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Haiti Cholera and Earthquake Response

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					                                                                         Haiti Earthquake and Cholera Response



Haiti Earthquake and Cholera Epidemic
3 contact hours: Free

Authors: Susan Walters Schmid, PhD
         Lauren Robertson, BA, MPT

Course Summary: Response to Haiti’s earthquake in the context of that country’s historical
development and preexisting social challenges. Presents treatment of quake-related injuries,
including crush injury syndrome, and looks at psychological after-effects. Describes the challenges
associated with the cholera epidemic.

COI/Commercial Support: The planners and authors of this course have declared no conflict of
interest and all information is provided fairly and without bias. We received no commercial
support for this activity and do not approve or endorse any commercial products displayed.

Off-Label Use: No off-label uses were discussed or recommended in this course.

Criteria for Successful Completion: 80% or higher on the post test, a completed evaluation form,
and payment where required. No partial credit will be awarded.

This course will be reviewed every two years. It will be updated or discontinued on December 31,
2011.

Accreditation Information
Nursing: ATrain Education is an approved provider of continuing nursing education by the
Arizona State Nurses Association* (AzNA), an accredited approver by the American Nurses
Credentialing Center's Commission on Accreditation (ANCC).

*AzNA and ANCC Commission on Accreditation do not approve or endorse any commercial products displayed.

Physical Therapy: ATrain Education is an approved reviewer and provider by the Physical
Therapy Board of California and an approved provider by the New York State Board for
Physical Therapy.

Occupational Therapy: ATrain Education is an approved provider by the American Occupational
Therapy Association. If you are an occupational therapist or occupational therapy assistants
please note the following:

Target Audience: Occupational Therapists, OTAs
Instructional Level: Introductory
Content Focus: Category 1—Domain of OT, Client factors

Other professions and accreditations: See the ATrainCEU Accreditation page at
http://www.ATrainCeu.com/accreditation.php.




ATrain Education, Inc.
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                                                                    Haiti Earthquake and Cholera Response




Instructions
1. Read the course material and then complete the following forms:
       A. Answer Sheet
       B. Evaluation Learning Activity
       C. Registration Form
2. If you are not paying by credit card, prepare a check for the amount of the course made out
     to: ATrain Education, Inc.
3. Mail the completed forms and your payment to:
     ATrain Education, Inc
     5171 Ridgewood Rd
     Willits, CA 95490

Once we receive your forms and payment, we will mail (or email, at your request) your
completion certificate. If you have any questions, please call or email Info@ATrainCEU.com.


Course Objectives
When you finish this course, you will be able to:

    •    Identify the major elements of disaster response.
    •    List the most critical public health concerns in Haiti after the earthquake.
    •    Describe common earthquake-related injuries and their treatment.
    •    Explain the cause of cholera, its transmission, it symptoms, and its treatment.
    •    Tell what is being done to address the cholera epidemic in Haiti—and what we can do.
    •    Outline key precautions and concerns for individual disaster responders.
    •    Assess the psychological effects of disasters on survivors and responders.
    •    Discuss gender issues as they apply to humanitarian relief.

Introduction
The tiny Caribbean nation of Haiti was wracked by a 7.0 earthquake on January 12, 2010. This
impoverished country endured a late afternoon temblor that was centered only about ten miles
from its capital city of Port-au-Prince. In the weeks following the earthquake, relief efforts poured
in from around the world but frustrations rose as the limitations of a tiny airstrip and lack of
adequate roads impeded well-meant actions.




ATrain Education, Inc.
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Map showing earthquake exposure level of the Haiti population on January 12, 1210. Source: United Nations Office
for the Coordination of Humanitarian Affairs (OCHA).

The effects of the earthquake have been devastating for the people of Haiti. The Haitian
government has estimated that more than 230,000 people have died and 3 million were directly
affected by the quake. A quarter of a million residences were destroyed and more than 1 million
people have been left homeless.




ATrain Education, Inc.
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A man exits a restaurant after looking for his belongings following the earthquake that rocked Port au Prince on
January 12, 2010. Source: Marco Dormino/The United Nations Development Programme.

In late 2010, nearly a year after the earthquake, Haiti is in the midst of the worst outbreak of
cholera in the nation’s history. Official sources have reported more than 2,000 deaths and an
estimated 90,000 people infected throughout the seven Departments (provinces) in the country—
although due to the difficulties of gathering accurate data, the United Nations believes that the
actual numbers could be double those figures.

This course is designed to shed some light on the medical and public health issues facing the
people of Haiti as a result of the earthquake and ensuing cholera epidemic. We begin with a
description of Haiti, its historical development and political background, then describe the major
health effects of the earthquake, followed by a description of cholera and it effects on the
population of Haiti.




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Haiti and Its History
The Nation of Haiti
Haiti is about 700 miles south of Miami, Florida, and occupies the western third of the island of
Hispaniola, which lies between Cuba and Puerto Rico in the line of islands forming the northern
edge of the Caribbean Sea. The Dominican Republic occupies the eastern two-thirds of the island.
Haiti is about the size of the state of Maryland and is the third largest Caribbean nation,
recording a population of 9.7 million people in 2007.




Source: Wikimedia.

Haiti’s climate is tropical, with some variations due to elevation. It experiences two rainy
seasons—from April to June and October to November—and a hurricane season in August and
September. The 2008 hurricane season was particularly devastating and it aggravated ongoing
humanitarian crises of many years standing, including fundamental deficiencies in safe water,
sufficient sanitation, and basic medical care.

In 2009, prior to the earthquake, 45% of the population did not have access to safe water and
83% did not have access to sufficient sanitation. Fifty-five percent of Haiti’s population lived
below the extreme poverty line of US $1 per person per day (WHO, 2010). All of these factors
affected the situation following the earthquake and will continue to affect recovery efforts.

A Troubled History
On his first voyage in 1492, Christopher Columbus “discovered” the Caribbean island of
Hispaniola. Spanish explorers who followed Columbus exploited native labor to mine for precious
metals, with the result that disease, brutality, and overwork decimated the indigenous population.
While not all researchers agree on the numbers, there is no debate that the original population
was virtually annihilated within fifty years of “discovery.” Of approximately 1 million people,
only about 500 remained in 1538.


ATrain Education, Inc.
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Without a supply of labor, mining was uneconomical, and the Spanish turned to raising cattle and
sugar cane, depending on the slave-based plantation system established by the Portuguese in
their Atlantic colonies. This system required prodigious amounts of both money and slaves, and
was thus dominated by a few very wealthy plantation owners.

In 1697 the island of Hispaniola was split between the French and Spanish, with the eastern third
going to the French, who named it Saint Domingue. The French king’s chief minister advocated
overseas expansion and encouraged development of (the slave-based) sugar colonies in the West
Indies, of which Saint Domingue was the largest. In the 1780s it produced almost 40% of British
and French sugar imports and 60% of the world’s coffee. Of the total 11 million slaves over the
entire history of the slave trade, about 35% came to the English and French Caribbean
plantations. In the 1780s there were upwards of 500,000 slaves on Saint Domingue, in a total
population of about 520,000 people.

What had been a rigidly hierarchical society based on skin color, class, and wealth, began to
come apart in the late eighteenth century. Contributing factors included runaway slave
communities, some militant, threatening the plantations; free people of color pursuing full
citizenship, property rights (including the ability to own slaves) and farm land; and revolutionary
ideas coming out of the 1789 French revolution. In 1790, when the French National Assembly in
Paris granted suffrage to landed and taxpaying free blacks, the white-dominated assembly in
Saint Domingue refused to accept this, and the country erupted in violence.

Slave revolts and Spanish and British military intervention were part of what was essentially a
struggle between French republican forces and Creole royalists backed by Spain and Britain.
Both sides used indigenous armies of black slaves, free blacks, and those of mixed race. Over the
next fourteen years, control of the country was in flux. In 1791 a talented and forceful black
leader, Toussaint Louverture, came out of the ranks of the rebel army of black slaves. Allied first
with the Spanish, Louverture then joined the French in 1794 when France abolished slavery. After
rising to be leader of all the republican forces in Saint Domingue, Louverture rebelled against the
French again and captured the Spanish port of Santo Domingo; thus in 1800 Louverture controlled
all of Hispaniola.

In 1801 France again sent an army to challenge Louverture, who eventually had to surrender
when his two top commanders joined the French. Louverture would eventually die in a French
prison. His commanders, Jean-Jacques Dessalines and Henry Christophe, soon joined forces with
another general and determined to drive the French out. The French, after losing 52,000 men to
combat and disease and needing to attend to renewed war in Europe, withdrew in late 1803.
With this loss, France no longer had an interest in the Louisiana territory, which they sold to the
United States in December 1803.

In 1804 Saint Domingue became only the second country in the Americas to gain its independence
and the first one to be governed by people of color.

The economic situation in the new country was shaky; warfare had ruined the plantations and
rural laborers were not interested in working for someone else. The French did not recognize the
new country, but eventually an agreement negotiated in 1825 exchanged official recognition for
a huge indemnity payment that Haiti did not finish paying until 1947.



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The nineteenth century saw a succession of Haitian leaders who were more concerned with
personal power than with the economic and social well-being of their country and its citizens.
Through most of the century the country suffered under ethnic hostilities, coups and assassinations,
constitutional interference, and the crushing weight of payments to France (LOC, 2006).

The twentieth century was just as politically and economically destructive. The United States
occupied Haiti from 1915 to 1934, having gone there on the pretext of a need to manage civil
unrest. New elections were held in 1930, but the presidents elected for the next twenty-seven
years were ineffective at best. Nineteen fifty-seven ushered in the Duvalier era—characterized
by violence, disruption, terror, and theft of government funds—that would not end until 1986
when “Papa Doc” Duvalier went into exile in France.

An interim government made no improvement, and in December 1990 a landmark free election
elevated Jean-Bertrand Artistide to the presidency; however, violence and a good deal of
internal conflict continued, and a military coup ousted Aristide after only seven months. Military
rule prompted thousands of Haitians to flee to the United States.

The United States was determined to restore Aristide, which it did with American troops and the
support of the UN Security Council. Aristide served out his term, and René Préval succeeded him.
Préval’s term was characterized by partisan politics, allegations of election fraud, a constitutional
crisis, and finally corruption and human rights violations.

Aristide was returned to office in 2000, but this second term brought continued problems, a
recession, and more violence. Rioting during the 2004 election turned into full-scale rebellion,
leading to Aristide’s resignation in February. The U.S. military airlifted him out of the country and
he has lived since in Africa. Following constitutional requirements, the president of the Supreme
Court became Haiti’s president, but a growing humanitarian crisis led to a request for UN
assistance (LOC, 2006; MINUSTAH, 2010).

In April 2004 the UN Security Council’s Resolution 1542 created the UN Stability Mission in Haiti
(MINUSTAH). The mission was authorized at 6,700 troops and 1,622 civilian police. The largest
single contingent of troops came from Brazil. MINUSTAH worked with the interim Haitian
government to establish law and order, restore incoming shipments of food and medical supplies,
and prepare for national elections. René Préval, the former president, won the election held in
early 2006 (LOC, 2006) and MINUSTAH’s mandate has been extended ever since (MINUSTAH,
2010a).

Haiti’s history is by no means simple, and this summary barely touches the surface of events and
perspectives. There are long-standing social conflicts, and the damage done by two centuries of
poor leadership, violence, economically devastating policies, and sometimes destructive outside
interference, has brought Haiti to its current situation as the poorest nation in the Western
Hemisphere.

