US officials discuss latest response to Cholera outbreak

The White House today issued a transcript of an on-the-record briefing held by officials at the US State Department to offer the latest information about the ongoing cholera epidemic in Haiti that has — so far— killed more than 1,100 people. A CDC official— Dr. Manoj Menon— said that, "We will likely never know where this came from." The strain of the disease is considered quite virulent and given Haiti's post-earthquake conditions, cholera will likely be a sustained threat for years to come, the officials said.

The briefing included remarks from Thomas C. Adams, the State Department's Special Coordinator for Haiti; Mark Ward, the USAID Acting Director of U.S. Foreign Disaster Assistance; and Dr. Manoj Menon of the Centers for Disease Control. The briefing was held on Nov. 18:

MR. TONER: Good afternoon, welcome to the State Department. Today’s special briefing is on the U.S. Government response to the cholera outbreak in Haiti. And we’re very fortunate to be joined today by the State Department’s Special Coordinator for Haiti Tom Adams and Mark Ward, the Acting Director of the Office of Foreign Disaster Assistance at USAID. And we’re also joined today by Dr. Manoj Menon, who is from the Center for Disease Control and Prevention. Dr. Menon is the CDC liaison to USAID for the Haiti cholera response, as well as a medical epidemiologist with the malaria branch of the CDC’s Center for Global Health. Without further ado, I’ll hand the mike over to Tom.

MR. ADAMS: Thanks, Mark. We’ll make just some very brief opening remarks and then take your questions. After the earthquake in Haiti, we knew that the island would be particularly susceptible to water-borne diseases and other medical threats. And we, along with the Ministry of Health and the international community, set up a robust surveillance system which did indeed detect the outbreak of cholera which was confirmed on October 20th.

The reasons this cholera is spreading, which also was predicted, are the poor sanitation in Haiti, which those of you who have been there certainly have seen. Also the fact that for at least 50 years and perhaps as long as a hundred years, Haiti has not had any cholera so there are no immunities amongst the population. Also, this strain of cholera seems to be more virulent than the normal strains. And CDC can talk more about that, and they’re doing some investigations to try get a better picture of that.

Because Haiti had such a poor health infrastructure, we, the United States, as part of our broad assistance there, have made this one of our pillars. We are going to invest a lot of money in the health system over the next five years, and we’ve already started on several parts of it. But the challenges as we go forward on cholera are many and we are meeting them and trying to overcome them, but this occupies us every day and our great team of people down there as well spend a lot of time on this. So with that introduction, I’m going to ask Mark Ward from the Office of Foreign Disaster Assistance of USAID, which has done a lot of the initial work in responding to this, to say a few words.

MR. WARD: Thank you, Tom. Hello, again. I think I was here last to talk about Tomas. I was in Haiti last week to take a look at the cholera situation. Let me begin by expressing a lot of confidence in the efforts that the Government of Haiti has undertaken in treating the disease from what we’ve seen so far. I was impressed by the professionalism that I saw when I was there last week among their medical professionals.

I think you know the numbers. The cases reported are going up, over 18,000 now, and unfortunately, the death toll is also going up, over 1,100 now. OFDA has provided about $9 million, committed about $9 million so far. That number is going up every day, and you’ll hear why.

Going forward, our strategy right now is to focus very much on prevention. Cholera’s not very hard to prevent or treat if you get it early. But we’ve got to provide the tools to treat it and make sure the people know how to use those tools and take better care of themselves. If we are successful, the number of severe cases will decline, we won’t – they won’t overtax the government’s treatment facilities, and the death rate will drop.

We’ve got an aggressive plan on prevention and it’s got four parts.

Number one, clean drinking water, a subject we talk about a lot. We talked about it certainly during the Pakistan floods. Clean drinking water is critical. Chlorinated clean drinking water is even more critical to stop cholera, because the chlorine kills – Manoj can tell us what it is – the nasty thing inside the water that causes the cholera. He can explain to us what that is.

Many Haitians get their water, particularly in the urban areas, from government sources, from public sources. When I was in Haiti, in Port-au-Prince on Friday, we saw people gathering and filling water containers from public pipes, and we tested that water on the spot. Good news. It was chlorinated. But we’ve got to ensure that there is plenty of chlorine coming into the country over the next couple of months so that they don’t run out and we will do that. And then for the rural areas where they do not have access to that public source of water, the public – the government source of water, we’re providing millions of aqua tabs that families can use to clean the water themselves.

