected population based controls being residents of Bauleni Township without watery diarrhoea. The standard case definition for suspected cholera case was any person of any age with profuse, effortless watery diarrhoea (three or more stools in 24 hours), with or without vomiting. Aconfirmed cholera case was defined as any person suspected to have cholera with a positive laboratory result. Univariate and multivariate analysis was performed using Epi-Info version 3.5.4 and Stata version 11.2.&#x0D; Results: On the Cholera Treatment Centre surveillance case-patients register, out of 441 cases, 241 (54.6%) cases were male while 200 (45.4 %%) cases were female, with an attack rate of 14.8/1,000 population and 4 (0.9%) fatalities. The study participants, who included 49 casepatients and 151 controls, had mean-age of 31 years [range, 29-34 years]. Positive Vibrio in stool cholera was associated with drinking inadequately treated borehole water [Adjusted OR=0.79; 95% CI (0.10-6.04), p&gt;0.05]. This odds ratio was adjusted for level education and gender to control and account for any confounding. Though this finding was not statistically significant at p&gt;0.05, the laboratory result was biologically significant as vibrio cholerae was isolated in the borehole water. Drinking treated water was protective [Adjusted OR 0.13; 95% CI (0.05-0.31, p&lt;0.05].&#x0D; Conclusion: Improving methods that promote safe drinking water are likely to be effective measures in averting future cholera outbreaks in this setting.

Clinical Features of Human Immunodeficiency Virus-Infected Patients Presenting with Cholera in Port-au-Prince, Haiti.

Human immunodeficiency virus (HIV) infection has been postulated to alter the natural history of cholera, including increased susceptibility to infection, severity of illness, and chronic carriage of Vibrio cholerae Haiti has a generalized HIV epidemic with an adult HIV prevalence of 1.9% and recently suffered a cholera epidemic. We conducted a prospective study at the cholera treatment center (CTC) of GHESKIO in Haiti to characterize the coinfection. Adults admitted at the CTC for acute diarrhea were invited to participate in the study. Vital signs, frequency, and volume of stools and/or vomiting were monitored, and single-dose doxycycline was administered. After counseling, participants were screened for HIV by enzyme-linked immunosorbent assay and for cholera by culture. Of 729 adults admitted to the CTC, 99 (13.6%) had HIV infection, and 457 (63%) had culture-confirmed cholera. HIV prevalence was three times higher in patients without cholera (23%, 63/272) than in those with culture-confirmed cholera (7.9%, 36/457). HIV prevalence in patients with culture-confirmed cholera (7.9%) was four times higher than the adult prevalence in Port-au-Prince (1.9%). Of the 36 HIV-infected patients with cholera, 25 (69%) had moderate/severe dehydration versus 302/421 (72%) in the HIV negative. Of 30 HIV-infected patients with weekly stool cultures performed after discharge, 29 (97%) were negative at week 1. Of 50 HIV-negative patients with weekly stool cultures, 49 (98%) were negative at week 1. In countries with endemic HIV infection, clinicians should consider screening patients presenting with suspected cholera for HIV coinfection.

Antibiotics susceptibility pattern of Vibrio cholerae O1 Ogawa, isolated during Cholera outbreak investigations in Mozambique from 2014 to 2015