Those with an interest in Haiti’s people and history and in the long-term goals of humanitarian aid
for Haiti can refer as a starting point to the various references and resources listed at the end of
this course.




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Essential Elements of Disaster Response
The Centers for Disease Control and Prevention (CDC), based on its experience with prior
disasters in Haiti and earthquakes elsewhere, made an early assessment of the most pressing
public health concerns and public health priorities likely to occupy disaster responders in Haiti:

    •    Adequate quantity and quality of water
    •    Food security
    •    Appropriate shelter and protection from the elements
    •    Prevention and treatment of gastrointestinal, respiratory, and vector-borne illnesses
    •    Prevention of violence and further unintentional injury
    •    Treatment of kidney failure due to crush injuries
    •    Prevention of deaths from infected wounds
    •    Prevention and treatment of inflamed lung tissue caused by concrete dust

Public health priorities were expected to be:

    1.   Reduce and prevent further deaths, injuries, and illnesses
    2.   Determine and meet critical needs for water and sanitation, healthcare, and food
    3.   Verify the status of healthcare facilities and assist in standing up healthcare services
    4.   Assess and address emergency maternal and infant health needs
    5.   Provide health education to help people protect their own health and safety
    6.   Conduct disease and injury surveillance in displaced and non-displaced populations (CDC,
         2010a)

These two lists help bring attention to the related but changing needs of the immediate aftermath,
short-term aftermath, and long-term aftermath of an earthquake or other natural disaster.

The pressing concerns highlight the immediate healthcare needs after a natural disaster and
reflect the fact that some issues will be specific to the type of disaster and the location. Despite
similarities, the second list reflects the need to begin to direct attention beyond emergency
treatments to the near term (days and weeks ahead) and how to minimize further loss and
stabilize humanitarian needs.

Most natural disasters also have long-term consequences and survivor needs. The physical,
financial, and environmental needs of an area before the disaster play a role in what will be
needed afterwards. In Haiti where there were longstanding problems and numerous humanitarian
crises before the earthquake, the situation has been referred to as a “double disaster.” In his
January 25, 2010, article for the UNICEF website, reporter Tim Ledwith writes that

         …the earthquake that killed so many is, in fact, a double disaster: The serious
         development constraints that Haiti already faced have now worsened significantly.” He
         highlights comments from the heads of a number of UNICEF’s major units, who point to
         things like the decline in the sanitation coverage rate in recent years, the country’s already
         limited ability to meet the needs of its children, and poor immunization coverage and
         health service in general. As one of them says, ". . . the issue is not an earthquake. It's the
         intersection, the interaction, between the earthquake and the situation in Haiti…”



ATrain Education, Inc.
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About two weeks after the earthquake, an OCHA situation report highlighted six items in its “Key
Priorities” box. The first two emphasized the ongoing need for 200,000 family-sized tents and
tens of millions of ready-to-eat meals, but the third one read, “Haiti's Ministry of Health is revising
its emergency response strategy and will gradually shift focus from emergency surgical cases to
primary health care. Thousands of amputees will require physical therapy,” while the fourth was
“Some 500 Haitian patients are being treated in nine hospitals in the Dominican Republic. The
influx of patients requiring emergency care in these hospitals is declining.” While there were still
critical needs for food and shelter, some of the medical needs were beginning to ease and the
government was turning its eyes toward a longer-term future (OCHA, 2010a, b).

Logistics and Infrastructure
About a week after the earthquake a graphic based on material in a UN Office for the
Coordination of Humanitarian Aid (OCHA) situation report highlighted the major challenges facing
the government and response management at that time:

    •    Seaport at Port-au-Prince non-operational
    •    Airport at Port-au-Prince small, damaged, and congested
    •    Shortage of warehouse space at the airport
    •    Lack of helicopters, trucks, cars, and facilities for responders to use
    •    Major fuel shortages
    •    Security needed for supply deliveries
    •    Humanitarian corridor between Haiti and the Dominican Republic congested
    •    Affected populations scattered
    •    Roads and bridges damaged; some still at risk of landslides
    •    Logistical bottlenecks due to uncoordinated shipments
    •    Many pledges not yet cash (OCHA, 2010)

In order to meet the pressing needs and public health priorities described in the section above,
authorities need to be able to receive relief supplies and relief workers and move them safely to
areas where they are needed. If all the usual means of moving people and goods have been
damaged or destroyed, responders need planning, coordination, and alternative means of
accomplishing their goals.

Even early priorities clearly operate within a web of other issues related to the infrastructure and
functioning of the municipality or country where a disaster has occurred. For medical personnel,
ongoing care becomes the next level of concern, along with prevention of new medical issues not
a direct result of the physical effects of the earthquake. For other responders, the next level will
include plans for reconstruction and reestablishment of the regular functions of government.




ATrain Education, Inc.
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Public Health Concerns
The World Health Organization (WHO) identified five immediate public health risks soon after
the Haiti earthquake: wounds and injuries, water/sanitation/hygiene–related and food-borne
diseases, diseases associated with crowding, vaccine-preventable diseases, and vector-borne and
zoonotic diseases. In addition to these five specific concerns, WHO also identified a long list of
related public-health concerns and issues.

Wounds and Injuries
Trauma is responsible for much earthquake-related mortality, and wounds and injuries are
expected to be numerous, resulting from both initial impact and subsequent rescue and clean-up
activities (WHO, 2010).

A majority of the people injured in the Haiti earthquake would be expected have minor cuts and
bruises, followed by those with simple fractures, and then fewer (although not necessarily a small
number) could have serious multiple fractures or internal injuries and crush syndrome. A significant
number of burns were also reported. The severely injured could require surgery, blood
transfusions, or other intensive treatment, and surgical capabilities are essential in the early days
and weeks (WHO, 2010).




Haitian boy receives treatment at an ad hoc medical clinic at MINUSTAH's logistics base
after the earthquake.
Source: Logan Abassi/The United Nations United Nations Development Programme.

With limited resources, treatment delays could be expected. Wound infection, tetanus, and
gangrene are all likely complications of such delays. Wound contamination can lead to gangrene,
requiring immediate attention to prevent limb loss and death. Tetanus risk is significant because of
the low vaccination rate among children and the fading of immunity in adults (WHO, 2010).

While individual healthcare workers will follow procedures specific to the location and as
mandated by their employer, WHO’s Core Principles and wound care Protocols (see boxes
below) clearly define essential steps in the care of the most likely categories of wounds.

ATrain Education, Inc.
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                                                   Core Principles

Never close infected wounds.* Systematically perform wound toilet and surgical debridement (described in Protocol
1 below). Continue the cycle of surgical debridement and saline irrigation until the wound is completely clean.

Do not close contaminated wounds** and clean wounds that are more than 6 hours old. Manage these with
surgical toilet, leave open, and then close 48 hours later. This is known as delayed primary closure.

To prevent wound infection:

    •   Restore breathing and blood circulation as soon as possible after injury.
    •   Warm the victim and at the earliest opportunity provide high-energy nutrition and pain relief.
    •   Do not use tourniquets.
    •   Perform wound toilet and debridement as soon as possible (within 8 hours if possible).
    •   Respect Universal Precautions to avoid transmission of infection.
    •   Give antibiotic prophylaxis to victims with deep wounds and other indications (described in Protocol 3).

Antibiotics do not reach the source of the wound infection. Antibiotics only reach the area around the wound; they
are necessary but not sufficient and need to be combined with appropriate debridement and wound toilet as
described above.

Use of topical antibiotics and washing wounds with antibiotic solutions are not recommended.

*An infected wound is a wound with pus present.
**A contaminated wound is a wound containing foreign or infected material.
Source: WHO, 2010.


                                                     Protocol 1

Wound Toilet and Surgical Debridement

Apply one of these two antiseptics to the wound:

    • Polyvidone-iodine 10% solution—apply undiluted twice daily. The application to large open wounds may
        produce systemic adverse effects.
    • Cetrimide 15% + chlorhexidine gluconate 1.5%. Note: The freshly prepared aqueous solution (0.05%) of
        chlorhexidine gluconate 5% is not recommended.

In Emergency Situations (risk of flakes according to water quality)

    1. Wash the wound with large quantities of soap and boiled water for 10 minutes, and then irrigate the wound
        with saline.
    2. Debridement: mechanically remove dirt particles and other foreign matter from the wound and use surgical
        techniques to cut away damaged and dead tissue. Dead tissue does not bleed when cut. Irrigate the wound
        again. If a local anesthetic is needed, use 1% lidocaine without epinephrine.
    3. Leave the wound open. Pack it lightly with damp saline disinfected or clean gauze and cover the packed
        wound with dry dressing. Change the packing and dressing at least daily.
Source: WHO, 2010.




ATrain Education, Inc.
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                                                       Protocol 2
Management of Tetanus-Prone Wounds

    1. Wounds are considered to be tetanus-prone if they are sustained either more than 6 hours before surgical
        treatment of the wound or at any interval after injury and show one or more of the following: a puncture-
        type wound, a significant degree of devitalized tissue, clinical evidence of sepsis, contamination with
        soil/manure likely to contain tetanus organisms, burns, frostbite, and high-velocity missile injuries.
    2. For patients with tetanus-prone injuries, WHO recommends tetanus toxoid (TT) or tetanus and diphtheria
        vaccine (Td) and tetanus immune globulin (TIG).
    3. When tetanus vaccine and tetanus immunoglobulin are administered at the same time, they should be
        administered using separate syringes and separates sites.

Tetanus Vaccine
ADULTS and CHILDREN over 10 years: Active immunization with tetanus toxoid (TT) or with tetanus and diphtheria
vaccine (Td); 1 dose (0.5 ml) by intramuscular or deep subcutaneous injection. Followup: 6 weeks, 6 months.

CHILDREN under 10 years:
Diphtheria and tetanus vaccine (DT); 0.5 ml by intramuscular or deep subcutaneous injection. Follow up at least 4
weeks and 8 weeks.
Tetanus immune globulin (TIG). In addition to wound toilet and absorbed tetanus vaccine. Also consider if
antibacterial prophylaxis (Protocol 3 below) is indicated.

ADULT and CHILD: Tetanus immunoglobulin (human) 500 units/vial; 250 units by intramuscular injection, increased
to 500 units if any of the following conditions apply: wound older than 12 hours; presence, or risk of, heavy
contamination; or if patient weights more than 9<0 kg.

Note: national recommendations may vary.
Source: WHO, 2010.


                                                       Protocol 3
Antibiotic prophylaxis is indicated in situations or wounds at high risk to become infected, such as: contaminated
wounds, penetrating wounds, abdominal trauma, compound fractures, lacerations greater than 5 cm, wounds with
devitalized tissue, high-risk anatomic sites such as hand or foot. These indications apply for injuries which may or may
not require surgical intervention. For injuries requiring surgical intervention, antibiotic prophylaxis is also indicated
and should be administered prior to surgery, within the 2-hour period before the skin is cut.

Recommended prophylaxis consists of penicillin G and metronidazole given once (more than once if the surgical
procedure is >6 hours).

    • Penicillin G, ADULT: IV 8–12 million IU once. CHILD: IV 200,000 IU/kg once.
    • Metronidazole, ADULT: IV 1,500 mg once (infused over 30 min). CHILD: IV 20 mg/kg once.

If infection is present or likely, administer antibiotics via intravenous and not intramuscular route.
Penicillin G and metronidazole for 5 to 7 days provide good coverage.

