HOURSContinuing Education

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CE

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 earth-

quake that had destroyed much of the island na-tion’s infrastructure and resulted in massive loss of life, Haiti now faced a rapidly growing cholera epi-demic. Numerous agencies, including nongovern-mental 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 respond-ing agencies. The organization sent the three of us—MLSF, an NP; TW, an epidemiologist; and LP, a physician—to Haiti on several occasions to part-ner 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.

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 strat-egies for educating the public, and the different require-ments for treating moderately and critically ill patients. We also discuss the etiology, pathophysiology, and epi-demiology of cholera, as well as its history in Haiti.

THE START OF A CHOLERA EPIDEMICCholera is caused by the comma-shaped, gram- negative, aerobic or facultative anaerobic bacillus, Vibrio cholerae (see Cholera: The Etiology, Patho-physiology, and Epidemiology1-9). Humans become infected with the bacillus upon consuming contami-nated water or food. Epidemics are often related to fe-cal 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

2.5

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 inter-vention campaigns their organization initiated, how they prepared for each, and the essential elements of their operations.

Keywords: cholera, cholera treatment center, cholera treatment unit, epidemic, Haiti, oral rehydration salts, prevention, treatment

How one group of health care workers established containment and intervention efforts in this 2010 disaster.

Responding to the Cholera Epidemic in Haiti

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

In the past 200 years, there have been seven chol-era pandemics, the most recent in the Western Hemi-sphere having spread throughout Latin America in 1991.3 On October 21, 2010, the Haitian National Public Health Laboratory confirmed a cholera out-break, and on December 3, the Haitian Ministry of Public Health and Population reported that the out-break had spread throughout the nation.10

COORDINATING A RESPONSEHaving responded to the 2010 earthquake, SP was already established in Haiti, with a field office lo-cated on the compound of the nonprofit, faith-based organization Global Outreach in Titanyen, about 24 kilometers from downtown Port-au-Prince. The com-pound, which had operated as a base for earthquake recovery efforts, was ideal for responding to the chol-era epidemic with both preventive and therapeutic in-terventions.

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 mega-phone

• conduct meetings with village leaders and residents to teach them how to recognize signs and symp-toms of cholera

• work with local health facilities to promote ad-ditional education and treatment coordination

• meet with local pastors to raise their awareness of cholera prevention and, through them, to dis-seminate information to their congregations

Therapeutic interventions included establishing cholera treatment units (CTUs), which operated dur-ing daylight hours to treat mildly and moderately dehydrated patients who required only oral rehy-dration, 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.

A severely dehydrated patient receives iv fluids from Kari Jones, MD, as she is carried by a family member from triage to a tent at the Bercy CTC. Photos courtesy of Samaritan’s Purse, Communications.

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PREPARING CHOLERA TREATMENT UNITSThere 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 al-ready 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 effec-

tive 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.

ESTABLISHING CHOLERA TREATMENT CENTERSTo 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 inci-dence of cholera and accessibility from SP headquar-ters. The second, a larger CTC, was constructed in Cité Soleil, because no other CTCs existed in this area.

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 al-lowed 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 hy-giene (WASH); security; health; and construction. Supplies and equipment procured by logistics included

Samaritan’s Purse health care workers Chad Cole, EMT (far left), Helen Adams, RN (in patterned scrubs), and Allison Rolston, PA (far right), care for patients in one of the tents at the Bercy CTC.

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tents, ORS, water containers, iv supplies, antibiotics, gurneys, stretchers, sphygmomanometers, adult dia-pers, 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 di-arrheal stools to be collected in buckets placed be-neath 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 mem-bers were required to walk when entering or exiting the CTC (see Hygiene and Sanitation Practices for Cholera Treatment Centers11, 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 logis-tics sector oversaw our inventory and stocked sup-plies, 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 avail-able locally for purchase. Other items, including some of the medications and ORS, were obtained from the World Health Organization and other UN agencies.

The health sector set up a triage area, staffed by physicians and nurses with triage experience, and de-veloped 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 di-vision of SP that places volunteer health care person-nel on temporary assignment in affiliate missionary hospitals throughout the world.

