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Volume 17, Number 11—November 2011

Volume 17, Number 11—November 2011   PDF Version [PDF - 6.97 MB - 199 pages]

THEME ISSUE
CHOLERA IN HAITI

Synopses

  • Lessons Learned during Public Health Response to Cholera Epidemic in Haiti and the Dominican Republic PDF Version [PDF - 295 KB - 7 pages]
    J. W. Tappero and R. V. Tauxe
    View Summary

    Safe water and sewage systems must be constructed to prevent future epidemics.

       View Abstract

    After epidemic cholera emerged in Haiti in October 2010, the disease spread rapidly in a country devastated by an earthquake earlier that year, in a population with a high proportion of infant deaths, poor nutrition, and frequent infectious diseases such as HIV infection, tuberculosis, and malaria. Many nations, multinational agencies, and nongovernmental organizations rapidly mobilized to assist Haiti. The US government provided emergency response through the Office of Foreign Disaster Assistance of the US Agency for International Development and the Centers for Disease Control and Prevention. This report summarizes the participation by the Centers and its partners. The efforts needed to reduce the spread of the epidemic and prevent deaths highlight the need for safe drinking water and basic medical care in such difficult circumstances and the need for rebuilding water, sanitation, and public health systems to prevent future epidemics.

  • Rapid Development and Use of a Nationwide Training Program for Cholera Management, Haiti, 2010 PDF Version [PDF - 315 KB - 5 pages]
    R. V. Tauxe et al.
    View Summary

    Rapid training of health care staff was followed by lower death rates.

       View Abstract

    When epidemic cholera appeared in Haiti in October 2010, the medical community there had virtually no experience with the disease and needed rapid training as the epidemic spread throughout the country. We developed a set of training materials specific to Haiti and launched a cascading training effort. Through a training-of-trainers course in November 14–15, 2010, and department-level training conducted in French and Creole over the following 3 weeks, 521 persons were trained and equipped to further train staff at the institutions where they worked. After the training, the hospitalized cholera patients’ case-fatality rate dropped from 4% to <2% by mid-December and was <1% by January 2011. Continuing in-service training, monitoring and evaluation, and integration of cholera management into regular clinical training will help sustain this success.

  • Cholera—Modern Pandemic Disease of Ancient Lineage PDF Version [PDF - 183 KB - 6 pages]
    J. Morris
    View Summary

    Cholera is a wily opponent. The cholera organism can live indefinitely in water and can survive in a changing environment by evolving genetically. And as it evolves, it is becoming more capable of causing severe disease. Recently, researchers found that the organism passed in diarrhea from an infected person is more capable of causing disease for several hours, during which time fast transmission from person to person can occur. Although the key to ultimate cholera control is good sanitation, prevention efforts should also focus on household transmission during the short period when it is more infectious.

       View Abstract

    Cholera has affected humans for at least a millennium and persists as a major cause of illness and death worldwide, with recent epidemics in Zimbabwe (2008–2009) and Haiti (2010). Clinically, evidence exists of increasing severity of disease linked with emergence of atypical Vibrio cholerae organisms that have incorporated genetic material from classical biotype strains into an El Tor biotype background. A key element in transmission may be a recently recognized hyperinfectious phase, which persists for hours after passage in diarrheal feces. We propose a model of transmission in which environmental triggers (such as temperature) lead to increases in V. cholerae in environmental reservoirs, with spillover into human populations. However, once the microorganism is introduced into a human population, transmission occurs primary by “fast” transmission from person to person (taking advantage of the hyperinfectious state), without returning to the aquatic environment.

  • Considerations for Oral Cholera Vaccine Use during Outbreak after Earthquake in Haiti, 2010−2011 PDF Version [PDF - 336 KB - 8 pages]
    K. A. Date et al.
    View Summary

    Many logistical and operational challenges prevented implementation of a vaccination campaign.

       View Abstract

    Oral cholera vaccines (OCVs) have been recommended in cholera-endemic settings and preemptively during outbreaks and complex emergencies. However, experience and guidelines for reactive use after an outbreak has started are limited. In 2010, after over a century without epidemic cholera, an outbreak was reported in Haiti after an earthquake. As intensive nonvaccine cholera control measures were initiated, the feasibility of OCV use was considered. We reviewed OCV characteristics and recommendations for their use and assessed global vaccine availability and capacity to implement a vaccination campaign. Real-time modeling was conducted to estimate vaccine impact. Ultimately, cholera vaccination was not implemented because of limited vaccine availability, complex logistical and operational challenges of a multidose regimen, and obstacles to conducting a campaign in a setting with population displacement and civil unrest. Use of OCVs is an option for cholera control; guidelines for their appropriate use in epidemic and emergency settings are urgently needed.

