[Source: Pan American Health Organization, Regional Office of the World Health Organization, full PDF document (LINK). Extract, edited.]
HEALTH CLUSTER BULLETIN - CHOLERA OUTBREAK IN HAITI – THURSDAY, NOVEMBER 11, 2010 – #1
More than 70 organizations are working in the response to the cholera outbreak in Haiti, including ICRC, MSF, MDM, Merlin, International Medical Corps, PIH, Save the Chldren as well as UN agencies and bilateral organizations.
The Pan American Health Organization (PAHO/WHO) coordinates the Health Cluster.
Dr. Dana van Alphen + (509) 3612-5351, Mr. Sam Vigersky + (509) 3106- 6764, Ms. Isabel López + (509) 3816-7300 .
Health Cluster partners are asked to contribute to this bulletin with information on needs and activities as well as corrections to content, by emailing firstname.lastname@example.org (subject heading: Health Cluster Bulletin). For useful information on meetings, guidelines, and health facility locations, visit: http://haiti.humanitarianresponse.info
Cholera continues to spread as response scales up
The cholera outbreak continues to spread throughout Haiti, impacting five departments and tens of thousands of lives. On November 11, the Ministry of Public Health (MSPP) released the latest case count: 796 deaths and 12,303 hospitalized cases (as of November 10). These numbers reflect data sent by the departments to the Directorate of Epidemiology and now include cases reported by NGOs and the Cuban medical mission.
Health partners are preparing for growing numbers of cases in currently affected areas, as well as in areas not yet affected. Scientific consensus suggest that now that cholera vibrio has a foothold in the environment it could impact Haiti for a number of years.
Outbreaks in remote rural areas are of special concern, both because there are fewer resources to treat cases and due to lack of infrastructure to implement cholera prevention measures.
The government and its partners are in the process of setting up 10 new cholera treatment centers (CTCs) for severe cases, each with a capacity of 100 to 400 beds, and have strengthened hospitals with cholera treatment units (CTUs). Most cholera cases are treatable with oral rehydration at community-level facilities, using oral rehydration salts (ORS). Prevention messages and chlorine tablets to disinfect water supplies are being distributed in both urban and rural areas.
Médecins Sans Frontières (MSF) reported on November 10 that, over the previous three days, more than 200 people suffering from severe diarrhea (a clinical symptom consistent with cholera) had been treated in Port-au-Prince by medical teams supporting MSPP facilities or working in their own independent medical facilities.
These reports coincide with laboratory confirmation of the first cases of cholera in Port-au-Prince, reported on November 9. Health partners have been preparing for this development over the last several weeks and are continuing to build capacity for treatment. Health promotion activities are ongoing, and training at the community level is being provided to reinforce public information strategies.
The UN Health Cluster is holding regular meetings to coordinate cholera response operations, and a small committee of NGOs operating CTCs has been formed. The Health, WASH and Camp Coordination Management clusters have developed an operational plan to ensure a predictable and coordinated response to the outbreak. This plan is intended to support MSPP and other government ministries in carrying out the National Cholera Response Plan. Both the Health and WASH clusters will carry out activities in health centers (CTCs, CTUs, oral rehydration centers) and for prevention in community settings, including in Internally Displaced Person Sites coordinated by Camp Coordination/Camp Management (CCCM) Cluster.
HEALTH CLUSTER RESPONSE
The National Response Strategy
The MSPP has developed a national strategy to respond to the cholera epidemic. It aims to protect families at the community level; strengthen primary health centers already operating across the nation; and establish a network of CTCs and strengthen hospitals for treatment of severe cases.
Cholera Treatment Centers (CTC), Cholera Treatment Units (CTU), and Oral Rehydration Centers (ORC)
The Health Cluster is maintaining a list of sites throughout the country, updated daily and shared with Health Cluster partners to coordinate response operations.
Currently, cholera services are being organized at three levels: CTCs, which are large stand-alone tents with an average capacity of 100-400 beds (currently 1,000 beds for the PaP metropolitan area); CTUs, which are typically in or next to health facilities and have a smaller capacity than CTCs (usually 15-20 beds); and ORCs (roughly 300 nationwide), which are to treat patients with non-life-threatening conditions. The CTUs are designed to allow hospitals or health centers to continue to function while providing care for cholera patients. The CTUs prevent the hospitals and healthcare centers from being overwhelmed and ensure that non-cholera patients are able to access cholera treatment. The need to develop CTUs was a lesson learned from St. Marc, where health facilitates were quickly overwhelmed by cholera patients.