Second, oral rehydration therapy. Cholera causes, as you know, severe diarrhea and dehydration and this is what kills. It’s easily treated with oral rehydration therapy, which is a simple mixture of sugar and salt and, very important, clean water. USAID’s pretty proud of the fact that about 50 years ago we developed this therapy in South Asia. And all of us in the Foreign Service know it very well from our service overseas. We all keep a couple of sachets of ORS in our desks at work. It’s easy to make. It’s easy to administer. You don’t need to go to a hospital or a clinic to use ORS. So it’s critical to our prevention effort in Haiti. And we, the U.S. Government alone, among many donors, will be sending two million sachets of ORS to Haiti over the next month. About a third of it will be distributed through USAID’s network throughout the country and the rest through the United Nations.

There are 400 points in the country now where people can go to get ORS and we’ll be adding more because we want to be sure that it’s available in all departments of the country, even those where the disease has not yet shown up.

Education and messaging, the third part of our new strategy. Cholera as you’ll hear, as you heard from Tom and you’ll hear from Manoj, is new to Haiti, at least this generation. And we’ve got to redouble our efforts to be sure that the Haitians know how to care for themselves and prevent its spread and more severe cases.

Now, the messages are pretty simple: Drink clean water. Well, we’re giving them aqua tabs and chlorine to do that. Wash your hands with clean water and soap. We’re distributing as many hygiene kits as we can as fast as we can. Currently, we’ve got enough hygiene kits in the country for about 80,000 people for two weeks. Use ORS if you or someone in your family develops diarrhea. And when we give it to people, we show them how to make it in case they have trouble reading the directions on the sachet.

And we’ve got a network of NGO partners, community health workers, across the country in 4,000 different locations where we can be spreading this message, as well as through text messaging, as well as through the local media.

And then finally, we know the fourth part of our approach – we know there will be some severe cases still developing. The prevention efforts won’t entirely succeed. And people need to have a place to go if they develop diarrhea and it’s not going away. So we will be adding additional money to expand the facilities that are available either in cholera treatment units or cholera treatment centers in places where the disease is showing up so that if the diarrhea presents and people need to get additional help – and that additional help is generally just an IV drip for a while and somebody to monitor your vital signs. But you need to get there quickly once the diarrhea develops.

And so we need to be sure that these treatment facilities are available to people without too long a journey, so we will be working with NGO partners that we’re already working with, particularly in the camps, to be sure that people have a place to get to quickly, and with the government to expand the bed space that they’ve got for people outside of the camps so that, again, if the diarrhea shows up, people can get to a treatment facility as quickly as possible.

Just finally, we’re not doing this alone. There are a number of other countries around the world that are also really stepping up and helping out with the cholera effort. Just to name a few, Brazil, the European Union, Spain and Japan. This prevention campaign I’ve talked about is going to cost more money. The number is going to go up every day. But we have to act now to keep those numbers are as low as possible, so I don’t think money is going to slow us down.

Thanks very much.

DR. MENON: Good afternoon. As was said by both Mark and Tom, cholera is a preventable and treatable disease. Sometimes the situation gets a little more severe based on the conditions on the ground, and we know that there are certain risk factors for cholera outbreaks. Those include a lack of access to safe drinking water, contaminated food, inadequate sanitation, and large numbers of either refugees or internally displaced people.

The earthquake on January 12th of this year worsened those conditions by damaging drinking water treatment facilities, piped water distribution systems, and displaced over 2.3 million Haitians, further increasing the risk of cholera and other water-borne diseases.

What the earthquake also did was it heightened surveillance. The laboratory capacity by the Ministry of Health and by the National Lab in conjunction with partners, including the U.S. Government and the Centers for Disease Control, has allowed for a heightened surveillance effort.

When the first case of cholera, or the first suspect case of patients with acute, watery diarrhea were announced on October 19th, those were reported to the Ministry of Health. And within four days, the National Public Health Public Laboratory confirmed the diagnosis of cholera. It’s really this rigorous effort of – to restore surveillance and lab capacity that really allowed for the effort that we’re working on now to have commenced.