Research

  • Comparative Genomics of Vibrio cholerae from Haiti, Asia, and Africa PDF Version [PDF - 360 KB - 9 pages]
    A. R. Reimer et al.
    View Summary

    A strain from Haiti shares genetic ancestry with those from Asia and Africa.

       View Abstract

    Cholera was absent from the island of Hispaniola at least a century before an outbreak that began in Haiti in the fall of 2010. Pulsed-field gel electrophoresis (PFGE) analysis of clinical isolates from the Haiti outbreak and recent global travelers returning to the United States showed indistinguishable PFGE fingerprints. To better explore the genetic ancestry of the Haiti outbreak strain, we acquired 23 whole-genome Vibrio cholerae sequences: 9 isolates obtained in Haiti or the Dominican Republic, 12 PFGE pattern-matched isolates linked to Asia or Africa, and 2 nonmatched outliers from the Western Hemisphere. Phylogenies for whole-genome sequences and core genome single-nucleotide polymorphisms showed that the Haiti outbreak strain is genetically related to strains originating in India and Cameroon. However, because no identical genetic match was found among sequenced contemporary isolates, a definitive genetic origin for the outbreak in Haiti remains speculative.

  • Characterization of Toxigenic Vibrio cholerae from Haiti, 2010–2011 PDF Version [PDF - 248 KB - 8 pages]
    D. Talkington et al.
    View Summary

    A virulent clone from Africa or southern Asia was likely introduced at a single time point.

       View Abstract

    In October 2010, the US Centers for Disease Control and Prevention received reports of cases of severe watery diarrhea in Haiti. The cause was confirmed to be toxigenic Vibrio cholerae, serogroup O1, serotype Ogawa, biotype El Tor. We characterized 122 isolates from Haiti and compared them with isolates from other countries. Antimicrobial drug susceptibility was tested by disk diffusion and broth microdilution. Analyses included identification of rstR and VC2346 genes, sequencing of ctxAB and tcpA genes, and pulsed-field gel electrophoresis with SfiI and NotI enzymes. All isolates were susceptible to doxycycline and azithromycin. One pulsed-field gel electrophoresis pattern predominated, and ctxB sequence of all isolates matched the B-7 allele. We identified the tcpETCIRS allele, which is also present in Bangladesh strain CIRS 101. These data show that the isolates from Haiti are clonally and genetically similar to isolates originating in Africa and southern Asia and that ctxB-7 and tcpETCIRS alleles are undergoing global dissemination.

Historical Reviews

  • Cholera in Haiti and Other Caribbean Regions, 19th Century PDF Version [PDF - 180 KB - 6 pages]
    D. Jenson and V. Szabo
    View Summary

    Epidemic cholera did not occur in Haiti before 2010.

       View Abstract

    Medical journals and other sources do not show evidence that cholera occurred in Haiti before 2010, despite the devastating effect of this disease in the Caribbean region in the 19th century. Cholera occurred in Cuba in 1833–1834; in Jamaica, Cuba, Puerto Rico, St. Thomas, St. Lucia, St. Kitts, Nevis, Trinidad, the Bahamas, St. Vincent, Granada, Anguilla, St. John, Tortola, the Turks and Caicos, the Grenadines (Carriacou and Petite Martinique), and possibly Antigua in 1850–1856; and in Guadeloupe, Cuba, St. Thomas, the Dominican Republic, Dominica, Martinique, and Marie Galante in 1865–1872. Conditions associated with slavery and colonial military control were absent in independent Haiti. Clustered populations, regular influx of new persons, and close quarters of barracks living contributed to spread of cholera in other Caribbean locations. We provide historical accounts of the presence and spread of cholera epidemics in Caribbean islands.

Dispatches

  • Risk Factors Early in the 2010 Cholera Epidemic, Haiti PDF Version [PDF - 186 KB - 3 pages]
    K. A. O’Connor et al.
       View Abstract

    During the early weeks of the cholera outbreak that began in Haiti in October 2010, we conducted a case–control study to identify risk factors. Drinking treated water was strongly protective against illness. Our results highlight the effectiveness of safe water in cholera control.