Background: Mozambique have registered cyclically epidemic outbreaks of cholera. Antibiotic therapy is recommended in specific situations for management and control of cholera outbreaks. However, an increase in antibiotics resistance rates of Vibrio cholerae has been reported in several epidemic outbreaks worldwide. On the other hand, there are few recent records of continuous surveillance of antibiotics susceptibility pattern of Vibrio cholerae in Mozambique. Methods & Materials: For susceptibility testing, we used Vibrio cholerae O1 Ogawa confirmed by culture, oxidase reaction and serology. Samples were collected in the context of surveillance and response to Cholera outbreaks, in the period of january –April from the years 2014 and 2015; Sent to and tested in the National Reference Laboratory of Microbiology from the National Institute of Health – Mozambique. Samples were from cholera treatment centers of Metangula (09), Memba (01), Moatize (01), Morrumbala (01) districts, Tete City (08), City of Quelimane (01), Lichinga (06) and Nampula (86). Antibiotics susceptibility pattern was determined by disk diffusion method Kirby Bauer. Antibiotic susceptibility results were interpreted by following recommendations of CLSI (Clinical and Laboratory Standards Institute) 2014. Results: Among 117 isolates from Vibrio cholerae O1 Ogawa we found resistance of 100% (53/53) to trimethoprim-sulfamethoxazole, 100% (54/54) ampicillin, 99% (73/74) for Nalidixic Acid, 97% (64/66) to Chloramphenicol, 95% (42/44) for Nitrofurantoin, 82% (80/97) Tetracycline, 56% (39/70) Azithromycin and 0% (0/101) for Ciprofloxacin. Conclusion: Our work shows that the strains of the Vibrio cholerae isolated during outbreak investigation in Mozambique in the years 2014-2015 have a high frequency of resistance to available antibiotics, with the exception of Ciprofloxacin; and a rapid evolution of the resistance of antibiotics such as Nalidixic Acid, Chlorafenicol, Nitrofurantoin, and Tetracyclin. I’ts outsatndind the appearance of resistant strains to Azythromycin, which is a recommended antibiotic for Cholera treatment. Since the appearance of this resistance can influence Cholera control strategies, continuous monitoring of epidemic strains is crucial.

Effectiveness of Oral Cholera Vaccine in Haiti: 37-Month Follow-Up.

The first oral cholera vaccine (OCV) campaign, since its prequalification by the World Health Organization, in response to an ongoing cholera epidemic (reactive vaccination) was successfully conducted in a poor urban slum of approximately 70,000 inhabitants in Port-au-Prince, Haiti, in 2012. Vaccine coverage was 75% of the target population. This report documents the impact of OCV in reducing the number of culture-confirmed cases of cholera admitted to the Groupe Haïtien d'Etude du Sarcome de Kaposi et des Infections Opportunistes (GHESKIO) cholera treatment center from that community in the 37 months postvaccination (April 2012-April 30, 2015). Of 1,788 patients with culture-confirmed cholera, 1,770 (99%) were either from outside the vaccine area (1,400 cases) or from the vaccinated community who had not received OCV (370 cases). Of the 388 people from the catchment area who developed culture-confirmed cholera, 370 occurred among the 17,643 people who had not been vaccinated (2.1%) and the remaining 18 occurred among the 52,357 people (0.034%) who had been vaccinated (P < 0.001), for an efficacy that approximates 97.5%. Despite not being designed as a randomized control trial, the very high efficacy is a strong evidence for the effectiveness of OCV as part of an integrated package for the control of cholera in outbreak settings.

Outbreak of Cholera, Greater Accra Region, Ghana, 2014

Aims: In 2014, a cholera outbreak occurred in Greater Accra region, affecting more than 1733 people, and 20 individuals died. We investigated to verify the diagnosis, identify risk factors and recommended control measures. Study Design: The study was both descriptive and un-matched community-based 1:2 case control study. Place and duration of study: The investigations were done between 24 July and 3rd August 2014 in the Greater Accra region of Ghana. Methods: We conducted a descriptive investigation, active case-search and conducted risk factor Original Research Article Dzotsi et al.; JSRR, 9(3): 1-12, 2016; Article no.JSRR.21461 2 assessment of the cases and environmental assessment of the communities. Standardized questionnaire was used to collect demographic, clinical and exposure history from the cases and controls and described the outbreak by place, age and sex. Rectal swabs from patients admitted in the Cholera Treatment Centres at health facilities were collected and tested by culture and antimicrobial sensitivity. Bivariate analysis was used to compare cases and controls and calculated odds ratio and 95% confidence interval. Results: We found 1733 cases with 20 deaths (CFR=1.2%) with an overall attack rate of approximately 25 per 100,000 population with sex specific attack rates of 31.2% and 19.6% for males and females respectively. The most affected districts were Osu Klottey Sub-Metropolis of the Accra Metropolis with an attack rate of 111 per 100,000 and La Dadekotopon with an attack rate of 76 per 100,000. Ninety stool samples yielded V. cholera O1 Ogawa with Ciprofloxacin and Tetracycline being sensitive to the cholera strains. Epidemiologic data suggested that the outbreak was due to drinking of vended sachet water [odds ratio = 6; 95 confidence interval: 1.7-20.9, p-value: 0.00]. Conclusion: The lack of personal hygiene, safe drinking water, open defecation, poor sanitation and consumption of street vended sachet water and food were some of the causes of the recent cholera outbreak in Greater Accra. We recommend the Ministries of Local Government and Rural Development, Works and Housing and Water Resources to ensure proper liquid and solid waste disposal systems and provide adequate potable water to the populace.

The transmission dynamics of the cholera epidemic in Kasese district, Uganda

Background: Cholera is still a big public health problem in the Kasese District of Uganda, which deserves effective intervention for a free and safe society. Objectives: to survey the transmission dynamics of cholera epidemics in the endemic Kasese District of Uganda. Materials and methods: A descriptive cross-sectional study was carried out among 240 adult participants (quantitative data) with a history of cholera and 7 key informants (qualitative data). SPSS conducted the analysis using multivariate linear regression and chi-square at the bivariate level. Statistical significance was assessed using p (&lt; 0.05). Results. The dynamics of the cholera epidemic were defined by environmental factors, effectiveness of existing interventions such as Cholera epidemic Task Force; Cholera Treatment Centers; Health education campaigns; and Village Community meetings about cholera. The poor uptake of cholera intervention programs and other factors support this. There are still gaps in the uptake of cholera control interventions in Kasese District manifested by the laxity of the District’s Cholera epidemic Task Force; inadequate disinfection and cholera treatment kits in the Cholera epidemic Treatment Centers; low PHC funds and low listenership to media campaigns for health education about cholera; and finally, rare and poorly attended village community meetings on cholera, which influenced the spread and development of cholera outbreaks in Kasese District. Conclusions and recommendations cholera epidemic in Kasese District was mainly induced by the consumption of cholera contaminated food and water. The interventions existing in the district are ineffective and inefficient, probably due to gaps in the uptake of existing cholera cholera epidemic control interventions. District Health Offices should therefore strengthen health education and promotion about cholera; through a case-control study that will give more focus on the importance of the factors contributing to cholera in Kasese District.

Minimizing the Risk of Disease Transmission in Emergency Settings: Novel In Situ Physico-Chemical Disinfection of Pathogen-Laden Hospital Wastewaters.

The operation of a health care facility, such as a cholera or Ebola treatment center in an emergency setting, results in the production of pathogen-laden wastewaters that may potentially lead to onward transmission of the disease. The research presented here evaluated the design and operation of a novel treatment system, successfully used by Médecins Sans Frontières in Haiti to disinfect CTC wastewaters in situ, eliminating the need for road haulage and disposal of the waste to a poorly-managed hazardous waste facility, thereby providing an effective barrier to disease transmission through a novel but simple sanitary intervention. The physico-chemical protocols eventually successfully treated over 600 m3 of wastewater, achieving coagulation/flocculation and disinfection by exposure to high pH (Protocol A) and low pH (Protocol B) environments, using thermotolerant coliforms as a disinfection efficacy index. In Protocol A, the addition of hydrated lime resulted in wastewater disinfection and coagulation/flocculation of suspended solids. In Protocol B, disinfection was achieved by the addition of hydrochloric acid, followed by pH neutralization and coagulation/flocculation of suspended solids using aluminum sulfate. Removal rates achieved were: COD >99%; suspended solids >90%; turbidity >90% and thermotolerant coliforms >99.9%. The proposed approach is the first known successful attempt to disinfect wastewater in a disease outbreak setting without resorting to the alternative, untested, approach of ‘super chlorination’ which, it has been suggested, may not consistently achieve adequate disinfection. A basic analysis of costs demonstrated a significant saving in reagent costs compared with the less reliable approach of super-chlorination. The proposed approach to in situ sanitation in cholera treatment centers and other disease outbreak settings represents a timely response to a UN call for onsite disinfection of wastewaters generated in such emergencies, and the ‘Coalition for Cholera Prevention and Control’ recently highlighted the research as meriting serious consideration and further study. Further applications of the method to other emergency settings are being actively explored by the authors through discussion with the World Health Organization with regards to the ongoing Ebola outbreak in West Africa, and with the UK-based NGO Oxfam with regards to excreta-borne disease management in the Philippines and Myanmar, as a component of post-disaster incremental improvements to local sanitation chains.

