shown in helping with large donations and the - The rapid reaction of the Ministry of Health- provision of human resources. which alerted the population quickly, organized The cost of lost exports has not been determined, medical services and carried out an appropriate but different sources place it between $US10 education campaign, with active com- million and $US400 million. This has led to con- health flicts between various sectors and the Ministry of munity participation-has resulted in a very low Health, with unfavorable consequences for the con- death rate and the early recovery of thousands of trol efforts. patients. Another negative development has been the - The costs of responding to the epidemic are decrease in sales of fish along the entire coastline. extremely high, and there have also been nega- The fish are caught by village fishermen who tive economic consequences for the production depend on this income to support their families. Although the Ministry of Health s recommendation and marketing of marine products. was not to eat raw fish or shellfish, there has been All of the above probably could have been a decrease in the consumption of seafood in general, avoided with timely investments in the water and with the consequences already mentioned. sanitation infrastructure. Conclusions - The epidemic can spread to neighboring - The cholera epidemic affecting Peru is of great countries, making it necessary to coordinate ac- magnitude, and is the largest of the known tions, exchange information and form ap- epidemics, at least in the last hundred years. propriate technical teams in order to minimize - The mode of introduction of the V. cholerae that the impact of the disease. triggered the epidemic is still undetermined. - The country offers highly propitious conditions (Source: Horacio Lores and Julio Burbano, PAHO/Peru; (poverty, lack of water and sanitation, extensive Eduardo Salazar, José Luis Seminario and Augusto E. pollution) for the spread of cholera. López, Ministry of Health, Peru.)

Cholera Situation in

* When the cholera epidemic in Peru was first pediatric suspension) were distributed to hospitals reported, the authorities in Ecuador immediately and health centers serving the most vulnerable embarked on active epidemiological surveillance in populations; beds were readied with special mat- all the populations on the Ecuador-Peruvian border tresses to accommodate cholera patients; and the and issued a decree declaring a public health emer- medical and paramedical personnel in the public gency in the Provinces of El Oro and Loja on the health universities were trained. Peruvian border. As a result, the health teams in the areas at At the same time, steps were taken to prioritize greatest risk were prepared to face the imminent the activities being undertaken by the National threat of cholera. Committee on Cholera Prevention with support from the following subcommittees: Epidemiologi- Presence of the First Cases of Cholera cal Surveillance; Patient Care; Education; Com- Despite the preventive measures taken by the munication and Logistics; Finances; Public Ministry of Public Health, on Friday, 1 March Relations; Laboratories; Environmental Health, 1991, the health authorities in El Oro Province and Sanitary Control. reported to the central level that 9 patients with a In the areas that were most at risk, an emergency clinical picture of profuse aqueous diarrhea, plan was implemented for action to be taken in the vomiting, and rapid dehydration had sought medi- event of a cholera epidemic in Ecuador, and an cal care at the hospital in (capital of El Oro epidemiological surveillance system was put into Province). effect in all the provincial health services The next day, 2 March, a team of national throughout the country. epidemiologists, with the active participation of Audiovisual materials were prepared and widely PAHO/WIHO, initiated an epidemiological inves- disseminated through the voice and print media. At tigation of the outbreak, with the following results: the same time, environmental sanitation activities were stepped up, as was the chlorination of water Clinical Diagnosis in urban water supply systems. In addition, adequate quantities of oral rehydra- The signs and symptoms observed in the patients tion salts, intravenous solutions (Hartman), and ranged from mild diarrhea with moderate dehydra- antibiotics (tetracycline and erythromycin in tion to profuse diarrhea with serious dehydration

7 and shock. Most of the patients had notable ob- Figure 5. Cholera affected areas in Ecuador. nubilation, dyspnea, hyperventilation, abdominal discomfort, severe muscle cramps, and coffee- colored evacuations at first that later took on a whitish coconut milk appearance. Most of them (85%) recovered with liquids given orally, while . the rest (15 %) needed intravenous rehydration. The signs and symptoms of these first patients were compatible with cholera.

