Volume 17, Number 11—November 2011
CHOLERA IN HAITI
Academic Consortia: Untapped Resources for Preparedness, Response, and Recovery—Examining the Cholera Outbreak in Haiti
On February 14, 2011, the Southeastern Center for Emerging Biologic Threats, the Southeastern Regional Center of Excellence for Emerging Infections and Biodefense, and the Emory Office of Critical Event Preparedness and Response convened a conference, Academic Consortia: Untapped Resources for Preparedness, Response, and Recovery—Examining the Cholera Outbreak in Haiti (www.secebt.org/conferences/detail.cfm?conference_id=19). The conference, one of a series hosted by Emory University (Atlanta, GA, USA), featured discussions of the response to and lessons learned from the 2010 cholera outbreak in Haiti and examined the role that US academic institutions can play in public health emergencies. The ongoing cholera outbreak in postearthquake Haiti (1,2) provided a framework for the conference. The objectives were to 1) explore challenges and identify gaps in responding to disasters and complex humanitarian emergencies (CHEs), 2) determine how consortia of academic institutions, with their range of resources, can augment planning, preparedness, response, and recovery efforts by emergency response agencies (e.g., United Nations and US government agencies), 3) explore the use of emerging technologies to augment responses, and 4) assess the contribution of workforce competencies in response and recovery. Challenges and opportunities faced during the cholera epidemic were highlighted, and lessons learned that could be broadly applied to other emergency settings were identified.
The opening speaker (Christopher Howard) discussed the differences between disasters and CHEs. Disasters are ecologic breakdowns in whichmost deaths result from trauma, whereas a CHE involves a complete breakdown of authority that goes beyond the mandate or response capacity of any single country or United Nations agency (3). Epidemics have been more frequently reported in association with CHEs; during 1995–2004, a total of 63% of large CHEs had >1 epidemic, compared with 23% of large disasters (4). The increased likelihood of epidemics during CHEs has been attributed to their longer duration and their larger, more prolonged population displacements. Understanding local context and patterns of endemic diseases is critical to organizing an appropriate response during a health crisis.
After a historical overview of cholera, presenters identified challenges encountered during the outbreak in Haiti. Foremost was the rapid, uncontrolled spread of cholera after its introduction because of preexisting factors exacerbated by the earthquake, such as deficient health care and sanitation systems, population displacement, poor or nonexistent clinical and public health infrastructure, and lack of political will. The situation was further aggravated by the lack of the availability of, acceptance of, and experience with using oral rehydration solution (ORS) therapy. The Haiti experience reinforced the need to rapidly prepare and train deployable teams in the United States before departure and locally and to provide guidance for provision of intravenous fluids and ORS.
The cholera outbreak is a reminder of the potential for infectious disease emergence during CHEs and disasters. Establishing infectious disease surveillance during CHEs and disasters—with an emphasis on diseases with outbreak potential, such as measles, other vaccine-preventable diseases, respiratory and enteric diseases (including cholera), malaria, and dengue—is crucial. At the conference, the necessity of establishing appropriate infection control protocols and creating a safe environment for staff and patients was emphasized. Several challenges and gaps in US workforce competencies were identified. Training was needed before responders arrived in the disaster setting; efficient ways to verify their credentials needed to be identified; and challenges in monitoring relief worker performance needed to be met. Steps would need to be taken to ensure that responders are prepared to minimize their risk for infections and trauma.
In keeping with the sustainability theme, presenters emphasized the need for partnerships with other organizations and education of in-country personnel by using a train-the-trainer approach. Understanding the target audience’s knowledge and knowledge gaps is crucial for creating an efficient and relevant educational model. The Haiti experience also highlighted the need for translators in the United States and in Haiti who had experience in disaster response and could interpret for patients and family members and deliver health education messages to communities. Academic institutions with activities and programs in Haiti before the earthquake were best positioned to contribute to the epidemic response.
Research priorities include development of user-friendly telemedicine programs; community-based research leading to sustainable outcomes; optimization of the use of modeling to project the course and magnitude of the epidemic and to help prioritize interventions (such as antimicrobial drug therapy and vaccination); conduct of molecular epidemiologic assessment of epidemic strains; identification of better early warning methods and systems; assessment of the acceptability, feasibility, and potential effectiveness of cholera vaccination; identification of better data collection and management approaches; and optimization of the availability of appropriate diagnostic tests, vaccines, and antimicrobial agents in urban setting and remote areas. Lack of funding was cited as the primary constraint on research; universities have the expertise but need rapid access to financial resources (e.g., short-term emergency grants) to support emergency responses.
Academic institutions and consortia have many opportunities to contribute to emergency responses and recovery through professional and public education, research, clinical care, and public health practice. Expertise exists, not only in infectious diseases, but also in business, management, engineering, logistics, and risk communication. Experts in these disciplines, in concert with behavioral and social scientists; water, sanitation, and hygiene experts; mental health professionals; and nutritionists can collaborate on multidisciplinary teams to augment the public health workforce. In addition, academics may have access to areas where foreign response agencies are not welcome.
In summary, the conference identified challenges and opportunities for US academic institutions and consortia to assist in preparedness, response, and recovery efforts. Although limited funding handicaps research into methods to improve health during response and recovery, the need for sustainability of interventions also is critical for strengthening health systems. Conference participants agreed that continued collaboration and development of long-term relationships are essential for coordination and avoidance of duplication of efforts. Development of distance learning courses sponsored by a consortium may help improve training of relief personnel and support for multidisciplinary teams during emergency responses.
We thank the presenters and the moderators, the program committee, and the Scientific Program Committee for assistance in organizing the conference. We also thank Dianne Miller and Kelly Howell for contributions to and support of this conference.
This symposium was supported by funds through grants H75 CI000739 from the Centers for Disease Control and Prevention of the US Department of Health and Human Services and the Southeastern Regional Center of Excellence for Emerging Infections and Biodefense/National Institutes of Health U54-AI-047157. We acknowledge our cosponsor, Emory Office of Critical Event Preparedness and Response, and the Emory Subvention Fund for their support.
- Centers for Disease Control and Prevention. Update: outbreak of cholera—Haiti, 2010. MMWR Morb Mortal Wkly Rep. 2010;59:1586–90.
- Dowell SF, Tappero JW, Frieden TR. Public Health in Haiti—challenges and progress. N Engl J Med. 2011;364:300–1.
- Inter-Agency Standing Committee. Definition of complex humanitarian emergency [cited 2011 Mar 21]. http://www.humanitarianinfo.org/iasc
- Spiegel PB, Le P, Ververs MT, Salama P. Occurrence and overlap of natural disasters, complex emergencies and epidemics during the past decade (1995–2004). Confl Health. 2007;▪▪▪:1.