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Source: Unpublished Mission Report by Renaud Piarroux, November 7-27, 2010 (in French). Translation from French to English by R. R. Frerichs with assistance of iGoogle, Jan. 1, 2011; translation correction, Jan. 24, 2011. Professor Renaud Piarroux 1. Mission activities The mission took place from 7 to 27 November 2010. Its objectives were to analyze the functioning of the epidemic and to develop a system of epidemiological information to monitor the epidemic on a daily basis in order to adapt control activities. During the stay, numerous meetings were organized and discussions were held with technical managers and policy makers, especially with the President of the Republic of Haiti, the health minister and his team (Director General of Health, chief of staff, members of the National Commission for the fight against cholera). Meanwhile, all the stakeholders involved in the sectors of health (officials of the Ministry of Health, those responsible for health care facilities, doctors at the WHO, MSF and Epicentre) and access to drinking water (CAMEP DINEPA, UNICEF) have been met, often repeatedly. Field visits were conducted at the University Hospital and near Cite Soleil in Port-au-Prince, in the cities of Hinche, Mirebalais, Saint Marc, Gonaives, Plaisance, Cap Haitien, Saint Michel de l'Atalaye . This was to better understand the circumstances of the contamination of people and evaluate the care of patients. The results of the investigations described below were discussed with the ambassador of France and the first counselor of the embassy, with the Haitian authorities (President of the Republic, Minister of Public Health and Population) and with the Special Representative of Secretary General Kofi Annan and key UN officials in Haiti. The end of the mission was specifically devoted to the establishment of an epidemiological information system to report daily and position on a map cases and deaths in each municipality of the country. Finally, three conferences were held for university students to the French Institute in Haiti, and to the Haitian Medical Association. 2. Circumstances of onset of the epidemic. The first confirmed case of cholera showed symptoms of cholera starting on Thursday, October 14 (see bacteriological results attached [not enclosed]). This case is a 20 year old man living near the village of Meille Mirebalais in the Central Department. The Cuban medical team of the hospital in Mirebalais, who we met at the hospital, has confirmed the occurrence of an abnormal number of cases of watery diarrhea (suspected cholera) during the 41st epidemiological week (from October 11 to 17) and more particularly from 16 October (see table attached to the investigative report done by the team of health department of the Centre [not enclosed]). Physicians who reported the first confirmed cases stated they were patients from Meille. After a few days, the epidemic has spread to the town of Mirebalais, a few miles away. At Mirebalais, the epidemic initially affected people living along the Artibonite River then spread gradually to other wards. This spread within Mirebalais was facilitated since the city is undergoing major work to its water supply network and many people are required to obtain water directly from the Artibonite River. Neighboring towns (not downstream of Mirebalais) have been affected several days or even weeks later (see casebook provided by Cuban doctors [not enclosed]). The warning was given on 18 October by the Cuban medical cooperation, the day when an investigation mission conducted by the Department of Health team visited the Centre (see full report attached [not enclosed]). The first cases received and the first deaths at the hospital in Mirebalais came from the same hamlet Meille. All had presented an array of profuse watery diarrhea and severe dehydration. We obtained the results of bacteriological tests that were performed on Mielle's patients and sent to the national laboratory in Port-au-Prince. Of six patients who became ill between 14 and 19 October 2010, five had a positive analysis for Vibrio cholerae O1 El Tor Ogawa. The oldest positive sample corresponded to a patient who got sick on October 14. The investigation conducted by the health department team of the Centre indicated that the first patients obtained their drinking water from a tributary of the Artibonite River flowing just below the base of MINUSTAH [United Nations Stabilization Mission in Haiti]. We went to this place. There the surveyed people reported that a nauseating liquid poured from pipes from the base at the time the outbreak occurred. These pipes were no longer present during the investigation because, according to residents, they were removed by the military shortly after the declaration of the cholera epidemic. The presence of a pipe from a septic tank in the MINUSTAH camp and pouring a dark liquid in the river had also been noted by the team of the Department of Epidemiology Centre during the initial investigation conducted