Accepted Article of Clinical a of ClinicalMicrobiology E © 2012 and Microbiology Clinical Authors The © 2012 0691.2012.03841.x Record. Please citethis article as an'Accepted Article', doi: process which may lead todifferences between this version and has notbeenthrough thecopyediting, typesetting, pagination a This article hasbeenaccepted for publication and undergone fu Authors: Title Article Article type:Original : 12-Mar-2012 Date Accepted Revised Date: : 11-Jan-2012 Date Received , Keywords: efforts. relief international rotation in early October 2010. Suchfindings have important policy implicationsfor shaping future Nations (UN)peacekeeping from troops Nepalas th factors.climatic Instead, recent to climaticfactors and others to human transmission. None of the evidence origin on supports beingmuchhigher. Questionsof origin have widely been with debated some attributing onset the of the thousand deaths have occurred, the largest epid cholera moreseven cholera casesand than government-acknowledged million Since then, Tor. one-half over forControl Disease and Prevention (CDC) as StatesCenters and the United (LNSP) Laboratory by Public National Haitian quickly the identified was history. causative agent The in the for recorded first 2010 time inOctober Haitiin appeared Cholera Abstract , . University, Aix Marseille Department andof 5) , Port-au-Prince, Haiti, Population, Health and Microbial and Genomics, NorthernArizona University, Flagstaff,AZ, USA, 4)Ministry of Public Pathogens Genomics, TranslationalResearch Genomics Institute Flagstaff,AZ, (TGen), 3)Center USA, for 1) Department of , UCLA School of Public Health,LosAngeles, CA, USA, 2)Division of : Nepalese origin of cholera epidemic Haiti in of cholera origin : Nepalese

R. R. Frerichs R. R. cholera, cholera in Haiti, Vibrio cholera in Haiti, origin of cholera in Haiti, cholera source in source in origin cholera in Haiti, cholera of cholera, cholera in cholera Haiti, Haiti,Vibrio 10-Mar-2012 10-Mar-2012 1 , P.S. Keim , P.S. epidemiologicalmolecular-genetic and evidence United point tothe nd Infectious Diseases 2,3 , R. Barrais Vibrio cholerae 4 , and R. Piarroux e source ofe source choleratheir toHaiti,following troop emic in the world, with likely deathemic toll real inworld, the the serogroup O1, serotype Ogawa, biotype El 5

10.1111/j.1469- nd proofreading ll peer review but the Version of uropean Society Accepted Article Society Clinical Microbi of © 2012 The Authors Clinic All internet and Spanish. Creole Haitian French, English, in words with equivalent HaitiNepal” “cholera Haiti,”and origin, “cholera, terms, using the search Google we the employed articles, news Haiti.” For 2010 to December 2011,using the“origin terms, of chol Referenceswere identified searches through of PubMed for articles, regardless of from language, October Methods disasters. similar of future prevention for vital are consequencemanagement of understanding Haiti,the of cholera in such no impact initial on the peacekeepingmission [5,6]. While understandingwhether the climatic orhuman hypotheses aretrue had UN the for Haiti abbreviation French the camp of MINUSTAH, military in a problems sanitary was first circulated by reporters from two different international news organizationswho noticed serious human hypothesis The [7]. (NGOs) organizations and on non-governmental in [5,6], country settled the bringingfrom endemic thepathogen an country,with earlyfocus on UNpeacekeeping recently troops, supported by cholera-expert Professor RitaColwell [3,4].Alternately, others suspected ahuman source, was also hypothesis climatic The of Haiti[2]. Department inArtibonite Marc theSaint thearound of Bay likelyfor explanation cholera the outbreak Haiti was arise temperature and in salinity in river the estuaries hypothesis to areporter in late October 2010 [4]. Accordingto the reporter, Sacks opined that themost the climatic mentioned David Sacks Professor coast, Haitian near the inArtibonite Valley the reported disturbs the localenvironment, leading toadisease Vibrio cholerae Earlyscientists some on, supported aclimatic hypothesis the for origin ofarguing cholera Haiti, in that camemanymicrobe from.wondered where thein pathogenic Haiti[2], Haiti, been reported 2011). Since 4, dayJan. cholera (MSPP, hadmid-December, before never per 2010 by caseswere observed throughout thewith country [1], dozens of deaths perday, peakingmore at than 100 focuswas water onmanagement, case chlorination hygiene and awareness.months, Within two cholera through January, 2012(MSPP,Haiti,January 20,2012). When thewas outbreakfirst observed, immediate 526,524 suspected cases and 7,025 deaths reportedby with during recentsuch decades, epidemic world’s has cholera largest epidemic been the The Haiti in Introduction E-mail: Marseille, France. de Hôpitaux Publique Assistance Aix-Marseille Université, MD3 Corresponding author [email protected] [email protected]

