Analyze the vulnerability situation in Haiti before the earthquake using Week 2 Coppola’s vulnerability types: physical, environm

n engl j med 364;1 nejm.org january 6, 2011

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nancially strapped and concerned about the cost of reform and its ability to meet their population’s needs.

Maine, Florida, Iowa, and other states have already indicated that they will seek waivers for some insurance rules that could desta- bilize local insurance markets. A recent proposal by Senators Ron Wyden (D-OR) and Scott Brown (R-MA) would grant states addi- tional f lexibility but falls short of giving them full authority to develop their own reform ap- proaches. Since reform cannot be implemented without them, states could choose to take a more in- dependent role even if Washing- ton is slow to give it to them.

Will the President’s health care reform look burdensome and un- workable 2 years from now? Re- form is no longer a 2000-page bill sitting on the desk of a sen- ator or representative. The exec- utive branch has been issuing guidance and regulations that are beginning to fill holes in the

legislation and will change the way the law works in practice. Much to the chagrin of the leg- islation’s most ardent support- ers, Secretary of Health and Hu- man Services Kathleen Sebelius has been granting waivers when the rules don’t work for every- one, albeit on a selective basis designed to avoid the worst po- litical heat.3 Although such de- cisions will soften the impact of reform, they neither alter the shift toward greater government control nor slow the growth of health care spending.

Despite the talk of repeal, Congress will not pass any major health legislation over the next 2 years, and the health sector and private employers will be hard at work preparing for 2014, when many ACA provisions take ef- fect. That does not make health care reform a fait accompli. Ab- sent a miracle, the country will still face crushing budget defi- cits when the next president takes office. A Republican president,

backed by a Republican Congress, would be wise to delay enroll- ment in the health insurance ex- changes, using the time and mon- ey to develop a more targeted plan that closes off open-ended sub- sidies for health insurance and gets the economic incentives right. A Democratic president would do the same thing out of neces- sity — but it would take longer.

Disclosure forms provided by the author are available with the full text of this arti- cle at NEJM.org.

From the American Enterprise Institute, Washington, DC.

This article (10.1056/NEJMp1012299) was published on December 8, 2010, at NEJM.org.

1. Streeter S. Continuing resolutions: FY2008 action and brief overview of recent practices. Washington, DC: Congressional Research Service, 2008. (CRS report RL30343.) (http:// www.rules.house.gov/archives/RL30343.pdf.) 2. Idem. The congressional appropriations process: an introduction. Washington, DC: Congressional Research Service, 2007. (CRS report 97-684.) (http://www.senate.gov/ reference/resources/pdf/97-684.pdf.) 3. Adamy J. Federal agency flexible on Mc- Donald’s plan. Wall Street Journal. October 1, 2010. Copyright © 2010 Massachusetts Medical Society.

Reforming Health Care Reform in the 112th Congress

Responding to Cholera in Post-Earthquake Haiti David A. Walton, M.D., M.P.H., and Louise C. Ivers, M.D., M.P.H.

Related article, p. 33

The earthquake that struck Haiti on January 12, 2010, decimated the already fragile country, leaving an estimated 250,000 people dead, 300,000 injured, and more than 1.3 mil- lion homeless. As camps for in- ternally displaced people sprang up throughout the ruined capital of Port-au-Prince, medical and humanitarian experts warned of the likelihood of epidemic disease outbreaks. Some organizations responding to the disaster mea- sured their success by the ab- sence of such outbreaks, though

living conditions for the dis- placed have remained dangerous and inhumane. In August 2010, the U.S. Centers for Disease Con- trol and Prevention (CDC) an- nounced that a National Surveil- lance System that was set up after the earthquake had confirmed the conspicuous absence of high- ly transmissible disease in Haiti.

However, on October 20, more than 55 miles from the nearest displaced-persons camp, 60 cases of acute, watery diarrhea were recorded at L’Hôpital de Saint Nicolas, a public hospital in the

coastal city of Saint Marc, where Partners in Health has worked since 2008. Stool samples were sent to the national laboratory in Port-au-Prince for testing. The hospital alerted Ministry of Health representatives in the region and in the capital, as well as World Health Organization representa- tives managing the Health Clus- ter, a coordinating group formed after the earthquake. In the next 48 hours, L’Hôpital de Saint Nico- las received more than 1500 ad- ditional patients with acute di- arrhea.

