LETTERS IN

9. Ivers LC, Farmer P, Almazor CP, Le- Table. Percentage of 233 hospital staff correctly answering cholera knowledge assessment questions near the start of a cholera in the Dominican Republic, andre F. Five complementary interven- 2010 tions to slow cholera: Haiti. Lancet. 2010;376:2048–51. doi:10.1016/S0140- Topic No. (%) 6736(10)62243-X Importance of rehydration 207 (89) 10. World Organization Global Task Suspected cholera case definitions 206 (88) Force on Cholera Control. Prevention Nutrition for cholera patients 198 (85) and control of cholera outbreaks: WHO Ideal type of intravenous fluid 189 (81) policy and recommendations. 2011 [cited control measures 175 (75) 2011 Jul 31]. http://www.who.int/cholera/ Environmental cleaning 168 (72) technical/prevention/control/en/index. Risk factors for disease 157 (67) html Handling cadavers 146 (63) Quantity and timing of intravenous fluid 128 (55) Address for correspondence: Elissa Meites, Uses of bleach solution 128 (55) Centers for Disease Control and Prevention, Treatment of mild dehydration 125 (54) 1600 Clifton Rd NE, Mailstop E02, Atlanta, GA Identification of severe dehydration 122 (52) 30333, USA; email: [email protected] Treatment of severe dehydration 108 (46) Disinfection methods 100 (43) staff who may provide direct care to References patients, such as nurses, and other 1. Centers for Disease Control and Preven- personnel who may share infection tion. Update on cholera—Haiti, Domini- control responsibilities. Hospital can Republic, and Florida, 2010. MMWR Understanding staff should maintain ongoing Morb Mortal Wkly Rep. 2010;59:1637– communication with public health 41. the Cholera 2. Ministry of Public Health of the Do- leadership. minican Republic. Cholera—special Epidemic, Haiti bulletin number 10, December 1, 2010 Consuelo Mendoza, [in Spanish] [cited 2011 Jul 31]. http:// To the Editor: After the Elissa Meites, Elizabeth Briere, www.sespasdigepi.gob.do/documentos/ devastating outbreak of cholera in Jacqueline Gernay, Octubre%202010%20Colera%20Haiti/ Haiti in mid-October 2010, several PDF/Boletines/Boletin_Colera_No%20 hypotheses have emerged regarding Oliver Morgan, 10_2010_12_1.pdf and Nelson Rodriguez Monegro, 3. Walton DA, Ivers LC. Responding to the origin of the outbreak. Some for the Hospital Preparedness cholera in post-earthquake Haiti. N Engl articles and media reports pointed Working Group1 J Med. 2011;364:3–5. doi:10.1056/ to the United Nations peacekeepers NEJMp1012997 Author affi liations: Ministerio de Salud from as the source. Piarroux 4. Ali A, Chen Y, Johnson JA, Redden E, Pública y Asistencia Social, Santo Domingo, Mayette Y, Rashid MH, et al. Recent clon- et al. drew a similar conclusion from Dominican Republic (C. Mendoza, N. al origin of cholera in Haiti. Emerg Infect their epidemiologic study (1). Nepal Rodriguez Monegro); Centers for Disease Dis. 2011;17:699–701. did experience an outbreak of cholera 5. Chin CS, Sorenson J, Harris JB, Robins Control and Prevention, Atlanta, Georgia, during August–October 2010, in WP, Charles RC, Jean-Charles RR, et al. USA (E. Meites, E. Briere, O. Morgan); and The origin of the Haitian cholera outbreak which 72 cases of infection with Vibrio Pan American Health Organization, Santo strain. N Engl J Med. 2011;364:33–42. cholerae O1, serotype Ogawa, were Domingo (J. Gernay) doi:10.1056/NEJMoa1012928 confi rmed, mostly among young adult 6. Sack DA, Sack RB, Nair GB, Siddique males. The cases peaked from mid- DOI: http://dx.doi.org/10.3201/eid1711.110703 AK. Cholera. Lancet. 2004;363:223–33. doi:10.1016/S0140-6736(03)15328-7 September to early October (Figure; 1Additional members of the Hospital 7. Ministry of Public Health of the Do- online Appendix Figure, wwwnc.cdc. Preparedness Working Group who minican Republic. Clinical guide to the gov/EID/article/17/11/11-0981-FA1. contributed data: Ada Compres, Edelmira diagnosis and treatment of cholera [in htm), and no deaths occurred. Despite Spanish] [cited 2011 Jul 31]. http://www. Espaillat, Carolina Garcia, Lucas Gomez, this similarity in timing, I believe Cesarina Hernandez, Rosa Sanchez, and sespasdigepi.gob.do/documentos/Octu- Lilian de los Santos, Ministerio de Salud bre%202010%20Colera%20Haiti/PDF/ several points need to be considered Pública y Asistencia Social, Santo Domingo, Guia%20de%20Diagnostico%20y%20 before a fi rm conclusion is reached. Dominican Republic; Javier Gabaldón and Tratamiento%20Colera.pdf Cholera strains isolated in Haiti Alberto Romero, Pan American Health 8. World Health Organization Global Task Force on Cholera Control. Cholera out- were genetically most similar to strains Organization/World Health Organization, break: assessing the outbreak response detected in Bangladesh in 2002 and Santo Domingo; and Robert Quick and and improving preparedness. Geneva: The Jennifer Verani, Centers for Disease 2008; thus, cholera was most likely Organization; 2004. Control and Prevention, Atlanta, GA, USA. introduced into Haiti from southern

