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AJN, American Journal of Nursing:
doi: 10.1097/01.NAJ.0000446773.84275.b8
Feature Articles

CE: Responding to the Cholera Epidemic in Haiti

Fisher, Mary Lou Schulz MSN, BSN, RN, NP; Wood, Tom ScD, MS, BS; Plyler, Lance MD, BS

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Author Information

Mary Lou Schulz Fisher is an NP and the international senior health advisor, Tom Wood is an epidemiologist, and Lance Plyler is a physician, all at Samaritan's Purse, a nondenominational evangelical Christian nongovernmental relief organization based in Boone, NC. Contact author: Mary Lou Schulz Fisher, The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.

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Overview: While Haiti was still recovering from the January 12, 2010, magnitude-7 earthquake, an outbreak of cholera spread throughout the nation, soon reaching epidemic proportions. Working through the faith-based nongovernmental organization Samaritan's Purse, an NP, an epidemiologist, and a physician joined the effort to prevent the spread of disease and treat those affected. Here they describe the prevention and intervention campaigns their organization initiated, how they prepared for each, and the essential elements of their operations.

In the fall of 2010, Haiti confronted its second major disaster in less than a year. Still recovering from the January 12, 2010, magnitude-7 earthquake that had destroyed much of the island nation's infrastructure and resulted in massive loss of life, Haiti now faced a rapidly growing cholera epidemic. Numerous agencies, including nongovernmental organizations (NGOs), sent workers there to help contain the epidemic and treat those affected. Samaritan's Purse (SP), a faith-based NGO located in Boone, North Carolina, was one of the responding agencies. The organization sent the three of us—MLSF, an NP; TW, an epidemiologist; and LP, a physician—to Haiti on several occasions to partner with SP staff from health care and other sectors who already had a presence there. We initiated a major cholera prevention and treatment campaign, successfully managing more than 23,000 cases of cholera and almost certainly preventing thousands more.

Figure. A severely d...
Figure. A severely d...
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In this article, we explain how cholera epidemics start and draw on our experiences in Haiti to show how one organization helped reduce the impact of a cholera epidemic. We describe the preparations and supplies that were essential to our operation, our strategies for educating the public, and the different requirements for treating moderately and critically ill patients. We also discuss the etiology, pathophysiology, and epidemiology of cholera, as well as its history in Haiti.

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Cholera is caused by the comma-shaped, gram-negative, aerobic or facultative anaerobic bacillus, Vibrio cholerae (see Cholera: The Etiology, Pathophysiology, and Epidemiology 1-9). Humans become infected with the bacillus upon consuming contaminated water or food. Epidemics are often related to fecal contamination of water supplies. A total of 3 to 5 million cases of cholera occur worldwide annually, and 100,000 to 120,000 of these result in death.4

Box. Cholera: The Et...
Box. Cholera: The Et...
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In the past 200 years, there have been seven cholera pandemics, the most recent in the Western Hemisphere having spread throughout Latin America in 1991.3 On October 21, 2010, the Haitian National Public Health Laboratory confirmed a cholera outbreak, and on December 3, the Haitian Ministry of Public Health and Population reported that the outbreak had spread throughout the nation.10

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Having responded to the 2010 earthquake, SP was already established in Haiti, with a field office located on the compound of the nonprofit, faith-based organization Global Outreach in Titanyen, about 24 kilometers from downtown Port-au-Prince. The compound, which had operated as a base for earthquake recovery efforts, was ideal for responding to the cholera epidemic with both preventive and therapeutic interventions.

Prevention. Expatriate and national employees of SP initiated a cholera-prevention campaign that incorporated the following strategies:

* create and distribute flyers written in the local language, Creole

* hire a popular local disc jockey to travel the streets of Port-au-Prince in a van and transmit a cholera-prevention message by electronic megaphone

* conduct meetings with village leaders and residents to teach them how to recognize signs and symptoms of cholera

* work with local health facilities to promote additional education and treatment coordination

* meet with local pastors to raise their awareness of cholera prevention and, through them, to disseminate information to their congregations

Therapeutic interventions included establishing cholera treatment units (CTUs), which operated during daylight hours to treat mildly and moderately dehydrated patients who required only oral rehydration, and cholera treatment centers (CTCs), which remained open 24 hours a day and were equipped to resuscitate the more severely dehydrated patients with iv rehydration as needed.

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There was little time to set up the first CTU, which we established in a temporarily vacated schoolhouse. Potable water and packets of oral rehydration salts (ORS), which contain electrolytes and glucose to be mixed with potable water, were CTU mainstays; cots and iv supplies were brought in to treat patients who could not tolerate the ORS solution and some of the more seriously dehydrated patients. Chairs were already available at the schoolhouse, and most of the patients were able to sit up. If patients were in need of further hydration or other treatments when the CTU closed for the day, they were transferred to a local health care facility for continued care.