The CTUs and rehydration centers are anticipated to serve as a first point of entry for those with acute severe watery diarrhea. Patients will either be stabilized and sent home or referred to CTCs for more treatment.
Training on case management will be provided in all of the CTUs in Port-au-Prince; training has already been provided in five of 14 sites. Training on water and sanitation will also be provided. While protocols already exist, training is essential in a country that has no recent experience with cholera.
MSF is supporting two MSPP hospitals in the Artibonite region (where the cholera outbreak originated), with teams in the main hospitals of St. Marc and Petite Riviere. Medical supplies including intravenous (IV) fluids, catheters, and oral rehydration salts as well as chlorine for disinfection, are also being provided.
To bolster health clinics in some of the more outlying areas in Haiti’s north and center—in places such as Gros Morne—MSF is supplying IV solution, ORS, IV sets, and hygiene materials. Supplies have also been provided to the hospital in the town of Port de Paix in the country’s far north.
Medecins du Monde (MDM)-Spain, which was already in Petit-Goave working on a sexual and reproductive health program with six dispensaries in the area, has established a triage and cholera treatment unit at the hospital as well as a field space 2 kilometers from the hospital. MDM is reporting its medical cases through the Cuban medical mission.
The Cuban medical mission, which includes both Cubans and Haitians trained in Cuba, has 252 staff active in the response: 118 doctors, 78 nurses, and 56 others (technicians, lab, engineers). This group is working in sites where CTUs are already operating or are planned. They are also part of the epidemic team supporting the MSPP, and PAHO/WHO is providing them with supplies and materials.
MSF-France is supporting the CTC in Gonaïves as well as health sites running north to Port de Paix, including Gros Morne, Bassin Bleu community health center, and the hospital at Port de Paix. The Cubans are active in both Gonaïves and St. Marc, where their presence predates the cholera outbreak. PAHO/WHO has deployed a field team to Gonaïves, with experts on case management, field epidemiology, and disaster management. They are undertaking assessments of hospitals and strengthening coordination of operations. The team carried with them two tons of medical supplies, including IV fluids, ORS, and antibiotics. In Gonaïves, UNICEF field coordination staff met with childprotection partners and facilitated a training workshop on cholera prevention (conducted by Save the Children) for staff working in residential care centers. The planned CTC in Gonaives – Raboteau – was put on hold due to Hurricane Tomas, but building will resume now that the storm has passed.
The North, Northeast and Northwest departments have received kits with enough medicines and supplies to care for 60,000 people for one month; another kit with enough medicines for 50 people was given to the Sisters of Charity of Port de Paix. PAHO/WHO coordinated with the MSPP to ensure adequate supply of ORS to Gros Morne, Bassin bleu and Port-de-Paix, in the Artibonite and Northwest departments.
A health cluster is coordinating response activities in Cap Haïtien, and PAHO/WHO, which has a fiveperson team in Cap Haïtien, is working to implement a plan whereby drugs and supplies are dropped into rural locales in collaboration with the MSPP. The plan, which includes human resources, will help provide essential care to those cut off from hospitals and health centers. Preliminary planning is under way to have a CTU in Ouanaminte, along the border with the Dominican Republic.
Preventing the spread of cholera and treating people who have diarrhea effectively will depend in large measure on health promotion activities. The Health and WASH clusters are working collaboratively to provide technical support to the Ministries of Health, Education, and Communication. A health promotion strategy has been developed to inform the population about the cholera outbreak and prevention measures. The strategy includes sensitization messages about food handling, hand hygiene, and actions to be taken in case of diarrhea, including how to take ORS at home.
Implementation plans now include harnessing the network of community based groups, including the Catholic Church, the Confederation of Evangelist and Anglican churches, and the voodoo network to disseminate health information.
At the beginning of the cholera outbreak, a communication plan with messages for the public through print media, TV, radio, SMS, and trainings was developed. A call-in hotline for cholera questions was set up by the Ministry of Communication and the Health Cluster and has been used to provide information to the general population. The hotline has also facilitated an understanding of the public’s information needs, which in turn helps guide adjustments in the communication strategy.
