Now, in the middle of week four of the cholera outbreak, we have been taken aback by the large number of new patients in the HAS cholera hospital, with more than 80 patients yesterday in both of the children’s and the adult units. Some of them probably wanted to avoid coming to the hospital in the rain, but others of them have arrived with first-day symptoms.
We showed the CDC team which is living at the house our run chart for daily admissions. They looked at it, and from their experiences throughout the world, nodded and reflected that this pretty much looks like a normal pattern for this phase of an epidemic. Even if we control for the surge of post-Tomas patients, we are noticing an increase in the past several days. Some are much sicker, and are taking longer to recover. Others are coming in with diarrhea, but no vomiting, so we do not connect them with an IV line, but provide them with oral rehydration solution, which they sip continuously, to restore their lost fluids.
We have learned, in the running post-graduate seminar which doubles as our dinner table, that the majority of people who have cholera do not exhibit any symptoms, but that they are nonetheless shedding pathogens in the environment. In others, the symptoms may be mild or not fully expressed, and thus the individuals do not see the need to come to the hospital.
We have also learned that cholera is most commonly transmitted directly through water, in which patients will have drunk from a polluted water source. However, the pathogen may also be shared through food contamination or by human-to human contact. Our education programs are widespread and simple, but some households do not have access to potable water, or the wood to boil water from the canal, or to afford the concrete water filters which have been provided to many households. In these environments, transmission between individuals would appear to be inevitable.
Every day, dozens of salvaged US school buses fly along the new roads which stretch from the capital to major cities such as Cap Haitien, Les Cayes, or the far-distant Jeremie. They are jammed with market goods, animals, and people, and some of these have asymptomatic cholera, and do not know that they are transmitting the disease to other parts of the country, far from the disease’s origins here in the Artibonite valley.
As a result, new cases are reported daily from the far corner of the island, and even into the neighboring Dominican Republic. What began as an outbreak is now classified as an “uncontrolled and uncontained” epidemic, which will affect all of Haiti within several weeks. In the 5-point international categorization of the disease’s incidence and preparedness, some of the refugee camps in the capital are rated at 5, indicating inadequate preparedness and a high probability for epidemic-level transmission. Here in the Artibonite, we have been downgraded to a level 3, which suggests that there is a rough balance between the demand for services and their availability. It gives us some comfort, but most of our neighbors cannot read or access the internet, so many of them would see their personal situation as a 5.