LaboratoryDiagnosis Headquarters were set up for training, super- vision, and advisory services in laboratory diag- nosis at the Leopoldo Izquieta Pérez National Institute of Hygiene in Guayaquil, and peripheral * Affected areas laboratories were set up in Machala, Santa Rosa, Arenillas, Huaquilas, and Macará (in the border area) for the collection and bacteriological ex- amination of fecal samples. Diagnosis was performed using dark-field microscopy, the cholera red test, and culture on agar TCBS medium. The 48 samples examined as of 15 March all Geographical Distribution yielded Vibrio cholerae 01, biotype El Tor, serotype Inaba. The outbreak began in Campamento La Puntilla, Bajo Alto Commune, El Guabo Canton, in El Oro Province on the Pacific Coast, which is located a Chronological Pattern few kilometers from the Peruvian town of Túmbez. The epidemiological studies carried out so far The commune has a population of approximately indicate that the outbreak began in Ecuador on 28 1,800, who live in poor socioeconomic conditions. February 1991. The average incubation period has Basic sanitation is precarious due to the lack of been three days. As of 10 April 1991, a total of drinking water, latrines, and excreta disposal, plus . 2,489 cases had been reported, of which 682 have widespread hawking of food and beverages without been confirmed, and 59 have died. The distribution any hygienic control. by province is shown in Table 3 and the cholera Secondary cases occurred in neighboring affected areas are shown in Figure 5. Machala, Santa Rosa, Arenillas, El Guabo, and Guayaquil. Carriers with mild symptomatology had fled to these places during the first hours when they began to suspect cholera. They had been aware Table 3. Cumulative number of probable and confirmed of its symptoms because of the intense dissemina- cases and deaths from cholera, by province. tion of preventive measures by the health Ecuador, 28 February to 10 April 1991. authorities. The secondary cases were rapidly located by the surveillance system that had been set up in the country. Chemoprophylaxis with tetracycline was given to household contacts. In the city of Machala, Province Probable Confirmed Deaths capital of El Oro Province, the cases reached the Azuay 1 5 population on the urban outskirts. Chimborazo 42 12 16 El Oro 1,352 215 11 Characteristics of the Cases Esmeraldas 36 2 - The majority of cases (83.6%) have been in the Guayas 691 391 16 over-15 age group, primarily affecting men Imbabura 59 1 2 (74.8%). In terms of occupation, the attack is con- Loja 72 32 5 centrated in a group who gather shrimp larvae along the Pacific coast. Los Ríos 235 21 8 Thanks to the prompt attention given to the Pichincha 1 3 1 patients, the case fatality rate has been low; 59 Total 2,489 682 59 deaths have been reported up to 10 April 1991.

8 Hypothesis - Distribution of oral rehydration salts and drugs to use for control (parenteral solutions, an- The characteristics and spread of the outbreak tibiotics) in the event of an epidemic. suggest a common source of contamination of - Immediate treatment of patients with oral hydric origin, located in Campamento La Puntilla, rehydration salts, intravenous hydration (in pre- where the presence of fecal matter and Vibrio shock), and administration of tetracycline 500 cholerae was confirmed in a septic tank built very mg every 6 hours for 4 consecutive days. near a well that overflowed at high tide and con- - Coordination with municipal councils and water taminated the drinking water supply. In the first boards to guarantee adequate chlorination of group of patients, all had drunk from this well. drinking water sources. The disease was then spread via contaminated - Provision of chlorine to the populations at seafood which, despite an intensive public health greatest risk. campaign, the patients had continued to eat raw, - Formation of health brigades for environmental claiming that it was difficult to get fuel to cook their sanitation and vector control. food and boil their water. - Sanitary surveillance of food and beverages. It is believed that the Vibrio choleraecontamina- - Design of special forms to be used by the attend- tion in Bajo Alto originated with larvae gatherers ing physicians. coming from Túmbez (Peru), a region that had - Meetings, round tables, and talks to health per- reported cholera two weeks earlier. According to sonnel on the clinical and epidemiological the people living in Bajo Alto Commune, since it aspects of cholera. was the laying season, a large number of Peruvian - Broad dissemination of messages in the com- fishermen and vendors had come to the La Puntilla munity (leaflets, instructions, bulletins) on beaches to collect shrimp larvae. The hygienic con- cholera prevention and hygienic measures that ditions had been deplorable: defecation in the open, the population should take. lack of drinking water, and very poor makeshift - Educational household interviews in the affected shelter consisting of cardboard, tin, or plastic sheets sectors. propped up with sugarcane stalks-the only hous- - Public information and education through press, ing available for the larvae-gatherers and their radio, television, and direct personal contact in families. the community. - Dispatch of epidemiological teams to investigate the problem on site. Health Sector Response - Creation and implementation of epidemiological control in the Provinces of El Oro, Loja, and Ever since the outbreak was identified, the health Zamora Chinchipe. authorities have insisted on the following - Reporting to the Ministry of National Defense on measures: control in ports and airports. - Outfitting of rooms in hospitals and health centers to accommodate patients.

Cholera Cases in Colombia

The Colombian Health Ministry's National On February 7 Colombia's Minister of Health Institute of Health confirmed the country's first established the National Committee for case of cholera on March 10 with the isolation of Epidemiological Surveillance of Cholera. Coor- Vibrio cholerae 01, El Tor, Inaba. The patient was dinated by the Director of the National Institute of an adult man from a community on the banks of the Health, the Committee includes: the Office of Mira River, 20 km south of Tumaco in Nariño Disaster Preparedness and Relief, Presidency of the Department, near the border with Ecuador. Republic; and, within the Ministry of Health, the The epidemiological investigation of the case Directors of Medical Care, Epidemiology, En- revealed that the patient had not traveled outside vironmental Sanitation, Direct Campaigns, and his home area, nor had he received visitors from Community Participation, and the Chief of the outside the country. Office of Disaster Preparedness. The Committee The water that the patient drank came from a has formulated a strategy for public education, source pipe upstream from the treatment plant. prevention, control and treatment of cholera cases. Thirty specimens taken from the patient's personal In response to the first reported case, surveillance contacts, and from water and food he consumed, was stepped up in the area, and a plan for public have all been negative for cholera. education was put into effect. In addition, the

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