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n engl j med 364;1 nejm.org january 6, 20114

By October 21, preliminary re- sults from the national laborato- ry confirmed our clinical impres- sions: though cholera had not been seen in Haiti in at least a century and may never have been recorded in laboratory-confirmed cases, it had somewhat unexpect- edly emerged in a densely popu- lated zone with little sanitary in- frastructure and limited access to potable water. As the contours of the epidemic began to take shape, following the winding course of a large river in the Artibonite re- gion, hospitals in central Haiti started recording rapidly increas- ing numbers of cases of acute diarrhea. Between October 20 and November 9, Partners in Health recorded 7159 cases of severe cholera. Among these patients, 161 died in seven of its hospitals in the Central and Artibonite re- gions.

In Port-au-Prince, sporadic cases were reported in the early phase of the outbreak; most were deemed “imported cases.” On No- vember 8, 48 hours after Hurri- cane Tomas caused flooding and worsening of living conditions in Parc Jean-Marie Vincent, one of the largest settlement camps, Partners in Health reported seven clinical cases of cholera within the camp. On the same day, Doc- tors without Borders reported see- ing as many as 200 patients with cholera in nearby slums. By No- vember 9, the Ministry of Health had reported 11,125 hospitalized patients and 724 confirmed deaths from cholera.

Although we responded as quickly as we could, we were ham- pered by the rapidity with which the epidemic spread, overwhelm- ing our hospitals with hundreds of patients and stretching already thin resources, staff, and mate- rials. Because there was minimal

practical institutional knowledge about cholera in Haiti, we worked with other nongovernmental or- ganizations to design treatment protocols and institute infection- control measures in affected hos- pitals. Our network of community health workers began distributing oral rehydration salts, water-puri- fication systems, and water filters and instructing people about hy- giene, hand washing, and decon- tamination of cadavers. Body bags were distributed to community leaders, and rehydration posts were set up throughout the coun- tryside. A network of cholera treatment centers and stabiliza- tion centers was established in coordination with the Ministry of Health.

The cholera outbreak took most people by surprise. Unexpectedly, it was centered in rural Haiti and not in the displaced-person camps that are situated mainly in the greater Port-au-Prince area. But history would suggest that an epidemic outbreak of waterborne disease was just waiting to strike rural Haiti. It is well known that Haiti has the worst water secu- rity in the hemisphere. In 2002, it ranked 147th out of 147 coun- tries surveyed in the Water Pov- erty Index.1 After the earthquake, more than 182,000 people moved from the capital to seek refuge with friends or family in the Artibonite and Central regions, increasing stress on small, over- crowded homes and communi- ties that lacked access to latrines and clean water. In addition, in many areas of Haiti, the costs associated with procuring water from private companies and the lack of adequate distribution sys- tems have rendered potable wa- ter even less accessible for those most at risk.

Waterborne pathogens and fe-

cal–oral transmission are favored by the lack of sanitation in Haiti. Typhoid, intestinal parasitosis, and bacterial dysentery are common. Only 27% of the country bene- fits from basic sewerage, and 70% of Haitian households have either rudimentary toilets or none at all.2 But the sudden ap- pearance of cholera, a pathogen with no known nonhuman host, raises the question of how it was introduced to an island that has long been spared this dis- ease. Speculations on this ques- tion have caused social and po- litical friction within Haiti in recent weeks. Early in the epi- demic, the CDC identified the cholera strain Vibrio cholerae O1, serotype Ogawa, biotype El Tor. Chin and colleagues (pages 33– 42) report on DNA sequencing of two isolates from the recent outbreak, which showed that the cholera strain responsible for the Haitian epidemic originated in South Asia and was most likely introduced to Haiti by human activity. The implications of the appearance of this strain are worrisome: as compared with many cholera strains, it is asso- ciated with increased virulence, enhanced ability to survive in the environment and in a human host, and increased antibiotic resistance. These factors have substantial epidemiologic ramifi- cations for the entire region and implications for optimal public health approaches to arresting the epidemic’s spread.

As the infection makes its way to the capital city, there is de- bate about the likely attack rate inside displaced-person camps, as compared with the rate in sur- rounding communities. The latter often have worse access to water and sanitation than the former. But 521 of 1356 displaced-person

Responding to Cholera in Post-Earthquake Haiti

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camps listed by the United Na- tions camp-management cluster reportedly have no water or sani- tation agency, and most are far from reaching the established guidelines for sanitation in hu- manitarian emergencies.3 The liv- ing conditions of most of Haiti’s poor, whether they’re living in camps or communities, are equal- ly miserable in terms of the risk of diarrheal disease.

