Global & Disaster Medicine

Archive for the ‘Cholera’ Category

Haiti: The United Nations’ strategy to fight the cholera epidemic (the “New Approach” )has failed to gain traction. A trust fund created to help finance the strategy has only about $2 million and only 6 of the 193 member states — Britain, Chile, France, India, Liechtenstein and South Korea — have donated.

NY Times

“…..Cholera, a waterborne bacterial scourge that can cause acute diarrhea and fatal dehydration if not treated quickly, has killed nearly 10,000 people and sickened nearly 800,000 in Haiti, the Western Hemisphere’s poorest country, since it was introduced there in 2010 by infected Nepalese members of a United Nations peacekeeping force. This year, as of late February, nearly 2,000 new cases had been reported, amounting to hundreds a week……”

 

 


Steven Johnson: How the “ghost map” helped end a killer disease

Steven Johnson

0:11If you haven’t ordered yet, I generally find the rigatoni with the spicy tomato sauce goes best with diseases of the small intestine.

0:21(Laughter)

0:23So, sorry — it just feels like I should be doing stand-up up here because of the setting. No, what I want to do is take you back to 1854 in London for the next few minutes, and tell the story — in brief — of this outbreak, which in many ways, I think, helped create the world that we live in today, and particularly the kind of city that we live in today. This period in 1854, in the middle part of the 19th century, in London’s history, is incredibly interesting for a number of reasons. But I think the most important one is thatLondon was this city of 2.5 million people, and it was the largest city on the face of the planet at that point. But it was also the largest city that had ever been built.

1:06And so the Victorians were trying to live through and simultaneously invent a whole new scale of living:this scale of living that we, you know, now call “metropolitan living.” And it was in many ways, at this point in the mid-1850s, a complete disaster. They were basically a city living with a modern kind of industrial metropolis with an Elizabethan public infrastructure. So people, for instance, just to gross you out for a second, had cesspools of human waste in their basement. Like, a foot to two feet deep. And they would just kind of throw the buckets down there and hope that it would somehow go away, and of course it never really would go away. And all of this stuff, basically, had accumulated to the point where the city was incredibly offensive to just walk around in.

1:57It was an amazingly smelly city. Not just because of the cesspools, but also the sheer number of livestock in the city would shock people. Not just the horses, but people had cows in their attics that they would use for milk, that they would hoist up there and keep them in the attic until literally their milk ran out and they died, and then they would drag them off to the bone boilers down the street. So, you would just walk around London at this point and just be overwhelmed with this stench. And what ended up happening is that an entire emerging public health system became convinced that it was the smell that was killing everybody, that was creating these diseases that would wipe through the city every three or four years.And cholera was really the great killer of this period.

2:41It arrived in London in 1832, and every four or five years another epidemic would take 10,000, 20,000 people in London and throughout the U.K. And so the authorities became convinced that this smell was this problem. We had to get rid of the smell. And so, in fact, they concocted a couple of early, you know,founding public-health interventions in the system of the city, one of which was called the “Nuisances Act,” which they got everybody as far as they could to empty out their cesspools and just pour all that waste into the river. Because if we get it out of the streets, it’ll smell much better, and — oh right, we drink from the river. So what ended up happening, actually, is they ended up increasing the outbreaks of cholera because, as we now know, cholera is actually in the water. It’s a waterborne disease, not something that’s in the air. It’s not something you smell or inhale; it’s something you ingest.

3:36And so one of the founding moments of public health in the 19th century effectively poisoned the water supply of London much more effectively than any modern day bioterrorist could have ever dreamed of doing. So this was the state of London in 1854, and in the middle of all this carnage and offensive conditions, and in the midst of all this scientific confusion about what was actually killing people, it was a very talented classic 19th century multi-disciplinarian named John Snow, who was a local doctor in Soho in London, who had been arguing for about four or five years that cholera was, in fact, a waterborne disease, and had basically convinced nobody of this. The public health authorities had largely ignored what he had to say. And he’d made the case in a number of papers and done a number of studies, but nothing had really stuck. And part of — what’s so interesting about this story to me is that in some ways, it’s a great case study in how cultural change happens, how a good idea eventually comes to win out over much worse ideas. And Snow labored for a long time with this great insight that everybody ignored.