It was declared a public health emergency and the government worked closely again with international and nongovernmental and governmental organizations to raise awareness of cholera and treatment and prevention measures. CDC also has a long history of working on cholera outbreaks in Asia, Africa, and in Latin America. And there’s really five areas that we would want to focus on and have continued to focus on while in Haiti.

One is we want to focus on patients who make it to the hospital to reduce the case fatality rate. In order to do that, we’re working with clinicians to educate them through a training-the-trainer program. Clinicians in Haiti, as was mentioned, aren’t used to seeing patients with cholera. It’s not reported to have been there in this generation, likely in past generations as well, so the education and training on how to diagnose and manage a patient with cholera is not present. And so we have a training system which will reach both the departmental hospitals and reach its way to the community as well, to community health workers.

Two, work with patients in the community who are sick who require ORS by providing health education and advising them, as Mark had mentioned, on the proper use of oral rehydration salts and,importantly, advising patients once they have acute watery diarrhea to seek healthcare.

Three is prevention, again, as was mentioned, via improved access to safe drinking water and education on improved hygiene, sanitation, and food preparation practices.

Four, working on surveillance, both laboratory surveillance and epidemiological surveillance to monitor the spread of disease and provide timely, detailed information about infections, death, and the fatality rate. And this information can be used to direct public health resources and support to the areas where it’s most needed.

And five, to continue to work on the science to adjust interventions, as necessary. Each cholera outbreak, the vehicle of transmission, the knowledge and attitude and practices of the local population may be slightly different. In Haiti, where cholera wasn’t present, again, the knowledge of cholera, the way it’s transmitted, the way to use oral rehydration salts, may not be the same as it is in other parts of the world where the disease is endemic.

And so working on those five aspects, we feel like we can help support Haiti and work on reducing the burden of disease. Thank you.

MR. TONER: We’ll go to questions if you want to --

QUESTION: Yeah, this question is for any and all of you. If, after the earthquake, you knew that this was likely to be a problem, how did this spread so quickly and so – how did it get so bad so fast? And if it was inevitable, and knowing what you know that Haiti hasn’t had a case of cholera in however long it is, why weren’t people being trained in recognizing this earlier? The four day diagnosis to confirmation seems to be a bit long to me. And I’m not suggesting that this is – that anyone’s to blame here, the U.S. or anyone else, but it just seems like if the international community was aware that this was going to be a problem, steps could have been taken to at least contain this before it got out of hand.

MR. ADAMS: I hope I didn’t say it was inevitable. We didn’t wish this on anybody, or we hoped Haiti would dodge this bullet. But they haven’t dodged many bullets, as you know. We knew they were susceptible to water-borne diseases, not necessarily cholera. It might be another disease. But we had prepared supplies for that and set up the surveillance system. Frankly, I think people thought that if it broke out, it would be in crowded Port-au-Prince and wouldn’t start in the Artibonite. So the disease fooled us. But I think the point there is that there were preparations made that allowed us to get an early start on tackling this problem. That said, it is a serious, major problem, and it’s going to present challenges as we go forward.

Want to add to that Manoj?

DR. MENON: Sure. I would just like to add, in the early ’90s, when there was a Latin American outbreak of cholera, again a naïve population, and cases spread throughout the continent of South America. And throughout the country, we saw cases in the United States as well. Surveillance was heightened both there and in the Caribbean, and since that time we’ve never seen a case of cholera in the Caribbean, despite heightened surveillance. We – there’s two factors.

QUESTION: Until now.

DR. MENON: Until now. There’s two factors that are required to have a cholera outbreak: one, the presence of the organism, and two, a breach in the water hygiene infrastructure. Currently, both of those factors are met. But previously, we had no reason to think the organism was there.

QUESTION: What was the breach, then?

DR. MENON: As was mentioned, there’s a couple aspects. One, after the earthquake, with the displacing over 2.3 million people, it created a population that was internally displaced, which is a known risk factor for cholera.

QUESTION: You mean that – you mean cholera can just appear magically? It doesn’t have to be introduced by anything?

DR. MENON: No, I’m not saying that. I’m saying the displaced people contributed to its – the spread that we’re seeing now.

QUESTION: Right, well, but as you’ve said all along, I mean, Haiti has confronted one disaster after another for the last God knows how many years.

DR. MENON: Right.

QUESTION: And this hasn’t happened before. So, I mean, there have been populations moved around Haiti and living in crowded, unsanitary conditions for a hundred years.