The reported numbers of cases and deaths, though shocking, rep- resent only a fraction of the epi- demic’s true toll. We have seen scores of patients die at the gates of the hospital or within minutes after admission. Through our net- work of community health work- ers, we have learned of hundreds of patients who died at home or en route to the hospital. In the first 48 hours, the case fatality rate at our facilities was as high as 10%. Though it dropped to less than 2% in the ensuing days as the health system was rein- forced locally and patients be- gan to present earlier in the

course of disease, mortality will most likely climb as the disease spreads and Haiti’s fragile health system falters.

This most recent crisis in Haiti has reinforced certain lessons regarding the provision of ser- vices to the poor. Complemen- tary prevention and care should be the primary focus of the re- lief effort. Vaccination must be considered as an adjunct for con- trolling the epidemic, and anti- biotics should be used in the treatment of all hospitalized pa- tients. These endeavors should proceed in concert with much- needed improvements to sanita- tion and accessibility of potable water. More generally, reliable partnerships are essential, espe- cially if local partners are depend- able and have practical experi- ence and complementary assets. Long-term reinforcement of the public-sector health system is a wise investment, permitting pro- vision of a basic minimum set of services that can be built upon in times of crisis. And community

health workers who can be rap- idly mobilized as educators, dis- tributors of supplies, and first responders are a reliable back- bone of health care. In Haiti, such workers can bring the time- sensitive lifesaving therapy of oral rehydration right to the pa- tient’s door.

Disclosure forms provided by the au- thors are available with the full text of this article at NEJM.org.

From the Department of Global Health and Social Medicine, Harvard Medical School; the Division of Global Health Equity, Brigham and Women’s Hospital; and Part- ners in Health — all in Boston.

This article (10.1056/NEJMp1012997) was published on December 9, 2010, at NEJM .org.

1. Sullivan CA, Meigh JR, Giacomello AM. The Water Poverty Index: development and application at the community scale. Nat Re- sour Forum 2003;27:189-99. 2. Ministère de la Santé Publique et de la Population, Haiti. Enquête mortalité, mor- bidité et utilisation des services (EMMUS- IV): Haiti, 2005-2006. (http://new.paho.org/ hai/index.php?option=com_docman&task= doc_download&gid=25&Itemid=.) 3. 101112 WASH Cluster situation report. November 12, 2010. (http://haiti.humanitarian response.info/Default.aspx?tabid=83.) Copyright © 2010 Massachusetts Medical Society.

Responding to Cholera in Post-Earthquake Haiti

Antibiotics for Both Moderate and Severe Cholera Eric J. Nelson, M.D., Ph.D., Danielle S. Nelson, M.D., M.P.H., Mohammed A. Salam, M.B., B.S., and David A. Sack, M.D.

Related article, p. 33

The 2010 Haitian cholera out-break has pressed local and international experts into rapid action against a disease that is new to many health care provid- ers in Haiti. The World Health Organization (WHO) has time- tested management protocols for emerging cholera outbreaks. These protocols have been used by the Haitian government to fight an epidemic that is merely one of several recent tragedies in Haiti. The use of these protocols has

allowed for a high standard of care in this complex and evolv- ing medical landscape. But where- as the current WHO cholera- treatment protocol (www.who.int/ mediacentre/factsheets/fs107/en/ index.html) recommends anti- biotics for only severe cases, the approach of the International Centre for Diarrhoeal Disease Re- search, Bangladesh (ICDDR,B), recommends antibiotics for both severe and moderate cases.

