CHOLERA Emergency needs in the Caribbean

CHOLERA Emergency needs in the Caribbean 3 December 2010 PAHO/WHO Figure 1: Caribbean Countries under the geographical scope of this needs assessment. 1 Majority of Caribbean population are susceptible to the infection by Vibrio cholera. 1 Anguilla, Antigua and Barbuda, Aruba, Barbados, Belize, Bermuda, British Virgin Islands, Cayman Islands, Curacao, Dominica, Dominican Republic, French Guyana, Grenada, Guadeloupe, Guyana, Jamaica, Martinique, Montserrat, Puerto Rico, Saint Lucia, St Maarten; St Martin, St. Vincent and the Grenadines, St. Kitts and Nevis, Suriname, The Bahamas, Trinidad and Tobago, and Turks and Caicos, US Virgin Islands. Page 1 of 6

The Caribbean populations, with the exception of mainland Countries [Belize, Suriname and Guyana] have not suffered outbreaks of cholera in generations. Majority of population are not immune to the current epidemic. Haiti has recorded a total of 66,593 hospital visits, 27,933 hospitalizations, and 1,523 deaths due to cholera at the national level, as of November 22, 2010. Cholera cases are now reported in all ten departments of Haiti. With respect to the number of deaths at the national level, 67% occurred at the health services level and 33% at the community level. The national in-hospital case fatality rate is 2.3%. As of December 2nd 2010, the Minister of Health of the Dominican Republic reported 12 confirmed cases. Imported cases have been confirmed in North America. Other Countries have identified suspected cases but all samples tested so far have been negative. During a press conference held on Tuesday, November 23, 2010, PAHO s Deputy Director, Dr. Jon Andrus, urged countries to ramp up readiness for cholera to protect their populations before the epidemic spreads further. Among the recommended measures were: (1) Stepped-up surveillance to ensure that any potential cholera cases are detected rapidly; (2) Strengthening preparedness and response plans to ensure that countries health systems are able to deal with any sudden surges or emergence of cholera; (3) Improving water and sanitation services to prevent the spread; and (4) Increased public education about the importance of hand washing, proper disposal of feces, and prompt treatment with oral rehydration salts or, for severe cases, specialized medical care. Models based on historical attack rates in Latin America in 1991 are projecting a most probable scenario of over 200,000 cases in the rest of the Caribbean, with the Dominican Republic being the first place where the epidemic will expand. For the following 18 months, several other Countries and territories may also detect imported cases. The capacity to respond early and appropriately will enable countries to contain outbreaks effectively. Pockets of poverty with poor hygiene conditions and lacking access to clean water and food are ideal entry points for vibrio cholera into the population. Urban shanty towns, remote underdeveloped rural areas and indigenous populations are especially at risk. Individuals with weakened immune systems such as people living with HIV/AIDS are more susceptible because the disease can fulminate in few hours causing death. PAHO and CAREC are already supporting several Countries in the region, providing advice on case detection and design of cholera plans. Other agencies such as UNICEF and the Red Cross are also planning strategies to support the Region. PAHO facilitated the first coordination meeting on December 1 st in Barbados. Next meeting is due 15 Dec @ PAHO 2. The group comprised of Eastern Caribbean Disaster Group included UN agencies, CDEMA, Red Cross and donors and other relevant agencies. They agreed in the 2 PAHO PED BARBADOS website: http://new.paho.org/disasters/index.php?option=com_content&task=blogcategory&id=828&itemid=807 Page 2 of 6

strategy to identify and prioritize actions towards protecting the most vulnerable groups. An initial list would comprise the following: Populations under poverty level + poor water & hygiene access + long referral time to public health facilities. Populations that suffered recent diarrhea disease outbreaks, e.g. typhoid fever. Urban crowded slums with under-supervised food markets. Places recently affected by natural disasters and pending recovery of the WASH (Water, Sanitation and Hygiene) sector. Remote indigenous and rural populations seeking traditional healers as first line of treatment. Pockets of legal and illegal immigrants living precariously. Areas with high prevalence of people living with HIV/AIDS. A preliminary analysis has identified an incomplete level of preparedness within many Ministries of Health to cope with this potential epidemic. The threat of cholera has provoked some unfounded responses such as limitations and bans in trading products; misconceptions and myths about the clinical features of the disease; and delay in reporting suspected and confirmed cases for fears of disrupting the tourist season. PAHO in collaboration with CAREC (Caribbean Epidemiology Center) is undergoing a comprehensive assessment of each country and territory readiness to cope with the epidemic in order to minimize negative effects. We have divided the problem tree analysis in 4 branches: 1. Coordination: Only Haiti has structured cluster coordination in place. There is an absence of a systematic regular coordination that captures all the Caribbean and stakeholders. This can generate duplication of technical efforts and divergent strategies. 2. Preparedness: Most countries have disasters plans suited to cope with natural climatic disasters and also for H1N1. However first simulation exercises for cholera conducted recently in one Eastern Caribbean island showed that the peculiarities of this aggressive diarrhea requires a specific plan suited to such scenario. Some islands have interrupted Port Health activities due to lack of resources. Limited capacity of health workers (doctors, nurses, paramedics and maintenance) on treatment protocols and patient management regardless training materials are being disseminated. This gap includes the private and pharmaceutical sector as well. Wrong traditional practices may have a detrimental effect worsening the signs of the disease. PAHO considers in collaboration with other communication experts of various agencies to enlarge the content of the cholera prevention messages to people and healers [e.g. eating more citrus increases the acidity of the digestive system protecting people from cholera; in the opposite extreme, antacids eliminate the ph barrier of the stomach favoring penetration of the bacteria into the human organism]. Page 3 of 6