from October 19, as well as by doctors who passed by MINUSTAH (this was explained to me during an interview organized by UN officials). The doctors told me that the MINUSTAH samples taken on October 21 at the latrines and these pipes have proved negative for Vibrio cholera, but it is impossible to know if the septic tank and/or the pipes had been disinfected before taking the samples (the outbreak began a week ago and the investigative report of Team Central Department shows that the epidemiological team was already investigating around the base and educating the population). Unfortunately, I could not find the methodology of the environmental analysis that was carried out or study the full results. Moreover, doctors said MINUSTAH, although the battalion in question had recently arrived from Kathmandu city (some soldiers arrived on October 8, others 12), while in the throes of an epidemic of cholera, no soldier of the camp had submitted a diarrhea sample and no environmental sample had yielded positive results. We must take this evidence with caution because, by October 21, it is difficult to imagine that the officers and caregivers of camp MINUSTAH were unaware of the suspicion of cholera (even though a fact-finding mission was engaged in the village below for several days), especially if an epidemic was underway within the camp. In this case, it cannot be ruled out that steps were taken to remove feces and erase traces of an epidemic of cholera among the soldiers. This first investigation team also visited the prison at Mirebalais where suspected cases of cholera had been reported. Sick prisoners were not hospitalized but four of them died at the Lascahobas hospital in Mirebalais. Regarding prisoners, these patients had not direct contacts with people outside and the only risk factor found was that the water in the prison was drawn from the same River involved in contamination of the village of Meille, but a little downstream. To conclude on this point, we wish to emphasize that our field investigation, including interrogation of the medical team at the hospital in Mirebalais, the investigation a few weeks earlier by the team's medical department of the Centre and analytical results obtained from the laboratory of Port-au-Prince, all confirm that the cholera epidemic of Mirebalais began during the 41st week of 2010 (probably on October 14 and certainly before October 19) in the village of Meille, located below Camp MINUSTAH. The origin of the first cases and contamination of prisoners from the prison of Mirebalais leave no doubt on the role played by the affluent of the Artibonite River flowing below the camp in the first case of contamination. Finally, the report writing and the interviewing of Meille residents confirm that the pipes, now removed, had been installed to discharge sewage into the river from the camp. During the interview I had with the doctors who had been sent on October 21 by MINUSTAH, the presence of these pipes was indirectly confirmed, since these doctors indicated that environmental sampling (which proved negative) was performed at the outlet of these pipes. During the interview with the representative of the Secretary General of the UN and the General Staff of MINUSTAH, we investigated whether an alternative explanation, although unlikely, could be advanced to explain the sudden onset of this epidemic of cholera. No other hypothesis could be found to explain the start of an epidemic of cholera in this village of Meille, a village untouched by the earthquake earlier this year and located dozens of miles from the coast, but by the indicated camp. 3. Evolution of the epidemic The occurrence of epidemic Meille/Mirebalais during the 41st week, even though it had quickly gained a certain extent, is not sufficient to explain the event which took place October 19 in the six communes [an administrative area coverring several towns and villages] watered by the Artibonite River and its delta, located down river dozens of miles from Mirebalais. Yet this event, the massive contamination of the Artibonite River throughout its delta, which has given its explosive nature of the epidemic, is unique in the recent history of cholera, and led to the devastation seen in the following days. After following the Artibonite river from the city of Mirebalais to its mouth, we went to the Health Management of the Artibonite Department, located in Gonaives [the Capital of the Artibonite Department] , and interviewed the director of the Department of Epidemiology and service. The Artibonite Departmental recorded its first alert on Tuesday, October 19. That day, three students at a school in Bocozelles had just died when they were in the classroom, exhibiting symptoms that included severe acute diarrhea with dehydration and vomiting. The same day the coordinator of the health center in Dessalines/Lesters reported cases of diarrhea and vomiting at the hospital Claire Heureuse Dessalines and deaths of people in the community, again with diarrhea and vomiting. On 20 October, epidemic alerts