    • Penicillin G, ADULT: IV 1 to 5 MIU every 6 hours. After 2 days it is possible to use oral penicillin: penicillin V, 2
         tablets every 6 hours. CHILD: IV 100 mg/kg daily in divided doses (with higher doses in severe infections).
    • In case of known allergy to penicillin use erythromycin. In case of sudden allergy reaction (seldom): IM
         adrenaline 0.5 to 1.0 mg to adults. 0.1 mg/10 kg body weight to children.
    • Metronidazole, ADULT: IV 500 mg every 8 hours (infused over 20 min). CHILD: IV 7.5 mg/kg every 8 hours.
Source: WHO, 2010.




ATrain Education, Inc.
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Crush Injury and Crush Syndrome
Crush injury and crush syndrome may result from structural collapse during an earthquake. Crush
injury is defined as compression of extremities or other parts of the body that causes muscle
swelling and/or neurologic disturbances in the affected areas of the body, typically lower
extremities, upper extremities, and trunk (CDC, 2010c).




Haitians pull out a body from the rubble of a school that collapsed after the earthquake that rocked
Port au Prince on January 12, 2010. Source: Marco Dormino/The United Nations.

Crush syndrome is localized crush injury with systemic manifestations. These systemic effects are
caused by a traumatic rhabdomyolysis (muscle breakdown) and the release of potentially toxic
muscle cell components and electrolytes into the circulatory system. Crush syndrome can cause
local-tissue injury, organ dysfunction, and metabolic abnormalities (CDC, 2010c).

The incidence of crush syndrome in previous earthquakes with major structural damage has been
2% to 15%. Approximately half of those with crush syndrome develop renal failure and more
than 50% need fasciotomy (a surgical procedure to cut away fascia to relieve tension or
pressure). Of those experiencing renal failure, 50% will need dialysis (CDC, 2010c).

Sudden release of a crushed extremity may result in reperfusion syndrome—acute hypovolemia
and metabolic abnormalities. This condition may cause lethal cardiac arrhythmias. Further, the
sudden release of toxins from necrotic muscle into the circulatory system leads to myoglobinuria,
which causes renal failure if untreated (CDC, 2010c).




ATrain Education, Inc.
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Ideally, intravenous (IV) fluids are administered before releasing the crushed body part. While
this is especially important when the crush has lasted longer than 4 hours, crush syndrome can
occur even with crush periods of less than 1 hour. If IV fluids are not available, short-term use of a
tourniquet on the affected limb may be indicated until IV hydration can be started (CDC, 2010c).

In crush casualties, healthcare personnel need to watch for these symptoms:

    •    Hypotension (low blood pressure)
    •    Renal failure
    •    Metabolic abnormalities
    •    Secondary complications, especially compartment syndrome (swelling within a closed
         anatomic space) (CDC, 2010c)

Compartment syndrome can be a result of what is called third-spacing, or the sequestering of
fluid in an area of the body not normally used for fluid storage. This effect requires considerable
fluid replacement in the first 24 hours. A patient may third-space more than 12 liters of fluid in
the crushed area over a 48-hour period (CDC, 2010c).

In the hospital, a crush casualty will be: treated with IV hydration to deal with hypotension and to
help prevent renal failure; monitored for metabolic abnormalities requiring chemical intervention
and for cardiac arrhythmias and cardiac arrest; and monitored for evidence of compartment
syndrome and the possible need for fasciotomy. In addition, any open wounds must be treated
appropriately, ice applied to injured areas, and the patient monitored for the 5 P’s: pain, pallor,
parasthesias, pain with passive movement, and pulselessness (CDC, 2010c).

All crush casualties should be observed, even those who appear to be well. Be alert for delayed
evidence of renal failure, especially in those for whom hydration was delayed more than 12
hours. Patients with acute renal failure may require up to 60 days of dialysis treatment; unless
sepsis is present, patients are likely to regain normal kidney function (CDC, 2010c).




ATrain Education, Inc.
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Water/Sanitation/Hygiene–Related and Food-Borne Diseases
Thousands of people in Haiti have been displaced from their homes, and displaced populations
are at high risk for water/sanitation/hygiene–related diseases and food-borne diseases.
Disrupted water and sewer services and unfamiliarity with an area may lead to consumption or
use of unsafe water. Salmonella typhi (which causes typhoid fever) and hepatitis A and E are
present and have epidemic potential in Haiti. Cholera is not endemic to Haiti but leptospirosis is
(see the section below on cholera). Diarrhea, a frequent symptom of water- and food-borne
diseases is already a problem in Haiti, especially for children under age 5, where it accounts for
16% of deaths (WHO, 2010).

Diseases Associated with Crowding
Displaced persons often find themselves resettled to facilities or locations that are overcrowded,
where the risk of transmission of some communicable diseases is increased. Diseases spread by
respiratory droplets such as measles, diphtheria, and pertussis, and acute respiratory infections
(ARI) all fall into this category. Poor ventilation increases the risk. Meningitis, and both water-
borne and vector-borne diseases, are also more likely in overcrowded conditions and may
become problems in the coming weeks and months in Haiti (WHO, 2010).




Homeless Haitians set up tents near the Presidential Palace in the aftermath of the 2010 Haiti earthquake.
Source: Marcello Casal, Jr./Agencia Brasil.




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Acute respiratory infection (ARI) includes infections of both the upper and lower respiratory tract.
In children under 5, acute lower respiratory infections (ALRIs) such as pneumonia, bronchiolitis, and
bronchitis are a particular concern. In 2000 WHO estimated that pneumonia accounted for 20%
of deaths in this group and undernourishment and overcrowding can both increase the risk of
pneumonia in these children.

Other diseases of concern in crowded conditions include H1N1 influenza, which is circulating in
Haiti, meningococcal disease, and tuberculosis (TB). Haiti has the highest TB rate in the Western
Hemisphere and it is one of Haiti’s leading causes of death. A national TB treatment effort was
underway at the time of the earthquake, and maintaining treatment and follow-up for patients
with TB (and other chronic diseases) will be a particular challenge (WHO, 2010).

Routine Immunization Coverage
Reports from 2007 show only 53% of 1-year-olds in Haiti have received the third dose of the
diphtheria-tetanus-pertussis (DTP) vaccine. There have been three outbreaks of diphtheria since
2004.

Clostridium tetani spores are present in soil, so even small wounds are susceptible to infection; thus,
healthcare workers have to be on the alert for early symptoms of tetanus—difficulty swallowing
and tonic contractions of jaw muscles—in order to treat patients early and avoid disability or
death. Wounds that are tetanus-prone call for prophylactic antibiotics and vaccination.

In populations with low vaccination coverage, overcrowding may increase the risk of outbreaks of
measles, pertussis, and diphtheria. While measles has not been confirmed in Haiti since 2001, the
vaccination rate among 1-year-olds is only 58%, increasing the risk of an outbreak (WHO,
2010).

Vector-Borne and Zoonotic Diseases
In Haiti these diseases include dengue and dengue hemorrhagic fever (DHF), malaria, human
rabies, leptospirosis, and lymphatic filariasis. Dengue is a mosquito-transmitted viral disease that
is endemic in Haiti, with epidemics occurring every 3 to 5 years. Its symptoms resemble a severe
influenza, and some people suffer a life-threatening complication known as dengue hemorrhagic
fever (DHF).

Malaria exists all over Haiti year around. The risk in the Port-au-Prince area is considered to be
low but with the potential to increase. Treatment is effective, so early diagnosis and treatment are
critical. The risk from dengue and malaria are increased in the current situation because
inadequate shelter and lack of protection from mosquitoes are common problems for displaced
persons.

Human rabies, leptospirosis, and lymphatic filariasis are other animal- or mosquito-borne
infections with a risk of post-earthquake increase. There was a mass rabies vaccination program
underway for dogs before the earthquake that was a priority in Haiti (WHO, 2010). Everyone
should use caution around stray animals and have any bite wound treated immediately. Relief
workers are discouraged from trying to adopt or rescue stray animals.




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Overall Priorities
Before offering specific protocols for treatment and advice for preventive steps, WHO’s
assessment presented a structure of immediate priorities that clearly shows the interrelationship
between immediate needs, prevention concerns, and long-term goals (see box).

                                                Immediate Priorities

Health Sector Priorities

    •    Access to surgical, medical, and emergency obstetric care and proper case management, particularly for
         trauma, wounds, and burns
    •    Priority immunizations, including mass vaccination campaign for measles/rubella, and tetanus immunization
         as part of wound care
    •    Communicable disease surveillance and response, including preparedness for epidemic-prone diseases
    •    Support for appropriate infant and young-child feeding and malnutrition management
    •    Continuity of care for chronic diseases (eg, HIV, TB, hypertension)
    •    Public health communication

Non-Health Sector Priorities Impacting Health

    • Shelter and site planning
    • Provision of sufficient and safe water, and sanitation
Source: WHO, 2010.


The Cholera Epidemic
The presence of cholera in Haiti was confirmed on October 21, 2010. It had not been
documented in Haiti for more than a century so an outbreak was considered unlikely immediately
following the earthquake. An outbreak might have been expected, however, because at least one
of the two conditions considered necessary for a cholera outbreak to occur, namely, significant
breaches in the water, sanitation, and hygiene infrastructure has been clearly present throughout
the country following the earthquake. The other condition—the presence of cholera in the
population—is controversial and it is unclear how cholera was re-introduced. Nevertheless, both
conditions now exist (CDC, 2010b).

The Haitian government and its partners are in the process of setting up new cholera treatment
centers for severe cases and are working to strengthen lower-level facilities that can treat less
severe cases. The majority of cases have been reported in the the Artibonite, Centre, North
(Nord), Northeast (Nord-Est), South (Sud), and West (Ouest) departments. The government of Haiti
is working closely with the United Nations and a number of other organizations to coordinate a
national response to the cholera outbreak. Thirty-six cholera treatment centers (CTC) and 61
cholera treatment units have been established across the country in order to keep the outbreak
from spreading to camps housing hundreds of thousands of people left homeless by the
earthquake.




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The Cholera Bacterium
In 2009, according to the World Health Organization, 221,226 cholera cases were reported in
45 countries, resulting in just under 5,000 deaths (case-fatality rate 2.24%) (CDC, 2010d).
Cholera is an acute bacterial infection of the intestines that causes profuse watery diarrhea,
vomiting, circulatory collapse, and shock.

Brackish and marine (navigable) waters are a natural environment for the agents of cholera,
Vibrio cholerae O1 or O139. Cholera has no known animal hosts; however, the bacteria attach
themselves easily to the chitin-containing shells of crabs, shrimps, and other shellfish, which can be
a source for human infections when eaten raw or undercooked.

The cholera bacterium is rod-shaped, with a tail (flagellum) that propels it. V. cholerae replicate
rapidly once they reach the host’s intestinal track, forming a multi-layered mat that covers the
small intestine. Although cholera can be life-threatening, it is easily prevented and treated.




Left: A rod-shaped bacterium with a single flagellum. Source: Zygote Media. Right: Scanning electron microscope
image of Vibrio cholerae bacteria, which infect the digestive system. Source: Courtesy of Ronald Taylor, Tom Kirn,
and Louisa Howard.

