Cholera - Haiti

Haiti is experiencing a resurgence of cholera, with the outbreak initially reported on 2 October 2022 after more than three years with no reported cases of cholera, evolving rapidly, and spreading to all parts of the country. There is also an ongoing complex humanitarian crisis that is rapidly deteriorating due to gang violence, socio-political conflicts, insecurity, fuel shortages, and economic instability. This has resulted in limited access to healthcare and essential services, including water, food, sanitation, and supply services. This situation makes the population of Haiti highly vulnerable to the ongoing cholera outbreak.

Between 2 October through 6 December 2022, a cumulative total of 13 672 suspected cholera cases, including 283 deaths (case fatality rate is 2.05%) have been reported by the Haiti Ministry of Public Health and Population from all ten departments in the country. Eighty-six percent (n=11 751) of all reported cases have been hospitalized. The Ouest department accounts for the highest percentage (89%, N=12 112) of suspected cases. Of the 13 672 suspected cholera cases reported, 59% are male and the most affected age groups are children aged 1 to 4 years (19%), followed by 20 to 29 years (15%) and 30 to 39 years (15%).

A total of 1193 confirmed cases have been reported. Three departments account for 94% of the reported confirmed cases: Ouest (79%; n= 943 cases), Centre (13%; n= 156 cases), and Artibonite (2%; n= 28 cases). Laboratory confirmation was by rapid diagnostic test and stool culture was done for identification of Vibrio cholerae. Of the confirmed cholera cases with available information, 57% are male (n=680) and the most affected age groups are those aged 1 to 4 years (19%) followed by 30 to 39 years (15%) and 5 to 9 years (14%).

As of 4 November 2022, a total of 368 suspected cases, including 14 confirmed cases and 14 deaths have been reported from the Port-au-Prince prison. These cases are included among the cases reported in the department of Ouest. Additionally, as of 21 November 2022, the Ministry of Public Health of the Dominican Republic has reported two confirmed imported cases of cholera, both from Haiti.

Cholera was first reported in Haiti in October 2010. Nationally, a total of 820 000 cases of cholera including 9792 deaths were reported between October 2010 and February 2019. The last confirmed case in this outbreak was reported in January 2019 in I’Estère in the Artibonite department of Haiti. The country did not report a single case of cholera in the three years from January 2019 to January 2022. The current outbreak is also occurring in the context of a complex humanitarian crisis that is exacerbating the burden of disease and hindering response measures. 

Figure 1: Number of suspected cholera cases (n=13 672) reported in Haiti from 2 October to 6 December 2022. 

Source: Haiti Ministère de la Santé Publique et de la Population (MSPP). Data reproduced by PAHO/WHO

Figure 2: Geographical distribution of suspected cholera cases (n=13 276) reported in Haiti, 29 September to 6 December 2022.

Source: Haiti Ministère de la Santé Publique et de la Population (MSPP). Data reproduced by PAHO/WHO.

Cholera is an acute enteric infection caused by ingesting the bacteria Vibrio cholerae present in contaminated water or food. It is mainly linked to inadequate sanitation and insufficient access to safe drinking water. It is an extremely virulent disease that can cause severe acute watery diarrhoea resulting in high morbidity and mortality, and can spread rapidly, depending on the frequency of exposure, the exposed population and the setting. Cholera affects both children and adults and can be fatal within hours if untreated.

The incubation period is between 12 hours and five days after ingestion of contaminated food or water. Most people infected with V. cholerae do not develop any symptoms, although the bacteria are present in their faeces for 1-10 days after infection and are shed back into the environment, potentially infecting other people. The majority of people who develop symptoms have mild or moderate symptoms, while a minority develop acute watery diarrhoea and vomiting with severe dehydration. Cholera is an easily treatable disease. Most people can be treated successfully through prompt administration of oral rehydration solution (ORS).

The consequences of a humanitarian crisis – such as disruption of water and sanitation systems, or the displacement of populations towards inadequate and overcrowded camps – can increase the risk of cholera transmission, should the bacteria be present or introduced.

A multi-sectoral approach including a combination of surveillance, water, sanitation and hygiene (WaSH), social mobilization, treatment, and oral cholera vaccines is essential to control cholera outbreaks and to reduce deaths.

Emergency response activities are being conducted by the Haiti Ministry of Public Health (MSPP), WHO and other partners as below.

Laboratory and Surveillance:

• WHO is supporting the Haiti Ministry of Public Health (MSPP) in strengthening epidemiological surveillance and laboratory capacity. Training of nurses and sampling teams have been conducted to perform rapid diagnostic tests in the Centre and Ouest departments.
• Given the complexity of land transport, WHO also facilitates the transport of samples to the National Reference Laboratory (LNSP) through United Nations Humanitarian Service (UNHAS) flights. A total of 35 samples from the Nord-Ouest departments have been transported to the LNSP.
• WHO is also supporting the Dominican Republic to strengthen its capacity to detect and respond to outbreaks and/or imported cases of cholera in its territory.

