The Forgotten Story of Cholera and the Upcoming Rainy Season

March 16, 2011

Although a new study today from The Lancet has brought the cholera epidemic back to the attention of the media, the story had faded from the headlines, replaced by elections, returns of former presidents (and dictators) and reconstruction projects. Many commentators have also failed to mention that the rainy season is set to begin in two weeks. One year ago, the Christian Science Monitor headlined a story,”Haiti races to house post-quake homeless before the rainy season.” One year later, the story would read much the same. Although overly optimistic reports from the International Organization of Migration have noted a decrease in the number of IDPs in the camps, even their rosy estimates put the number around 800,000. It may be the case that a large number of IDPs returned to homes that had been marked either Red (needing to be destroyed) or Yellow (needing repairs). This is hardly a solution. In terms of transitional shelters, the most recent data show 43,000 of the planned 111,000 having been built. Even the most optimistic acknowledge that there will still be hundreds of thousands left without any meaningful shelter at the end of 2011, let alone in two weeks for the onset of the rainy season.

A report today in The Lancet medical journal sheds new light on the extent of the cholera epidemic and should come as a wake up call to an international community that has seemed more focused on imposing election results and impeding the constitutional return of former president Aristide than solving the crisis on the ground of inadequate shelter and an inadequate response to the cholera epidemic. The inadequate response was well documented by Mark Schuller and researchers from City University of New York and Faculte d’Ethnologie. Their report noted that:

Still using the random sample of 108 IDP camps from this summer, a team of three State University of Haiti students investigated 45 camps that lacked either water or toilets from the summer. The results show a minimum of progress: 37.6 percent instead of 40.5 percent still do not have water, and 25.8 instead of 30.3 percent of camps still do not have a toilet.

The cholera outbreak – combined with the continued lack of services – is a key factor in the rap-id depopulation of the IDP camps. According to the IOM only 810,000 remain as of January 7. One in four camps researchers visited disappeared since the last visit, eight because of IDPs’ fear of cholera, and three because of landowner pressure.

New research from Harvard Medical School and the University of California shows that the far from leveling off, the cholera epidemic could infect as many as one million Haitians:

By contrast with the UN projection of 400 000 cases of cholera from December, 2010, to December, 2011, our dynamic model of cholera, which incorporates key features of disease transmission and pathogenesis, projected more than 750 000 cases in the 9 months from March to December, 2011. Although the prevalence of cholera is decreasing in Haiti, the projections from our model suggest that this is the expected natural course of the epidemic, and should not necessarily be interpreted as indicative of successful intervention.

The estimate of 400,000, according to the study, “is essentially a guess—based on no data, and ignoring the dynamics of cholera epidemics, such as where people acquire the infection, how they gain immunity, and the role of human interventions such as water allocation or vaccination.”

The study, which uses 95% confidence intervals in its estimations, predicts a caseload of 779,000 from March 1 – November 30, 2011 and an additional 11,100 deaths. The most recent data from the Haitian Ministry of Health show a caseload of around 250,000 with over 4,600 deaths. Worryingly, the study could not take into consideration the effect the rainy season might have, as the authors note:

[I]n the absence of historical data for the interaction between the rainy season (May—July) and cholera in Haiti, our model could not estimate the precise effect of these factors. Should the rainy season worsen water contamination, our projections might be seen as conservative, lower-bound estimates of future cholera burden.

Given the continued dire situation on the ground, this seems likely. The WASH cluster, in their most recent report, note that:

The excreta situation has not improved or advanced since December. The construction work at the modern disposal site of Titanyen that halted in December has not restarted. Various other sites were identified, all of them with limitations, and no decision of made. The currently preferred site will take 45 days to complete, and the contamination of the ground water and the coastal zone is at high risk. Given the impending rainy season, and the potential increase in cases, this environmental contamination potential is worrisome. However, the continued absence of an adequate discharge site more than 4 months after the start of the cholera epidemic and 13 months after the earthquake is an important public health issue and needs a resolution.

The report adds that:

The lack of public sanitation remains of huge concern. Of the 1,152 camps registered in the earthquake affected area by IOM in the Data Tracking Matrix, only 600 have latrines and only 499 have excreta removal services (43%). This leaves thousands of people without proper sanitation. In addition, the current funding cycle for many of the NGOs providing excreta removal services from these sites has ended or will end within the next month. Transition strategies had limited implementation and there is concern over the public health conditions that this situation will create.

With another rainy season upcoming, and cholera continuing to spread through the country, there is no excuse that the UN appeal for cholera funding is still less than 50 percent funded. Furthermore, of the $4.5 billion in recovery pledges, only 30 percent has been disbursed. Perhaps this is why, on the one-year anniversary of the earthquake, Michaëlle Jean, former governor general of Canada and UN special envoy to Haiti together with Irina Bokova, the head of UNESCO wrote:

More than a million people are still living amid rubble, in emergency camps, in abject poverty; cholera, meanwhile, has claimed thousands of lives. As time passes, what began as a natural disaster is becoming a disgraceful reflection on the international community. Official commitments have not been honoured; only a minuscule portion of what was promised has been paid out. The Haitian people feel abandoned and disheartened by the slowness with which rebuilding is taking place.

The Lancet also estimated the effects of different efforts to contain the epidemic, including increasing access to clean water and use of vaccinations and antibiotics. The report finds that:

Improvements in access to clean water, modelled as a 1% per week reduction in the proportion of the population consuming contaminated water, were projected to avert 105 000 cases (95% CI 88 000—116 000) and 1500 deaths (1100—2300) from March to November, 2011 (table). Vaccination of 10% of the population was projected to avert 63 000 cases (48 000—78 000) and 900 deaths (600—1500)—vaccination of 5% of the population averted 32 000 cases (24 000—35 000) and vaccination of 25% averted 159 000 cases (118 000—193 000). Expansion of early antibiotic use to all severe and half of moderate cases was projected to avert 9000 cases (8000—10 000) and 1300 (900—2000) deaths. On the basis of our model, we expect the implementation of both vaccination of 10% of the population and antibiotic expansion would avert 72 000 cases (57 000—86 000) and 2100 deaths (1400—3300). Vaccination was projected to avert more new cholera cases, whereas antibiotics had a greater effect on the prevalence of cases by reducing the duration of illness (figure 4). We estimated that all three interventions would avert 170 000 cases (138 000—193 000) and 3400 deaths (2300—5200; table).

The international community has an opportunity and a responsibility to immediately step up efforts to provide adequate shelter, sanitation, and protection to the IDP communities before the rainy season and to live up to their pledges of support and provide the treatment necessary to prevent the cholera epidemic from claiming even more lives.

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