  • Rapid Assessment of Cholera-related Deaths, Artibonite Department, Haiti, 2010 PDF Version [PDF - 273 KB - 4 pages]
    J. A. Routh et al.
       View Abstract

    We evaluated a high (6%) cholera case-fatality rate in Haiti. Of 39 community decedents, only 23% consumed oral rehydration salts at home, and 59% did not seek care, whereas 54% of 48 health facility decedents died after overnight admission. Early in the cholera epidemic, care was inadequate or nonexistent.

  • Epidemic Cholera in a Crowded Urban Environment, Port-au-Prince, Haiti PDF Version [PDF - 181 KB - 4 pages]
    S. E. Dunkle et al.
    View Summary

    Cholera is a problem in areas where sanitation is poor and clean water is scarce. Such were the conditions in Port-au-Prince, Haiti, after the January 2010 earthquake destroyed the city’s vital water and sanitation infrastructure. By the time the cholera epidemic hit, >1 million people were living in camps or crowded slums, where poverty, poor nutrition, and inadequate water and sanitation were the norm. A recent study conducted in Port-au-Prince identified 3 actions that seemed to protect some persons from cholera: disinfecting drinking water, washing hands, and eating a diverse diet. The protective effects of clean water and handwashing are well known but the effects of the diverse diet might reflect higher socioeconomic status (more access to a variety of foods) or higher nutritional content (and subsequent health benefits), which may have helped prevent persons from getting sick.

       View Abstract

    We conducted a case–control study to investigate factors associated with epidemic cholera. Water treatment and handwashing may have been protective, highlighting the need for personal hygiene for cholera prevention in contaminated urban environments. We also found a diverse diet, a possible proxy for improved nutrition, was protective against cholera.

  • Toxigenic Vibrio cholerae O1 in Water and Seafood, Haiti PDF Version [PDF - 192 KB - 4 pages]
    V. R. Hill et al.
       View Abstract

    During the 2010 cholera outbreak in Haiti, water and seafood samples were collected to detect Vibrio cholerae. The outbreak strain of toxigenic V. cholerae O1 serotype Ogawa was isolated from freshwater and seafood samples. The cholera toxin gene was detected in harbor water samples.

  • Drug-Resistance Mechanisms in Vibrio cholerae O1 Outbreak Strain, Haiti, 2010 PDF Version [PDF - 276 KB - 4 pages]
    M. Sjölund-Karlsson et al.
    View Summary

    Drug-resistant cholera is a global health concern; infections with drug-resistant strains can be more difficult to treat. Although the main treatment for cholera is replacing the fluid lost through diarrhea, the volume and duration of diarrhea can be reduced with antimicrobial drugs. Resistance to these drugs, however, has been emerging and has been found in the cholera strain that caused the outbreak in Haiti. A study of the genetic mechanisms behind this resistance showed that the Haiti strain carries several drug-resistance genes. Continued monitoring of resistance in the cholera bacteria in Haiti is necessary to know if further resistance develops and to guide antimicrobial drug–use policy if it does.

       View Abstract

    To increase understanding of drug-resistant Vibrio cholerae, we studied selected molecular mechanisms of antimicrobial drug resistance in the 2010 Haiti V. cholerae outbreak strain. Most resistance resulted from acquired genes located on an integrating conjugative element showing high homology to an integrating conjugative element identified in a V. cholerae isolate from India.

  • Cholera Management and Prevention at Hôpital Albert Schweitzer, Haiti PDF Version [PDF - 189 KB - 3 pages]
    S. Ernst et al.
       View Abstract

    In October 2010, Hôpital Albert Schweitzer Haiti treated some of the first patients with cholera in Haiti. Over the following 10 months, a strategic plan was developed and implemented to improve the management of cases at the hospital level and to address the underlying risk factors at the community level.

  • Knowledge, Attitudes, and Practices Related to Treatment and Prevention of Cholera, Haiti, 2010 PDF Version [PDF - 209 KB - 4 pages]
    V. E. De Rochars et al.
       View Abstract

    In response to the recent cholera outbreak, a public health response targeted high-risk communities, including resource-poor communities in Port-au-Prince, Haiti. A survey covering knowledge and practices indicated that hygiene messages were received and induced behavior change, specifically related to water treatment practices. Self-reported household water treatment increased from 30.3% to 73.9%.

