UNICEF Haiti - Cholera Outbreak - 22 November 2010

HEADLINES
Situation Update
◊ As of 19 November 56,901 people had sought care for episodes of
cholera, 23,817 cases required hospitalisations and 1344 deaths
were reported. All departments are now affected with reports of sus-
picious cases in Nippes, Grande Anse, and Sud Est (see map page 4).
◊ Tensions around the presidential elections on 28 November led to
deterioration of the security situation in the North, causing disrup-

© UNICEF/2010/Dormino
tions to humanitarian efforts over two to three days. Responses have
resumed but concerns are high as the situation remains volatile.
◊ While UNICEF is bringing in additional supplies and deploying more
staff in the field, lack of partners and human resources including
medical staff in an overstretched health system is a serious obstacle
in the effort to contain the epidemic and reduce mortality.
UNICEF response
A girl on her way to buy water
◊ Shifting to full office mobilisation mode and working with over 70 pushes a wheelbarrow with empty
partners, UNICEF is investing in nationwide response and prevention water containers past a garbage-
efforts—more than following the epidemic as it spreads the focus is filled gully.
on building capacity and readiness nationally to anticipate outbreaks
and reduce mortality. With serious gaps in sanitation and
◊ To date more than 720,000 bars of soap and 6.45 million aquatabs risks of contamination in Port-au-
have been distributed along with other WASH supplies and more than Prince’s slums, preventing cholera is
1.2 million sachets of Oral Rehydration Salts/Zinc. an uphill battle.
◊ More than 40 health facilities received a combination of support
including tents to set-up cholera treatment centres, medical, nutrition UNICEF therefore is working at the
and WASH supplies and technical assistance to ensure proper care. community level with partners to
◊ 5,000 schools to be provided with supplies to improve hygiene and ensure blanket distributions of aqua-
tabs to purify water, focusing on
ensure access to safe water for 1.2 million children. where needs are greatest—including
◊ A second round of hygiene promotion, soap and ORS distributions here in Cité de l’Eternel.
is taking place in residential care centres for children throughout the
country, serving more than 30,000 children.

On 15 November, a young boy reads

a cholera-prevention poster taped on
the open door of a dwelling in the
impoverished Cité de l’Eternel neigh-
bourhood of Port-au-Prince.
The posters includes messages in Cre-
ole on the need to immediately refer
patients to the nearest health centres,
and provides tips on how to prepare
home-made Oral Rehydration Salts.
It also insists on basic hygiene tips
to prevent contamination: regular
© UNICEF/2010/Dormino

disinfection of latrines, proper ways

to dispose of excreta when someone
becomes sick at household level, and
the key practices of handwashing with
soap and exclusive maternal breast-
feeding for infants.