Cholera and pregnancy in Haiti: factors related to foetal death in pregnant women presenting to MSF cholera treatment centres, September 2011 to December 2013

Cholera and pregnancy in Haiti: factors related to foetal death in pregnant women presenting to MSF cholera treatment centres, September 2011 to December 2013

Importance of Cholera and Other Etiologies of Acute Diarrhea in Post-Earthquake Port-au-Prince, Haiti

We estimated the proportion of diarrhea attributable to cholera and other pathogens during the rainy and dry seasons in patients seen in two urban health settings: a cholera treatment center (CTC) and oral rehydration points (ORPs). During April 1, 2011-November 30, 2012, stool samples were collected from 1,206 of 10,845 patients who came to the GHESKIO CTC or to the community ORPs with acute diarrhea, cultured for Vibrio cholerae, and tested by multiplex polymerase reaction. Vibrio cholerae was isolated from 409 (41.8%, 95% confidence interval [CI] = 38.7-44.9%) of the 979 specimens from the CTC and in 45 (19.8%, 95% CI = 14.8-25.6%) of the 227 specimens from the ORPs. Frequencies varied from 21.4% (95% CI = 16.6-26.7%) during the dry season to 46.8% (95% CI = 42.9-50.7%) in the rainy season. Shigella, enterotoxigenic Escherichia coli, rotavirus, and Cryptosporidium were frequent causes of diarrhea in children less than five years of age.

Predictors of Disease Severity in Patients Admitted to a Cholera Treatment Center in Urban Haiti

Cholera, previously unrecognized in Haiti, spread through the country in the fall of 2010. An analysis was performed to understand the epidemiological characteristics, clinical management, and risk factors for disease severity in a population seen at the GHESKIO Cholera Treatment Center in Port-au-Prince. A comprehensive review of the medical records of patients admitted during the period of October 28, 2010–July 10, 2011 was conducted. Disease severity on admission was directly correlated with older age, more prolonged length of stay, and presentation during the two epidemic waves seen in the observation period. Although there was a high seroprevalence of human immunodeficiency virus (HIV), severity of cholera was not greater with HIV infection. This study documents the correlation of cholera waves with rainfall and its reduction in settings with improved sanitary conditions and potable water when newly introduced cholera affects all ages equally so that interventions must be directed throughout the population.

Uptake of household disinfection kits as an additional measure in response to a cholera outbreak in urban areas of Haiti

Médecins Sans Frontières-Operational Centre Amsterdam piloted the distribution of household disinfection kits (HDKs) and health promotion sessions for cholera prevention in households of patients admitted to their cholera treatment centres in Carrefour, Port au Prince, Haiti, between December 2010 and February 2011. We conducted a follow-up survey with 208 recipient households to determine the uptake and use of the kits and understanding of the health promotion messages. In 61% of surveyed households, a caregiver had been the recipient of the HDK and 57.7% of households had received the HDKs after the discharge of the patient. Among surveyed households, 97.6% stated they had used the contents of the HDK after receiving it, with 75% of these reporting using five or more items, with the two most popular items being chlorine and soap. A significant (p < 0.05) increase in self-reported use items in the HDK was observed in households that received kits after 24 January 2011 when the education messages were strengthened. To our knowledge, this is the first time it has been demonstrated that during a large-scale cholera outbreak, the distribution of simple kits, with readily available cleaning products and materials, combined with health promotion is easy, feasible, and valued by the target population.