Partners in Health Haiti Continues to Battle Cholera Outbreak

Situation at a glance

After more than 3 years with no reported cases of cholera in Haiti, on 2 October 2022, the national authorities reported two confirmed cases of Vibrio cholerae O1 in the greater Port-au-Prince area.

The current cholera outbreak is taking place in Port-au-Prince and Cité Soleil. These are areas that are experiencing civil unrest with several thousand people having been displaced as a result of the increase in violence.

Description of the cases

Between 25 September and 8 October 2022, the Haiti Ministry of Public Health and Population (MSPP per its acronym in French) reported 32 laboratory-confirmed cases of Vibrio cholerae (including two identified as serogroup O1), and 224 suspected cases from Port-au-Prince and Cité Soleil. A total of 189 cases have been hospitalized, of which 16 deaths have been reported. Of the total reported cases, 55% are males and 49% are aged 19 years or younger. The most affected age group is 1 to 4-year-olds (Figure 3).

The first cholera outbreak was reported in Haiti in October 2010. Nationally, a total of 820 000 cases of cholera including 9792 deaths were reported between October 2010 and February 2019 (Figure 4). The last confirmed case of cholera was reported in January 2019 in I'Estère in the Artibonite department of Haiti. The country did not report a single confirmed case of cholera in the three years from January 2019 to January 2022.

Epidemiology of Cholera

Cholera is an acute enteric infection caused by ingesting the bacteriaVibrio cholerae present in contaminated water or food. It is mainly linked to inadequate sanitation and insufficient access to safe drinking water. It is an extremely virulent disease that can cause severe acute watery diarrhoea resulting in high morbidity and mortality, and can spread rapidly, depending on the frequency of exposure, the exposed population and the setting. Cholera affects both children and adults and can be fatal if untreated.

The incubation period is between 12 hours and five days after ingestion of contaminated food or water. Most people infected withV. cholerae do not develop any symptoms, although the bacteria are present in their faeces for 1-10 days after infection and are shed back into the environment, potentially infecting other people. Among people who develop symptoms, the majority have mild or moderate symptoms, while a minority develop acute watery diarrhoea with severe dehydration. Cholera is an easily treatable disease. Most people can be treated successfully through prompt administration of oral rehydration solution (ORS).

The consequences of a humanitarian crisis – such as disruption of water and sanitation systems, or the displacement of populations to inadequate and overcrowded camps – can increase the risk of cholera transmission, should the bacteria be present or introduced.

A multisectoral approach including a combination of surveillance, water, sanitation and hygiene, social mobilization, treatment, and oral cholera vaccines is essential to control cholera outbreaks and to reduce deaths.

Public health response

Emergency response activities are being conducted by the Ministry of Health, WHO and other partners as below.

• The Incident Management Support Team (IMST) has been activated for outbreak response activities
• Regular epidemiological alerts are being published by WHO for enhanced information sharing and wider community awareness about the current epidemiological situation.
• Updated information on the event has been provided to the other Member States through the International Health Regulations (IHR) National Focal Points (NFPs) network.
• Support has been provided to Haiti health authorities for control and response actions as well as resources such as cholera kits.
• Event-based surveillance has been strengthened to monitor official and unofficial reports for information regarding the local situation.
• The multisectoral response plan has been developed with a focus on case management, water, hygiene and sanitation (WASH), vaccination, communication and psychosocial support, strengthening preparedness in unaffected departments, and advocating to improve security conditions to facilitate the response.
• WHO is working in coordination with the public health authorities to characterize this event and support the response.

WHO risk assessment

The current cholera outbreak in Haiti, combined with the ongoing crisis related to gang violence, social unrest, and insecurity, has strained the health system's response capacity. In addition, the country is highly vulnerable and at risk of natural hazards, which have exacerbated previous humanitarian crises.

The overall risk assessed for this outbreak is very high at the national level, due to the following reasons:

1. The current socio-economic situation, ongoing humanitarian crisis and poor health conditions are affecting a large proportion of the population leaving them vulnerable to the risk of cholera infection and recurrence of cholera.
2.  In the affected areas of Port-au-Prince metropolitan area and southern departments, there are 24 200 internally displaced people who have been displaced due to gang violence.
3. Limited access of the general population to safe drinking water and to sanitation facilities.
4. Due to the insecurity, the public health system and international partners have limited human resources in Haiti, reducing the capacity to respond.
5. Logistics issues and lack of access to fuel and insecurity lead to difficulties to import supplies and challenges to access the affected areas. Therefore, timely assessment of the epidemiological situation is complex. Additionally, for the same reasons the shipment of biological samples from healthcare facilities to reference laboratories could also be hampered.