4:46And then on one day, August 28th of 1854, a young child, a five-month-old girl whose first name we don’t know, we know her only as Baby Lewis, somehow contracted cholera, came down with cholera at 40 Broad Street. You can’t really see it in this map, but this is the map that becomes the central focus in the second half of my book. It’s in the middle of Soho, in this working class neighborhood, this little girl becomes sick and it turns out that the cesspool, that they still continue to have, despite the Nuisances Act, bordered on an extremely popular water pump, local watering hole that was well known for the best water in all of Soho, that all the residents from Soho and the surrounding neighborhoods would go to.

5:31And so this little girl inadvertently ended up contaminating the water in this popular pump, and one of the most terrifying outbreaks in the history of England erupted about two or three days later. Literally, 10 percent of the neighborhood died in seven days, and much more would have died if people hadn’t fledafter the initial outbreak kicked in. So it was this incredibly terrifying event. You had these scenes of entire families dying over the course of 48 hours of cholera, alone in their one-room apartments, in their little flats. Just an extraordinary, terrifying scene. Snow lived near there, heard about the outbreak, and in this amazing act of courage went directly into the belly of the beast because he thought an outbreak that concentrated could actually potentially end up convincing people that, in fact, the real menace of cholera was in the water supply and not in the air. He suspected an outbreak that concentrated would probably involve a single point source. One single thing that everybody was going to because it didn’t have the traditional slower path of infections that you might expect.

6:42And so he went right in there and started interviewing people. He eventually enlisted the help of this amazing other figure, who’s kind of the other protagonist of the book — this guy, Henry Whitehead, who was a local minister, who was not at all a man of science, but was incredibly socially connected; he knew everybody in the neighborhood. And he managed to track down, Whitehead did, many of the cases of people who had drunk water from the pump, or who hadn’t drunk water from the pump. And eventually Snow made a map of the outbreak. He found increasingly that people who drank from the pump were getting sick. People who hadn’t drunk from the pump were not getting sick. And he thought about representing that as a kind of a table of statistics of people living in different neighborhoods, people who hadn’t, you know, percentages of people who hadn’t, but eventually he hit upon the idea that what he needed was something that you could see. Something that would take in a sense a higher-level view of all this activity that had been happening in the neighborhood.

7:33And so he created this map, which basically ended up representing all the deaths in the neighborhoodsas black bars at each address. And you can see in this map, the pump right at the center of it and you can see that one of the residences down the way had about 15 people dead. And the map is actually a little bit bigger. As you get further and further away from the pump, the deaths begin to grow less and less frequent. And so you can see this something poisonous emanating out of this pump that you could see in a glance. And so, with the help of this map, and with the help of more evangelizing that he did over the next few years and that Whitehead did, eventually, actually, the authorities slowly started to come around. It took much longer than sometimes we like to think in this story, but by 1866, when the next big cholera outbreak came to London, the authorities had been convinced — in part because of this story, in part because of this map — that in fact the water was the problem.

8:30And they had already started building the sewers in London, and they immediately went to this outbreakand they told everybody to start boiling their water. And that was the last time that London has seen a cholera outbreak since. So, part of this story, I think — well, it’s a terrifying story, it’s a very dark story and it’s a story that continues on in many of the developing cities of the world. It’s also a story really that is fundamentally optimistic, which is to say that it’s possible to solve these problems if we listen to reason, if we listen to the kind of wisdom of these kinds of maps, if we listen to people like Snow and Whitehead, if we listen to the locals who understand what’s going on in these kinds of situations. And what it ended up doing is making the idea of large-scale metropolitan living a sustainable one.

9:14When people were looking at 10 percent of their neighborhoods dying in the space of seven days, there was a widespread consensus that this couldn’t go on, that people weren’t meant to live in cities of 2.5 million people. But because of what Snow did, because of this map, because of the whole series of reforms that happened in the wake of this map, we now take for granted that cities have 10 million people, cities like this one are in fact sustainable things. We don’t worry that New York City is going to collapse in on itself quite the way that, you know, Rome did, and be 10 percent of its size in 100 years or 200 years. And so that in a way is the ultimate legacy of this map. It’s a map of deaths that ended up creating a whole new way of life, the life that we’re enjoying here today. Thank you very much.