To prevent the spread of cholera, CTU staff

* exercised universal precautions.

* wore shoe covers to avoid tracking pathogens into or out of the unit.

* established handwashing stations and used effective handwashing techniques, reinforcing these for all who entered the unit.

* provided disposable, protective undergarments to the patients who were unable to control fecal elimination.

* disinfected stretchers with a bleach solution.

About two weeks later, we established a second CTU in the social hall of a church in Cité Soleil, an impoverished and densely populated commune in downtown Port-au-Prince. This CTU required the same supplies and incorporated the same precautions.

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To address the rising need to treat critically affected patients, we opened two CTCs. The first was in the township of Bercy, selected because of its high incidence of cholera and accessibility from SP headquarters. The second, a larger CTC, was constructed in Cité Soleil, because no other CTCs existed in this area.

Figure. Samaritans P...
Figure. Samaritans P...
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Information sharing. Like CTUs, CTCs had to be established in cooperation with local community leaders, but CTCs also required collaboration with the Ministry of Public Health and Population and United Nations (UN) representatives. Health cluster meetings between the NGOs and these groups allowed all parties to share information and report on activities in a timely manner, which is essential during an epidemic. Initially, the meetings were held daily, although they were held less frequently as the epidemic continued.

Setting up a CTC required input from several SP sectors, including logistics; water, sanitation, and hygiene (WASH); security; health; and construction. Supplies and equipment procured by logistics included tents, ORS, water containers, iv supplies, antibiotics, gurneys, stretchers, sphygmomanometers, adult diapers, buckets, disposable bed pads, blankets, and other patient supplies. The WASH and construction sectors created latrines, and construction built 100 stretchers with openings in the middle to allow for diarrheal stools to be collected in buckets placed beneath them. They covered the stretchers with heavy plastic sheeting to allow for easier cleaning and set up handwashing stations and troughs containing a bleach solution through which personnel and family members were required to walk when entering or exiting the CTC (see Hygiene and Sanitation Practices for Cholera Treatment Centers 11, 12). They constructed the semipermanent tents in which we stored supplies and treated patients, and set up makeshift tents on days when patient volume was particularly high. The logistics sector oversaw our inventory and stocked supplies, which became critically low at times because of the high patient volume. Lactated Ringer's solution and nitrile gloves were sometimes in short supply. Certain items such as bleach and buckets were available locally for purchase. Other items, including some of the medications and ORS, were obtained from the World Health Organization and other UN agencies.

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Box. Hygiene and San...
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The health sector set up a triage area, staffed by physicians and nurses with triage experience, and developed a rapid assessment tool, based on signs and symptoms of dehydration such as altered mentation, sunken eyes, a weakened radial pulse, and reduced skin turgor. Volunteer nurses, physicians, paramedics, pharmacists, and emergency medical technicians from the United States, Canada, and the United Kingdom were recruited through World Medical Mission, a division of SP that places volunteer health care personnel on temporary assignment in affiliate missionary hospitals throughout the world.

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During a cholera epidemic, nurses are the health care providers at the front line in preventing unnecessary deaths due to hypovolemic shock. Vigilant assessment is crucial, particularly in the absence of laboratory support, because cholera can kill within hours if rehydration is inadequate. A mortality assessment undertaken in Artibonite, the largest of Haiti's 10 departments, found that deaths sometimes occurred as quickly as two hours after symptom onset (see Samaritan's Purse: Cholera Response Timeline 13).

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Box. Samaritans Purs...
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Because so much of cholera management is synonymous with nursing care, nurses are in greater demand than any other health care professional when responding to a cholera epidemic. The cholera training manual produced in response to this epidemic by Haiti's Ministry of Public Health and Population and the U.S. Centers for Disease Control and Prevention recommends that a CTC designed to treat as many as 50 inpatients and 50 outpatients would require 20 nurses and four physicians.12

In the context of a cholera epidemic, nurses serve many important functions, which include

* providing direct patient care.

* instructing family members and enlisting their help in reporting the frequency of emesis and stooling, the amount of ORS solution consumed, and the number of iv bags used.

* offering counseling and emotional support to patients.

Cholera is not only physically devastating but often psychologically devastating as well. Because it frequently requires young, normally vital adults to wear diapers and involves incessant stooling, which necessitates repeated bodily exposure and cleaning, patients often feel totally dependent, vulnerable, and humiliated.

