Meeting Cholera's Challenge to Haiti and the World: A Joint Statement on Cholera Prevention and Care

This joint statement argues for a comprehensive, integrated cholera response in Haiti. The cholera epidemic in Haiti is particularly devastating because of the vulnerability of Haiti's population after the January 12, 2010, earthquake, the long-standing weakness of its health, water, and sanitation systems, and the observed virulence of the El Tor hybrid strain. From October 19, 2010-when the first cases were confirmed in the National Public Health Laboratory-to April 4, 2011, 274,418 cases of cholera and 4,787 deaths related to cholera had been reported across all ten departments of Haiti [1]. The Haitian Ministere de la Sante Publique et de la Population (MSPP, the Ministry of Health) and the Direction Nationale de l'Eau Potable et de l'Assainissement (DINEPA, the government body charged with water and sanitation) have, with the support of many nongovernmental and international groups, made great strides against cholera. Case-fatality rates have dropped to 2.1% from 7% at the outset of the epidemic (and up to 10% in certain regions); incidence has also declined across Haiti, according to recent reports [1]. But fewer cases in the dry season (November-April) should not lead to complacency: seasonal variation is expected in epidemics of waterborne disease. Some have raised doubts about the sustainability of free water distribution within internally displaced persons (IDP) camps. But we believe that such efforts are an essential service that has contributed to the relatively few cases of cholera in the camps (as compared to other urban and rural areas). Given the likelihood of case resurgence and endemicity of cholera in Haiti, this document argues for a comprehensive, integrated strategy for cholera prevention and care in Haiti. We must reduce suffering and preventable death in the short term, and we must build effective water, sanitation, and health delivery infrastructure to fortify Haiti against cholera and other diseases of poverty in the long term. The document identifies three principal goals. First, we must continue aggressive case finding and scale up treatment efforts, including oral rehydration therapy, intravenous rehydration, antibiotic therapy (for moderate and severe cases), and complementary supplementation with zinc and vitamin A. Second, we must shore up Haiti's water infrastructure by building systems for consistent chlorination and filtration at public water sources and by distributing point-of-use water purification technologies. We must also strengthen sanitation infrastructure by improving and expanding waste management facilities (such as sewage systems and latrines) and waste monitoring. Third, we must link prevention to care by bolstering surveillance, education campaigns (about hand-washing, for example), and water, sanitation, and hygiene (WASH) efforts. Prevention must also include advocacy for scaled-up production of cholera vaccine and the development of a vaccine strategy for Haiti. A vaccination campaign should be implemented if adequate vaccine and resources can be mobilized without undermining efforts to treat acutely ill patients or strengthen water and sanitation infrastructure. This document identifies key challenges and outlines the components of a comprehensive cholera response to aid medical and public health practitioners in Haiti and elsewhere. With leadership from the Haitian government, we must work together to bolster responses to the acute problem of cholera today and strengthen Haiti's health, water, and sanitation infrastructure to prevent similar outbreaks in the future.