An Epidemic after an Earthquake: The Cholera Outbreak in Haiti, Part 2

Written by Matt Fisher and Alisha Kramer

Ten months after suffering “the largest urban disaster in modern history” – a devastating 7.0-magnitude (MMS) earthquake on January 12, 2010 that killed over 316,000 and affected 3 million – Haiti faced an outbreak of cholera. Although the nation has made progress in controlling the outbreak, ending the epidemic requires a concerted, multi-sectoral effort from the Haitian government and its international partners: water, sanitation and hygiene (WASH) infrastructure needs to be (re)constructed; hygiene education needs to improve; and access to cholera treatment needs to be made universally accessible. To this end, PAHO, the Centers for Disease Control and Prevention (CDC), United Nations Children's Fund (UNICEF), and the Presidents of Haiti and the Dominican Republic recently called on the international community to invest in revitalizing Haiti’s WASH infrastructure; the “call to action” emphasized that controlling cholera “will only be possible” through investments in WASH infrastructure. Despite this high-level attention, Haiti faces a variety of challenges to rebuilding this infrastructure and preventing cholera from becoming endemic to the nation.

The Response

Haiti’s government was physically devastated by the earthquake: the natural disaster destroyed “twenty-eight of twenty-nine government ministry buildings,” including “the building housing the Haitian Ministry of Public Health and Population” and killed a large number of Haiti’s civil servants. Despite its physical devastation, the Haitian Ministry of Public Health and Population – aided by PAHO, the CDC, USAID, and other non-governmental organizations – responded relatively well to the cholera outbreak; the low case-fatality ratio supports this view. In addition, the Haitian National Directorate for Potable Water Supply and Sanitation (DINEPA), worked with non-governmental organizations, international groups, and government agencies to implement measures to improve access to clean water and adequate sanitation facilities.

Current WASH improvement efforts in Haiti are numerous and varied. On the national level, the distribution and administration of oral rehydration therapy is an effective and inexpensive treatment method for cholera infection. The Haitian government is also working to improve the nation’s WASH infrastructure through projects in both urban and rural areas. On a local scale, the construction of latrines; training of community health workers; distribution of soap, bleach, and water-purification tablets to households; and the launch of aggressive public hygiene education campaigns aim to reduce the risk of contracting cholera by halting its transmission. Through these education campaigns, individuals are encouraged to wash their hands; this public health intervention – when compared with point-of-use water treatment, sanitation improvements, and source water treatment – yields the greatest reduction in diarrheal morbidity.

An additional strategy has been the introduction of an oral cholera vaccine into Haiti. In January, 2012, Partners In Health (PIH), a particularly active non-profit organization working in Haiti, introduced a WHO-approved oral cholera vaccine  as part of its comprehensive package of prevention and treatment efforts. A vaccination campaign has the potential to play a key role in halting the transmission and stemming the tide of rapid cholera spread. However, some public health advocates contend that a vaccination campaign in Haiti may fail to end the cholera epidemic due to the vaccine’s multiple-dose requirement; the immense number of people who would require vaccination; the transitory immunity that the vaccine provides; and the possibility for gaps in vaccine distribution.

The Challenges

The recent “call to action” acknowledged that building WASH infrastructure in Haiti could cost upwards of $1 billion (USD): an immense sum, especially during this era of fiscal austerity. In addition, donors have already failed to fully honor their pledges to contribute financially to Haiti’s reconstruction. Even if the funds become available, building infrastructure requires a significant amount of time. However, despite the challenges of building adequate WASH facilities in Haiti, “without improving access to clean water and proper sanitation, cholera will undoubtedly keep coming back.”

While the long-term focus should be on constructing WASH infrastructure in order to prevent future cholera outbreaks, Haiti should continue utilizing effective, low-cost tactics for managing the cholera outbreak in the short-term – especially in light of the upcoming rainy season, when cases are predicted to spike as a result of flooding. Embracing the multi-faceted approach outlined in the recent “call to action” is essential; failure to do so risks worsening the cholera epidemic and increases the likelihood that the disease becomes endemic to Haiti.

Click here to read Part 1 about the origins of Haiti's cholera outbreak.

Alisha Kramer is an intern with the CSIS Global Health Policy Center; Matt Fisher is the project coordinator of the CSIS Project on Global Water Policy and a Research Assistant at the Global Health Policy Center

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