In addition, an SMS campaign was developed in partnership with Digicel. In total, five messages were broadcast to cell phone users, including information on how to continue to breastfeed, how to treat water, how to find a health center, and proper hand washing. Twelve audio messages were developed for radio spots, with themes similar to the SMS campaign but also including information on how to wash vegetables with treated water, how to properly use prepackaged ORS, how to prepare homemade ORS solutions with sugar and salt, the proper ways to dispose of excreta and clean toilets.
Two detailed posters were produced that graphically depict information broadcast over SMS and in radio spots. As of Monday, 8 November, 40,000 of these two posters were being distributed throughout Haiti by MSPP, DINEPA, ACF, MSF, MCC, Save the Children, MDM, and PAHO/WHO.
A brochure that supports the poster content in greater detail is being finalized, as is a poster specifically aimed at health workers, which will provide key messages and instructions on dealing with cholera cases.
PAHO/WHO and other UN agencies are working to ensure that all relevant ministries adopt a universal communication strategy as outlined above to avoid inconsistencies. The goal is to have, for example, the Ministry of Education promote the same messages in schools as the Ministry of Communication is promoting over the airwaves. In the weeks ahead, government agencies and health partners will be working to develop other multimedia tools to reinforce cholera prevention and treatment messages.
MSPP and PAHO/WHO are working on training for community health promoters, with promotional materials based on a book of images and important cholera-related messages for sensitizing the population. Key messages cover hand washing, the use of ORS, and other sanitation measures. The manuals will be finished in the next few days and sent to departments for training to begin.
WASH CLUSTER RESPONSE
WASH partners are supporting the 14 hospitals in Port au Prince as well as hospitals in other parts of the country that have been identified for CTUs, to ensure they have WASH services including water, latrines, and disinfection procedures and supplies.
WASH partners are organizing a collection system for excreta from CTCs and CTUs. There will also be training for personnel on infection control in CTC and CTU sites. Instructions on disinfection using WHO guidelines are being provided.
Finally, estimations of WASH supplies and equipment are being developed to cover the 40 hospitals and 300 healthcare facilities where CTUs and rehydration centers are planned nationwide.
PROMESS, the government warehouse for essential medicines and supplies (managed by PAHO/WHO) has released standard operating procedures for procurement and distribution of supplies. Institutions and NGOs requesting cholera-related medicines are requested to contact PROMESS and provide details on their needs. Partners can contact the Health Cluster (see box page 1) with questions in this regard.
The Master Cholera Response Packing List for CTCs and CTUs has been developed by MSPP, PAHO/WHO, UNICEF and other health partners. The list includes items for infection control (chlorine, disinfectant, sprayers), treatment support (waste bags, buckets), module installation (plastic sheeting, ropes, tents, cholera beds), water distribution (water tanks/bladders) and treatment and consumables (ORS, IV fluids, antibiotics, soap). These supplies will be distributed to 14 hospitals in Port-au-Prince.
GAPS & NEEDS
Health authorities in the Artibonite department report the following needs to respond to the cholera epidemic: 1,000,000 water purification tablets, 100,000 sachets of oral rehydration salts, 1,500 body bags, 150 45-kilogram drums of chlorine powder (which must be administered by trained experts) and other medical supplies.
Management of Dead Bodies
The Haitian Red Cross has provided guidelines for the management of dead bodies, which include standardized disinfection measures. However, once a body has been disinfected, procedures need to be adapted at the local level for where the body goes, including the role of mortuaries. A message went from MSPP to mayors’ offices nationwide yesterday on the management of dead bodies, detailing strategies to most effectively limit transmission of cholera.
Health promotion should be included in each area of intervention to provide information about cholera prevention measures. Implementing partners should contact the Health Cluster to help bridge gaps and acquire resources such as training manuals and posters. Going forward, health partners will develop initiatives and interventions at the community level that take account of the customs of the population.
Water and Sanitation
WASH human resources will be needed to staff health centers, including CTCs and CTUs, and will need to be trained in WASH-related functions. Adequate water and sanitation should be ensured before new cases arrive.