Once established in the intestinal track, the V. cholerae bacteria release a toxin that causes
dramatically increased secretion of water and chloride ions, which leads to the excretion of
massive amounts of pale, fluid stools. Infected individuals can lose up to 30% of their body
weight in a matter of hours. The fluid expelled from the body contains flecks of epithelial cells
from the lining of the small intestine, giving the fluid a characteristic “rice water” look.

Clinical features of cholera include profuse watery diarrhea, vomiting, circulatory collapse, and
shock. Many infections cause only mild diarrhea or are asymptomatic.




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Transmission
Cholera is transmitted by drinking water or by eating food contaminated with the cholera
bacterium. In an epidemic, the source of the contamination is often the feces of an infected person.
The disease can spread rapidly in areas with inadequate treatment of sewage and drinking
water. The disease is not likely to spread directly from one person to another; therefore, casual
contact with an infected person is not a risk for becoming ill.

The mode of transmission of cholera by water was proven in 1849 by a London physician named
John Snow, who established the presence of cholera in the Broad Street well in London. In 1883
John Koch established V. cholerae as the causative agent in cholera by isolating the bacterium
from the intestinal discharges of cholera patients. It is well-known that cholera has been
transmitted throughout the world by travelers, and along trade routes, and even in bilge water
from ships returning home from endemic areas of the world.




In an 1849 cartoon, a man, apparently turning on a water pipe, is blamed by a little boy for
turning on the cholera. Source: public domain.

Symptoms
The incubation period from infection to onset of symptoms is about 24 to 72 hours and the
infection is often mild or even without symptoms. Approximately 1 in 20 infected persons has
severe disease characterized by profuse painless watery diarrhea, vomiting, and leg cramps. In
these individuals rapid loss of body fluids leads to dehydration and shock. If the infection is
severe and no treatment is available, death can occur within hours.

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Most people infected with V. cholerae do not become ill, although the bacterium can remain in the
feces for 7 to 14 days and a carrier can infect others. Illness is mild to moderate in 80% to 90%
of cases and may be difficult to distinguish clinically from other types of diarrheal disease.

In the most severe cases dramatic fluid loss from the continuous diarrhea can lead to hypovolemic
shock and collapse within 1 to 4 hours. Depending upon the treatment provided, unconsciousness
and death can occur any time from 12 to 18 hours afterwards, although some individual cases
may persist for several days.

Symptoms can vary from mild to severe and include:

    •    Sudden onset of watery diarrhea (with a “fishy” odor)
    •    Stool looks like water with flecks of rice in it (“rice water” stools)
    •    Rapid dehydration and excessive thirst
    •    Rapid weight loss
    •    Low urine output
    •    Rapid heart rate
    •    Dry skin and dry mucous membranes or dry mouth
    •    Glassy or sunken eyes and lack of tears
    •    Lethargy or unusual sleepiness or tiredness
    •    Sunken fontanelles in infants
    •    Abdominal cramps, nausea, and vomiting

Natural infection confers long-lasting immunity against the disease.

Cholera Pandemics
Prior to the nineteenth century, cholera was not a well-known disease. During the first known
cholera pandemic of 1816 to 1826, there was debate about its cause and mode of transmission.
Some associated cholera with weather phenomena, others with “miasma”—poisonous emissions
from rotting vegetation and human “filth” (National Library of Scotland, 2007).




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Left: Drawing about “The Cholera” in Le Petit Journal. Source: public domain. Right: A representation of the cholera
epidemic of the nineteenth century. Before 1830 cholera was unknown in the Western Hemisphere. It became one of
the most feared epidemic diseases of the nineteenth century.

In 1870, W.R. Cornish wrote, “Until quite recently our notions in regard to the causes influencing,
the movements, and the effects of season or climate in the development of cholera have been
extremely vague and unsatisfactory. During the last sixty years many theories have been
propounded to account for the phenomena of cholera epidemics, and even in the present day so
unsettled are the views of the profession that the old battle between the ‘contagionists’ and ‘non-
contagionists’ bids fair to be fought over again with all its original fierceness” (National Library of
Scotland, 2006).

Despite the growing awareness of the contagious nature of cholera, British medical authorities
continued to reject the contagion theory well into the nineteenth century. The British government in
India held to a philosophy of limited intervention in public health and opposed quarantines
despite growing evidence of cholera’s contagiousness. The miasmic theory survived into the 1890s,
when knowledge of the cholera bacillus and its mode of transmission became widely accepted
(National Library of Scotland, 2007).

In India and southern Asia, cholera has been a disease of the rural poor, while in the West it has
taken its greatest toll in the urban and industrial slums. Cholera occurs in epidemics when
conditions of poor sanitation, crowding, war, and famine are present. Endemic areas include
India, Asia, Africa, the Mediterranean, and more recently, South and Central America and
Mexico. Cholera’s fatality rate is greatly increased when it coincides with a famine. Since 1816,
there have been seven cholera pandemics recorded. The seventh pandemic started in 1961 and
continues to the present day.



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No major outbreaks of cholera have occurred in the United States since 1911. However, sporadic
cases occurred between 1973 and 1991, suggesting the possible reintroduction of the organism
into the U.S. marine and estuarial environment. The cases between 1973 and 1991 were
associated with the consumption of raw shellfish or of shellfish either improperly cooked or re-
contaminated after proper cooking (FDA, 2007).

In 1991 cholera was reported for the first time in this century in South America, starting in Peru.
The outbreaks quickly grew to epidemic proportions and spread to other South American and
Central American countries, and into Mexico. More than 1 million cases and 10,000 deaths were
reported in the Western Hemisphere between January 1991 and July 1995 (FDA, 2007).

Although the South American strain of V. cholerae O1 has been isolated from Gulf Coast waters,
presumably transmitted by ships off-loading contaminated ballast water, no cases of cholera
have been attributed to fish or shellfish harvested from U.S. waters. However, over a hundred
cases of cholera caused by the South American strain have been reported in the United States.
These cases arose in travelers returning from South America, or were associated with illegally
smuggled, temperature-abused crustaceans from South America (FDA, 2007).

In the autumn of 1993, a non-O1 strain never before identified was implicated in outbreaks of
cholera in Bangladesh and India. The organism V. cholerae serogroup O139 (Bengal) causes
characteristic severe cholera symptoms. Previous illness with V. cholerae O1 does not confer
immunity and the disease is now endemic. In the U.S., V. cholerae O139 has been implicated in
one case, a traveler returning from India. The strain has not been reported in U.S. waters or
shellfish (FDA, 2007).




Hand bill from the New York City Board of Health, 1832. The outdated public health advice demonstrates the lack of
understanding of the disease and its actual causative factors. Source: public domain.

Predicting how long a cholera epidemic will last is difficult. One cholera epidemic in Africa has
lasted more than thirty years. In areas with inadequate sanitation, a cholera epidemic cannot be
stopped immediately, and, although far fewer cases have been reported from Latin America and
Asia in recent years, there are no signs that the global cholera pandemic will end soon. Major
improvements in sewage and water treatment systems are needed in many countries to prevent
future epidemic cholera.

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Various predictions are being made about the length of the Haiti epidemic. Because cholera was
not present in the population, no immunity exists and some have predicted that the epidemic will
not stop until the entire population is infected.

Treatment
         The discovery of oral rehydration therapy is as important as the discovery of penicillin.
                        Mamdouh Gabr
                        Cairo University, Faculty of Medicine

Cholera can be simply and successfully treated by immediate replacement of the fluid and salts
lost through diarrhea—even when the rehydration fluid is contaminated with cholera bacteria.
Patients can be treated with oral rehydration solution (ORT—also called oral rehydration salts or
solutions [ORS]), a prepackaged mixture of sugar and salts mixed with water and drunk in large
amounts. This solution is used with good success throughout the world to treat diarrhea. Severe
cases also require intravenous fluid replacement (IV drips of Ringer Lactate or, if not available,
normal saline and oral rehydration salts). With prompt rehydration, fewer than 1% of cholera
patients die. If left untreated, 25% to 50% of typical cases are fatal.

Dehydrated patients who can sit up and drink should be given the oral rehydration salts (ORS)
solution immediately and be encouraged to drink. It is important to offer ORS solution frequently,
measure the amount drunk, and measure the fluid lost as diarrhea and vomitus. Patients who vomit
should be given small, frequent sips of ORS solution, or ORS solution by nasogastric tube. ORS
solution should be made with safe water. Safe water means the water has been boiled or treated
with a chlorine product or household bleach (CDC, 2010e).




This cholera patient is drinking oral rehydration solution (ORS) in order to counteract
his cholera-induced dehydration. Cholera patients should be encouraged to drink
ORS. Even patients who are vomiting can often be treated orally if they take small
frequent sips. Their vomiting will subside when their acidosis is corrected.
Source: CDC, 1992.



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The World Health Organization recommends a 1-liter preparation of ORT solution that contains:

    •    Sodium chloride (NaCl): 2.6g
    •    Trisodium citrate dehydrate: 2.9g
    •    Potassium chloride (KCl): 1.5g
    •    Anhydrous glucose: 13.5g
    •    Zinc supplement is recommended, especially for children

When commercial products are not available, the Rehydration Project recommends a “home-
made” ORS solution, which creates 1 liter of ORS:

    •    One level teaspoon of salt
    •    Eight level teaspoons of sugar
    •    One litre of clean drinking or boiled water and then cooled
    •    Five cupfuls (each cup about 200 ml) (Rehydration Project, 2008)

An antibiotic given orally will reduce the volume and duration of diarrhea, although treatment is
recommended for severely ill patients only. Antibiotics should not be given to asymptomatic
individuals. Zinc given orally can reduce the duration of most infectious diarrhea in children. No
drugs besides antibiotics and zinc for treatment of diarrhea or vomiting should be given.
Antibiotics shorten the course and diminish the severity of the illness, but they are not as important
as rehydration (CDC, 2010e).

Cholera Treatment Centers
[The following section, including photos, is reprinted with permission courtesy of Doctors Without Borders (Medecins
Sans Frontieres).]

A cholera treatment center (CTC) is a specialized isolation ward for patients, designed to prevent
the spread of the disease. It is a vital tool in managing and treating severely sick cholera patients
and provides efficient treatment and stabilization. A cholera treatment center might include 100
beds in the acute area, 30 beds in observation, and 30 beds in recovery. The treatment center
includes clean water, hydration, specialized beds, a disinfection area, equipment and supplies,
waste disposal, and latrines.




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Clean Water
A clean water supply is essential because treatment involves rehydrating patients for the fluids
they have lost through diarrhea and vomiting. The water supply is chlorinated to ensure that
bacteria levels are safe for human consumption.




Clean water supply for a village.
Source: Cecile Dehopre/MSF.
Reprinted with permission.

Hydration
Patients displaying severe symptoms are hospitalized in the acute area of the CTC, where they
will receive treatment involving use of an IV to administer a saline solution for rehydration. As
they recover they progress to the use of oral rehydration salts (ORS) that are mixed with water.
Patients in high-risk categories, such as children, elders, and pregnant women are given antibiotics
and zinc supplements.




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Source: Copyright MSF.
Reprinted with permission.

Specialized Beds
Acute patients are treated on specialized beds that allow efficient excreta disposal via a hole
with a bucket below. Buckets are also provided beside the bed for patients who are vomiting.
Buckets are changed regularly, the waste is disposed hygienically, and the buckets are
disinfected with chlorine. A dedicated hygiene team ensures that any spills are cleaned up
promptly and disinfected with chlorine.




Source: Copyright Susan Sandars/MSF.
Reprinted with permission.




