Spreading cholera, maybe polio: Now will we care about Haiti?

It's been two weeks since the one-year anniversary of the devastating Haitian earthquake, and the ongoing crisis in that desperately poor island has once again sunk below the news-radar horizon. Which is of course outrageous: Most of the infrastructure has still not been rebuilt, and 800,000 people are still living in tent cities parked precariously in the rubble. The non-profit Oxfam has pinned some of the responsibility on Haiti's long-standing political chaos: "It doesn't matter how much money you pour in unless you build up a government that is strong enough to take decisions." Simultaneously, the United Nation's special envoy, former Canadian Governor-General Michaelle Jean, has scolded the industrialized world in an open letter published on the anniversary: "What began as a natural disaster is becoming a disgraceful reflection on the international community."

Well, maybe this will get their attention.

Independent public health networks are reporting that the post-earthquake cholera epidemic, which began last fall and has caused more than 194,000 infections and almost 4,000 deaths, has now spread beyond Haiti: not just to the Dominican Republic with which it shares a permeable border, but through the DR to Mexico, the United States and Spain. The Canadian health blogger Crawford Kilian, who speaks Spanish, posted early this morning a report of 33 cholera cases in Venezuelans who attended a wedding in the DR. Quoting DominicanToday.com, he posted:

[Health minster Eugenia Sader] added that two people who also attended the activity, reportedly a wedding, had later flown to Madrid; one who traveled to Boston and another to Mexico. "All have symptoms and are currently being attended."

Later today, Crof, as he's known, posted the Spanish and English of a story from Prensa Latina:

*Se confirmó que existen 37 ciudadanos contagiados, quienes se encuentran bajo tratamiento médico, de ellos, tres por ciento presentan diarrea y deshidratación, pero el riesgo de muerte esta controlado, señaló Sader en una conferencia de prensa. *
Thirty-seven citizens have been confirmed infected, who are under treatment; of those, three percent present with diarrhea and dehydration. But the risk of death is controlled, Sader said in a press conference.
La titular venezolana puntualizó que el cólera es importado, pues, proviene de un grupo que el pasado 22 de enero asistió a una celebración familiar en República Dominicana, donde se reunieron más de 450 personas.
The Venezuelan minister noted that the cholera is imported, since it affected a group who on January 22 attended a family celebration in the Dominican Republic where over 450 persons attended.

He followed that up with a third report, also from DominicanToday.com, that two "tycoon" business leaders were among the attendees who got sick.

Simultaneously, the listserv/alert service ProMED posted a report from the TV arm of the Venezuelan News Agency, AVN, that the Venezuelan cases are in several major cities and the outbreak has been discussed by President Hugo Chavez during a national TV broadcast.

Meanwhile, the Pan American Health Organization (an affiliate of the WHO) and the US Centers for Disease Control and Prevention have sent outbreak investigatorsto Haiti to assess a cluster of cholera patients — maybe 7, maybe 4, with 3 dead — who are all afflicted with the floppy paralysis that can be a sign of polio infection.

Cholera is an emergency, but polio would be worse: It spreads through fecal contamination of water just as cholera does, but since as few as 1 in 200 cases show symptoms, it can expand into a roaring epidemic before it is detected. Polio was eradicated in the Americas in 1994, but it returned once, in 2000, in the Dominican Republic, thanks to a vaccine virus that had reverted back to to the virulence of wild-type polio.

PAHO reported today:

Experts including toxicologists are investigating possible contamination at a hospital or at home from medication, food or another source as the cause of death in these cases. PAHO and CDC officials are conducting field studies and will report their findings as soon as laboratory results are available.

Polio was one of the 1st possibilities looked into because of the public health implications. However, the clinical characteristics and epidemiology of these cases make poliomyelitis a remote possibility; in simple terms, polio does not produce a high mortality rate. Although considered highly unlikely, polio has not been completely ruled out, pending laboratory results of samples.

One of the early reports, not confirmed, mentions a rumor of an 8th patient, a child who was subsequently transferred to a hospital in North Carolina.

In case it needs reinforcing: The confirmed cholera and possible polio cases underline, one more time, that infectious diseases do not respect borders — as China found out during SARS and Nigeria when it refused polio vaccination. For as long as Haiti suffers these post-earthquake epidemics, there will be a risk of those epidemics traveling to the rest of the world.

If there is any upside to these reports, it is that the informal networks that move faster than governments were alert to the possibility of spread, and are cooperating. Pro-MED's post today dissects the cross-border communication:

The initial cases were seen at a private medical center by Dr Raul Isturiz, a former [International Society for Infectious Diseases] president who promptly notified the ProMED-ESP [Spanish-language] moderator. A preliminary report was posted less than one hour later with a description of the epidemiological situation and a clinical summary of the most relevant findings of the 1st 5 patients. In parallel, local health authorities were notified and appropriate microbiology confirmatory samples taken.

The same day, a local Venezuelan physician became aware of a potential additional case in Boston after a telephone medical consultation and notified the ProMED-ESP moderator. The Boston individual was notified and advised to seek medical attention. At the same time expert advice on the handling of the situation was provided by Dr Eduardo Gotuzzo, also a former ISID president and one of the foremost Latin American cholera specialists. Within 24 hours, information was exchanged indicating that Vibrio cholerae had been isolated and identified from the stool samples of several patients in Venezuela, and suspicious colonies were recovered as well from the patient in Boston.

One day after the original ProMED-ESP report, the Venezuelan minister of health, accompanied by Dr Isturiz and epidemiological authorities, officially announced the occurrence of the outbreak, during a Presidential TV and radio national broadcast. Of note, in the same broadcast the Venezuelan president mentioned that until that moment, he was aware of only 5 clinical cases, the exact number of cases described by Dr Isturiz in the initial ProMED-ESP report, which happened to be the single source of information acknowledging the existence of the outbreak.

Update: ProMED has also posted an email from a Boston physician describing the Boston cholera case.

Update 2: The Miami Herald reports Friday that the Haitian Ministry of Health has ruled out polio, but "tests continue" and the PAHO/WHO and CDC investigators are still on the ground. Meanwhile, a commenter at ProMED raises the possibility that the paralysis may be an unintended consequence of the patients' treatment for cholera, a stunning irony if the hypothesis is correct. Niklas Danielsson of the European CDC writes:

The symptoms ... fit a rare but well described condition called osmotic demyelination syndrome (ODS). The syndrome has high mortality and is associated with intravenous correction of hyponatremia. Cholera itself, as well as oral and IV rehydration treatment for cholera, can result in hyponatremia [low blood sodium, a consequence of cholera's very rapid fluid loss]. A typical feature of ODS is the biphasic presentation. Patients initially respond well to the treatment for dehydration and hyponatremia but later deteriorate rapidly. The patients [in Haiti] first recovered, but then deteriorated within 72 hours. Classical symptoms include symmetrical quadriplegia, dysarthria, dysphagia, confusion, and pseudobulbar palsy.

Update 3: As of Friday p.m., the cholera count in Venezuela has risen to 111 and in Boston is up to 6. (Both via Crof.)

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