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Haiti Cholera Update #17

The latest MSPP (Ministère de la Santé Publique et de la Population) report as of 24 November 2010 showed 72,017 cases of cholera accounting for1,648 deaths since the outbreak began. There have been 31,210 hospitalizations. The hospital mortality rate is 3.6%. Cholera promptly treated has a mortality rate of 1-2%. There are reasons  to believe, as noted below, that these numbers are suspect.

At less than 48 hours of the elections, the last official assessment of the Ministry of Public Health and Population (MSPP) for the Wednesday 24 and published on Friday 26 indicates that for the area of Port-au-Prince region Metropolitan (Port-au-Prince, Carrefour, Cité Soleil, Delmas, Kenscoff, Petion-Ville, Port-au-Prince, Croix des Bouquets and Tabarre) there was 0 death and 0 hospitalization between November 23 and 24… Already yesterday, we had questioned the validity of the mortality figures published by the Ministry , which indicated an increase in deaths abnormally low +0.4%, whereas in the previous 48 hours (November 21 and 22) the death rate average was +23.68% per day.

Knowing that health personnel in the ground, informs us that the area of Port-au-Prince represents nearly 50% of cholera cases, the only explanation to this brutal and instantaneous stop of the epidemic, must find its answer in political reasons and not in treatment efficacy (unfortunately).

This article obliged me to go back and look at earlier reports. From November 17 to 23, the cumulative number of hospitalizations in Port-au-Prince increased from 1,457 to 3,097. The cumulative number of deaths rose from 64 to 146.

But something’s wrong with the cumulative totals:
11/19: 1,618 hospitalizations; 77 deaths
11/20: 2,140 (h); 95 (d)
11/21: 2,066 (h); 85 (d)
11/22: 2,866 (h); 140 (d)
11/23: 3,097 (h); 146 (d)
11/24: 3,097 (h); 146 (d)

We see a sharp jump in hospitalizations and deaths on November 20, then a drop in hospitalizations and deaths the next day. That makes no sense.

Then hospitalizations and deaths both jump on the 22nd, rise a bit more on the 23rd, and then stop on the 24th. Apart from these updated numbers, the Ministry has offered no interpretation or analysis.

  • Jon Kim Andrus, Deputy Director Pan American Health Organization (PAHO), presser, 23 November 2010. (Transcript ~ YouTube) The situation, he says, is bad, and there are no resources, either human or material:

We believe certain critical issues need to be addressed if our efforts to treat patients and save lives are to be successful. Safe water and sanitation are lacking. In the short term, efforts must focus on distributing chlorine tablets as well as oral rehydration salts to everyone. In the long term, we must create the systems and infrastructure to ensure equitable access to these basic services.

Official reports confirm 8 of 10 departments with cases of cholera. We know that in the other 2 departments, clusters of cases are now being investigated. So, for all intents and purposes, as we fully expected before, cholera is virtually everywhere in the country. Given the extremely poor sanitary conditions that existed well before the earthquake, the recent hurricane, and now the epidemic, we expect the number of cases to continue to grow. We have not yet reached a peak and we don’t know when that peak will occur.

[snip]

For many of us here, this brings up memories of the cholera epidemic that began in Peru in 1991 and spread to more than 16 countries in the Americas within two years.

Considering the intensity of travel and trade in the Americas, we know it’s difficult to prevent importations of isolated cases of cholera in other countries, but there are important steps that can be taken to prevent cholera from spreading and causing epidemics.

[snip]

We are working with other UN agencies and many NGOS to respond to the outbreak, but a lot more is needed, especially in providing safe water and adequate sanitation to Haitians particularly in Port-au-Prince and the provinces. About 58% of the population before this crisis lacked access to potable water. About 76% of Haitians earn less than $2 a day. We now know that about 1.6 million Haitians are living in precarious conditions, particularly those in the 1,300 displacement camps.