2178 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 11, November 2011 CHOLERA IN HAITI LETTERS

In Response: We read with great interest the letter by Pun, which suggests that Bangladeshi policemen in Mirebalais could have introduced cholera into Haiti (1). However, we want to emphasize that the fi rst Haitian cholera case occurred in Meille, just next to the Nepalese military camp— Figure. Patients with confi rmed and suspected cases of cholera admitted to Sukraraj not in Mirebalais or Hinche, where Tropical and Infectious Disease Hospital, by week, Katmandu, Nepal, July–November Bangladeshi policemen served. The 2010. Case defi nitions: suspected cholera, acute watery diarrhea, with or without vomiting, location of the fi rst case was stated in in a child >5 years of age; confi rmed cholera, isolation of Vibrio cholerae O1 or O139 from our article (2) and confi rmed by the feces of any patient with diarrhea. United Nations (UN) panel of experts on the cholera outbreak in Haiti (3). The UN panel also reported that major sanitation defi ciencies likely resulted Asia (2). Despite the genetic similarity References in contamination of a stream fl owing in the strains, no attempt was made within a few meters of the Nepalese by the researchers to ascertain and 1. Piarroux R, Barrais R, Faucher B, Haus R, Piarroux M, Gaudart J, et al. Understand- camp. No other humanitarian forces rule out the source of the outbreak in ing the cholera epidemic, Haiti. Emerg were working in the small hamlet of Bangladeshi policemen stationed at Infect Dis. 2011;17:1161–8. doi:10.3201/ Meille. Mirebalais between September and eid1707.110059 As acknowledged by Pun, October 2010. Another, although less 2. Chin CS, Sorenson J, Harris JB, Robins WP, Charles RC, Jean-Charles RR, et al. Nepalese soldiers left for Haiti just likely, source for the introduction of The origin of the Haitian cholera outbreak when a cholera epidemic was raging cholera into Haiti could have been strain. N Engl J Med. 2011;364:33–42. in their country. According to the UN travelers or relief workers who may doi:10.1056/NEJMoa1012928 panel report, “a careful analysis of the have recently been to southern Asia. 3. Tarantola A, Ioos S, Rotureau B, Paquet C, Quilici ML, Fournier JM. Retrospective MLVA [multilocus variable-number Most relief workers probably come analysis of the cholera cases imported to tandem-repeat analysis] results and from countries without endemic from 1973 to 2005. J Travel Med. the ctxB gene indicated that the strains cholera, but they cannot defi nitely 2007;14:209–14. doi:10.1111/j.1708- isolated in Haiti and Nepal during be ruled out as a source of cholera in 8305.2007.00129.x 4. National Travel Health Network and Cen- 2009 were a perfect match.” Nepalese Haiti. For example, in industrialized tre. Travel health information sheets; up- strains had been made available to countries, cholera has been detected dated October, 2010: cholera. Health Pro- the UN Panel from the International among travelers, albeit in smaller tection Agency [cited 2011 Jun 28]. http:// Vaccine Institute in Seoul, South numbers, returning home from www.nathnac.org/pro/factsheets/cholera. htm Korea (3). cholera-endemic areas (3,4). However, 5. United Nations. Press conference by Referring to UN press con- Piarroux et al. offered no information Under-Secretary-General for Peacekeep- ferences, Pun stated that “none of the about travelers or relief workers or ing Operations, December 15, 2010 [cited Nepalese peacekeepers was found whether they had been screened for V. 2011 Jun 28]. http://www.un.org/News/ briefings/docs/2010/101215_Guest.doc. to be positive for the [V. cholerae] cholerae infection before coming to htm strain in Haiti.” However, it should Haiti (1). Of note, the United Nations be remembered that no testing of the reported that none of the Nepalese Address for correspondence: Sher Bahadur Pun, soldiers was performed. Although peacekeepers was found to be positive Clinical Research Unit, Sukraraj Tropical and the UN panel reported that “no cases for the strain in Haiti (5); hence, other Infectious Disease Hospital, Teku, Kathmandu, of severe diarrhea and dehydration possible explanations for the origin Nepal; email: [email protected] occurred among MINUSTAH [United of the outbreak simply cannot be Nations Stabilization Mission in overlooked. Haiti] personnel during this period,” Sher Bahadur Pun the panel provided no information Author affi liation: Sukraraj Tropical and concerning mild or moderate diarrhea. Infectious Disease Hospital, Teku, Nepal Overall, evidence overwhel- mingly supports the conclusion that DOI: http://dx.doi.org/10.3201/eid1711.110981 the UN military camp in Meille was the source of the Haitian cholera