Several antibiotics are effec-

tive in the treatment of cholera, including doxycycline, ciprof lox- acin, and azithromycin, assuming that the cholera strain is sensi- tive. Currently, the epidemic strain in Haiti is susceptible to tetracy- cline (a proxy for doxycycline) and azithromycin but is resistant to nalidixic acid, sulfisoxazole, and trimethoprim–sulfamethoxazole. The WHO advocates giving anti- biotics to patients with cholera only when their illness is judged to be “severe.” This recommen-

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After epidemic cholera emerged in Haiti in October 2010, the disease spread rapidly in a country devastated by an earthquake earlier that year, in a population with a high proportion of infant deaths, poor nutrition, and frequent infectious diseases such as HIV infection, tuberculosis, and malaria. Many nations, multinational agencies, and nongovernmental organizations rapidly mobilized to assist Haiti. The US government provided emergency response through the Offi ce of Foreign Disaster Assistance of the US Agency for International Development and the Centers for Disease Control and Prevention. This report summarizes the participation by the Centers and its partners. The efforts needed to reduce the spread of the epidemic and prevent deaths highlight the need for safe drinking water and basic medical care in such diffi cult circumstances and the need for rebuilding water, sanitation, and public health systems to prevent future epidemics.

Cholera is a severe intestinal infection caused by strains of the bacteria Vibrio cholerae serogroup O1 or O139, which produce cholera toxin. Symptoms and signs can range from asymptomatic carriage to severe diarrhea, vomiting, and profound shock. Untreated cholera is fatal in ≈25% of cases, but with aggressive volume and electrolyte replacement, the number of persons who die of cholera is limited to <1%. Since 1817, cholera has spread throughout the world in 7 major pandemic waves; the current and longest pandemic started in 1961 (1). This seventh pandemic, caused by the El Tor biotype of V. cholerae O1 and O139, began in Indonesia, spread through Asia, and reached Africa in 1971. In 1991, it appeared unexpectedly in Latin America,

causing 1 million reported cases and 9,170 deaths in the fi rst 3 years (2). The other biotype of V. cholerae O1, called the classical biotype, is now rarely seen.

Cholera is transmitted by water or food that has been contaminated with infective feces. The risk for transmission can be greatly reduced by disinfecting drinking water, separating human sewage from water supplies, and preventing food contamination. Industrialized countries have not experienced epidemic cholera since the late 1800s because of their water and sanitation systems (3). The risk for sustained epidemics may be associated with the infant mortality rate (IMR) because many diarrheal illnesses of infants spread through the same route. In Latin America, sustained cholera transmission was seen only in countries with a national IMR >40 per 1,000 live births (4). Although cholera persists in Africa and southern Asia, it recently disappeared from Latin America after sustained improvements in sanitation and water purifi cation (5,6). Although the country was at risk, until the recent outbreak, epidemic cholera had not been reported in Haiti since the 1800s, and Haiti, like other Caribbean nations, was unaffected during the Latin America epidemic (7,8).

Haiti: A History of Poverty and Poor Health Haiti has extremely poor health indices. The life

expectancy at birth is 61 years (9), and the estimated IMR is 64 per 1,000 live births, the highest in the Western Hemisphere. An estimated 87 of every 1,000 children born die by the age of 5 years (9), and >25% of surviving children experience chronic undernutrition or stunted growth (10). Maternal mortality rate is 630 per 100,000 live births (10).

Haitians are at risk of spreading vaccine-preventable diseases, such as polio and measles, because childhood vaccination coverage is low (59%) for polio, measles-

Lessons Learned during Public Health Response to Cholera

Epidemic in Haiti and the Dominican Republic

Jordan W. Tappero and Robert V. Tauxe

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 11, November 2011 2087

Author affi liation: Centers for Disease Control and Prevention, Atlanta, Georgia, USA

DOI: http://dx.doi.org/10.3201/eid1711.110827

SYNOPSIS CHOLERA IN HAITI

rubella, and diphtheria-tetanus-pertussis vaccines (9). Prevalence of adult HIV infection (1.9%) and tuberculosis (312 cases per 100,000 population) in the Western Hemisphere is also highest in Haiti (11,12), and Hispaniola, which Haiti shares with the Dominican Republic, is the only Caribbean island where malaria remains endemic (13).

Only half of the Haitian population has access to health care because of poverty and a shortage of health care professionals (1 physician and 1.8 nurses per 10,000 population), and only one fourth of seriously ill persons are taken to a health facility (14). Before the earthquake hit Haiti in January 2010, only 63% of Haiti’s population had access to an improved drinking water source (e.g., water from a well or pipe), and only 17% had access to a latrine (15).

Aftermath of Earthquake The earthquake of January 12, 2010, destroyed homes,

schools, government buildings, and roads around Port- au-Prince; it killed 230,000 persons and injured 300,000. Two million residents sought temporary shelter, many in internally displaced person (IDP) camps, while an estimated 600,000 persons moved to undamaged locations.