Two strains of Vibrio cholerae, V. cholerae O1 and O139, are known to cause clinical disease in humans by pro-ducing an enterotoxin (cholera toxin) that promotes excessive fluid and electrolyte loss through the small intestine. The El Tor biotype of V. cholerae O1 was re-sponsible for the 2010 cholera epidemic in Haiti.1, 2 V. cholerae O1 had been identified as the etiologic agent of cholera elsewhere in Latin America, but 2010 was its first known appearance in Hispaniola, the island oc-cupied by Haiti and the Dominican Republic.1

Fluid loss from cholera originates in the duodenum and upper jejunum and often overwhelms the capac-ity of the lower bowel, resulting in acute watery diar-rhea, sometimes accompanied by vomiting. If fluid and electrolytes are not adequately replaced, shock, circulatory collapse, and acidosis from bicarbonate loss may ensue within hours of presenting symp-toms.3

V. cholerae O1 and O139 are found in brackish es-tuarial environments.4 Although the bacteria have no known animal hosts, they can attach to the shells of crabs, shrimp, other shellfish, snails, and crustaceans, which if eaten raw or partially cooked can be a source of infection for humans.

Warm, coastal waters are natural reservoirs from which eradication is unlikely. Poor sanitation and crowding can escalate cholera transmission.4 V. chol-erae has also been recovered from houseflies in Delhi, India, during a cholera outbreak, suggesting that houseflies are potential vectors.5 Subsequent research, however, suggests that the role of the housefly in transmission is unlikely to be significant because

the housefly retains little of the bacteria on its wings.6 People whose immune systems are compromised, including those who are malnourished, are at ele-vated risk for dying if infected with cholera.4 Fortu-nately, transmission by direct person-to-person contact is rare.

Epidemiologic data suggest that the V. cholerae strain responsible for the 2010 outbreak in Haiti stemmed from a pipe that discharged raw sewage into the Meye River in central Haiti from the campsite of United Nations (UN) peacekeepers from Nepal, where cholera is endemic.2, 7 According to an inde-pendent panel convened by the UN to investigate the source of the 2010 cholera outbreak in Haiti, mo-lecular genetic testing indicated that the cholera strains isolated in Haiti in 2010 and in Nepal in 2009 were “a perfect match.”7 Poor sanitation, overcrowd-ing, and a lack of reliable clean water sources resulted in “the perfect storm” that was responsible for the de-velopment of the epidemic.

The index case of cholera in Haiti was believed to be a 28-year-old man with an untreated mental disor-der. He developed acute, watery diarrhea after drink-ing water from the Latem River, which is downstream of the Meye River.8 The disease is presumed to have spread by way of the Artibonite River downstream of Mirebalais all the way to the seashore, affecting com-munes along the way.7 Within days, it became appar-ent that an epidemic was under way. According to the Pan American Health Organization, as of October 28, 2012, Haiti had seen 606,951 cases of cholera and 7,615 resultant deaths.9

Cholera: The Etiology, Pathophysiology, and Epidemiology

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NURSES AT THE FRONT LINEDuring a cholera epidemic, nurses are the health care providers at the front line in preventing unnecessary deaths due to hypovolemic shock. Vigilant assess-ment is crucial, particularly in the absence of labora-tory support, because cholera can kill within hours if rehydration is inadequate. A mortality assessment undertaken in Artibonite, the largest of Haiti’s 10 de-partments, found that deaths sometimes occurred as quickly as two hours after symptom onset (see Samar-itan’s Purse: Cholera Response Timeline13).

Because so much of cholera management is syn-onymous with nursing care, nurses are in greater de-mand than any other health care professional when responding to a cholera epidemic. The cholera train-ing 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 Pre-vention 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 fre-quently requires young, normally vital adults to wear diapers and involves incessant stooling, which necessi-tates repeated bodily exposure and cleaning, patients often feel totally dependent, vulnerable, and humil-iated.