3. Mitigation: Many health facilities, from small clinics to bigger hospitals lack the proper space to allocate cholera cots; sufficient water and utensils to scale up cleaning duties; improper sewage disposal; and clinical waste disposal methods to eliminate contaminated biohazards. Many islands depend on sending samples abroad to referral laboratories for confirmation. More precise training on collection and sending specimens is needed. Some laboratories can be easily upgraded to process samples locally. The general population needs to be further informed about potential sources of cholera and how to prepare and ingest the live saving oral rehydration solution and soft diet to manage the disease at home, avoiding the collapse of hospital services which should be reserved for severe dehydration cases. 4. Response: Most of the NGOs and medical teams are being deployed to Haiti. There is a need to organize additional outbreak management and medical teams to be quickly deployed to emerging outbreaks. Competition for supplies of several relief items such as IV fluids may delay procurement and availability of treatment supplies in the rest of the Caribbean. There is a need to organize additional procurement, storage and distribution centers in the Caribbean in order to gain critical time when responding to a surge in cases in a particular Country or overseas territory. There are over 64 different listed items required to manage a cholera response and they should be managed in a comprehensive way rather than through scattered donations. Only in Dominican Republic the budget deficit to procure supplies for the first 20,000 expected cases in the next 3 months surpass one million US dollars. Correct home management of diarrhea with fluids to prevent rapid deterioration during the first hours of a cholera attack will have a direct effect on mortality by this and other diarrheal diseases in the Dominican Republic 3. These four main problem categories may be properly addressed and converted into four solutions/results. PAHO believes that with the four pillar strategy proposed, the Caribbean may avoid introduction of cholera in several territories. This strategy aims to produce concrete results, such as limiting the geographic expansion to most vulnerable pockets; managing cases at home to reduce the number of severe cases and avoid overburdening hospital services; and most importantly, avoiding high fatality rates. In parallel, decreased panic and sense of control is expected to alleviate the negative effects on trade and tourism that cholera epidemics often cause. This strategy needs to be sustained at least during the next 18 months. Substantial funding must be secured to ensure a comprehensive approach and ongoing support to the Countries and territories of the Region. See the logical framework (Table 1) and initial 18 months budget (Table 2) for description of planned results and activities. 3 PAHO strategy mainstreams HIV/AIDS in cholera settings as well as gender, pregnant, elder, disabilities and mental/psychosocial support. Page 4 of 6

Table 1: CHOLERA CARIBBEAN OPERATIONAL LOGICAL FRAMEWORK (excludes Haiti) Title of the Action Principal Objective Specific Objective Results Activities Cholera preparedness, mitigation and response in selected Caribbean countries Prevent, mitigate and palliate the effects of cholera in the Sub-Region. Intervention Logic Objectively Verifiable Indicators Sources of Verification Prevent, mitigate and palliate the effects of cholera in the Sub-Region Regional and national initiatives coordinated Improved preparedness Mitigation measures effective Response supported Attack and mortality rates 50% less than Haiti Regular coordination meetings established Plans updated in all countries Health facilities and personnel ready to handle cases Treatments and teams deployed within 72 hours of confirmed outbreak 1. Coordination teams in place, Dominican Republic and Barbados 2. Assist implementing port health regulations 3. Establish cholera plans for all countries and upgrade existing ones. 4. Train health workers on cholera guidelines. 5. Improve water and sanitation of health facilities, including clinical waste management. 6. Public education, information, dissemination. 7. Upgrade Laboratory and diagnostic equipment. 8. Deploy emergency response teams to focal outbreaks. 9. Management of relief supplies [SUMA]. 10. Procure and distribute treatment supplies. Epidemiological reports Minutes and website Directory of plans Checklist Monitoring reports Page 5 of 6

Table 2: PROPOSAL BUDGET PAHO CHOLERA GAPS 18 months December 2010 May 2012 Sub-Regional Caribbean [excludes Cuba, Haiti 4 Most probable scenario: See estimates Annex. DOM Rep DRAFT02 Other Carib TOTAL COORDINATION 250,000 250,000 Sub Total 250,000 250,000 500,000 PREPAREDNESS Ports Health 130,000 Assist establish/update cholera plans & simulations 170,000 Health workers education 300,000 300,000 Sub Total 300,000 600,000 900,000 MITIGATION WASH health facilities/emergency sanitation 800,000 600,000 Public education information dissemination 400,000 700,000 Lab & equipment gaps 800,000 400,000 Sub Total 2,000,000 1,700,000 3,700,000 RESPONSE Emerg. Response Teams deployment to focal outbreaks 320,000 220,000 Management of response and supplies [EOC & SUMA] 240,000 180,000 Treatment supplies 1,200,000 600,000 Sub Total 1,760,000 1,000,000 2,760,000 7 to 13% Administrative Cost 560,300 461,500 TOTAL 4,870,300 4,011,500 8,881,800 765,000 pledged from DFID/UKaid 4 Haiti Relief gap analysis in separate appeal in PAHO website. http://new.paho.org/disasters/index.php?option=com_content&task=blogcategory&id=828&itemid=807 Page 6 of 6