Situation Report
Cholera Outbreak 1
22 November 2010
 Situation Update: Trends, behaviours
and growing public health challenges
Epidemiological trends
By all accounts Haiti is facing one of the biggest chol-
era epidemics in recent memory, and the outbreak
has yet to peak. Epidemiological data suggests that
the peak can be expected as late as end-December,
although different partners on the ground are also
projecting a peak within two to three weeks. In some
areas, including Artibonite where the first cases were
reported, the number of daily cases has tended to
decline (see below), although there remains concern
on community-level under-reporting.
Artibonite Trends
600
500
400
300 Daily Cases
200
Daily Fatalities
100
30 October 7 November 17 November
Source: Ministry of Health.
There also remains uncertainty on whether the peak
of the epidemic will stay localised or reach a national
scale. In view of the context and available epidemio-
logical data, the outbreak in Haiti corresponds to no
pre-existing model.
To date, scenarios for the future course of the epi-
demic remain under discussion among specialisted
technical agencies including the World Health Or-
ganization and the Centers for Disease Control and
Prevention (CDC).
Quick survey on behaviours and attitudes
With cases and fatalities still growing and projections
that the peak of the epidemic has yet to be reached,
UNICEF conducted a quick study on perceptions and
health-seeking behaviours among patients in three
Cholera Treatment Centres in Port-au-Prince. The ob-
Cholera Outbreak
jective was to identify possible bottlenecks at the very
immediate level of community behaviours which may
contribute to the high case fatality rates observed, the
high number of severe cases that are reported, and
the continued spread of the epidemic.
A small sample of patients were surveyed last week
(25 patients, all of them reporting severe cases) and
the following behaviours and attitudes were reported:
(i) 80 per cent of patients said that they had Oral
Rehydration Salts (ORS) at home and had taken
ORS, but reported that they had waited to see the
effect before seeking care. This behaviour was the
single largest reason for people not immediately
seeking treatment. Those who had no ORS imme-
diately went to consult at the nearest health centre.
(ii) Fatalities
Daily All patients reported that they had considered
their first symptoms as related to “normal” diar-
rhoea, delaying health-seeking behaviours.
Daily Cases
(iii) 75 per cent of patients said that they did
not drink water from bladders, although not out
of taste but out of “distrust” and general prefer-
ence for sachets of water, which are deemed to be
“safer”. Understanding on what kind and source
of water is safe remains unclear, with one patient
reporting that they drank chlorinated water, had
stopped eating raw vegetables, but continued to
use untreated water from wells for dishwashing.
(iv) Two patients reported that fear of stigmatisa-
tion had delayed their seeking care.
(v) Only 20 per cent of patients surveyed had
come from spontaneous settlements.
A few members of the community who were not
patients were also rapidly canvassed on their knowl-
edge and attitudes vis-à-vis the disease. One belief is
that once cholera is contracted there is no cure, while
another belief is that Cholera Treatment Centres only
provide rehydration and do not cure from cholera,
with a belief that rehydration can be done just as well
at home.
Results from this rapid study, despite the small
sample of people surveyed, tend to reveal that misin-
formed reflexes and gaps in knowledge of key practic-
es are partly contributing to the spread of the disease
and the severity of cases. It also raises concerns that
even the most basic practices—such as handwashing
with soap—are not yet appropriated and systemati-
cally practiced throughout Haiti.
Situation Report
2
22 November 2010
Managing corpses of the deceased
While efforts are underway to expand the capacity
of the health system for treatment, health authori-
ties and partners are also increasingly concerned on