ORIENTATION AND TREATMENT Because we needed to start treating cholera patients immediately, the orientation we received on our ar-rival was limited to one or two hours. The health care team received and discussed handouts that in-cluded epidemiologic information about cholera and treatment protocols. The following were key treat-ment 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 drink-ing it early in the course of treatment.4

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

Sarah Parsons Green, RN, and Taryne Lepp, RN, provide ORS solution to a young child.

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Approximate amount of ORS solution to give in the first 4 hours:

Agea < 4 mo 4–11 mo 12–23 mo 2–4 y 5–14 y ≥ 15 y

Weight, kg b < 5 5–7 8–10 11–15 16–29 ≥ 30

ORS, mLc 200–400 400–600 600–800 800–1,200 1,200–2,200 2,200–4,000

ORS = oral rehydration salts.a Use the patient’s age only when you do not know the weight. A rough estimate of the oral rehydration rate for older children and adults is 100 mL ORS every five minutes until the patient stabilizes. For infants, encourage the mother to continue breastfeeding.b The approximate amount of ORS (in mL) can also be calculated by multiplying the patient’s weight in kg by 75. c If the patient requests more than the prescribed ORS solution, give more. Notes:1. The time and volumes shown are guidelines based on usual needs. If necessary, amount and frequency can be increased, or the ORS solution can be given at the same rate for a longer period to achieve adequate rehydration. Similarly, the amount of fluid can be decreased if hydration is achieved earlier than expected.2. During the initial stages of therapy, while still dehydrated, adults can consume as much as 1,000 mL of ORS solution per hour, if necessary, and children as much as 20 mL/kg per hour.3. Reassess the patient after 1 hour of therapy and then every 1–2 hours until rehydration is complete.4. Resume feeding with a normal diet when vomiting has stopped.

Table 1. Guidelines for Treating Patients with Some Dehydration14

Start iv fluids immediately. If the patient can drink, give ORS solution by mouth while the iv drip is set up. Give 100 mL/kg lactated Ringer’s solution divided as follows:

Age First give 30 mL/kg iv in: Then give 70 mL/kg iv in:

Infants (< 12 mo) 1 ha 5 h

Older patients (> 12 mo) 30 mina 2.5 h

Table 2. Guidelines for Treating Patients with Severe Dehydration14

ORS = oral rehydration salts.a Repeat once if radial pulse is still very weak or not detectable.Notes:1. Reassess the patient every 1–2 hours and continue hydrating. If hydration is not improving, administer the iv drip more rapidly. During the first 24 hours of treatment, 200 mL/kg or more may be needed.2. Also give ORS solution (about 5 mL/kg per hour) as soon as the patient can drink.3. After 6 hours (infants) or 3 hours (older patients), perform a full reassessment. Switch to ORS solution if hydration is improved and the patient can drink.

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. Con-sequently, potassium replacement was an empiric clinical decision made by care providers based on es-timated volume loss or on such signs and symptoms as lethargy, slow clinical recovery, palpitations, and muscle cramps.

Patients who were able to drink the ORS solu-tion received the benefits of the potassium it con-tained; 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

• Successful treatment of cholera requires strict doc-umentation of intake and output and adherence to recommended oral or iv rehydration therapy guidelines (see Tables 114 and 214).

Monitoring intake and output. Health care per-sonnel 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 lac-tated Ringer’s solution or normal saline. These pa-tients 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.

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Patient Classification First Choice Second Choice

Adults (nonpregnant)

Doxycycline: 300 mg in one dose

Azithromycin: 1 g in one dose

Tetracycline: 500 mg 4 times a day for 3 days

Erythromycin: 500 mg 4 times a day for 3 days

Pregnant women Azithromycin: 1 g in one dose Erythromycin: 500 mg 4 times a day for 3 days