The secretary general of the United Nations appealed for $825 million in aid to address drought and cholera in Somalia on the brink of famine.  The money was needed to help 5.5 million people, about half of Somalia’s population, survive the next six months.

NY Times

  • 330,000 acutely malnourished children
  • That number that could rise to a million; 3.3 million people in need of medical care to deal with diseases in a country that lacks health infrastructure;
  • 7,731 cases of cholera — 183 fatal — in the past two months.

 


Cholera cases in Yemen, 7 March 2017

WHO

Weekly update: cholera cases in Yemen, 7 March 2017

7 March 2017 – The Ministry of Public Health and Population in Yemen released additional figures for the ongoing outbreak of cholera. Since the last update on 26 February 2017, 1598 new suspected cases of cholera and zero deaths have been reported.

The trend of suspected cholera cases per week appear to be on the decline in most districts or governorates. Nearly 85% of the new cases recorded since the last update was in 10 districts within Al Hudaydah, Al Bayda, Hajjah, Sana’a and Ta’izz governorates.

Since the start of the outbreak in October 2016, a cumulative total of 22 181 suspected cases of cholera, including 103 associated deaths, have been reported across the country, with a case-fatality rate of 0.45%. Of these reported cases, Vibrio Cholerae 01 has been laboratory confirmed in 195 stool samples collected so far from 15 governorates.

The Health Cluster led by WHO, in partnership with the Ministry of Public Health and Population, UNICEF, OCHA and other nongovernmental organizations, continues to scale up the integrated cholera response activities in those districts still reporting cholera cases. Early warning surveillance has been strengthened in districts to ensure that all suspected cases are investigated and reported on time.

Related links

All cholera updates


Cholera in Yemen

WHO

Cholera monthly report for Yemen

  • A total of 3130 new suspected cholera cases and 0 deaths were reported in Yemen for January 2017.
  • The cumulative number of suspected cases of cholera reported since the start of the outbreak in October 2016 is 18 973 cases, including 99 deaths with a case-fatality rate of 0.5%. More than one third of the cases were children under the age of 5.
  • Of the new cases reported, 11 stool samples were laboratory-confirmed for Vibrio Cholerae 01.
  • The trend of suspected cholera cases has been declining over the past few weeks as prevention measures take hold across the country.
  • In 2016, the cumulative number of suspected cholera cases was 15 843, including 531 associated deaths, with a case-fatality rate of 0.6%.

Introducing Haiti’s cholera plight “into the minds and hearts of people of power and influence, and people who wish to do good in key places.”

Miami Herald

“…building a consortium to finance long-term water and sanitation needs in Haiti….”

“….The United Nations announced the long-term project last month as part of a new approach to eliminating the water-borne disease in Haiti. The proposal is part of a $400 million package then-U.N. Secretary General Ban Ki-moon laid out after delivering a long sought after apology to the people of Haiti for the U.N.’s role in introducing the deadly disease in Haiti with the arrival of Nepalese peacekeepers nearly seven years ago. Since then, the disease has killed more than 9,400 Haitians and infected more than 802,000 people….”

 


Oral Cholera Vaccine Coverage during an Outbreak and Humanitarian Crisis, Iraq, 2015

EID

During November–December 2015, as part of the 2015 cholera outbreak response in Iraq, the Iraqi Ministry of Health targeted ≈255,000 displaced persons >1 year of age with 2 doses of oral cholera vaccine (OCV). All persons who received vaccines were living in selected refugee camps, internally displaced persons camps, and collective centers. We conducted a multistage cluster survey to obtain OCV coverage estimates in 10 governorates that were targeted during the campaign. In total, 1,226 household and 5,007 individual interviews were conducted. Overall, 2-dose OCV coverage in the targeted camps was 87% (95% CI 85%–89%). Two-dose OCV coverage in the 3 northern governorates (91%; 95% CI 87%–94%) was higher than that in the 7 southern and central governorates (80%; 95% CI 77%–82%). The experience in Iraq demonstrates that OCV campaigns can be successfully implemented as part of a comprehensive response to cholera outbreaks among high-risk populations in conflict settings.