the lack of protocols and options for safe manage-
ment of corpses of the deceased.
According to Haitian law this is the responsibility of
Mayors and Town Councils, however there is often
serious gaps in capacity and knowledge to handle
bodies appropriately to avoid further contamina-
tion. In Anse Rouge for instance UNICEF dispatched
medical consumables to support not only health
structures but also the town council to ensure
proper management and burrial of corpses, includ-
ing supplies for disinfection and personal protective
equipment.
Temporary storage of bodies at facility level is a
growing concern in all affected areas including in
Port-au-Prince, creating critical conditions in cer-
tain facilities which are already overwhelmed and
under-staffed to handle the caseload. Bodies are
also at times returned to families with no precau-
tions taken to avoid further contamination, while
local rituals associated with burials of the deceased
present clear risks for acceleration of transmission
of the cholera bacteria (such as community wakes
and gatherings around the body of the deceased).
Locations where victims of the January 2010 earth-
quake have been buried meanwhile cannot be used
as many of these mass graves are too close to the
water table and there are risks of contamination of
groundwater sources.
© UNICEF/2010/Dormino
On 17 November, a worker burns a cholera patient’s
infected clothing, outside a health centre in the impov-
erished Wharf Jérémie neighbourhood of Port-au-Prince,
the capital.
Cholera Outbreak
Integrating Responses
Nationwide to Reduce Mortality
Today all ten of Haiti’s departments are affected by
the outbreak with newly suspected cases reported
in Grande Anse and Nippes.
Only following the epidemic’s geographic spread
will however yield insufficient results. Efforts are
rather needed at national level to prevent as much
as possible potential outbreaks, anticipate cases,
have immediate capacity to prevent high mortality,
and halt any acceleration in the pattern of transmis-
sion once a new source of contamination is identi-
fied anywhere in the country.
UNICEF is therefore mobilising supplies to support
a nationwide response and all UNICEF staff are now
devoted to full-time cholera response, with invest-
ments in directly ensuring and building capacity for
treatment at the medical level. UNICEF is also fully
engaged in support of actors and responses in the
WHO-coordinated Health Cluster, which includes
supporting more efforts to expand the network of
Cholera Treatment Centres/Units, and ensuring that
they have the necessary health, nutrition and WASH
supplies.
Water, Sanitation and Hygiene:
Fighting Back at the Community Level
In Artibonite a water treatment unit was installed in
Grande Saline to provide a safe option for drinking
water in one of the areas that was hardest hit by the
outbreak from the very first days of the crisis.
WASH interventions also continue to scale-up at
community level, with UNICEF supporting an initia-
tive by Oxfam GB to implement a fully integrated
water, sanitation and hygiene cholera response plan
in the commune of Petite Rivière de l’Artibonite in-
cluding the installation of 20 handpumps across 13
communities in Bas Coursin and Labady, for a total
catchment area of more than 90,000 people.
In the West Department a similar effort is underway
in partnership with the Haitian and Netherlands
Red Cross, with distributions of 10,000 bars of soap
and 5,000 buckets to 10,000 households in Jacmel,
Cayes-Jacmel, Marigot and La Valee. UNICEF is
also supporting the Spanish Red Cross to conduct
three rounds of disinfections of latrines in Léogane
in 14 communities in the Grande Rivière section of
the district, representing a catchment population of
more than 34,000 people.
Situation Report
3
22 November 2010
Meanwhile with protests in the Nord Department
last week, UNICEF and partners had to temporarily
suspend WASH assessments in Cap Haïtien, Limbé,
Plaisance and Pilate, although activities could
resume as road blocks were cleared over the past
week-end in the city and on main highways leading
out of town.