Children ≥ 12 mo and capable of swallowing pills and/or tablets

Azithromycin: 20 mg/kg in one dose

Erythromycin: 12.5 mg/kg 4 times a day for 3 days

Doxycycline: 2–4 mg/kg in one doseb

Tetracycline: 12.5 mg/kg 4 times a day for 3 days

Children < 12 mo and others unable to swallow pills and/or tab-lets

Azithromycin oral suspension: 20 mg/kg in one dose

Erythromycin oral suspension: 12.5 mg/kg 4 times a day for 3 days

Doxycycline oral suspension: 2–4 mg/kg in one doseb

Tetracycline oral suspension: 12.5 mg/kg 4 times a day for 3 days

Table 3. Oral Antibiotics Used to Treat Cholera14, a

a These recommendations are based on the antibiotic resistance profile of Vibrio cholerae isolates from the Haiti cholera outbreak as reported on December 14, 2010, and local drug availability. b Doxycycline is safe for treatment of cholera in children at the recommended dose. The Pan American Health Organization recommends doxycy-cline as a second-line choice because of limited regional availability and to avoid future overuse in children.

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 admin-istered without the benefit of laboratory values. Pa-tients with recalcitrant vomiting can be given iv potassium, if available, although it must be adminis-tered slowly and closely monitored to prevent car-diac arrhythmias or cardiac arrest. In our practice, nurses administered iv bags of normal saline pre-mixed with 20 mEq/L of potassium in increments of 10 mEq per hour while closely monitoring the in-fusion 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 pa-tients 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 hypo-glycemia were treated with ORS solution or ba-nanas, 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 quanti-ties 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 pa-tient 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 dura-tion 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

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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 remain-ing 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 unremit-ting 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 Re-search, 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

Recognizing improvement. For patients who were rehydrated intravenously, nurses assessed mental sta-tus, ability to drink the ORS solution without vomit-ing, 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 follow-ing signs of rehydration: • normal urination• no diarrhea or vomiting• good skin turgor• improved appetite• the ability to stand and walk without assistance

MENTORING AND CAPACITY BUILDINGAn integral part of SP’s effort in Haiti was devoted to mentoring and capacity building. For this rea-son, 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 pro-vided an opportunity for the Haitian nurses to en-hance their cholera treatment skills and fostered intercultural bonds and friendships. Language bar-riers were challenging, requiring us to enlist the skills of several Creole- and English-speaking inter-preters on each shift. Over the weeks that followed, however, progressively fewer expatriate nurses were used in the response effort, and the burden of re-sponsibility 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 ex-perienced colleagues.

CONTINUED EFFORTSSP 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 ef-fort. The staff remains vigilant for evidence of rising cholera incidence and continues devoting attention to prevention efforts related to hygiene and sanita-tion. The staff continues to meet with other NGOs, the UN, Haitian government representatives, and others to improve the lives of the Haitian people.

Hygiene and Sanitation Practices for Cholera Treatment Centers

Guidelines for hygiene and sanitation practices at our cholera treat-ment centers (CTCs) were provided by Haiti’s Ministry of Public Health and Population and the Sphere Project (www.sphereproject.org), a volunteer program whose stated goal is to bring “a wide range of hu-manitarian agencies together around a common aim—to improve the quality of humanitarian assistance and the accountability of hu-manitarian actors to their constituents, donors and affected popu-lations.”11 The following practices are essential elements of these guidelines.

• Footbaths. Anyone entering or exiting the CTC was required to walk through a trough filled with a spongy material that had been soaked in a 0.5% bleach solution. These footbaths were changed twice a day.11, 12

• Handwashing. All who entered or exited the CTC were required to wash their hands thoroughly with soap and chlorinated water.11, 12

Security staff monitored and enforced this practice. • Excrement collection. Buckets containing a 2% bleach solution, about a centimeter deep, were placed beneath each patient’s bed, directly under a portal that allowed diarrheal stools to fall through. Buckets were emptied and cleaned after each episode of diarrhea.11, 12

• Feces disposal. Large latrines constructed at the site and regu-larly disinfected accommodated feces disposal in accordance with Ministry of Public Health and Population guidelines.12

• Universal precautions were exercised when caring for patients and when preparing patient remains for release to the family.11, 12

• Preparing patient remains for release. A morgue was construc-ted away from the direct patient care area and used to prepare the bodies of deceased patients for release to family members for burial. Body preparation followed a unique protocol designed to prevent seepage of bodily fluids, as infected corpses have been known to transmit cholera. Wearing protective gowns, masks, and double gloves, the nurses washed the bodies with a 2% bleach so-lution and filled all orifices with cotton wool soaked in a 2% bleach solution. Body bags were zippered shut, taped, and tagged with patient identification and demographic information.12

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The incidence of cholera has declined in Haiti, al-though new cases continue to emerge in all 10 de-partments of the country.