Lam E, Al-Tamimi W, Russell S, Butt M, Blanton C, Musani A, et al. Oral Cholera Vaccine Coverage during an Outbreak and Humanitarian Crisis, Iraq, 2015. Emerg Infect Dis. 2017;23(1):38-45. https://dx.doi.org/10.3201/eid2301.160881

 


Cholera cases in Yemen

WHO

Weekly update – Cholera cases in Yemen

The Ministry of Public Health and Population in Yemen has reported new cases of cholera in Yemen.

Since the last update on 6 December, 1173 new suspected cases of acute watery diarrhoea/ cholera and 3 additional deaths have been reported. As of 13 December, a cumulative total of 10 148 suspected cases of cholera, including 92 associated deaths have been reported across all affected governorates, with a case–fatality rate of 1%. The number of laboratory-confirmed cases of Vibrio cholerae 01 has risen to 156.

The affected areas include 135 districts in the governorates of Abyan, Aden, Al-Bayda’a, Al-Dhale’a, Al Hudaydah, Al Jawf, Amran, Dhamar, Hajjah, Ibb, Lahij, Raymah, Sana’a, Ta’izz as well as Sana’a City. However, over 65% of the reported cases were from Aden, Al-Bayda, Al Hudaydah and Ta’izz. About 70% of the reported deaths occurred in the governorates of Aden, Al Bayda’a, Al Hudaydah, Ibb and Ta’izz.

The cholera taskforce led by WHO, in partnership with the Ministry, UNICEF, OCHA and other partner organizations, continues to strengthen cholera response activities at the national and governorate levels. The prevention and intervention efforts taken so far have been effective in reducing the number of cases in some governorates, while new cases continue to be reported in others.

The taskforce continues to support the 26 cholera treatment centres and the 2 national health emergency control rooms in Aden and Sana’a. Rapid response teams have been deployed in the affected areas for effective and timely epidemiological investigation and response.

WHO has strengthened the capacity of local health workers through training on case management, infection control, water source chlorination and solid waste disposal and drainage network management.

Essential supplies such as rapid diagnostic test kits, IV fluids, oral rehydration solutions and water chlorination tablets have been provided in affected communities. WHO has also supported social mobilization and health education campaign among citizens to raise their awareness on prevention of cholera and other diarrhoeal diseases.

Acute watery diarrhoeal diseases are endemic in Yemen, however the ongoing conflict has stretched the capacity of the national health systems.

More than 7.6 million people, and more than 3 million internally displaced persons currently live in areas affected by the outbreak.


WHO: Update on cholera cases reported in Yemen

WHO

Update on cholera cases reported in Yemen

8 December 2016 – The Ministry of Public Health and Population in Yemen has published updated figures on cases of cholera in Yemen.

To date, 8975 suspected cases of cholera, including 89 associated deaths have been reported, with a case–fatality rate of 1%.  The number of laboratory-confirmed cases of Vibrio cholerae 01 is 138.

The affected areas include 135 districts in the governorates of Abyan, Aden, Amran, Al Hudaydah, Al-Bayda’a, Al-Dhale’a, Dhamar Ibb, Hajjah, Lahij, Raymah, Sana’a, Ta’izz and Sana’a City. New cases have also been reported in the governorate of Al Jawf for the first time.

The prevention and intervention efforts by WHO, in partnership with the Ministry, UNICEF, OCHA and other partner organizations, has helped to reduce the spread of the disease some governorates, while new cases continue to be reported in others.

26 cholera treatment centres have been set up in the affected governorates and surveillance for acute watery diarrhoea has been enhanced in all governorates of the country. WHO is providing support to the 2 national health emergency control rooms in Aden and Sana’a to ensure quality data collection and has mobilized rapid response teams for effective and timely epidemiological investigation and response.

WHO has strengthened the capacity of local health workers through training on case management and infection control. Essential supplies such as rapid diagnostic test kits, IV fluids, oral rehydration solutions and water chlorination tablets have been provided in affected communities.

WHO has also supported social mobilization and health education campaign among citizens to raise their awareness on prevention of cholera and other diarrhoeal diseases.

Acute watery diarrhoeal diseases are endemic in Yemen, however the ongoing conflict has stretched the capacity of the national health systems.

More than 7.6 million people, and more than 3 million internally displaced persons currently live in areas affected by the outbreak.


Haiti begins vaccination campaign against cholera in areas most affected by Hurricane Matthew

PAHO

vaccination-cholera-haiti-1000px


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