Scaling Up Health and Nutrition Responses

© UNICEF/2010/Dormino
In La Pointe (Nord Ouest), UNICEF health specialists
provided technical assistance for the Beraca Health
Centre to set-up a cholera treatment area with
proper isolation of patients and proper measures to
avoid contamination. In Pilate (Nord), UNICEF sup-
Men carry emergency medical supplies to a United Na-
plied the local health centre with 5,000 ORS sachets
tions helicopter, at the airport in Gonaïves in Artibonite.
for rehydration of cholera patients, while 100,000 These supplies, which included emergency health kits
sachets were dispatched to the Direction Sanitaire Ringers Lactate and ORS were airlifted and distributed
de l’Artibonite in Gonaïves for onward distribution Anse Rouge and Marmelade in Upper Artibonite.
in the department’s different health centres.

Situation Report
Cholera Outbreak 4
22 November 2010
Field missions to bring supplies to hard-to-reach
areas were also an opportunity to conduct health
assessments in Port-de-Paix, La Pointe, Saint Louis
du Nord and Anse-à-Foleur in the Nord Ouest. Weak
local capacity, lack of partners and lack of trained
health staff remains the main concern in these
areas, which continue to report among the highest
case/fatality rates from the disease.
UNICEF meanwhile dispatched nine tents to ex-
pand coverage of health interventions in the Nord
(Cap Haïtien, Limbé) and Nord Est departments
with plans to set-up Cholera Treatment Centres in
Ouanaminthe, Trou du Nord, Terrier Rouge and Fort
Liberté. The aim is notably to decongest the struc-
tures in Limbé at the Hopital Eben Ezer and Hopital
Saint Jean by expanding the capacity of Hopital Bon
Samaritain so referrals can be made to one struc-
ture, while others can continue to provide regular
care for other patients—most hospitals and health
centres have indeed been overwhelmed by the
number of cases, undermining continuity of care for
all other primary health needs.
Meanwhile, with cases reported in the Ouest De-
partment on Haiti’s southern peninsula, UNICEF is
supporting the extension of the Cholera Treatment
Centre in Petit Goave run by MDM-Spain. Fifty beds
are planned to extend the capacity of Hopital Notre
Dame which to date only had a seven-bed capacity.
To date, UNICEF has supported close to 40 health
centres, dispensaries and hospitals throughout the
country with a combination of tents to set-up CTCs/
CTUs; ORS/Zinc; Ringers Lactate solution; Emer-
gency Health, Diarrhoea and Hygiene Kits; along
with WASH items and support to upgrade sanitation
and water access at health facility level (see map on
previous page).
Meanwhile in Nutrition, UNICEF in collaboration
with WHO developed a treatment protocol to be
used in all CTCs and health centres for appropriate
rehydration of children with severe acute malnutri-
tion (considering their physiologic and metabolic
aspects). This is particularly important as children
with severe acute malnutrition are at higher risk of
congestive heart failure and death if inappropriate
rehydration protocols are applied, because of elec-
trolyte disequilibrium.
UNICEF also supported the Ministry of Health in
designing messages to promote exclusive breast-
Cholera Outbreak
© UNICEF/2010/Dormino
On 15 November, a water seller gives a resident a packet
of aquatabs (water purification tablets), in the impover-
ished Cité de l’Eternel neighbourhood of Port-au-Prince.
UNICEF, through several partners, is providing free
packets of aquatabs and cholera-prevention information
posters in the neighbourhood.
feeding and is strengthening its partnerships with
NGOs to maximize their involvement and contribu-
tion to reduce the burden (morbidity and mortality)
of cholera on children.
Nationwide Prevention
and Preparedness
Ensuring access to safe water and sanitation
UNICEF continues to support DINEPA and partners’
efforts to distribute aquatabs in particularly vul-
nerable neighbourhoods in Port-au-Prince. Some
320,000 aquatabs were newly dispatched to partner
GRET (Groupe de Recherche et d’Echanges Tech-
nologique) for onward distributions in Bicenten-
naire in the slums of Cité de l’Eternel and Village de
Dieu, 100,000 aquatabs were also dispatched to the
International Committee of the Red Cross for distri-
butions in Cité Soleil and 100,000 to GHESKIO for
distributions in wells in Cité de l’Eternel and Village
de Dieu.
Oxfam GB is meanwhile starting distributions of
450,000 aquatabs in Croix des Bouquets and
UNICEF is suplying the International Organization
for Migration for distributions in 245 private water
basins and camps (so far 100,000 have been dis-
tributed) in Cité Soleil. To date, 2.5 million aquatabs
have been distributed by UNICEF working with
DINEPA out of a total of 4.65 million dispatched.
Another dimension of the effort has been conduct-
ing random testing of water in different collec-
tion points and at household level. Fifteen agents
Situation Report
5
22 November 2010
UNICEF is supporting in DINEPA are conducting an
average 100 tests a day throughout Port-au-Prince,
with SMS technology introduced recently to feed
back timely information on residual chlorination
levels.
Latest reports show that 42 per cent of bladders
and reservoirs tested and 73 per cent of household
samples still do not meet DINEPA and WASH Cluster
defined standards of a minimum 0.5 mg per litre
of chlorine to ensure water is safe from any con-
tamination from cholera bacteria. Bacteriological
testing will also begin this week by this same team
with technical support from the Centers for Disease
Control (CDC).
UNICEF is meanwhile working with DINEPA and
UNOPS to dedicate a fleet of five de-sludging trucks
for work exclusively in Cholera Treatment Centres
in the city. UNICEF and DINEPA have also convened
private de-sludging companies and will ensure
training of staff on sanitary protocols for de-sludg-
ing of liquid wastes from cholera treatment sites.