is primarily an aquatic bacterium, typically living dormant in coastal waters, untilwaters, an event coastal in living dormant typically aquaticbacterium, isprimarily an and reprint requests and reprint ology andInfectious Diseases al Microbiology andInfe : Pr.Renaud Piarroux, Laboratoire deparasitologie UMR outbreak [3].Noting that early caseswere cholera the governmentHaitian from mid-October 2010 era in Haiti,” “cholera,era in “vibrio Haiti,” Haiti,”and cholera ction © 2012 European

Accepted Article Society Clinical Microbi of © 2012 The Authors Clinic section. Information information containsmentioned sources in the article but described more completely in Supporting the 1. Table refersPrimary tosources information extensively in addressed while the secondary the article, in summarized in Haitiare origin of cholera of the the to assessment related directly publications prior The of (PSK). us by one isolates Nepalese and Haitian similar-timed and on were alone researchers, by other done isolates Haitian of the laboratoryus investigations The (RB). by one of new assisted foci) cholera following and (i.e., investigating the epidemic of MSPP Surveillance and the of Department Epidemic (LNSP) Laboratory Health Public byyear the of the National epidemic Haitian investigations,November one in 2010and the second, in April 2011. was thirdThe during the first joint French- firstwere The two us RP). (RB, two inwere of conducted Haitiby field investigations Three the of MINUSTAH). staff in Haiti,and of UNSecretary-General representative of Health,special the of Haiti,the Minister President the Haiti(including in authorities and political with sanitarian meetings Haiti,and casesin cholera first of the investigation and diagnostic the in treatment, involved and epidemiologists microbiologists with physicians, discussions direct information, potentially interesting having and reporters bibliographicThe research invo also was deleted. cite the original inretrieval case items, searchedweekly on a basis starting inDecemberwere 2010, computer-archived for subsequent uhr rfrnenme) Type Authors (referencenumber) Table 1. 1. Table l ,Ce ta,(3 1) aoaoy Haiti Haiti Haiti Haiti Haiti Laboratory Laboratory Haiti, Laboratory Laboratory Haiti S14) al(15, M,et CeccarelliD,Spagnoletti Laboratory Haiti specimens time-similar or field investigation of * Location S15) G,etal(14, AR,Van Reimer Domselaar Laboratory S13) Yetal,(13, Chen A, Ali Epidemiological S12) etal,(12, J C, Sorenson Chin Epidemiological S11) (11, and CDC, LNSP LB etal,(17) RS, Price Hendriksen S7) R etal,(9, R,Barrais Piarroux S5) A, etal,(8, Lanata CF Cravioto PRIMARY INFORMATION SECONDARY INFORMATION SECONDARY INFORMATION Prior publications on cholera in cholera Haiti. publications on Prior ology andInfectious Diseases al Microbiology andInfe lved collection of available reports oflvedwith in collection available field, the exchanges email

ction © 2012 European fivsiain Location* of investigation

Accepted Article Society Clinical Microbi of © 2012 The Authors Clinic (see Figure 1). walk from pit” hill the “a the down that short the flowed river local reported of scientists where the panel near Mirebalais, by the in pit camp an septic open and deposited trucked to were campsfrom water allthree mademedical of records of Nepalese troops assigned to the two otherneighboring camps.Septicwaste- was review no cases.In addition, diarrhea moderate mild or mention of no made they and dehydration, panel of scientists in their review of the camp’s earlymedical records reported no cases of severe diarrhea fecal contaminationneighboring the of wate river, the preventwere to not sufficient conditions thatsanitation the and concluded hygiene deficiencies important many reported They [8]. the epidemic of the investigate origin UNto by the assembled of scientists, by apanel near Mirebalais camp MINUSTAH in the were assessed Sanitation conditions 1). towns (Figure neighboring in settlements insmaller two and the other near Mirebalais werehoused acamp in soldiers most of the In testing. Haiti, stool or amedical to examination subjected were not Haiti,theto soldiers embark to their battalion to Once returned they leaving Haiti. to for prior visit home aten-day likely during exposed toacholera epidemic in shows that in early October2010,aNepalese contingentUN peacekeepers ofwith 1,280personnelwas in the detail in ispresented information Background Background information Results Nepal either possibly during the three-month training period or more ology andInfectious Diseases al Microbiology andInfe Supporting Information r source forr source localcooking drinking. and Although the ction © 2012 European