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Because we needed to start treating cholera patients immediately, the orientation we received on our arrival was limited to one or two hours. The health care team received and discussed handouts that included epidemiologic information about cholera and treatment protocols. The following were key treatment considerations.

* Rehydration is the hallmark of effective treatment.

* Up to 80% of patients with cholera can be treated successfully with ORS solution if they begin drinking it early in the course of treatment.4

* Patients who are in shock and unable to receive oral rehydration require iv therapy.

* Successful treatment of cholera requires strict documentation of intake and output and adherence to recommended oral or iv rehydration therapy guidelines (see Table 1 14 and Table 2 14).

Table 1
Table 1
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Table 2
Table 2
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Monitoring intake and output. Health care personnel were taught how to closely monitor intake and output. Often, if patients were not severely ill and were able to drink ORS solution, they or their family members were able to help count and record their stools and the amount of ORS solution they drank. It was more of a challenge to document the intake and output of patients receiving iv rehydration with lactated Ringer's solution or normal saline. These patients exhibited an altered level of consciousness and had very frequent stools. Nurses were responsible for initiating iv therapy and hanging new bags of fluid. Intake and output were recorded on flow sheets taped to the tent walls above the patients’ stretchers.

Potassium replacement. Although arrhythmias and changes revealed by electrocardiograph (ECG)—such as flat T waves, prominent U waves, and ST depression—occur with hypokalemia, neither ECG machines nor cardiac monitors were available. Consequently, potassium replacement was an empiric clinical decision made by care providers based on estimated volume loss or on such signs and symptoms as lethargy, slow clinical recovery, palpitations, and muscle cramps.

Figure. Sarah Parson...
Figure. Sarah Parson...
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Patients who were able to drink the ORS solution received the benefits of the potassium it contained; when food was slowly reintroduced, patients were encouraged to eat bananas, which are easily digestible and rich in potassium. Those who were unable to drink the ORS solution or eat food were given supplemental potassium, generally 10 to 20 mEq in single doses (higher doses may be caustic to the stomach) given two to three hours apart. It is widely accepted that, under these conditions, up to 100 mEq of potassium per day can be safely administered without the benefit of laboratory values. Patients with recalcitrant vomiting can be given iv potassium, if available, although it must be administered slowly and closely monitored to prevent cardiac arrhythmias or cardiac arrest. In our practice, nurses administered iv bags of normal saline premixed with 20 mEq/L of potassium in increments of 10 mEq per hour while closely monitoring the infusion rate. We decided not to stock individual vials of potassium supplement in the inventory for fear that the supplement might be mistakenly added to a liter bag of the iv solution.

Hypoglycemia is also of great concern in patients with cholera. Patients with significant hypo-glycemia may present with symptoms such as weakness, lethargy, diaphoresis, tachycardia, and palpitations. Hypoglycemia can be confirmed with a glucometer. Patients with clinical signs of hypoglycemia were treated with ORS solution or bananas, if tolerated. Patients who were comatose or too lethargic to receive oral sources of glucose were given iv glucose. Because the characteristic “rice water stools” of cholera, often accompanied by vomiting, cause patients to lose enormous quantities of fluid very rapidly, the weight of resuscitative fluids administered can exceed the actual weight of the patient on admission. At the Bercy CTC, a patient in his early 80s received 76 liters of lactated Ringer's solution over a four-day period. In such cases, accurately documenting intake and output can be daunting.

Zinc replacement is known to reduce the duration and severity of diarrhea, while supporting the immune system.15 Pediatric patients should receive a 10-day course of zinc replacement at a dosage of 20 mg per day if over six months of age and 10 mg per day if under six months of age.15 If the children are discharged before completing zinc administration, the caregiver should be sent home with the remaining doses and explicit instructions to have the child complete the 10-day regimen.

Oral antibiotics are used to reduce the volume and duration of diarrhea in both moderately and severely ill patients, especially those with unremitting diarrhea (see Table 3 for guidelines14). The World Health Organization recommends that they be given only to patients with severe disease, but the International Centre for Diarrhoeal Disease Research, Bangladesh, advises that they be used for moderate disease as well.16 Antibiotics are not to be given to patients with mild clinical disease. Ideally, antibiotics should be administered while patients are being rehydrated, as long as any vomiting has stopped.16

Table 3
Table 3
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Recognizing improvement. For patients who were rehydrated intravenously, nurses assessed mental status, ability to drink the ORS solution without vomiting, and the formation of solid stools. When assessed favorably in these areas, patients were moved to the ORS treatment tent where they received standard oral rehydration therapy.

