Research Article: Geographic Distribution and Mortality Risk Factors during the Cholera Outbreak in a Rural Region of Haiti, 2010-2011

Date Published: March 26, 2015

Publisher: Public Library of Science

Author(s): Anne-Laure Page, Iza Ciglenecki, Ernest Robert Jasmin, Laurence Desvignes, Francesco Grandesso, Jonathan Polonsky, Sarala Nicholas, Kathryn P. Alberti, Klaudia Porten, Francisco J. Luquero, Edward T. Ryan.

Abstract: BackgroundIn 2010 and 2011, Haiti was heavily affected by a large cholera outbreak that spread throughout the country. Although national health structure-based cholera surveillance was rapidly initiated, a substantial number of community cases might have been missed, particularly in remote areas. We conducted a community-based survey in a large rural, mountainous area across four districts of the Nord department including areas with good versus poor accessibility by road, and rapid versus delayed response to the outbreak to document the true cholera burden and assess geographic distribution and risk factors for cholera mortality.Methodology/Principal FindingsA two-stage, household-based cluster survey was conducted in 138 clusters of 23 households in four districts of the Nord Department from April 22nd to May 13th 2011. A total of 3,187 households and 16,900 individuals were included in the survey, of whom 2,034 (12.0%) reported at least one episode of watery diarrhea since the beginning of the outbreak. The two more remote districts, Borgne and Pilate were most affected with attack rates up to 16.2%, and case fatality rates up to 15.2% as compared to the two more accessible districts. Care seeking was also less frequent in the more remote areas with as low as 61.6% of reported patients seeking care. Living in remote areas was found as a risk factor for mortality together with older age, greater severity of illness and not seeking care.Conclusions/SignificanceThese results highlight important geographical disparities and demonstrate that the epidemic caused the highest burden both in terms of cases and deaths in the most remote areas, where up to 5% of the population may have died during the first months of the epidemic. Adapted strategies are needed to rapidly provide treatment as well as prevention measures in remote communities.

Partial Text: The cholera epidemic in Haiti, which began in 2010 spread rapidly in both urban and rural areas. One month after confirmation of the first case in Mirebalais, in the department of Centre, the whole country had been affected [1,2]. During the first few days, the focus was on case management in hospitals, which were quickly overwhelmed [1]. Gradually, the Ministry of Health (MSPP), together with partners including non-governmental organizations (NGOs), started setting up dedicated treatment facilities ranging from large specialized centers to decentralized oral rehydration points (ORP) in more isolated communities, cholera-specific health education messages, and water and sanitation activities [1,3]. A national training program for cholera management was developed to train clinical staff, nearly all of whom were unfamiliar with the disease [4]. Despite these efforts, over 600,000 cases of cholera and 7,000 deaths were reported by the national health-structure based surveillance system within two years of the first case [5], and, at the time of writing this article, cases are still being reported (

The results of this large community-based survey on the burden of cholera during the first six months of the outbreak in a rural and mountainous area in the northern part of Haiti show very high attack rates and case fatality rates. It highlights important geographical disparities in the four districts investigated, and in particular, the higher risk of both disease and death in the most remote areas. Both the attack rate and case fatality rate found through the survey were more than four times higher than those calculated using data recorded by the national surveillance system in the same period in the Nord department. Moreover, the extrapolated number of cases in the rural populations of these four communes only (21,681 for a population of 173,903) almost reached the total number of cases reported in the national surveillance for the whole department until May 22nd (29,295 for a population of 1,004,247), while the extrapolated number of diarrhea-related deaths in the four communes (2,375) was 3.5 times higher than the total number of deaths (654) reported in the whole department over the same period. This acute underreporting of cases and deaths through the national surveillance system derived from health facility-based cases highlights the importance of community data to better estimate disease burden in areas where national surveillance system may encounter major limitations due to the limited access of the population to health structures. Such data are crucial for targeting the most urgent responses to the highest-priority areas. To achieve this goal, local social leaders (head of villages, religious leaders, etc.) and associations should be mobilized early on to participate in both sensitization and community-based surveillance.



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