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Disinfection
Anyone who enters the CTC walks through a basin of chlorinated water to disinfect the feet.
Hands must also be washed. Patients are then assessed and taken for treatment. Their clothes are
laundered in a chlorine solution, and if a shower is available they may wash their body after
receiving treatment.




Source: Copyright Sally McMillan/MSF.
Reprinted with permission.

Supplies and Administration
Logistics personnel ensure that medical supplies are always kept in stock. Especially important is
the supply of ORS, chlorine, water, IV equipment, and saline solutions. Medical personnel at CTCs
of Médecins Sans Frontières follow the provided cholera guidelines to ensure the center is run as
efficiently as possible and that patients receive the best treatment.




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Waste Management
Contaminated waste is incinerated or buried in a pit to control the spread of cholera. This includes
soft waste (eg, cloth and plastics), sharps (eg, needles and glass), and organic waste.




Source: Copyright Robin Meldrum/MSF.
Reprinted with permission.

Latrines
Latrines are provided to ensure that any human waste is contained, helping to prevent the spread
of cholera.




Source: Copyright MSF.
Reprinted with permission.




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Did You Know…

                         •   Rapid high-volume rehydration will save lives.
                         •   Many patients can be rehydrated entirely with oral rehydration solution
                             (ORS).
                         •   Even if patients get intravenous (IV) rehydration, they should start
                             drinking ORS as soon as able. (CDC 2010c)

Prevention
In areas where a cholera outbreak occurs, the following five basic preventative precautions are
recommended:

    1. Drink and use safe water. (Piped water sources, drinks sold in cups or bags, or ice may
       not be safe and should be boiled or treated with chlorine.) Bottled water with unbroken
       seals and canned/bottled carbonated beverages are safe to drink and use. Use safe
       water to brush your teeth, wash and prepare food, and to make ice. Clean food
       preparation areas and kitchenware with soap and safe water and let dry completely
       before reuse. To be sure water is safe to drink and use:

         •    Boil it or treat it with a chlorine product or household bleach.
         •    If boiling, bring your water to a complete boil for at least 1 minute.
         •    To treat your water with chlorine, use one of the locally available treatment products
              such as Aquatabs, Dlo Lavi, or PuR and follow the instructions.
         •    If a chlorine treatment product is not available, you can treat your water with
              household bleach. Add 8 drops of household bleach for every 1 gallon of water (or 2
              drops of household bleach for every 1 liter of water) and wait 30 minutes before
              drinking.
         •    Always store your treated water in a clean, covered container.

    2. Wash your hands often with soap and safe water. If no soap is available, scrub hands
       often with ash or sand and rinse with safe water:

         •    Before you eat or prepare food
         •    Before feeding your children
         •    After using the latrine or toilet
         •    After cleaning your child’s bottom
         •    After taking care of someone ill with diarrhea




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    3. Use latrines or bury your feces (poop); do not defecate in any body of water. Use
       latrines or other sanitation systems, like chemical toilets, to dispose of feces. Wash hands
       with soap and safe water after defecating. Clean latrines and surfaces contaminated with
       feces using a solution of 1 part household bleach to 9 parts water. If a latrine or chemical
       toilet is not available:

         •    Defecate at least 30 meters away from any body of water and then bury your feces.
         •    Dispose of plastic bags containing feces in latrines, at collection points if available, or
              bury it in the ground. Do not put plastic bags in chemical toilets.
         •    Dig new latrines or temporary pit toilets at least a half-meter deep and at least 30
              meters away from any body of water.

    4. Cook food well, keep it covered, eat it hot, and peel fruits and vegetables. Avoid raw
       foods other than fruits and vegetables you have peeled yourself. Be sure to cook seafood,
       especially shellfish, until it is very hot all the way through. A simple rule of thumb is "Boil it,
       cook it, peel it, or forget it."

    5. Clean up safely. In the kitchen and in places where the family bathes and washes clothes.
       Wash yourself, your children, diapers, and clothes, 30 meters away from drinking water
       sources. (CDC, 2010f)

Vaccine
A recently developed oral vaccine for cholera is licensed and available in other countries
(Dukoral, from SBL Vaccines). The vaccine appears to provide somewhat better immunity and
have fewer adverse effects than the previously available vaccine. However, CDC does not
recommend cholera vaccines for most travelers, nor is the vaccine available in the United States.
When outbreaks of cholera occur, efforts should be directed toward establishing clean water,
food, and sanitation, because vaccination is not very effective in managing outbreaks.

Cholera Response
CDC is working closely with other U.S. government agencies and international partners in support
of the Haitian government’s response to the cholera outbreak in that country. CDC is collaborating
with the U.S. Agency for International Development, the Pan American Health Organization, the
United Nations Children’s Fund, and a host of other organizations to assist the Haiti Ministry of
Public Health and Population (MSPP) in a concerted effort to control the outbreak.




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The top priority of the response is to save lives and control the spread of disease. CDC’s
assistance in the response is focusing on the following areas:

    •    Increasing access to life-saving oral and IV rehydration therapy
    •    Improving access to safe water, sanitation, and hygiene supplies
    •    Establishing a national surveillance system for accurate and timely identification of cholera
         cases
    •    Consulting on clinical management and treatment of patients with cholera, and advising on
         ways to prevent cholera’s spread among those who don’t have it
    •    Performing laboratory testing of suspected cholera cases in collaboration with Haiti’s
         National Public Health Laboratory
    •    Conducting environmental health assessments, such as testing of the water supply, in
         various communities throughout the country
    •    Carrying out site inspections at hospitals and clinics to assess their capacity to deliver
         health care
    •    Conducting epidemiologic surveys and studies to find out more about the outbreak and
         how to contain it
    •    Planning and conducting cholera training for clinical staff and community health workers
    •    Developing guidelines for household infection control for possible cases of cholera brought
         into the United States
    •    Developing messages in support of cholera prevention and control efforts (including
         information translated into French, Creole, and Spanish)
    •    Working with partners to monitor the progress of [tropical storms] and consult about the
         potential impact of the storm on the response to the outbreak (CDC, 2010g)

On November 1, 2010, CDC provided the Haitian government with the results of laboratory
testing showing that the cholera strain linked to the outbreak is most similar to cholera strains
found in south Asia. More work is needed to determine the origin of the cholera strain in Haiti.

Relief Efforts
More often than not, the arrival of uncoordinated goods and volunteers is more disruptive than
helpful in a disaster situation. Those most able to be effective—even those with medical
training— are usually associated with a group or organization and are trained to deal with the
specific type of disaster.

In recent years the UN has worked to address complaints stemming from recent disasters, such as
the 2004 tsunami, by working to centralize and organize the many and complex elements of a
large-scale disaster response.

Donations
For most citizens, the most useful contribution to disaster relief will be cash or pledges that are
immediately convertible to cash. Donors may not realize that it can be many weeks before some
kinds of donations become usable. For example, texting a donation on your phone usually means
the money will not become usable to anyone until you have paid your phone bill.




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Donations in kind—things such as used clothing, household items, or prescription medicines, even
blood and blood derivatives—are almost never appropriate, and can actually create more
problems with the need to store, process, and safely dispose of unusable materials. The need for
additional medical or paramedical personnel and large items such as field hospitals or
construction supplies will depend very much on the specifics of the situation. If you are in a position
to donate such things and believe they are needed, take the time to find out who is managing the
efforts and let them know of your interest in making a donation, but let them make the decision
whether to accept it.

Many legitimate organizations are accepting and disbursing monetary donations for Haitian
disaster relief. But, as always, there will be criminals looking to take advantage of people’s
concern and generosity. If you have any question about a site or organization, don’t give them
money or personal information until you have fully verified their credentials.

The Center for International Disaster Information (http://cidi.org/) is a kind of clearinghouse for
donation guidance. There you can find information about what to donate, what not to donate,
and why. In addition to a great deal of information you will find links to other information sources
for current and past disasters, along with specialized resources for individuals, corporations,
NGOs, the media, and teachers. An especially important article is posted under the “Articles” tab
and is entitled “Stop Propagating Disaster Myths” by Dr. Claude de Ville de Goyet, the former
head of the Pan American Health Organization (PAHO). Although written in 1999, it is an
important discussion and perspective that all disaster responders and those interested in disaster
response should read.

Some large and well-known organizations that are spearheading donation efforts include
UNICEF, WHO in conjunction with the Pan American Health and Education Foundation, the
American Red Cross (and the International Federation of Red Cross and Red Crescent Societies, of
which it is a member), and the Clinton Bush Haiti Fund, an effort by former presidents George W.
Bush and Bill Clinton at the request of President Obama.

Every one of these organizations has a website that you will find listed in the Resources section at
the end of the course. Each has a link on its home page to a donation page and to current
information about fundraising efforts and relief efforts in Haiti.

Travel to Haiti
The CDC recommends the following vaccines for those going to Haiti to provide relief services:

    •    All routine vaccines should be up-to-date including MMR, DPT, polio, seasonal and H1N1
         flu, varicella, and tetanus
    •    Hepatitis A or immune globulin
    •    Typhoid
    •    Hepatitis B (CDC, 2010b)

Knowledge of a number of diseases that occur in Haiti is essential to relief workers. Insect-borne
diseases include malaria and dengue, for which there are no vaccines. Other infectious diseases
include HIV, which has a high prevalence in Haiti, TB, and anthrax. Healthcare providers should
consult CDC guidelines (and their organization’s guidelines) regarding personal protective
equipment (PPE) relative to each type of potential exposure (CDC, 2010b).


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In addition, healthcare workers (like all relief workers) need to be prepared to be self-sufficient,
which means your basic supplies must include:

    •    Food and water to last your entire stay
    •    Soap and alcohol-based hand cleaner
    •    Insect protection: repellant and bed net
    •    Medications: anti-malaria, anti-diarrhea, personal prescriptions and OTC items, and
         copies of all prescriptions
    •    Extra set of prescription eyeglasses or contacts
    •    Water purification supplies
    •    Alert bracelet for medical conditions/contact card
    •    Appropriate PPE
    •    Personal first aid kit containing: bandages, sterile gauze pads, disposable gloves, scissors,
         tweezers, cold compress, antiseptic wipes, antibiotic ointment, hydrocortisone ointment,
         commercial suture/syringe kits to be used by local healthcare provider (will require letter
         from prescribing physician and packing in checked baggage) (CDC, 2010b)

Staying Safe and Healthy in Haiti
While you are in Haiti the CDC recommends washing hands often with soap and water or alcohol-
based hand cleaner (minimum 60% alcohol), especially before preparing or eating food. To keep
your food and water safe, observe the following:

    •    Eat only food that is either packaged or freshly cooked and hot
    •    Drink only water that is bottled, boiled, or chemically treated, or bottled or canned
         carbonated beverages (check that all seals are intact before consuming)
    •    Do not drink tap water, fountain drinks, or ice cubes
    •    Use only bottled, boiled, or chemically treated water to wash dishes, brush your teeth,
         wash and prepare food, or make ice (CDC, 2010b)

To protect yourself against insects and animals you should:

    •    Use approved insect repellants, on yourself and in rooms
    •    Wear protective clothing
    •    Stay indoors during peak biting hours or be extra vigilant with repellants
    •    Use a bed net when sleeping if not in air-conditioned or well-screened quarters
    •    Use caution around animals, clean bites and scratches, seek immediate medical care, and
         advise your doctor of any wound when you return home (CDC, 2010b)




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In addition, be alert to the fact that, after an earthquake, the risk of injury is high. Possible risks
include: electrocution from downed power lines, unstable buildings, damaged roads, leaking
water or chemicals, and personal violence. Always wear proper clothing, including heavy boots
and hard hats when appropriate (CDC, 2010b).

