By Ben Fox, The Associated Press, January 24, 2011. (See also, below, "Cholera causing more deaths, experts urge vaccination .")
SAINT-MARC, Haiti | The cholera epidemic that has raged across this country is claiming fewer victims, with a sharp drop in new cases everywhere from the shimmering rice fields of the Artibonite Valley to the crowded urban slums.
It is a welcome development, but tinged with doubt: It's not yet known whether the epidemic that has killed nearly 4,000 people is fading or merely taking a break, only to surge again perhaps with the onset of the next rainy season.
"The general situation is improving. It's clear," Stefano Zannini, chief of mission for the aid group Doctors Without Borders, said Sunday. "The problem is that the possible development of the epidemic is unpredictable. It is impossible to say whether the situation will continue stabilizing."
Any progress on controlling the disease would be a rare bit of good news for Haiti, which is passing through a particularly gloomy period. The country is on edge amid a political crisis over a disputed presidential election, and could see more of the violent protests that paralyzed cities and hampered cholera treatment in December.
Meanwhile, hundreds of thousands are still homeless from last year's earthquake, and a much-reviled former dictator suddenly returned and took up residence in the past week.
Dr. Zannini, whose group is contemplating scaling back its more than
40 cholera-treatment centers, was unable to muster even cautious optimism regarding the disease. The best he could say was that he was happy new cases and deaths are decreasing to levels not seen since soon after the disease emerged in October.
"I would not be optimistic," he said in an interview with the Associated Press at his Port-au-Prince office.
For the moment, at least, the statistics are moving in the right direction. The number of new cases has dropped to about 4,700 per week, down from more than 12,000 per week in November, and the trend is downward in all 10 of Haiti's departments, or regions, according to the Health Ministry's latest bulletin, released Thursday. The only places it appears to be still rising are in a few isolated spots in the northwest and south.
A new network of cholera-treatment centers staffed by Haitian doctors and nurses, nongovernmental organizations and international volunteers has made it easier for victims to get oral and intravenous rehydration. The disease is relatively easy to treat if caught in time.
There also have been extensive efforts to ensure access to clean water, as well as public health campaigns. Finally, the dry conditions of recent weeks have slowed the spread of the bacteria.
Some 40 patients a day are still coming to the Doctors Without Borders treatment center in Saint Marc, where the disease first exploded, but that's a third of what it was in December and there hasn't been a death in six weeks, said field coordinator Oscar Sanchez Rey.
"Is this is the end? Nobody really knows, but the situation is better," Dr. Sanchez said as he took a break from treating patients, including a family of six that all came down with the disease together.
He cautioned that even though fewer people are getting sick, the center's work is still critical: "If no one is treating patients, they are going to die, because it's a lethal disease."
Lilane Estime, 42, tried to sleep on a wooden bench as doctors attended to three of her children. She said all four had piled onto a motorcycle taxi and traveled an hour along a dusty coastal road to reach the clinic. Seemingly healthy, she said she could feel cholera inside her, though she hadn't gotten sick yet.
"If there's a disease going around killing people, you're going to be scared," Ms. Estime said.
In Cite Soleil, the dense slum at the northern edge of Port-au-Prince, the number of new cases is now about 15 per week, down from a high of
700, and there are similar reports from nearby neighborhoods. In the hard-hit Artibonite Valley, the weekly new caseload is about 700, compared with more than 4,800 in November.
"We don't want to say, 'OK, cholera is finished,' because it's not," said Cinta Pluma, a spokeswoman for the aid group Oxfam. "But it does seem to be going down."
Caused by a bacteria that spreads through contaminated water, the disease so far has sickened more than 194,000 people and killed about
3,890 nationwide. It can lead to a rapid, painful death through complete dehydration, but is easily treatable if caught in time.
In December, U.N. Secretary-General Ban Ki-moon warned the outbreak could affect as many as 650,000 people over six months, but that seems less likely now. The Pan-American Health Organization still projects cholera will sicken about 400,000 people over a year.
The U.N. Food and Agriculture Organization (FAO) warned in December that cholera also would worsen hunger in the impoverished nation. Surveys showed workers in the Artibonite, Haiti's main agriculture zone, were afraid to wade into rice fields, and the public was shunning the region's produce, causing steep price drops in the local street markets.
Jackson Dorgil, an FAO agricultural technician in the area, said prices for staple crops such as onions, tomatoes and melons plummeted — and much couldn't be sold at all.