  • Cholera Prevention Training Materials for Community Health Workers, Haiti, 2010–2011 PDF Version [PDF - 222 KB - 4 pages]
    A. Rajasingham et al.
       View Abstract

    Stopping the spread of the cholera epidemic in Haiti required engaging community health workers (CHWs) in prevention and treatment activities. The Centers for Disease Control and Prevention collaborated with the Haitian Ministry of Public Health and Population to develop CHW educational materials, train >1,100 CHWs, and evaluate training efforts.

  • Cholera in United States Associated with Epidemic in Hispaniola PDF Version [PDF - 173 KB - 3 pages]
    A. E. Newton et al.
    View Summary

    Sometimes history really does repeat itself. In the 1990s, increases in cholera in Latin America led to increasing numbers of cases in the United States. So, when the Haiti cholera epidemic began in 2010, experts expected to see an uptick in US cases. And they did. Since the Haiti epidemic began, 23 cases of imported cholera have been reported among those living in 8 US states—nearly 4 times the annual average in recent years. All but 1 patient had travelled to Haiti or the Dominican Republic, including 9 who attended a wedding in the Dominican Republic. (The nontraveler ate contaminated seafood brought back from Haiti by a relative). Most of the 23 US cholera patients had gone to Hispaniola to visit friends or relatives. Although the risk of spreading cholera to others in the United States is low, this study underscores the need to educate those visiting friends or relatives about steps they should take to prevent infection and importation of disease into the United States.

       View Abstract

    Cholera is rare in the United States (annual average 6 cases). Since epidemic cholera began in Hispaniola in 2010, a total of 23 cholera cases caused by toxigenic Vibrio cholerae O1 have been confirmed in the United States. Twenty-two case-patients reported travel to Hispaniola and 1 reported consumption of seafood from Haiti.

  • Travel Health Alert Notices and Haiti Cholera Outbreak, Florida, USA, 2011 PDF Version [PDF - 246 KB - 3 pages]
    M. U. Selent et al.
       View Abstract

    To enhance the timeliness of medical evaluation for cholera-like illness during the 2011 cholera outbreak in Hispaniola, printed Travel Health Alert Notices (T-HANs) were distributed to travelers from Haiti to the United States. Evaluation of the T-HANs’ influence on travelers’ health care–seeking behavior suggested T-HANs might positively influence health care–seeking behavior.

  • Multinational Cholera Outbreak after Wedding in the Dominican Republic PDF Version [PDF - 146 KB - 3 pages]
    M. L. Jiménez et al.
       View Abstract

    We conducted a case–control study of a cholera outbreak after a wedding in the Dominican Republic, January 22, 2011. Ill persons were more likely to report having consumed shrimp on ice (odds ratio 8.50) and ice cubes in beverages (odds ratio 3.62). Travelers to cholera-affected areas should avoid consuming uncooked seafood and untreated water.

Commentaries

Letters

Etymologia

Conference Summaries

About the Cover

Volume 17, Number 11—November 2011 - Continued

Research

  • Medscape CME Activity
    Deaths Associated with Pandemic (H1N1) 2009 among Children, Japan, 2009–2010 PDF Version [PDF - 253 KB - 8 pages]
    A. Okumura et al.
    View Summary

    Encephalopathy and unexpected cardiopulmonary arrest were the leading causes of death.

       View Abstract

    To clarify the cause of deaths associated with pandemic (H1N1) 2009 among children in Japan, we retrospectively studied 41 patients <20 years of age who had died of pandemic (H1N1) 2009 through March 31, 2010. Data were collected through interviews with attending physicians and chart reviews. Median age of patients was 59 months; one third had a preexisting condition. Cause of death was categorized as unexpected cardiopulmonary arrest for 15 patients, encephalopathy for 15, and respiratory failure for 6. Preexisting respiratory or neurologic disorders were more frequent in patients with respiratory failure and less frequent in patients with unexpected cardiopulmonary arrest. The leading causes of death among children with pandemic (H1N1) 2009 in Japan were encephalopathy and unexpected cardiopulmonary arrest. Deaths associated with respiratory failure were infrequent and occurred primarily among children with preexisting conditions. Vaccine use and public education are necessary for reducing influenza-associated illness and death.

  • Medscape CME Activity
    Global Distribution and Epidemiologic Associations of Escherichia coli Clonal Group A, 1998–2007 PDF Version [PDF - 308 KB - 9 pages]
    J. R. Johnson et al.
    View Summary

    This group was associated with the Western world, trimethoprim/sulfamethoxazole resistance, and diverse hosts/specimens.