Disaster workers who may be exposed to human remains should be aware that, while dead
bodies rarely spread disease, human remains may contain blood-borne viruses and diarrhea-
causing bacteria. If you will be handling remains, take precautions to avoid exposure by using
plastic face shields, gloves, and proper footwear. Wash hands immediately after removing
gloves and promptly care for any injury received when working with remains, including obtaining
a tetanus booster if indicated. More information can be obtained from CDC at
http://emergency.cdc.gov/disasters/handleremains.asp (CDC, 2010b).

Psychological and Emotional Stress
Disasters, by default, place great stress on those who have survived them. In order to help those
people, first responders and relief workers need to remember that they too can encounter
extremely stressful situations in which they will observe and can be affected by significant loss of
life, serious injuries, missing and separated families, and widespread physical destruction (CDC,
2010b).

Normal reactions that are common for disaster responders include:

    •    Profound sadness, grief, and anger
    •    Not wanting to leave the scene until the work is finished
    •    Trying to override stress and fatigue with dedication and commitment
    •    Denying the need for rest and recovery time (CDC, 2010b)

In order to combat these effects and help manage stress, observe the following:

    •    Limit on-duty work time to no more than 12 hours per day.
    •    Rotate work assignments between high-stress and lower-stress functions.
    •    Drink plenty of water and eat healthy snacks and energy foods.
    •    Take frequent, brief breaks from the scene when you are able.
    •    Keep an object of comfort with you such as a family photo, favorite music, or religious
         material.
    •    Stay in touch with family and friends.
    •    Pair up with another responder so that you can monitor one another’s stress. (CDC, 2010b)

Maintaining awareness of stress reactions in yourself and fellow workers and knowing how to
alleviate them can help preserve your ability to respond to and care for those primarily affected
by the disaster. Once you have returned home you may experience depression even if you felt
your experience was positive and fulfilling. A mental health professional may be helpful in
readjusting. Additional self-help materials and links to materials, including podcasts on stress
management are available on the CDC website.




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Mental Health and Psychosocial Supports for Disaster Survivors
In order to improve humanitarian relief and address concerns raised about previous disaster relief
efforts, including the 2004 tsunami, the UN has adopted a “cluster” system to provide better
coordination of services. Supporting these clusters are a number of standing committees that
address particular areas of need and provide comprehensive general resources as well as
targeted guidance for specific disasters.

Based on research and previous experience with other emergencies, the Inter-Agency Standing
Committee (IASC) on Mental Health and Psychosocial Supports (MHPSS) put together a guide
document for those who expected to be working in Haiti and providing mental health services. At
the heart of these services is the concept that the most successful programs evolve from local
resources and are targeted for local cultural needs and norms.

Nearly everyone in Haiti has been affected by the earthquake, and most people will experience
a normal response of intense emotional distress. In spite of this, “self-recovery and resilience in the
face of disasters is the norm.” Healthcare providers need to be able to distinguish between
normal and severe responses in order to recognize and assist those who are experiencing
difficulties that may require intervention.

Normal reactions can include:
    •    Grief, sadness, hopelessness, and sense of being overwhelmed
    •    Emotional difficulties including anxiety, fear, anger, guilt
    •    Behavioral problems (lack of concentration; increased risk of use of violence, drugs,
         alcohol)
    •    Social problems (isolation; family tension or violence; increased collective fear, anger, and
         frustration regarding humanitarian aid)
    •    Increased social tension and violence due to unmet basic needs, lack of law and order, or
         difficulties ensuring fair and timely assistance

Severe reactions include:
    •    Disorientation (not knowing where you are)
    •    Not responding to conversation
    •    Putting oneself or others in danger
    •    Threatening to harm oneself or others
    •    Inability to manage tasks of daily life (walking, talking, grooming, eating) (MHPSS, 2010)




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Even intense normal reactions will usually be alleviated by receiving basic services in a safe and
dignified way, by the presence of psychological first aid, and by support from family and
community; further, there is a need for constant communications about the relief response and for
positive, useful personal information. When aid distributions are planned they should be
conducted in a safe and dignified manner, pay close attention to marginalized groups, address
gender norms and family roles, accommodate dietary practices whenever possible, and include
community members. Assisting in the relief effort can help survivors regain a sense of control. It
has been found that local support improves the chances for long-term sustainability of programs
(MHPSS, 2010).

Groups Requiring Special Attention
In Haiti a number of groups may be particularly vulnerable including:
    • People with severe reactions
    • Children
    • Women and girls
    • Isolated persons
    • Institutionalized persons
    • Adults and children with disabilities or special needs
    • Adults and children with pre-existing mental/neuropsychiatric disorders (MHPSS, 2010)

As anywhere, persons who are experiencing severe reactions should be referred to general
health and mental health services if available and, if necessary and possible, they should be
removed from danger to a place where they are safe and cared for. Every effort should be
made to ensure that those who require regular assistance, treatments, or medications continue to
receive them, and that isolated or institutionalized persons are visited and receive food and care
(MHPSS, 2010).

Children will generally recover from emotional distress once their basic needs are being met, they
feel safe and secure, and normal activities can be re-established. In the meantime, normal
responses may include nightmares; some social withdrawal; difficulty concentrating; and,
sometimes, regressive developmental behaviors such as thumb sucking, bedwetting, or clinginess.

Children respond best when they can remain with family and their usual caregivers. Because
children will often mirror their parents’ behavior, a parent in distress should receive priority
attention. If at all possible, children should not be separated from parents or caregivers, even for
medical treatments. Particularly vulnerable caregivers—widows, elders, very young mothers—
should be supported so they can remain with and care for the children (MHPSS, 2010).

Women and girls can be at particular risk in Haiti because they are already exposed to sexual
and other forms of gender-based violence (GBV). Because of this, the MHPSS advocates
immediate targeted responses to protect against additional post-earthquake violence in
communities and camp situations. See the section on gender issues later in the course (MHPSS,
2010).




ATrain Education, Inc.
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Coordinated Assistance Plan
The IASC MHPSS recommends a coordinated plan encompassing the four essential levels of aid,
which build upon each other as shown in the diagram below.




Source: IASC Reference Group on Mental Health and Psychosocial Support in Emergency Settings
(MHPSS). (2010).

Basic services and security include food, shelter, livelihood, protection and health care, and
education—the core needs of any human being. Provision of aid to meet these needs should be
done in a way that supports psychosocial well-being, preserves dignity, and involves community
members.

It is important to exercise care in the disposal of dead bodies. Customs and rituals need to be
observed and the dumping of bodies into mass graves is to be avoided. People should be
supported in their decisions regarding burial or cremation and in their need to grieve. It is more
important to identify bodies and allow family members to follow their customs than it is to bury
bodies quickly.

Knowledge helps reduce anxiety. People need to receive consistent and reliable information
about past and current events and future expectations. Information should be uncomplicated and
delivered in the local language.




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Once basic needs are met, mental well-being for most people will be restored with a return to
normal community and family support structures. For some people this will include religious or
traditional cultural practices, especially those surrounding mourning. People need to have a role in
the running of their communities and spaces in them for groups to assemble. Re-establishing
routines and being able to engage in meaningful activities helps people of all ages, although such
activity can be especially critical for adolescents. Group activities help members build new social
networks. Information should be made available on effective, positive coping methods. These
should combine local habits with what has been learned from previous disasters, and messages
should be consistent across all agencies.

The top two levels of the pyramid reflect the fact that some community members will need
additional assistance to return to full mental well-being. While top-level situations will require
skilled practitioners and facilities for treatment, those in need of non-specialized support will
benefit from “psychological first aid,” which is “simple, easily taught, and involves a practical and
compassionate approach” based on the following points:

    •    A = Assess (assess for safety, obvious urgent physical needs, people with serious reactions,
         and individuals’ needs and concerns)

    •    B = Be (be attentive, respectful, and aware)

    •    C = Comfort (comfort through your presence, through good communication, and by
         helping people to cope)

    •    D = Do (do address practical needs, do help problem-solve, do link people with loved
         ones and supports)

    •    E = End/exit strategy (end your own assistance by referring the individual to other
         supports as needed, end for yourself taking time for self-care) (MHPSS, 2010).




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Gender Equality in Humanitarian Assistance
Another of the UN IASC members is the Gender Standby Capacity Project (GenCap), which can
provide targeted written and human resources to clusters in times of disaster relief need.

In their advisory on the Haiti emergency, GenCap argues that an effective humanitarian response
must address the differing needs of women, girls, boys, and men. It finds from experience that
gender issues generally go unrecognized or unaddressed. This leads to additional problems for
vulnerable populations who may be unable to get their basic needs met because they lack the
resources or political power to assert and protect themselves.

GenCap urges those working in Haiti to use an ABC approach:

    •    Assess needs.
    •    Be alert to risks of sexual violence, exploitation, and abuse.
    •    Collect and analyze data by sex and age.

Needs assessment should distinguish among women, girl, boys, and men, as their needs vary in
emergency situations. Women and men should both be included on teams that are performing
assessments and no group should be overlooked when data is collected.

Prior to the earthquake, Haiti had a documented high prevalence of gender-based violence
(GBV) and exacerbation of this problem was expected after the earthquake. Every group
responding in Haiti needs to be aware of this and how it might affect the program they are
administering and the safety of survivors who need their services. Processes need to be designed
to ensure that all groups have safe access. GenCap also urges regular communication to
recipients about what they are entitled to receive to help avoid abuse by those delivering
assistance. All reports of exploitation and abuse must be taken seriously.

Efforts should be made to collect data, by gender and age, about those affected by the
earthquake and its aftermath, including deaths, injuries, displacements, and aid recipients. This
information should be used to ensure that all groups are receiving assistance.

GenCap provides targeted advice for meeting gender-based needs in several relief areas
including camp management, emergency shelters, individual protection, health, water and
sanitation, and distribution of non-food items. Common to most of these are the need for:

    •    Inclusion of women and men on planning or assessment teams
    •    Vigilance about security (proper lighting, reporting mechanisms, policing)
    •    Awareness of differing gender needs for facilities such as latrines
    •    Protecting vulnerable groups such as single- or child-headed households
    •    Assuring privacy for all and safe areas for unaccompanied girls, boys, and young women
         separate from those for adolescent and adult males
    •    Inclusion of women in health planning and implementation, and attention to reproductive
         needs
    •    Ensuring equal access to supply distributions, including for non-food items (GenCap, 2010)



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                                                                    Haiti Earthquake and Cholera Response



Conclusion
What do we see in Haiti that is applicable to disasters closer to home? While a certain amount of
the information included here is specific to the situation in Haiti, much of it is applicable to any
natural disaster anywhere. Even much smaller-scale events benefit from organization, planning,
understanding the elements of response, knowing emergency medical treatments, understanding
how to deal with stress and psychological issues, and emphasizing coordination among all the
affected responders—government, police, healthcare (including skilled mental health care),
infrastructure managers, and volunteers.

Something that may get overlooked in all the practical activity is the importance and effect of
cultural differences and communication in disaster relief efforts. In 1999 then-director of the
PAHO, Claude de Ville de Goyet, wrote an essay entitled “Stop Propagating Disaster Myths.”
Submitted to both The New York Times and the Washington Post as a letter to the editor, it was
never published in either paper. It is, however, available online at the Center for International
Disaster Information’s website (http://cidi.org/articles/paho.htm). This essay should be read by
anyone who wants to better understand the myths and mistaken notions that have grown up in the
wake of disaster relief efforts.