We must work together to manage the impact of this outbreak, particularly to minimize loss of life. This requires an integrated approach bringing together those who provide clean water, improve sanitary conditions, and those who provide treatment to the ill. We need more of everything: more training for staff in Haiti, more doctors, more nurses, more treatment centers, more medications, more toilets, more clean water.

We have asked for $164 million for this emergency, and so far have received about 10 percent of this amount. It is clear the country will need more funding. Our response, along with all the partners, has not been as rapid as we would like. The reason is that, even before the crisis, the country lacked the building blocks of health, which are water, sanitation, safe food, and adequate health services. Our aim is to help Haiti overcome these obstacles and build self-sufficiency in these vital areas. [Emphasis mine]

The head of the UN mission in Haiti (Minustah), Edmond Mulet, gave us last Saturday, one of his statements that he has the secret, to make us share his idyllic reading of the situation has 1 week of the elections. He says that presidential and parliamentary elections next Sunday will take place in a “Haitian climate calm, tranquil, serene, and without violence” (!!), adding “in the circumstances of Haiti”.

Should we understand if his words, that there are “Haitian circumstances” where the climate of violence may be considered “as serene or acceptable” according to its criteria? Of course, Mulet, skilful desinformator with the service of UN, was quick to qualify his remarks by stating “If we compare the current electoral process, the election campaign last year, or the 2006 presidential or even presidential before”. Compare with worse, does not justify the current situation of violence. Know Mulet one death is one death too many, and no level of violence in our country is unacceptable, violence does not trivialize.

The kind of movement and congregating you see with people going to vote is not the kind of movement that creates an increased risk of cholera transmission,” Andrus said. “Close contact does not put people at greater risk of cholera the way it would, for example, for flu.

As with any crisis or disaster of any etiology, blame is a common feature.  The same is true in infectious disease disasters, particularly when there is a strong suspicion of accidental (and potentially culpable) virgin soil introduction of an exotic agent.  Nigel Fisher’s recent comments on behalf of the United Nations are typical of a bureaucracy facing intense scrutiny that has not engaged in effective management of risk communication and public accountability.  The scrutiny is warranted.

If you want some understanding on how a disease which is easily treated is rapidy becoming a disaster, it’s a must-read.

About 1,000 trained nurses and at least 100 more doctors were urgently needed to control the epidemic, which has struck the impoverished Caribbean nation months after a destructive earthquake.

The outbreak has killed more than 1,400 Haitians in five weeks and the death toll is climbing by dozens each day.

“We clearly need to do more,” Valerie Amos, the U.N.’s Undersecretary-General for Humanitarian Affairs, told Reuters in Port-au-Prince during a visit seeking to increase the scale and urgency of the cholera response.

“But it’s not just money, it’s crucially people, in terms of getting more doctors, nurses, more people who can help with the awareness-raising and getting information out there,” she said in an interview late on Tuesday at the U.N. logistics base in Port-au-Prince.

The real death toll may be closer to 2,000, U.N. officials say. Hundreds of thousands of Haitians are likely to catch the disease, they say, and the epidemic could last a year, complicating an arduous recovery from the Jan. 12 earthquake.

I will post the next update Monday, or sooner if events warrant. (I apologize for the delay of a day with this one.) For more immediate updates, I highly recommend Crawford Killian at his blog H1N1.

More resources:

#Haiti Daily (Twitter newspaper)

Haiti Information Project.

Haiti: Operational Biosurveillance (Twitter)

H5N1

HaitiLibre (English) (français) (Twitter — English and French)

Mediahacker: Independent multimedia reporting from Haiti (Twitter) (Flikr)

Ministère de la Santé Publique et de la Population (Homepage) (Cholera Updates) (in French)

PAHO’s Haiti Cholera page. (PAHO Situation Reports and other documentation.) (Blog.)

Praecipio International (HEAS)

On the ground, good sources of information and of course needing donations:

Partners in Health (Twitter).

Médecins sans frontières

[Cross-posted at Those Emergency Blues]

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