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 11, November 2011 2179 LETTERS CHOLERA IN HAITI epidemic. The person who brought Author affi liations: Université de la 2. Piarroux R, Barrais R, Faucher B, Haus R, cholera into Haiti could not be Méditerranée, , France (R. Piarroux M, Gaudart J, et al. Understand- ing the cholera epidemic, Haiti. Emerg Piarroux, B. Faucher, J. Gaudart, D. identifi ed because of the lack of an Infect Dis. 2011;17:1161–8. doi:10.3201/ early, independent investigation in the Raoult); Ministère de la Santé Publique et eid1707.110059 camp. de la Population, Port-au-Prince, Haiti (R. 3. Cravioto A, Lanata CF, Lantagne DS, Nair Barrais, R. Magloire); Service de Santé GB. Final report of the independent panel of experts on the cholera outbreak in Haiti Renaud Piarroux, des Armées, , France (R. Haus); and [cited 2011Sep 2]. http://www.un.org/ Robert Barrais, Benoît Faucher, Université de Franche-Comté, Besançon, News/dh/infocus/haiti/UN-cholera- Rachel Haus, Martine Piarroux, France (M. Piarroux) report-fi nal.pdf Jean Gaudart, Roc Magloire, DOI: http://dx.doi.org/10.3201/eid1711.111318 and Didier Raoult Address for correspondence: Renaud Piarroux, Université de la Méditerranée, UMR MD3, References Faculté de Médecine de la Timone, 27 Blvd 1. Pun SB. Understanding the cholera epi- Jean Moulin, Cedex 05, 13385, demic, Haiti [letter]. Emerg Infect Dis. France; email: [email protected] 2011;17:2178–9.

Correction

Vol. 16, No. 11 In the article Reassortment of Ancient Neuraminidase and Recent Hemagglutinin in Pandemic (H1N1) 2009 Virus (P. Bhoumik, A.L. Hughes), errors were made in selection of the hemagglutinin (HA) and neuraminidase (NA) sequences for the initial and subsequent data sets. As a result, the authors incorrectly concluded that the NA gene of the pandemic (H1N1) 2009 virus is of a more ancient lineage than the HA. Other researchers (and the authors) have not been able to reproduce the fi ndings when using HA and NA matched pairs from viruses chosen on the basis of geography and time and correctly have pointed out errors in the data set that make the original conclusions invalid.

Submitted by Priyasma Bhoumik and Austin L. Hughes; corresponding author: Austin L. Hughes, Department of Biological Sciences, University of South Carolina, Columbia, SC 29208; email: [email protected]

DOI: http://dx.doi.org/10.3201/eid1711.C11711

2180 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 11, November 2011