Even if you are working in your own country, it is important to remember that local customs and
the needs of particular religious, ethnic, or social groups may be different from what you are
accustomed to. And, when it comes to donations, what is important is not what donors want to
give, but what survivors need.



(Resources begin on next page)




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                                                                   Haiti Earthquake and Cholera Response



Resources and Donations
American Public Health Association—a comprehensive list of organizations providing food,
medical aid, and basic services in Haiti.
http://www.apha.org/programs/globalhealth/issues/

American Red Cross
http://www.redcross.org/

Centers for Disease Control and Prevention
http://www.cdc.gov/ (Haiti Earthquake link from this page)
http://emergency.cdc.gov/ (Emergency Preparedness and Response page).

Center for International Disaster Information
http://www.cidi.org/incident/haiti-10a/.

Clinton Bush Haiti Fund
http://clintonbushhaitifund.org/

Doctors Without Borders—for those interested in working in the field in Haiti in your profession to
provide direct humanitarian aid.
www.doctorswithoutborders.org

Google Crisis Response—a good overview of volunteer organizations involved in Haiti along
with maps, videos, news, and updates.
http://www.google.com/relief/haitiearthquake/

Haiti Working Group—part of the United States Institute for Peace—focuses the attention of
Washington policymakers on Haiti. Supporting the international community’s recovery efforts
following the January 12th earthquake.
http://www.usip.org/programs/initiatives/haiti-working-group.

InterAction—alliance of U.S.-based international nongovernmental organizations (NGOs). Visit
their website to see a comprehensive list of its member organizations activities in Haiti.
http://www.interaction.org/crisis-list/interaction-members-respond-cholera-outbreak-haiti.

International Federation of Red Cross and Red Crescent Societies
http://www.ifrc.org/

Library of Congress
Country Study: Haiti
http://lcweb2.loc.gov/frd/cs/httoc.html#ht0013 (book length study)

Pan American Health Organization/World Health Organization (PAHO/WHO)
Area on Emergency Preparedness and Disaster Relief
http://new.paho.org/disasters/index.php.




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The Rehydration Project—an organization dedicated to the control, management, treatment, and
prevention of diarrhea and dehydration.
www.rehydrate.org.

UNICEF
http://www.unicef.org/

United Nations—Office for the Coordination of Humanitarian Aid (OCHA)
http://ochaonline.un.org/

USAID
http://www.usaid.gov/helphaiti/

United States Department of State—Haiti page
http://www.state.gov/p/wha/ci/ha/

Whirlwind Wheelchair International—In addition to lifesaving medical and rescue efforts,
thousands of Haitians will need durable wheelchairs capable of navigating the rough debris-
covered terrain. This kind of environment is exactly where Whirlwind wheelchairs excel.
Whirlwind is raising funds to build and deliver wheelchairs to Haiti. To make a donation visit
http://www.whirlwindwheelchair.org/.

World Health Organization & Pan American Health and Education Foundation
http://www.who.int/hac/crises/hti/donations/en/index.html
https://www.pahef.org/donate/donate.aspx?source=Her.

For more information on the cluster idea and gender response issues in humanitarian aid:
http://www.humanitarianreform.org/humanitarianreform/Default.aspx?tabid=70
http://www.humanitarianreform.org/Default.aspx?tabid=452#.



(References begin on next page)




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References
Centers for Disease Control and Prevention (CDC). (2010a). Public health issues and priorities for the Haiti
earthquake. Retrieved January 24, 2010 from
http://emergency.cdc.gov/disasters/earthquakes/healthconcerns_haiti.asp.

Centers for Disease Control and Prevention (CDC). (2010b). Announcement: Guidance for relief workers and others
traveling to Haiti for earthquake response. Retrieved January 24, 2010 from
http://wwwnc.cdc.gov/travel/content/news-announcements/relief-workers-haiti.aspx.

Centers for Disease Control and Prevention (CDC). (2010c). After an earthquake: Management of crush injuries and
crush syndrome. Retrieved January 24, 2010 from http://emergency.cdc.gov/disasters/earthquakes/crush.asp.

Centers for Disease Control and Prevention. (CDC). (2010d). Cholera Epidemiology and Risk Factors. Retrieved
November 16, 2010 from http://www.cdc.gov/cholera/epi.html.

Centers for Disease Control and Prevention. (CDC). (2010e). Defeating Cholera: Clinical Presentation and
Management for Haiti Cholera Outbreak, 2010. Retrieved November 16, 2010 from
http://www.cdc.gov/haiticholera/clinicalmanagement/.

Centers for Disease Control and Prevention. (2010f). Five Basic Cholera Prevention Messages. Retrieved December 6,
2010 from http://www.cdc.gov/haiticholera/five_messages.htm.

Centers for Disease Control and Prevention (2010g). CDC Responds to Cholera Outbreak in Haiti. Retrieved
November 16, 2010 from http://www.cdc.gov/haiticholera/update/.

Centers for Disease Control and Prevention (CDC). (2008). Cholera. Retrieved December 25, 2008 from
http://www.cdc.gov/nczved/dfbmd/disease_listing/cholera_gi.html.

Central Intelligence Agency (CIA). (2010). World Fact Book: Haiti. Retrieved January 24, 2010 from
https://www.cia.gov/library/publications/the-world-factbook/geos/ha.html.

Coffin JG, Stacey RC. (2005). Western Civilizations, 15th ed. Vol I. New York: Norton.

Food and Drug Administration (FDA). (2007). Vibrio cholerae Serogroup O1. In: Foodborne Pathogenic
Microorganisms and Natural Toxins Handbook. Retrieved December 26, 2008 from
http://www.cfsan.fda.gov/~mow/chap7.html.

Hunt L, et al. (2005). The Making of the West: Peoples and Cultures, 2nd ed. New York: Bedford/St. Martin’s.

IASC Gender Standby Capacity Project (GenCap). (2010). Importance of gender issues in the Haiti emergency.
Retrieved January 30, 2010 from http://oneresponse.info/
crosscutting/gender/Documents/Gender%20ABC%20Haiti%20emergenc%2020100121.pdf.

IASC Reference Group on Mental Health and Psychosocial Support in Emergency Settings (MHPSS). (2010). Guidance
note for mental health and psychosocial support: Haiti earthquake emergency response – January 2010. Retrieved
January 31, 2010 from http://www.who.int/entity/hac/crises/hti/haiti_guidance_note_mhpss.pdf.

Kishlansky MA, et al. (2006). Civilization in the West. 6th ed. Vol B. New York: Pearson.

Levack B, et al. (2007). The West: Encounters and Transformations, 2nd ed. New York: Pearson.

Ledwith T. (2010, January 25). UNICEF. Haiti's double disaster. Retrieved January 25, 2010 from
http://www.unicefusa.org/news/news-from-the-field/haitis-double-disaster.html.

Library of Congress (LOC), Federal Research Division. (2006). Country Profile: Haiti. Retrieved February 1, 2010
from http://lcweb2.loc.gov/frd/cs/httoc.html#ht0013.




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National Library of Medicine, Medline Plus. (2007). Cholera. Retrieved December 26, 2008 from
http://www.nlm.nih.gov/medlineplus/ency/article/000303.htm#Prevention.

National Library of Scotland. (2007). Medical History of British India. Retrieved December 26, 2008 from
http://www.nls.uk/indiapapers/highlights.html.

National Library of Scotland. (2006). Cholera in Southern India, Chapter 1: Introductory Remarks. In: Cholera in
southern India: a record of the progress of cholera in 1870, and resume of the records of former epidemic invasions
of the Madras Presidency/by W.R. Cornish. Retrieved December 26, 2008 from
http://www.nls.uk/indiapapers/find/vol/index.cfm?vbid=3734947.

Nicolas G, et al. (2009). “Weathering the storm like bamboo: The strengths of Haitians in coping with natural
disasters. In A. Kalayjian, et al. (eds.), International Handbook of Emotional Healing: Ritual and Practices for Resilience
After Mass Trauma. Greenwood. Retrieved February 1, 2010 from http://education.miami.edu/News/pdfs/Haiti.pdf.

Pan American Health Organization/World Health Organization (PAHO). (2010). Emergency Operations Center
Situation Report #17: Haiti Earthquake. Retrieved February 1, 2010 from
http://new.paho.org/disasters/index.php?option=com_docman&task= doc_download&gid=732&Itemid=.

Pan American Health Organization/World Health Organization (PAHO). (2010a). Health Cluster in Haiti Bulletin
#13. Retrieved February 1, 2010 from
http://new.paho.org/disasters/index.php?option=com_docman&task=doc_download&gid=736&Itemid=.

Rehydration Project. (2008). Oral Rehydration Solutions: Made at Home. Retrieved December 26, 2008 from
http://www.rehydrate.org/solutions/homemade.htm#recipes.

Reliefweb/OCHA. (2010). Haiti Earthquake – Humanitarian Operational Challenges map. Based on material in the
OCHA Situation Report 7 of January 17, 2010. Map accessed January 20, 2010 from
http://inside.unicefusa.org/site/R?i=3EI7WdiA7_Siv1n7AFkjnA.
[also available at http://www.reliefweb.int/rw/301save.gi]

United Nations Office for the Coordination of Humanitarian Affairs (OCHA). (2010a). OCHA’s Response – Fact Sheet,
25 January 2010. Retrieved January 27, 2010 from
http://ochaonline.un.org/OCHAHome/WhereWeWork/Haiti/HaitiOCHAsResponse/tabid/6422/language/en-
US/Default.aspx.

United Nations Office for the Coordination of Humanitarian Affairs (OCHA). (2010b). Haiti Earthquake Situation
Report #13, 25 January 2010. Retrieved January 27, 2010 from
http://www.reliefweb.int/rw/rwb.nsf/retrieveattachments?openagent&shortid= MUMA-
8237QG&file=Full_Report.pdf.

United Nations Stabilization Mission in Haiti (MINUSTAH). (2010). MINUSTAH Background. Retrieved February 3,
2010 from http://www.un.org/en/peacekeeping/missions/minustah/background.shtml.

United Nations Stabilization Mission in Haiti (MINUSTAH). (2010a). MINUSTAH Facts and Figures. Retrieved February
3, 2010 http://www.un.org/en/peacekeeping/missions/minustah/facts.shtml.

United States Agency for International Development (USAID). (2010). AID fact sheet. Retrieved from
http://www.usaid.gov/helphaiti/documents/01.24.10-USAID-DCHAHaitiEarthquakeFactSheet12.pdf.

United States Agency for International Development (USAID). (2010). Haiti state page. Retrieved January 25, 2010
from http://www.usaid.gov/locations/latin_america_caribbean/country/haiti/Haiti_Country_Profile.pdf.

World Health Organization (WHO). (2010). Public health risk assessment and interventions, Earthquake: Haiti,
January 2010. Retrieved January 24, 2010 from
http://www.who.int/diseasecontrol_emergencies/publications/who_hse_gar_dce_2010_1/en/index.html.

World Health Organization (WHO). (2010a). Earthquakes – Technical Hazard Sheet – Natural Disaster Profile.
Retrieved January 31, 2010 from http://www.who.int/hac/techguidance/ems/earthquakes/en/index.html.