       View Abstract

    Escherichia coli clonal group A (CGA) was first reported in 2001 as an emerging multidrug-resistant extraintestinal pathogen. Because CGA has considerable implications for public health, we examined the trends of its global distribution, clinical associations, and temporal prevalence for the years 1998–2007. We characterized 2,210 E. coli extraintestinal clinical isolates from 32 centers on 6 continents by CGA status for comparison with trimethoprim/sulfamethoxazole (TMP/SMZ) phenotype, specimen type, inpatient/outpatient source, and adult/child host; we adjusted for clustering by center. CGA prevalence varied greatly by center and continent, was strongly associated with TMP/SMZ resistance but not with other epidemiologic variables, and exhibited no temporal prevalence trend. Our findings indicate that CGA is a prominent, primarily TMP/SMZ-resistant extraintestinal pathogen concentrated within the Western world, with considerable pathogenic versatility. The stable prevalence of CGA over time suggests full emergence by the late 1990s, followed by variable endemicity worldwide as an antimicrobial drug–resistant public health threat.

  • Group A Streptococcus emm Gene Types in Pharyngeal Isolates, Ontario, Canada, 2002–2010 PDF Version [PDF - 361 KB - 8 pages]
    P. R. Shea et al.
    View Summary

    Determination of emm variations may help improve vaccine design.

       View Abstract

    Group A Streptococcus (GAS) is a human-adapted pathogen that causes a variety of diseases, including pharyngitis and invasive infections. GAS strains are categorized by variation in the nucleotide sequence of the gene (emm) that encodes the M protein. To identify the emm types of GAS strains causing pharyngitis in Ontario, Canada, we sequenced the hypervariable region of the emm gene in 4,635 pharyngeal GAS isolates collected during 2002–2010. The most prevalent emm types varied little from year to year. In contrast, fine-scale geographic analysis identified inter-site variability in the most common emm types. Additionally, we observed fluctuations in yearly frequency of emm3 strains from pharyngitis patients that coincided with peaks of emm3 invasive infections. We also discovered a striking increase in frequency of emm89 strains among isolates from patients with pharyngitis and invasive disease. These findings about the epidemiology of GAS are potentially useful for vaccine research.

  • Medscape CME Activity
    Close Similarity between Sequences of Hepatitis E Virus Recovered from Humans and Swine, France, 2008−2009 PDF Version [PDF - 433 KB - 8 pages]
    J. Bouquet et al.
    View Summary

    Autochthonous human infection may result from consumption of pork products such as raw liver.

       View Abstract

    Frequent zoonotic transmission of hepatitis E virus (HEV) has been suspected, but data supporting the animal origin of autochthonous cases are still sparse. We assessed the genetic identity of HEV strains found in humans and swine during an 18-month period in France. HEV sequences identified in patients with autochthonous hepatitis E infection (n = 106) were compared with sequences amplified from swine livers collected in slaughterhouses (n = 43). Phylogenetic analysis showed the same proportions of subtypes 3f (73.8%), 3c (13.4%), and 3e (4.7%) in human and swine populations. Furthermore, similarity of >99% was found between HEV sequences of human and swine origins. These results indicate that consumption of some pork products, such as raw liver, is a major source of exposure for autochthonous HEV infection.

  • Dynamics of Cholera Outbreaks in Great Lakes Region of Africa, 1978–2008 PDF Version [PDF - 877 KB - 9 pages]
    D. B. Nkoko et al.
    View Summary

    Outbreaks fluctuate on the basis of season, rainfall, plankton bloom, and fishing activities.

       View Abstract

    Cholera outbreaks have occurred in Burundi, Rwanda, Democratic Republic of Congo, Tanzania, Uganda, and Kenya almost every year since 1977–1978, when the disease emerged in these countries. We used a multiscale, geographic information system–based approach to assess the link between cholera outbreaks, climate, and environmental variables. We performed time-series analyses and field investigations in the main affected areas. Results showed that cholera greatly increased during El Niño warm events (abnormally warm El Niños) but decreased or remained stable between these events. Most epidemics occurred in a few hotspots in lakeside areas, where the weekly incidence of cholera varied by season, rainfall, fluctuations of plankton, and fishing activities. During lull periods, persistence of cholera was explained by outbreak dynamics, which suggested a metapopulation pattern, and by endemic foci around the lakes. These links between cholera outbreaks, climate, and lake environments need additional, multidisciplinary study.

Dispatches

Letters

Books and Media

Corrections

News and Notes

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