DR. MENON: That’s correct.

QUESTION: So what was – so something had to introduce the –

DR. MENON: Well, that’s absolutely correct. But two things. One, we don’t know how the surveillance system prior to the earthquake would have even detected this case. The laboratory capacity and the epidemiological surveillance is heightened now, post-earthquake, through the help of partners.

QUESTION: Okay, I’ll stop after this, but I just –

DR. MENON: I will address your question now. Specifically, how the organism was introduced, we don’t know. I mean, it’s very difficult, through the spread of infectious diseases, where the strain of this organism came from, how it got there, what the origin was. We will never know that answer.

QUESTION: Okay, but then I’m not – I’ll stop after this, but if –well, I’ll let someone else go.

QUESTION: Can I just follow up on that actually?

MR. WARD: Well, let me just say – tell you something I saw on Friday, just to dispel the notion that we were not taking steps to prevent the spread of some kind of an infectious disease by water. I visited a very large camp in Port-au-Prince on Friday, 26,000 residents. And they had set up a cholera treatment center. Very impressive, all the steps that you go through. I walked through it. I walked through so many puddles of chlorine, I think my shoes are going to dissolve. They had followed the protocols. They were ready. They hadn’t had one patient yet because in that camp there were the ingredients to avoid cholera: clean drinking water, clean latrines, and families being taught every day how to keep their children and their families clean.

I wish services like that were available in all the camps. And part of our new strategy is to make more services like that available in the camps where we haven’t had as big a presence.

MR. ADAMS: Sure, go ahead.

QUESTION: I’d just like to follow up, actually, on the question about the sources of this strain. I know you said you – there’s no indication of where it came from yet. Can you rule anything out? There’s been a lot of political backlash and violence against the UNfor perhaps some of these South Asian – I think it was Nepalese – troops who were there providing services. Can you rule any of that out? There was also some suggestion that perhaps it was the cause of some mismanagement of latrines, that kind of thing, being dumped upstream or something.

DR. MENON: We can’t rule in or rule out either scenario. The CDC, in conjunction with the laboratory in Haiti, are conducting a variety of laboratory tests to further characterize the strain of cholera. But again, with global trade, with global movement of the population, it – we’ll never know how the strain arrived in Haiti.

QUESTION: Well, what’s the timeline on the analysis that you’re talking about?

DR. MENON: So there’s a host of different types of laboratory analysis that we’re doing. We’ve done already DNA fingerprinting of the organism. We’ve cultured the organism, and now, we’ve made available to the scientific community the whole genome of the organism. We’ll – so that’s available to the scientific community to assess as well, and they can compare it to other isolates of cholera. The problem is there’s not that many isolates of cholera to compare it to in terms of the genomic sequencing.

QUESTION: So you don’t have any sense of when we’ll know where this came from or --

DR. MENON: We’ll likely never know where this came from.

QUESTION: Okay. I do want to ask one other question, sorry, and then I’ll be done. There was a – on kind of the political side, one of you had mentioned some praise for the Haitian Government’s response. There was some suggestion down there that President Preval had even – this is an election period and had, at some point, even suggested that people avoid even bottled water to – a matter of how it’s branded or that kind of thing, just trying to stir this pot a little bit.

I’m wondering if you could speak a little bit about how this – how the government’s trying to push people one way or the other.

MR. ADAMS: Yeah. I mean, the government response has been very good, very strong. The Ministry of Health responde immediately. They asked us to set up treatment centers in Port-au-Prince, and they identified the sites rapidly. They have worked on their messaging. There’s a lot of messages going out. President Preval has gone around the country telling people to take steps, to seek treatment. And so the government has done very well, helped by international partners, PAHO, and the other countries in on this.

So I guess your question is: Is there some other agenda here being pushed politically? I didn’t quite --

QUESTION: There was some reporting on President Preval’s suggesting to some people that they avoid all water, no matter if it’s branded or something like that, and --

MR. ADAMS: I didn’t see that, so --

QUESTION: Okay. And then just broadly about how this is being whipped up in the election campaign. Are you seeing a lot of that going on down there, a lot of candidates --

MR. ADAMS: Some opposition candidates are using the anti-MINUSTAH sentiment a bit, but it’s not getting very far, frankly. I think most candidates have been responsible on this. So – and the other question related to the elections is so far, the government has given no indication that this will postpone the elections.