simultaneously affect the Hospital of St. Nicolas de Saint Marc, the health center Drouin Grande Saline, the health center Desdunes, hospital Pierre Payen de Saint Marc, the hospital Dumarsais Estimé de Verettes, Medical Center Charles Colimon de Petite Rivière de l’Artibonite, the Albert Schweitzer Hospital in the town of Deschapelles (near Verettes) and the health center of Desarmes de Verette. The same day a suspect case was hospitalized in Gonaives (health center Eben-Ezer); this patient actually came from Villard, a locality in the town of Dessalines. That day 514 patients were hospitalized, all living in the lower Artibonite, near the riverbed or delta, well downstream of Mirebalais. Forty-one of them died in hospital, while 31 additional deaths were recorded in the community. The next two days, nearly 2,000 additional cases were hospitalized and at least 120 new deaths were recorded in six communes in Lower Artibonite and the neighboring communities that had welcomed those who fled before the outbreak of sudden deaths. By Friday, October 22 at noon, there were 4,470 cholera cases and 195 deaths in 21 different communes occupying a territory of about thirty miles radius around the delta of the Artibonite. The expansion of cholera cases between 16 and 22 October has been displayed on maps and is presented in the Appendix. The simultaneous nature of the contamination of a large number of people, with common living or working in the delta of the Artibonite, can be explained by a person-to-person transmission exclusively. Even within an urban area, cholera is spread for weeks in all areas at risk. To illustrate this point we can provide the epidemiological curve of dozens of outbreaks recorded in recent years in the Comoros, Guinea, Guinea Bissau and the Democratic Republic of Congo. Moreover, the severity of the symptoms presented by patients first seen on October 19 cannot be explained by massive contamination with inocula exceeding one million of Vibrio cholerae and probably more. This massive and widespread contamination throughout the Artibonite Delta may have been caused by a spill all at once into the river by a tremendous amount of feces from a large number of patients. In the days that followed, the health teams find the movement of groups of inhabitants of the lower Artibonite bringing with them the disease to other municipalities, particularly in St. Michel de l'Attalaye and Gonaives. The deathly epidemic provoked a panic that made people flee to their home places. Because cholera was unknown in Haiti, their relatives did not protect themselves from the contamination, and within a few days, all these new foci were experiencing outbreaks. After a few days, transmission began to slow, but continued though. The rural communes of the mountainous areas mainly north of the Artibonite Delta have been hit very quickly. Populations of these municipalities were working in paddy fields and travelling on roads in the Artibonite and fled when they were faced with the deadly outbreak of 19, 20 and 21 October. Unfortunately, these communities are particularly underserved in health facilities and access to drinking water. This resulted in the successive occurrence of small epidemics, affecting one village after another, not spectacular regarding the numbers of patients counted, but extremely deadly. We thus made in the commune of Saint Michel de l'Attalaye, we had identified as particularly affected by the health information system in place during the mission. There, we found a lack of resources and inadequate organization of care for patients with suspected cholera. The doctor we interviewed acknowledged that he was not able to medically staff the unit for the treatment of cholera during the night, leading to the death of some patients for lack of renewal of their infusion (a cholera patient requires an average of 8 liters of infusion fluids in the first 24 hours of rehydration). The camp was not provided with chlorinated water at the inlet and outlet taps, and due to lack of staff, families were accompanying the patients to ensure the essential acts of nursing. In addition, due to lack of transportation, patients most often were arriving by foot from the affected villages and many died en route. In total, less than a month after the beginning of the epidemic in the county, more than one inhabitant in 1000 died of cholera, most often before reaching the hospital in Saint Michel (70% of deaths in the community). This situation is representative of all rural communes located between the north coast and the plains of the Artibonite and appears to extend to rural communes of the department's central and northern department of the West. It will expand, but more gradually, to departments in the South. Some areas of the major coastal cities of North and Northwest, and the Cité Soleil neighborhood on the outskirts of Port-au-Prince have experienced, and still experience for certain cities, major outbreaks. This is particularly affected socially disadvantaged neighborhoods, with a very high