But that too seems to have improved. At the region's main market in Pont-Sonde on Saturday, prices and sales were back to normal, with hundreds of women selling produce, fish and other products in neat little pyramids spread over burlap sacks.
"Life is starting to be normal again," Mr. Dorgil said during a tour of the region.
Rice fields there were filled with barefoot workers up to their ankles in muddy water believed to be contaminated with the cholera bacteria, planting the crop under a blistering sun. Most earn about $2.50 for a six-hour workday.
Fresnel Louis, president of a workers association in the area, said radio commentators were warning people not to go into the water at the start of the outbreak, but there were few options.
"If you tell people in the Artibonite not to touch the water, you are telling them not to work — because that's what we have here," Mr. Louis said.
Those rice fields could lead to a resurgence of the disease. There were no latrines in sight, nor any supplies of potable water — the same conditions that helped spread cholera so rapidly in the first place.
Dr. Zannini said any immunity typically lasts six to eight weeks, so people will be prone to catching it again when the rainy season starts in the spring, sending the bacteria coursing through rivers and streams.
"Lack of immunization, lack of access to clean water and a difficult hygienic situation still keep the population exposed to a new outbreak," he said.
Cholera causing more deaths, experts urge vaccination
By Tan Ee Lyn - Reuters, January 26, 2011
HONG KONG (Reuters) - The cholera bacterium has undergone important mutations in recent years, causing longer outbreaks of the disease with increased fatalities, researchers reported on Wednesday.
In a package of papers published in the journal PLoS Neglected Tropical Diseases, they said mass vaccinations should be considered as a solution even after outbreaks have begun.
Experts have differed over the usefulness of cholera vaccine once an outbreak has occurred, a debate reignited by a recent epidemic in Haiti.
Edward Ryan, a researcher at Massachusetts General Hospital and Harvard University in the United States, said a hybrid strain of cholera underwent two major changes in the last 20 years.
The first mutation resulted in the bacterium infecting patients thought to be immune because of previous exposure to an older strain. The second made it more dangerous.
"Cholera caused by the hybrid strain may be more clinically severe and ... may explain why we are seeing case fatality rates of 1 to 5 percent in recent outbreaks as opposed to under 1 percent historically accepted as the goal for response teams," Ryan wrote in an editorial.
Many experts oppose cholera vaccines, saying resources in an outbreak should focus on rehydrating the sick and providing safe water and improved sanitation.
The controversy re-emerged in Haiti when cholera broke out in October 2010 in the aftermath of a January earthquake that killed more than 250,000. The cholera epidemic has since made at least 105,000 people ill and killed more than 2,000.
But with the new cholera strain posing a greater threat, lasting longer and with the availability of improved vaccines, the time has come for a rethink, Ryan wrote.
Cholera is a global threat and remains a challenge to countries without safe drinking water and adequate sanitation.
CAN KILL WITHIN HOURS
Caused by a water-borne bacteria called vibrio cholera, it is transmitted when contaminated human fecal matter gets into water, food or onto someone's hands. It can cause severe diarrhea and vomiting that dehydrates victims and can kill within hours.
Many people show no symptoms but can pass the bacterium further. Most patients can be treated with oral rehydration solution and, if these are not tolerated, intravenous fluids. Antibiotics are used for severe cases.
There are only about 200,000 to 300,000 doses of cholera vaccine available in the world, and only two companies produce it. Sanofi Aventis's India-based division Shantha Biotechnics makes a vaccine called Shanchol for about $1 a dose, with up to three doses needed for protection, while Netherlands-based Crucell makes another called Dukoral.
The PLoS package also included a study from Vietnam, which showed how mass vaccination helped control the disease in Hanoi even after an outbreak occurred in 2007.
Fifteen percent of patients given the oral vaccine came down with cholera subsequently, compared to 30 percent of those not vaccinated, wrote the team led by Dang Duc Anh at the National Institute of Hygiene and Epidemiology in Hanoi.
Another team led by Rita Reyburn at the International Vaccine Institute in Seoul published another paper using data from a 2008-2009 cholera epidemic in Zimbabwe, which infected 100,000 people and killed 4,287.
Using mathematical models, the study showed that if vaccination had taken place after the first 400 cases, as many as 34,900 cases and 1,695 deaths might have been prevented.
There are an estimated 3 to 5 million cholera cases and 100,000 to 120 000 deaths due to cholera every year, according to the World Health Organisation.