QUESTION: I have a question just about – given the current state of the outbreak and the interventions that you have underway, I’m wondering if you can tell us what models you may have about where we are in the epidemic. I mean, is this something that we’re going to continue to see rising, rising fast, or is it peaking? Where – how does that work?

DR. MENON: Sure, thank you. It’s very difficult, as you can imagine, to project the number of cases or the number of deaths that we’re going to see in an outbreak of any infectious disease, including cholera. We do have some figures in terms of comparing the scope of this outbreak in terms of the number of cases we’re seeing now compared to previous outbreaks, and that helps us guide, for planning purposes, to – for the provision of the different preventive measures that we have discussed, the establishment of cholera treatment centers. But to give a number of where we are in the outbreak is very difficult, as you can imagine.

QUESTION: Is it possible to sort of rate this outbreak as a severity compared to previous ones that you’ve experienced?

DR. MENON: So one thing that they did after the Latin American epidemic is that they looked at what factors internal to the country allowed to evaluate for the transmission of cholera. And they found a couple things, the most important being infant mortality. The higher the infant mortality, the increased spread of cholera, which seems quite intuitive, but their modeling suggested that. And so we – and Haiti has a high – a relatively high infant mortality. And so we expect, using that model, that Haiti is going to have sustained transmission for a number of years.

We hope that given the current preventive and treatment measures we have, transmission will – the biggest burden will be early on in the epidemic, and that’s what we’re seeing now. But we expect that cases will continue, and the organism will likely present – bevpresent in the environment for a number of years.

MR. WARD: Let me just add – because this may be a little bit counterintuitive – a big part of our messaging is: if you get sick, seek treatment. So in some ways, we hope the numbers that are seeking treatment go up because it shows that people are listening to us and taking advantages of the centers and the units that we’re setting up around the country. So when I get a daily report about more people going to seek treatment, it’s unfortunate that they have something to seek treatment about, but it tells us that they’re getting the messaging. And in those treatment centers, they can get the IV drip; they can get the ORS if they haven’t already got it, and take steps to turn this around.

QUESTION: There’s a current case of a woman in Florida who has gotten – contracted cholera and she had just come back from Haiti. So I’m wondering if there are any containment measures for that.

DR. MENON: So again, based on our evidence from the Latin American epidemic and the current state of cholera in – all over the world, in Asia and Africa, we do receive cases each year who have travelled to an endemic country, arrive here, and are diagnosed with cholera. One thing that facilitates that is that a large percentage, up to 75 percent of patients with cholera are asymptomatic, and a smaller percentage have less severe illness. They may arrive in country not knowing that they contracted the infection in another country.

We expect that cases are going to be seen in Florida in the United States. Nearly half of the Haitian population that resides in the United States is in Florida, so surveillance is heightened for the case of cholera. And clinicians – we put out a message to clinicians that they should seek diagnosis and treatment for cholera but – to think of cholera in their diagnosis for anyone with acute watery diarrhea.

We don’t have any expectation that cholera transmission will continue in the United States. We’ll have a case here or a case there, but there won’t – will not be any sustained transmission of cholera in the United States, given the health and sanitation infrastructure that we have here.

MR. TONER: Do you have any questions?

QUESTION: Yeah. MINUSTAH, the anti-MINUSTAH sentiment – do you think it would undermine the troops enough that they won’t be able to supervise the elections appropriately?

MR. ADAMS: We hope not, and two days ago there we’re, as you know, very violent demonstrations against MINUSTAH up north. There were some deaths. Things seemed to have calmed down pretty much yesterday. There’s a little bit of protesting today, but it’s kind of a national day of victory. And the protests – I just had a report -- in Port-au-Prince -- are reportedly pretty small, 200 to 250 demonstrators. So we hope they don’t get out of hand.

President Preval, as you know, has condemned this violence against MINUSTAH and urged calm. So we hope it passes and doesn’t keep MINUSTAH from doing the very important job they’re doing for the elections.

QUESTION: There were some reports today of some growing protests outside the presidential palace.

MR. ADAMS: Yeah, Champs de Mars.

QUESTION: Yeah. Do you have any reports of what’s going on there?

MR. ADAMS: That’s what I just said. I think it was a fairly small number of protesters, the last report I saw.

QUESTION: Thank you.

MR. ADAMS: Thank you guys.