population density. These neighborhoods are further located on floodplains, sometimes built on old landfills, and have drinking water which is especially vulnerable. The water provision is sometimes provided by wells, but more often they are reservoirs in homes filled by tanker trucks. Until the arrival of the epidemic, the water was not chlorinated but only used reverse osmosis, a technique that produces sterile water, but does not prevent its subsequent contamination. Field investigations in Cité Soleil and Cap Haitien have revealed the vulnerability of private reservoirs from contamination by dirty buckets. Besides this contamination associated with the ingestion of water, is added poor management of excreta, especially near Fougerolles in Cap Haitien. Access to care, however, is much easier than in rural areas and these areas are particularly vulnerable to cholera, which currently provides the largest number of patients seen in cholera treatment centers. In other urban areas, particularly the vast majority of neighborhoods in Port-au-Prince, only a few cases are already identified. There the situation is properly controlled and healthcare facilities are able to cope. It should be noted that most emergency camps established after the earthquake of January 2010 are in this situation. Cholera has made its appearance, but without causing the damage anticipated by many humanitarian actors. In fact, the inhabitants of these camps have access to water and sanitary facilities often better than in the surrounding slums and are subject to specific epidemiological surveillance in place since the earthquake with the support of the US Centers for Disease Control. The probability of a major outbreak in the camps and in the neighborhoods of Port-au-Prince outside flood zones is low and will remain so unless major social unrest impedes the current treatment of cholera in Port-au- Prince. There will be no additional disaster if the response continues to gain momentum as we have seen in recent days and if the surveillance is used to select areas for priority action. Conclusion and Recommendations In conclusion, the fact-finding mission conducted last three weeks has revealed the severe and unusual nature of this epidemic, with the origin no doubt being imported. It started around the camp of MINUSTAH and was spread explosively due to massive contamination of the water in the Artibonite River and one of its tributaries with feces of patients with cholera. After the first wave of deadly cases along the Artibonite River and the neighboring rural communes, the situation appears to be stabilizing and mortality tends to decrease. For conduct in the weeks and months ahead we have several recommendations:
The epidemiologist who wrote this report, Professor Renaud Piarroux, is with the Université de la Méditerranée in Marseille, south of France, and the teaching Hospital of Assistance Publique-Hôpitaux de Marseille, located in the city. He is an acknowledged expert on cholera. According to the details described in Part 2 of the above report, the first confirmed case of cholera had onset of symptoms on Thursday, October 14, 2010 and was located near the village of Meille by the city of Mirebalais, close to the United Nations base. The replacement UN peacekeeping troops were reported to have come from Nepal between October 8 and 15, 2010 (note: Dr. Piarroux wrote that "...some soldiers arrived on October 8, others 12). Hence, taking into account an incubation period of 2-3 days, the two events (i.e., arrival of troops and onset time of initial case) were closely related in both place and time. Dr. Piarroux also reported on a group of prisoners who died of suspected cholera, who had no contact with persons in the surrounding community. He stated, "...water in the prison was drawn from the same location at the Artibonite River involved in contamination of the village of Meille, but a little downstream." The mechanism of the initial water contamination is purported to have been a pipe that came from "... a septic tank in the [UN] camp and pouring a dark liquid in the river." Professor Piarroux concluded, "No other hypothesis could be found to explain the start of an epidemic of cholera in this village of Meille..." While Dr. John Snow's cholera investigations occurred nearly 156 years earlier, his report on London's Broad Street Pump Outbreak in 1854 is not unlike that which was written by Professor Piarroux, although the latter features more modern scientific details. The Piarroux report as noted elsewhere on this web site was met by scepticism by various international officials, and was dismissed by some who questioned the value of "origin studies," citing curious justifying notions such as "avoiding the blame game." Yet following weeks of deliberations, the Secretary General of the United Nations finally decided in late December, 2010 to establish a panel of experts to review the Piarroux report and determine what might have started the Haiti cholera epidemic.
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