Clinical Management:

• WHO supported MSPP to conduct field missions to Artibonite and Centre Departments. The field missions aimed to assess the quality of services provided in Cholera Treatment Centres (CTCs), the capacity for scaling up case management, and to determine the needs and gaps for the cholera response.
• WHO continues to provide essential medicines and medical supplies to the Health Directorates in all 10 departments by land and air, with 49 tons of supplies, such as ringer lactate, oral rehydration salts and infusion sets delivered in the last 15 days.
• In addition, WHO continues to support the MSPP in the coordination and quality assessment for Cholera Treatment Centers (CTCs). Currently, there are 70 active CTCs throughout the country: 22 in Ouest (including the CTC of the Civil Prison), 11 in Artibonite, eight in Sud and 6 in Sud-Est,, six in Grand’ Anse, six in Nord,  4 in Nord-Est, 4 in Nord-Ouest, two in Centre, one in Nippes.  

Access to safe WASH facilities:

• Training of the departmental health officials have been conducted on cholera outbreak response at the community level
• An investigation of WASH (Water, Sanitation and Hygiene) conditions in cholera hotspots have been conducted.

Risk Communication and Community Engagement:

• In Haiti, WHO produced and distributed over 90 000 printed brochures and posters with cholera prevention messages in the Ouest Department, with the support of partner agencies and NGOs.
• WHO, in coordination with UNICEF and the Communications Unit of the Ministry of Health (MSPP), developed a communication strategy to support the cholera vaccination campaign.

Reactive Vaccination Campaigns:

• As a part of the outbreak response, an emergency reactive vaccination campaign of Oral Cholera Vaccination (OCV) has been authorized by MSPP. The country applied to the International Coordinating Group (ICG) for OCV vaccine provision. The ICG partially approved the request for 1.6 million doses of OCV for implementation of the reactive vaccination campaign.

The current cholera outbreak in Haiti, combined with the ongoing crisis related to gang violence, social unrest, and insecurity, has strained the health system’s response capacity. The overall risk for this outbreak in Hispaniola is assessed as very high, due to the following reasons:

1. The current socio-economic situation, ongoing humanitarian crisis, food insecurity and poor health conditions are affecting a large proportion of the population, leaving them vulnerable to the risk of cholera infection and recurrence of cholera.
2. Limited access of the general population to safe drinking water and to sanitation facilities.
3. Due to violence and insecurity, the public health system and international partners have limited human resources in Haiti, reducing the capacity to respond.
4. Logistics issues, lack of access to fuel and insecurity lead to difficulties to import supplies and challenges to access the affected areas. Therefore, timely assessment of the epidemiological situation is complex. Additionally, for the same reasons the shipment of biological samples from healthcare facilities to reference laboratories is hampered. These challenges further increase the risk of undetected cases and delayed response efforts. The insecurity and access to fuel hinders the population's access to health care, leading to delayed treatment and potentially severe outcome.

Considering the magnitude and wide spread of the cholera epidemic that is ongoing in Haiti, in conjunction with the complex humanitarian crisis the country is currently facing, the limited resources to control the epidemic, as well as the constant migration flows towards the Dominican Republic, the risk in Hispaniola is assessed as very high.

In the Region of the Americas, considering the constant migration flow from Haiti to the countries and territories of the Region of the Americas, the heterogeneous capacity of the States Parties to detect and respond to cholera outbreaks, as well as the burnout of health workers from concurrent public health emergencies, the regional risk is assessed as moderate.

The risk posed by the event on the Island of Hispaniola (Haiti and the Dominican Republic) at the global level is assessed as low.

WHO will continue to evaluate the epidemiological situation.

WHO recommends improving access to proper and timely case management of cholera cases, improving access to safe drinking water and sanitation infrastructure, as well as improving infection, prevention, and control in healthcare facilities. These measures along with the promotion of preventive hygiene practices and food safety in affected communities are the most effective means of controlling cholera.

OCV should be used in conjunction with improvements in water and sanitation to control cholera outbreaks and for prevention in targeted areas known to be at high risk for cholera as recommended by the Global task force for cholera control (GTFCC). Key public health communication messages should be provided to the population.

Given the re-emergence of cholera in Haiti and the imported cases reported in the Dominican Republic, WHO recommends that Member States strengthen and maintain cholera surveillance in order to prevent and respond in a timely manner to possible imported cases or outbreaks.

WHO does not recommend any restrictions on international travel or trade to or from Hispaniola based on the currently available information.

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7. Médecins Sans Frontières (MSF). Relief web. An urgent scale up in response to cholera must be mobilized. 17 November 2022. Available at: https://reliefweb.int/report/haiti/urgent-scale-response-cholera-must-be-mobilised
8. Médecins Sans Frontières (MSF). Haiti. Available at: https://www.msf.es/territorio/haiti
9. Save the Children. Relief web. Haiti: 200,000 more children pushed into hunger since March, as nearly half the population goes hungry. 14 November 2022. Available at: https://reliefweb.int/report/haiti/haiti-200000-more-children-pushed-hunger-march-nearly-half-population-goes-hungry
10. UNICEF. Haiti. Available at: https://www.unicef.org/topics/haiti
11. WHO. Shortage of cholera vaccines leads to temporary suspension of two-dose strategy, as cases rise worldwide. 19 October 2022.

Citable reference: World Health Organization (13 December 2022). Disease Outbreak News; Cholera – Haiti. Available at: https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON427