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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. 707 459-1315 1 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 email@example.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. 707 459-1315 2 Haiti Earthquake and Cholera Response 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. 707 459-1315 3 Haiti Earthquake and Cholera Response 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. ATrain Education, Inc. 707 459-1315 4 Haiti Earthquake and Cholera Response 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. 707 459-1315 5 Haiti Earthquake and Cholera Response 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. ATrain Education, Inc. 707 459-1315 6 Haiti Earthquake and Cholera Response 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. ATrain Education, Inc. 707 459-1315 7 Haiti Earthquake and Cholera Response 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. 707 459-1315 8 Haiti Earthquake and Cholera Response 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. 707 459-1315 9 Haiti Earthquake and Cholera Response 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. 707 459-1315 10 Haiti Earthquake and Cholera Response 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. 707 459-1315 11 Haiti Earthquake and Cholera Response 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. 707 459-1315 12 Haiti Earthquake and Cholera Response 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. 707 459-1315 13 Haiti Earthquake and Cholera Response 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. 707 459-1315 14 Haiti Earthquake and Cholera Response 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. ATrain Education, Inc. 707 459-1315 15 Haiti Earthquake and Cholera Response 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. ATrain Education, Inc. 707 459-1315 16 Haiti Earthquake and Cholera Response 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. ATrain Education, Inc. 707 459-1315 17 Haiti Earthquake and Cholera Response 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. ATrain Education, Inc. 707 459-1315 18 Haiti Earthquake and Cholera Response 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. ATrain Education, Inc. 707 459-1315 19 Haiti Earthquake and Cholera Response 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). ATrain Education, Inc. 707 459-1315 20 Haiti Earthquake and Cholera Response 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. ATrain Education, Inc. 707 459-1315 21 Haiti Earthquake and Cholera Response 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. ATrain Education, Inc. 707 459-1315 22 Haiti Earthquake and Cholera Response 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. ATrain Education, Inc. 707 459-1315 23 Haiti Earthquake and Cholera Response 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. ATrain Education, Inc. 707 459-1315 24 Haiti Earthquake and Cholera Response 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. ATrain Education, Inc. 707 459-1315 25 Haiti Earthquake and Cholera Response 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. ATrain Education, Inc. 707 459-1315 26 Haiti Earthquake and Cholera Response 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. ATrain Education, Inc. 707 459-1315 27 Haiti Earthquake and Cholera Response 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. ATrain Education, Inc. 707 459-1315 28 Haiti Earthquake and Cholera Response 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 ATrain Education, Inc. 707 459-1315 29 Haiti Earthquake and Cholera Response 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. ATrain Education, Inc. 707 459-1315 30 Haiti Earthquake and Cholera Response 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. ATrain Education, Inc. 707 459-1315 31 Haiti Earthquake and Cholera Response 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). ATrain Education, Inc. 707 459-1315 32 Haiti Earthquake and Cholera Response 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) ATrain Education, Inc. 707 459-1315 33 Haiti Earthquake and Cholera Response 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. ATrain Education, Inc. 707 459-1315 34 Haiti Earthquake and Cholera Response 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) ATrain Education, Inc. 707 459-1315 35 Haiti Earthquake and Cholera Response 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. 707 459-1315 36 Haiti Earthquake and Cholera Response 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. ATrain Education, Inc. 707 459-1315 37 Haiti Earthquake and Cholera Response 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). ATrain Education, Inc. 707 459-1315 38 Haiti Earthquake and Cholera Response 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) ATrain Education, Inc. 707 459-1315 39 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) ATrain Education, Inc. 707 459-1315 40 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. ATrain Education, Inc. 707 459-1315 41 Haiti Earthquake and Cholera Response 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) ATrain Education, Inc. 707 459-1315 42 Haiti Earthquake and Cholera Response 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. ATrain Education, Inc. 707 459-1315 43 Haiti Earthquake and Cholera Response 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. ATrain Education, Inc. 707 459-1315 44 Haiti Earthquake and Cholera Response 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. ATrain Education, Inc. 707 459-1315 45 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 firstname.lastname@example.com. And thanks for taking the ATrain! ATrain Education, Inc. 707 459-1315 53
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