In response, the Haitian government developed strategies for health reform and earthquake response (16,17) and called on the international community for assistance. The Ministère de la Santé Publique et de la Population (MSPP) requested assistance from the Centers for Disease Control and Prevention (CDC) to strengthen reportable disease surveillance at 51 health facilities that were conducting monitoring and evaluation with support from the US President’s Emergency Plan for AIDS Relief (PEPFAR) (18) and at health clinics for IDPs (19). MSPP also asked CDC to help expand capacity at the Haiti Laboratoire National de Sante Publique to identify reportable pathogens, including V. cholerae (20,21), and help train Haiti’s future epidemiologic and laboratory workforce. These actions, supported through new emergency US government (USG) funds to assist Haiti after the earthquake, laid the groundwork for the rapid detection of cholera when it appeared.

Cholera Outbreak On October 19, 2010, MSPP was notifi ed of a

sudden increase in patients with acute watery diarrhea and dehydration in the Artibonite and Plateau Centrale Departments. The Laboratoire National de Sante Publique tested stool cultures collected that same day and confi rmed V. cholerae serogroup O1, biotype Ogawa, on October 21. The outbreak was publicly announced on October 22 (22).

A joint MSPP-CDC investigation team visited 5 hospitals and interviewed 27 patients who resided in communities along the Artibonite River or who worked

in nearby rice fi elds (23). Many patients said they drank untreated river water before they became ill, and few had defecated in a latrine. Health authorities quickly advised community members to boil or chlorinate their drinking water and to bury human waste. Because the outbreak was spreading rapidly and the initial case-fatality rate (CFR) was high, MSPP and the USG initially focused on 5 immediate priorities: 1) prevent deaths in health facilities by distributing treatment supplies and providing clinical training; 2) prevent deaths in communities by supplying oral rehydration solution (ORS) sachets to homes and urging ill persons to seek care quickly; 3) prevent disease spread by promoting point-of-use water treatment and safe storage in the home, handwashing, and proper sewage disposal; 4) conduct fi eld investigations to defi ne risk factors and guide prevention strategies; and 5) establish a national cholera surveillance system to monitor spread of disease.

National Surveillance of Rapidly Spreading Epidemic Health offi cials needed daily reports (which established

reportable disease surveillance systems were not able to provide) to monitor the epidemic spread and to position cholera prevention and treatment resources across the country. In the fi rst week of the outbreak, MSPP’s director general collected daily reports by telephone from health facilities and reported results to the press. On November 1, formal national cholera surveillance began, and MSPP began posting reports on its website (www.mspp.gouv.ht). On November 5–6, Hurricane Tomas further complicated surveillance and response efforts, and many persons fl ed fl ood-prone areas. By November 19, cholera was laboratory confi rmed in all 10 administrative departments and Port-au- Prince, as well as in the Dominican Republic and Florida (24,25) (Figure 1). Though recently affected departments in Haiti experienced high initial CFRs, by mid December, the CFR for hospitalized case-patients was decreasing in most departments, and fell to 1% in Artibonite Department (26). Reported cases decreased substantially in January, and the national CFR of hospitalized case-patients fell below 1% (Figure 2). As of July 31, 2011, a total of 419,511 cases, 222,359 hospitalized case-patients, and 5,968 deaths had been reported.

Field Investigations and Laboratory Studies To guide the public health response, offi cials

needed to know how cholera was being transmitted, which interventions were most effective, and how well the population was protecting itself. Therefore, CDC collaborated with MSPP and other partners to conduct rapid fi eld investigations and laboratory studies. Central early fi ndings included the following.

First, identifying untreated drinking water as the primary source for cholera reinforced the need to provide

2088 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 11, November 2011

CHOLERA IN HAITI Cholera in Haiti and Dominican Republic

water purifi cation tablets and to teach the population how to use them. Although most of the population had heard messages about treating their drinking water, many lacked the means to do so.

In addition, in Artibonite Department, those with cholera-like illness died at home, after reaching hospitals, and after discharge home, which suggests that persons were unaware of how quickly cholera kills and that the overwhelmed health care system needed more capacity and training to deliver lifesaving care. Also, water and seafood from the harbors at St. Marc and Port-au-Prince were contaminated with V. cholerae, which affi rmed the need to cook food thoroughly and advise shipmasters to exchange ballast water at sea to avoid contaminating other harbors.