The three of us were profoundly affected by the rapid progression and overwhelming effects of chol-era 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 success-fully 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, psy-chological 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. ▼

Mary Lou Schulz Fisher is an NP and the international senior health advisor, Tom Wood is an epidemiologist, and Lance Ply-ler 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, mary-lounp@aol.com. The authors and planners have disclosed no po-tential conflicts of interest, financial or otherwise.

REFERENCES1. 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; http://www.who.int/mediacentre/factsheets/fs107/en.

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 do-mestica L.): importance in mechanical transmission of Vibrio cholerae. Trop Biomed 2008;25(1):1-8.

7. Cravioto A, et al. Final report of the independent panel of experts on the cholera outbreak in Haiti. New York: United Nations; 2011 4 May. http://www.un.org/News/dh/infocus/haiti/UN-cholera-report-final.pdf.

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 up-date. Washington, DC; 2012 Nov 2. Epidemiological alert; http://www.paho.org/hq/index.php?option=com_docman& task=doc_view&gid=19243&Itemid.

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

11. Sphere Project. Humanitarian charter and minimum stan-dards in humanitarian response. Bourton on Dunsmore, Rugby, UK: Practical Action Publishing; 2011. http://www.sphereproject.org/resources/download-publications/?search=1&keywords=&language=English&category=22.

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. http://www.cdc.gov/haiticholera/pdf/haiticholera_trainingmanual_en.pdf.

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; http://www.who.int/hac/crises/hti/sitreps/health_cluster_bulletin/en/index.html.

14. Centers for Disease Control and Prevention. Defeating chol-era: clinical presentation and management for Haiti cholera outbreak, 2010. Atlanta; 2010 Nov. http://www.cdc.gov/haiticholera/clinicalmanagement/pdf/clinicalmanagement.pdf.

15. Khan WU, Sellen DW. Zinc supplementation in the manage-ment 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 more photos on relief efforts during the cholera outbreak in Haiti, see a photo-essay by Gerald Martone, nurse and former director of humanitarian affairs for the International Rescue Committee: www.rescue.org/news/photo-essays/cholera.

For 50 additional continuing nursing education activities on gastrointestinal topics, go to www.nursingcenter.com/ce.

Samaritan’s Purse: Cholera Response Timelinea

• The cholera treatment unit (CTU) at Villard, Artibonite, was es-tablished on October 24, 2010, and closed on November 8, 2010, after treating 738 patients, one of whom died.

• The CTU at Cité Soleil in downtown Port-au-Prince was estab-lished on November 8, 2010, and closed on January 10, 2011, after treating 415 patients, none of whom died.

• The cholera treatment center (CTC) in the township of Bercy, north of Port-au-Prince, began treating patients on October 16, 2010, and closed on November 19, 2011, after treating 12,071 patients, 35 of whom died.

• The Cité Soleil CTC opened its doors the week of November 21, 2010, and closed on July 15, 2011. A total of 9,986 patients were treated, 17 of whom died.

• When the Bercy CTC ceased operations, thereby closing the last of the four treatment facilities, a total of 23,210 patients had been seen and treated by health care personnel.

• The total mortality rate for all four facilities was 0.23%. As of Jan-uary 28, 2011, the overall fatality rate for patients with cholera at all CTCs in Haiti was 2.3%.13

a Data are from Samaritan’s Purse Haiti Cholera Response Monitoring and Evaluation Report, November 2011, except where indicated.