Ideally, once patients were able to retain ORS, they were to be observed for at least six hours before being discharged. In assessing readiness for discharge, nurses were taught to consider the amount of ORS solution the patients had consumed and to look for the following signs of rehydration:

* normal urination

* no diarrhea or vomiting

* good skin turgor

* improved appetite

* the ability to stand and walk without assistance

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An integral part of SP's effort in Haiti was devoted to mentoring and capacity building. For this reason, the expatriate nurses, who hailed from the United States, Canada, and the United Kingdom, were each assigned two Haitian nurses to mentor in assessing patients with dehydration. This provided an opportunity for the Haitian nurses to enhance their cholera treatment skills and fostered intercultural bonds and friendships. Language barriers were challenging, requiring us to enlist the skills of several Creole- and English-speaking interpreters on each shift. Over the weeks that followed, however, progressively fewer expatriate nurses were used in the response effort, and the burden of responsibility was transferred to the Haitian nurses as they acquired excellent clinical skills in treating cholera as well as managerial and mentoring skills that proved invaluable as they took on the role of providing oversight and instruction to their less experienced colleagues.

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SP continues to provide health care in Cité Soleil, Port-au-Prince, and other regions of Haiti. Primary and maternal–child health care are part of this effort. The staff remains vigilant for evidence of rising cholera incidence and continues devoting attention to prevention efforts related to hygiene and sanitation. The staff continues to meet with other NGOs, the UN, Haitian government representatives, and others to improve the lives of the Haitian people. The incidence of cholera has declined in Haiti, although new cases continue to emerge in all 10 departments of the country.

The three of us were profoundly affected by the rapid progression and overwhelming effects of cholera in people who had been well just hours earlier. Fortunately, when cholera infection is managed correctly, its resolution is as dramatic as its onset. Few diseases that are as devastating and can kill as abruptly as cholera can be so quickly and successfully managed. Because cholera often causes patients to feel humiliated and vulnerable, the SP providers feel it is valuable to provide holistic care in the form of patient and family education, physical care, psychological support, and spiritual aid (if the patient wants to pray with someone or to have a visit from clergy, for example). Nurses, always needed at the front line in cholera management, can be educated and prepared to provide such care, which can save the lives of patients with cholera throughout the world.

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1. Chin CS, et al. The origin of the Haitian cholera outbreak strain N Engl J Med. 2011;364(1):33–42

2. Piarroux R, et al. Understanding the cholera epidemic, Haiti Emerg Infect Dis. 2011;17(7):1161–8

3. Thaker VV Cholera. New York: Medscape reference; 2011..

4. World Health Organization. Cholera. Geneva, Switzerland: World Health Organzation, Media Centre; 2012 Jul. Fact sheet no. 107;

5. Fotedar R. Vector potential of houseflies (Musca domestica) in the transmission of Vibrio cholerae in India Acta Trop. 2001;78(1):31–4

6. Yap KL, et al. Wings of the common house fly (Musca domestica L.): importance in mechanical transmission of Vibrio cholerae Trop Biomed. 2008;25(1):1–8

7. Cravioto A, etal. Final report of the independent panel of experts on the cholera outbreak in Haiti. New York: United Nations; 2011 4 May.

8. Ivers LC, Walton DA. The “first” case of cholera in Haiti: lessons for global health Am J Trop Med Hyg. 2012;86(1):36–8

9. Pan American Health Organization. Cholera situation update. Washington, DC; 2012 Nov 2. Epidemiological alert;

10. . Centers for Disease Control and Prevention. Update: outbreak of cholera—Haiti, 2010 MMWR Morb Mortal Wkly Rep. 2010;59(48):1586–90

11. Sphere Project Humanitarian charter and minimum standards in humanitarian response. Bourton on Dunsmore, Rugby, UK: Practical Action Publishing; 2011.

12. Ministry of Health and Population in Haiti and the Centers for Disease Control and Prevention. Haiti cholera training manual: a full course for healthcare providers. Atlanta; 2011 Jan 24.

13. Ministry of Health and Population in Haiti and the Pan American Health Organization. Cholera Outbreak in Haiti. Washington, DC: World Health Organization; 2011 Jan 28. Health cluster bulletin;

14. Centers for Disease Control and Prevention. Defeating cholera: clinical presentation and management for Haiti cholera outbreak, 2010. Atlanta; 2010 Nov.

15. Khan WU, Sellen DW. Zinc supplementation in the management of diarrhoea: biological, behavioural and contextual rationale. Geneva, Switzerland: World Health Organization; 2011.

16. Nelson EJ, et al. Antibiotics for both moderate and severe cholera N Engl J Med. 2011;364(1):5–7

For 50 additional continuing nursing education activities on gastrointestinal topics, go to


cholera; cholera treatment center; cholera treatment unit; epidemic; Haiti; oral rehydration salts; prevention; treatment

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