The epidemic strain was resistant to many antimicrobial agents but susceptible to azithromycin and doxycycline. Guidelines were rapidly disseminated to ensure effective antimicrobial drug treatment.

Cholera affected inmates at the national penitentiary in Port-au-Prince in early November, causing ≈100 cases and 12 deaths in the fi rst 4 days. The problem abated after the institution’s drinking water was disinfected and inmates were given prophylactic doxycycline.

Finally, investigators found that epidemic V. cholerae isolates all shared the same molecular markers, which suggests that a point introduction had occurred. The epidemic strain differed from Latin American epidemic strains and closely resembled a strain that fi rst emerged in Orissa, India, in 2007 and spread throughout southern Asia and parts of Africa (27). These hybrid Orissa strains have the biochemical features of an El Tor biotype but the toxin of a classical biotype; the later biotype causes more severe

illness and produces more durable immunity (28,29). A representative isolate was placed in the American Type Culture Collection, and 3 gene sequences were placed in GenBank (23).

Training Clinical Caregivers and Community Health Workers

CDC developed training materials (in French and Creole) on cholera treatment and on November 15–16 held a training-of-trainers workshop in Port-au-Prince for locally employed clinical training staff working at PEPFAR sites across all 10 departments. These materials were also posted on the CDC website (www.cdc.gov/haiticholera/ traning). The training-of-trainers graduates subsequently led training sessions in their respective departments; 521 persons were trained by early December.

During the initial response ≈10,000 community health workers (CHWs), supported through the Haitian government and other organizations, staffed local fi rst aid clinics, taught health education classes, and led prevention activities in their communities. Training materials for CHWs developed by CDC were distributed at departmental training sessions, shared with other nongovernmental organization (NGO) agencies, and used in a follow-up session for CHWs held on March 1–3, 2011 (see pages 2162–5). The CHW materials discussed treating drinking water by using several water disinfection products; how to triage persons coming to a primary clinic with diarrhea and

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 11, November 2011 2089

Figure 1. Administrative departments of Haiti affected by the earthquake of January 12, 2010; the path of Hurricane Tomas, November 5–6, 2010; and cumulative cholera incidence by department as of December 28, 2010.

Figure 2. Reported cases of cholera by day, and 14-day smoothed case-fatality rate (CFR) among hospitalized cases, by day, Haiti, October 22, 2010–July 25, 2011. UN, United Nations; CDC, Centers for Disease Control and Prevention; PAHO, Pan American Health Organization; MSPP, Ministère de la Santé Publique et de la Population.

SYNOPSIS CHOLERA IN HAITI

vomiting; making and using ORS; and disinfecting homes, clothing, and cadavers with chlorine bleach solutions. Materials were posted on the CDC website as well.

Working with Partners to Increase Capacity for Cholera Treatment

Supply logistics were daunting as cholera spread rapidly across Haiti. Sudden, unexpected surges in cases could easily deplete local stocks of intravenous rehydration fl uids and ORS sachets, and resupplying them could be slow. The national supply chain, called Program on Essential Medicine and Supplies, was managed by MSPP, with technical assistance from the Pan American Health Organization, and received shipments of donated materials and distributed them to clinics.

Early in November the USG provided essential cholera treatment supplies through the US Agency for International Development’s Offi ce of Foreign Disaster Assistance (OFDA) to the national warehouse and IDP camps. CDC staff also distributed limited supplies to places with acute needs. To complement efforts by MSPP and aid organizations to establish preventive and treatment services, OFDA provided emergency funding to NGO partners with clinical capacity.

When surveillance and modeling suggested that the spread of cholera across Haiti could outpace the public health response, the USG reached out to additional partners to expand cholera preventive services and treatment capacity. PEPFAR clinicians were authorized to assist with clinical management of cholera patients and participated in clinical training across the country. In December, CDC received additional USG emergency funds and awarded MSPP and 6 additional PEPFAR partners $14 million to further expand cholera treatment and prevention efforts through 4,000 CHWs and workers at 500 community oral rehydration points. Funds were also used to expand cholera treatment sites at 55 health facilities. In addition, CDC established the distribution of essential cholera supplies to PEPFAR partners through an existing HIV commodities supply chain management system.

Improvements in Water, Sanitation, and Hygiene To increase access to treated water and raise awareness

of ways to p

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