Looking at the entire cycle to ensure all steps are
done safely, UNICEF is also advocating with DINEPA
and Port-au-Prince’s solid waste management
authority SMCRS (Société Mixte de Collecte des
Résidus Solides) for the establishment of sanitary
protocols for disinfection of trucks exiting the Trut-
tier dump and disposal site.
Mobilising Partners for Prevention
Side by side with the Ministry of Education
UNICEF is launching a nationwide effort to assist
5,000 schools representing a total 1.2 million chil-
dren with interventions geared towards prevention
and upgrading of water and sanitation facilities in
schools. This also includes support for disinfection
in schools when cases of cholera are reported, so
school facilities can be disinfected and learning can
resume as soon as possible in a safe environment.
Distributions of supplies has started in Artibonite
where UNICEF is working with the Haitian Red
Cross in Gonaïves for the distribution of 60,000 bars
of soap, 510,000 aquatabs and 1,350 hygiene pro-
motion posters, targeting 450 schools and 135,000
children.
UNICEF is also assisting the Ministry to strengthen
the capacity of teachers and schools supervisors on
Cholera Outbreak
© UNICEF/2010/Dormino
A worker sets up tents in the impoverished Cité Soleil
neighbourhood of Port-au-Prince. The tents are among a
total of fifteen that UNICEF is providing to Medecins Sans
Frontieres at a 300-bed cholera treatment centre in Sarthe
which is serving as a referral facility for all severe cases
in Cité Soleil.
cholera prevention in the targeted schools at nation-
wide level. Training started on 22 November and will
span over the next month in all of Haiti’s ten depart-
ments and 3,000 teachers and school supervisors
will be skilled up on the detailed curriculum which
was revised to include a component on sensitization
messages for prevention of cholera in schools.
Under this effort, twenty-six trainers already spe-
cialised on psychosocial training were trained in the
Ouest Department on 20 November and will now
roll-out training on psychosocial support and chol-
era prevention in schools to reach 2,400 teachers
and school supervisors.
Another wave of trainings will start on 25 November
for 600 teachers and school supervisors in Sud Est.
Overall, between 22 November and 23 December,
46 trainers, 6,040 teachers and school supervisors
will be trained in Haiti’s ten departments which will
benefit 300,000 children.
At the same time, to protect the most vulnerable
children living in residential care centres, UNICEF
has started a second round of distributions of
soaps, Oral Rehydration Salts, bleach and chlorine
along with hygiene promotion posters to all resi-
dential care centres throughout the country.
According to official numbers more than 35,000
children reside in over 750 residential care centers
throughout the country, but many centres are not
Situation Report
6
22 November 2010
registered and numbers are likely higher. Over a
period of one week more than 30,000 bars of soap,
2,000 gallons each of bleach and chlorine, and
61,000 sachets of ORS/Zinc are being distributed to
these centers for all children to be reached within
the next seven to ten days.
With the effort involving nine NGO partners, includ-
ing Save the Children, World Vision, Heartland Alli-
ance, Catholic Relief Services, International Rescue
Committee, Terres des Hommes and International
Medical Corps and others. UNICEF and partners will
reach more than 35 000 children, including more
than 20,000 children in the Port-au-Prince metro-
politan area. UNICEF has also conducted training of
trainers in hygiene promotion and cholera preven-
tion for more than 100 social workers and NGO staff
which will be replicated in all the 750 residential
care centers all over the country.
The anniversary of the adoption of the Convention
on the Rights of the Child on 20 November was
meanwhile a further opportunity to bring partners
together and organise sensitisation. Over 20-21 No-
vember Catholic Relief Services, IBESR and UNICEF
conducted hygiene promotion sessions in 7 resi-
dential centres in Gonaïves reaching close to 700
children with sensitization on the theme of Child
Cholera Outbreak
Rights to Health in the context of cholera. UNICEF
has meanwhile approached Church networks and
community leaders to start sensitisations and hy-
giene promotion during week-end services over the
past week-end.
UNICEF appeal and requirements
On 20 November, only 10 per cent of requirements
are met against the Inter-Sector plan launched on 11
November. As part of this response plan, UNICEF
appealed for US$ 19.4 million for WASH and US$
5.8 million for Child Health and first pledges have
been made for US$ 2 million by Canada and US$
100,000 by the French Embassy in Haiti.
Sector Requirements
Child Health 5,808,341
Water Sanitation and Hygiene 19,418,566
Total 25,226,907
For more information please contact:
Jean Jacques Simon, Chief of Communication
jsimon@unicef.org
Stephanie Kleschnitzki, Reporting Manager
skleschnitzki@unicef.org
Jeremy Shusterman, Reports Specialist
jshusterman@unicef.org
On 15 November, a boy heads back
home with a container of water he
is bringing back home, in the Cité de
l’Eternel neighbourhood of Port-au-
Prince.
Customers at these different water
kiosks—there are close to 300 which
UNICEF is supporting—are now re-
ceiving for free a packet of five water
purification tablets for each bucket of
water. One tablet helps ensure five to
ten litres are purified, and agents op-
erating water kiosks make sure that
people who come to purchase water
systematically use one tablet for the
buckets they have just bought.
The extra tablets handed out come
with a leaflet explaining how to use
them, and are distributed so house-
holds can build up a small stock at
home so there is always a way to
make sure water is safe.
Situation Report
7
22 November 2010