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Post Test
Use the Answer Sheet following the test to record your answers.
1. Nineteenth- and twentieth-century Haiti was characterized by:
   a. Occasional bad leaders and modest economic growth.
   b. Nothing but bad leaders yet some modest economic growth.
   c. An even mix of good and bad leaders and notable economic growth.
   d. Almost no competent leaders and economic devastation.

2. Public health priorities can be expected to include all but one of the following:
   a. Provision of food and water.
   b. Management of water safety.
   c. Repairing roads and bridges.
   d. Treatment of wounds and injuries.

3. Most injuries in an earthquake disaster are expected to be:
   a. Simple fractures.
   b. Severe and requiring surgery.
   c. Minor cuts and bruises.
   d. Kidney failure.

4. Crush syndrome can cause:
   a. Systemic tissue injury, organ dysfunction, and metabolic abnormalities.
   b. Local tissue injury, hyperventilation, and organ dysfunction.
   c. Local tissue injury, organ dysfunction, and hallucinations.
   d. Local tissue injury, organ dysfunction, and metabolic abnormalities.

5. Nearly everyone who is involved in an earthquake with major structural damage will
   experience crush injury.
   a. True.
   b. False.

6. Diarrhea, a frequent symptom of water- and food-borne diseases, is already a problem in
   Haiti, especially for:
   a. Pregnant women.
   b. Adolescents.
   c. Children under age 5.
   d. People over age 65.

7. Tuberculosis (TB) in Haiti:
   a. Has been completely eradicated.
   b. Is a leading cause of death.
   c. Is only found in children.
   d. Is not treatable.


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                                                                    Haiti Earthquake and Cholera Response


8. The effects of overcrowding include:
   a. Lower risk of transmission for most diseases.
   b. Increased risk of water-borne diseases only.
   c. Greater risk of transmission for a variety of diseases.
   d. No observable change in transmission risk.

9. Tetanus risk is a widespread concern in Haiti for:
   a. Anyone who receives a wound, even a small one.
   b. Only relief workers.
   c. Only children because they have low vaccination coverage.
   d. Only adults because of their waning immunity.

10. Vaccination coverage for Haitian 1-year-olds averages at about:
    a. 70%.
    b. 50%.
    c. 10%.
    d. No one knows.

11. The most effective disaster response is given by:
    a. A variety of trained groups requested to assist.
    b. Only members of the UN.
    c. All available able-bodied persons.
    d. Only groups from the affected country.

12. The best donation to disaster relief is almost always cash.
    a. True.
    b. False.

13. There are a number of mosquito-borne diseases in Haiti and relief workers:
    a. Can obtain vaccinations against all of them and need no other precautions.
    b. Should bring insect repellants and bed nets with them.
    c. Should wait to purchase insect repellants in Haiti to get the right kind.
    d. Must have only air-conditioned or tightly screened sleeping accommodations.

14. Relief workers going to Haiti need to be self-sufficient and should bring:
    a. Food and water sufficient for their entire stay.
    b. Food and water for the first week.
    c. Food only.
    d. Water only.




ATrain Education, Inc.
707 459-1315                                                                                         46
                                                                   Haiti Earthquake and Cholera Response



15. Normal reactions that are common for disaster responders include:
    a. Profound sadness, grief, and anger.
    b. Wanting to take excessive rest time.
    c. Arguing with relief recipients.
    d. Violent outbursts.

16. Ways for a relief worker to alleviate stress include:
    a. Taking no personal items with them that could get lost.
    b. Working additional duty hours to get more done.
    c. Staying in touch with family and friends.
    d. Limiting contact with other relief workers.

17. An example of a normal stress response in a disaster survivor is:
    a. Threatening to hurt oneself.
    b. Not responding to conversation.
    c. Violence toward others.
    d. Anxiety and fear.

18. Dead bodies should be buried immediately even if only mass graves are available.
    a. True.
    b. False.

19. Psychological first aid is simple and does not involve:
    a. Assessing safety needs.
    b. Administering medications.
    c. Offering good communication.
    d. Addressing practical needs.

20. Gender-based violence (GBV) in Haiti:
    a. Is a rare occurrence.
    b. Should only be addressed by trained personnel.
    c. Can usually be ignored by outsiders.
    d. Has increased post earthquake.

21. Cholera is:
    a. A virus that is spread through blood and body fluids.
    b. A retrovirus that is sexually transmitted.
    c. Very difficult to prevent and treat.
    d. Caused by ingestion of food or water infected with the bacterium Vibrio cholera.




ATrain Education, Inc.
707 459-1315                                                                                        47
                                                                   Haiti Earthquake and Cholera Response



22. During a cholera epidemic, the disease is usually transmitted:
    a. Directly from one person to another.
    b. Through airborne droplets.
    c. By eating food or drinking water contaminated with the cholera bacterium.
    d. To people who have not been immunized.

23. People infected with V. cholerae:
    a. May suffer hypovolemic shock within 1 to 4 hours in the most severe cases.
    b. Become ill and die of hypovolemic shock within 24 hours in most cases.
    c. Do not become ill in most cases, and are not infectious.
    d. May infect other people for up to 2 weeks because of the severe cough associated with
       the disease.
24. V. cholerae infection causes all of the following except:
    a. Sudden onset of watery diarrhea with a fishy odor.
    b. Rapid heart rate.
    c. High urine output.
    d. Long-lasting immunity against the disease.

25. Cholera occurs in epidemics when conditions of poor sanitation, crowding, war and famine are
    present. The seventh and ongoing pandemic:
    a. Began in Haiti in 2010.
    b. Began in the southern United States after hurricane Katrina.
    c. Is considered the most deadly in recorded history.
    d. Began in 1961in Indonesia.

26. The most important treatment for cholera is:
    a. Antibiotics.
    b. Oral rehydration solution or intravenous rehydration.
    c. Immunization against cholera.
    d. Antiemetics.
27. In areas where a cholera outbreak occurs, a simple rule of thumb to prevent infection is:
    a. Get immunized as soon as possible.
    b. Take prophylactic penicillin.
    c. Go to a doctor at the first signs of vomiting or diarrhea.
    d. “Boil it, cook it, peel it, or forget it”, when preparing food.

28. The most important long-term preventive measure against cholera is a recently developed
    oral vaccine.
    a. True
    b. False

(Answer sheet on next page)



ATrain Education, Inc.
707 459-1315                                                                                        48
                                                        Haiti Earthquake and Cholera Response




Answer Sheet
Haiti Earthquake and Cholera Response
Name (Please print your name): _______________________________________________
Date: __________________

Passing score is 80%

    1.     _____
    2.     _____
    3.     _____
    4.     _____
    5.     _____
    6.     _____
    7.     _____
    8.     _____
    9.     _____
    10.    _____
    11.    _____
    12.    _____
    13.    _____
    14.    _____
    15.    _____
    16.    _____
    17.    _____
    18.    _____
    19.    _____
    20.    _____
    21.    _____
    22.    _____
    23.    _____
    24.    _____
    25.    _____
    26.    _____
    27.    _____
    28.    _____

ATrain Education, Inc.
707 459-1315                                                                             49
                                                                      Haiti Earthquake and Cholera Response



Course Evaluation
Please use this scale for your course evaluation. Items with asterisks (*) are required.

    •    5 = Strongly agree
    •    4 = Agree
    •    3 = Neutral
    •    2 = Disagree
    •    1 = Strongly disagree

*1. Upon completion of the course, I was able to:

    a. Identify the major elements in disaster response.

             5      4    3   2     1

    b. List the most critical public health concerns in Haiti after the earthquake.

             5      4    3   2     1

    c. Describe the most likely earthquake-related injuries and their basic treatment.

             5      4    3   2     1

    d. Describe the cause of cholera, its treatment, its transmission, and it symptoms.

             5      4    3   2     1

    e. Describe what is being done to address the cholera epidemic in Haiti and what we can do.

             5      4    3   2     1

    f. Outline key precautions and concerns for individual disaster responders.

             5      4    3   2     1

    g. Assess the psychological effects of disasters on survivors and responders.

             5      4    3   2     1

    h. Discuss gender issues as they apply to humanitarian relief.

             5      4    3   2     1



ATrain Education, Inc.
707 459-1315                                                                                           50
                                                                    Haiti Earthquake and Cholera Response


*2. The course was written in a way that facilitated my learning.

             5      4    3   2      1


*3. This course was free from commercial bias.

             5      4    3   2      1


*4. The course met my continuing education needs.

             5      4    3   2      1


*5. The material presented was supported by evidence.

             5      4    3   2      1


*6. The author avoided the use of anecdotal information as the main source of material.

             5      4    3   2      1


*7. The course was free of product promotion.

             Yes             No**
     ** If you answered “No”, please answer #8.

8. Was product promotion the sole purpose of the presentation?

             Yes             No


* 9. It took me 60 minutes per contact hour to complete the course, test, and evaluation.

             Yes             No**
** If your answer was “No”, how long did it take? _____________________________




ATrain Education, Inc.
707 459-1315                                                                                         51
                                                                            Haiti Earthquake and Cholera Response


10. My professional educational level is (check one):

   Nursing
              Nurse Aide         LVN/LPN       RN (diploma)       RN (AD)
              BSN        MSN      Nurse Practitioner / Advanced Practice Nurse
              PhD / DNSc
    Therapy
              OT Aide      COTA         OT     MOT    OTD
              PT Aide      PTA     PT        MPT   MSPT     DPT      PhD
    Other (please specify): _________________________________________


11. I heard about ATrain Education from:
          Search engine                               Advertisement
             Government or Board website              Returning customer
             Friend                                   Publication (Magazine, etc.)
             Other __________________________


12. I found the ATrainCEU.com website easy to use:
           Yes No

13. Comments or suggestions (optional): _____________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________



(Registration information on next page)




ATrain Education, Inc.
707 459-1315                                                                                                 52
                                                                   Haiti Earthquake and Cholera Response



Registration Information
Please answer all of the following questions (*required).
* Name: _____________________________________________________________________
* Address: _____________________________________________________________________
* City: _______________________________________________State:______ Zip: _________
* Phone: ______________________________________________________________________
* Professional Designation: ______________________________________________________
* License Number and State: ______________________________________________________
Please e-mail my certificate:     Yes    No
Email (required if you want your certificate sent by email): _______________________________
(Note: If you request an email certificate we will not send a copy of your certificate by US Mail.)
Payment Options
This course is free of charge until December 31, 2011.
If you want to order a printed certificate, the charge is $5.00.
Credit card information:
Name ________________________________________________________________________
Address (if different from above): __________________________________________________
City: _____________________________________________________State:____ Zip: ________

Card type:     Visa    MC     American Express    Discover
Card number __________________________________________________________________
Expiration date ____________________________________________ CVS #_______________
Test Completion and Mailing Instructions
1. Complete all forms:
      Answer Sheet
        Evaluation Learning Activity
        Registration Form (this page)
2. If you order a printed certificate and are not paying by credit card, prepare a check for
     $5.00 made out to ATrain Education, Inc. There is no charge for the class if you only want an
     electronic certificate.
3. Mail the completed forms and your payment to:
     ATrain Education, Inc
     5171 Ridgewood Rd
     Willits, CA 95490
Once we receive your forms and payment, we will mail or email your certificate. Please call if
you have questions or email Sharon@ATrainCEU.com. And thanks for taking the ATrain!

ATrain Education, Inc.
707 459-1315                                                                                        53

				
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