The risk at the regional level is assessed as moderate, due to the following reasons:

1. Since 2010, confirmed cases of cholera have predominantly been reported from Haiti, followed by the Dominican Republic, Cuba, and Mexico.
2. Sporadic imported cases have also been reported in other countries in the Region. However, there is greater capacity in other countries to detect and control outbreaks of cholera. Neighboring Dominican Republic which is likely the most at risk of an increase in cases, has the capacity to detect and control cholera.

The risk at the global level was assessed as low.

WHO will continue to evaluate the epidemiological situation in Haiti.

WHO advice

WHO recommends improving access to proper and timely case management of cholera cases, improving access to safe drinking water and sanitation infrastructure, as well as improving infection, prevention, and control in healthcare facilities. These measures along with the promotion of preventive hygiene practices and food safety in affected communities are the most effective means of controlling cholera. Targeted public health communication messages are a key element for a successful campaign.

Oral cholera vaccine (OCV) should be used in conjunction with improvements in water and sanitation to control cholera outbreaks and for prevention in targeted areas known to be at high risk for cholera.

Given the re-emergence of cholera in Haiti, WHO recommends that Member States strengthen and maintain surveillance for cholera for the early detection of suspected cases and to provide adequate treatment and prevent its spread. Early and adequate treatment limits the case fatality ratio (CFR) of hospitalized patients to less than 1%.

WHO does not recommend any travel or trade restrictions on Haiti based on the currently available information.

Further information

• Pan American Health Organization / World Health Organization. Epidemiological Alert Resurgence of cholera in Haiti. 2 October 2022, Washington, D.C.: PAHO/WHO; 2022: https://bit.ly/3M1F9Jk
• Pan American Health Organization / World Health Organization. Epidemiological Update - Resurgence of cholera in Haiti - 7 October 2022, Washington, D.C.: PAHO/WHO; 2022: https://bit.ly/3CqR4f8
• Haiti Ministère de la Santé Publique et de la Population (MSPP): Report of cholera cases in Port-au-Prince, Haiti: 1 October 2022. Available at: https://bit.ly/3UWGkhm
• MSPP  Direction of Epidemiology, Laboratories and Research (DELR). Report of the National Surveillance Network Cholera. SE 11 of 2019 (10 to 16 March 2019).Available at:https://bit.ly/3rGdJiV
• Weekly Epidemiological Bulletin. Cholera Annual Report 2021. WHO. Available at: https://apps.who.int/iris/handle/10665/362858
• Weekly Epidemiological Bulletin. Cholera Annual Report 2019. WHO. Available at: https://apps.who.int/iris/handle/10665/334242
• Epidemiological Update: Cholera – 11 October 2018, Washington, DC; PAHO/WHO. Available at: https://bit.ly/3RwfJVo
• Epidemiological Update: Cholera – 6 August 2018, Washington, DC; PAHO/WHO. Available at: https://bit.ly/3Sv3jhN
• WHO cholera information. Available at: https://www.who.int/news-room/fact-sheets/detail/cholera
• PAHO Health Topics: Cholera. Available at: https://www.paho.org/en/topics/cholera
• PAHO/WHO. Cholera cases in the Americas since 1987. Available at: https://ais.paho.org/phip/viz/ed_colera_casesamericas.asp
• PAHO/WHO. Recommendations for the clinical management of cholera. 2010. Available at: https://bit.ly/3RthjXZ
• OCHA. United Nations Office for the Coordination of Humanitarian Affairs. Haiti: Impact of social unrest on the humanitarian situation – Flash Update #1 As of 22 September 2022. https://bit.ly/3SInn00
•  UNICEF. Humanitarian Situation Report #1. Reporting Period: 1 January to 30 June 2022. https://www.unicef.org/media/126286/file/Haiti-Humanitarian-SitRep-June-2022.pdf
• OCHA. United Nations Office for the Coordination of Humanitarian Affairs. HAITI Fuel crisis and social unrest: Impact on the humanitarian situation. As of 29 September 2022. Available at: https://bit.ly/3Elf6uG

Citable reference: World Health Organization (12 October 2022). Disease Outbreak News; Cholera - Haiti. Available at: https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON415

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Source: https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON415

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