section. Briefly, section. findings our Accepted Article precedingweek) sameThat toMSPP. day,worsened, the situation with 28new admissions and two deaths. (see Figure 1)reported an increase ofwatery acute First cluster. by the centrifugal epidemic during spread November 2010[9]. whichclusters,willnot bediscuss were here, somenorth distance and of south Artibonite the River, caused 19). secondThe was along lower the Artibonite River (occurring October 20–28). thirdThe through fifth that identified five significantcholera clusters. Th who travelledmost tothe areas affected of the country. second The team didspatiotemporal also analyses wasinvestigation conducted fromNovember 7–27,2010 by researcha joint team fromandFrance Haiti the Mirebalais region by ateam of Haitian epidemiologistsduring October 19–24, 2010. secondThe field inmade was field firstinvestigations of The the two [9]. field investigations findings of two the that relates scientists appointed by [8],and the UN the other is an articlepublished in ascientific peer-reviewed journal inby Haiti.One areport of panel is the the of cholera origin addressing only documents public been two but they didnot address the origin issue, orthe causeexplosive of the have outbreak followed. that There atCDC, investigators in Haiti,notably by were conducted of cholera studies field epidemiological Several information Epidemiological rivers and open septic pit (Google earth; Image © 2011GeoEye; Sept. 8,2010). Figure 1 Society Clinical Microbi of © 2012 The Authors Clinic . Location of first cholera cases and Nepalese MINUSTAH camp near Mirebalais with villages, near Mirebalais camp MINUSTAH casesand Nepalese . Location of cholera first On October 18, Cuban doctors working at the Mirebalais community hospital in central Haiti in central Haiti hospital community workingMirebalais atthe doctors Cuban 18, On October ology andInfectious Diseases al Microbiology andInfe e firstwas cluster near Mirebalais (occurring October 16– diarrhea (61cases treatedin Mirebalais during the ction © 2012 European

Accepted Article area experiencing a cholera outbreak and the appearance of the first cases in Meille a few days after. The The experiencingfewarea after. and the days acholera of Meillea outbreak first casesin the appearance from battalion was an between the of places exact aNepalese arrival Haiti. There in an correlation and time of in cholera importation an confirming arguments additional several provides study “Our epidemiologic Followingof statistical analyses the clusters, spatiotemporal the Frenchwrote, and researchers Haitian Society Clinical Microbi of © 2012 The Authors Clinic 1). (seeFigure atMirebalais River Artibonite into the flows north La and Thème River the becomes Meille/Mèyé drinking. The and cooking for Meille/Mèyé waterfrom River the used regularly thatvillagers Katznoted the reporter and epidemiologists the Haitian Both [6]. location same 27th the visit to Katzduring October his by reporter whatwas reported to similar is finding This river. the into camp the from sewage discharging pipe a including camp, MINUSTAH the epidemio Haitian investigation, field During their from October 16-19 is shownin the top row Figure of with 2, all cases remaining in the Mirebalais region. space-timeThe the distribution early cases of cholera is presented in first 2.The Figure cluster of cases yielded 14–19, October during sick who became outpatients, inthese Meillefrom collected samples Five 6 of the October 19th, the investigators identified 10other cases in the16houses near thefamily’s index house. On 1). (Figure Mirebalais of south kilometers asmall village Mèyé), two spelled (also living Meille in arrival of thefirst group of Nepalese troops). firstThe hospitalized patientsweremembers of afamily five (i.e. 2010 14, the days after October on that began first epidemic reporting the the identified cases, formally team This Investigation Haitian [9]." team investigation aHaitian immediatelysent MSPP V. cholerae Figure 2. Evolution of cholera cases during the first week of the Haitian cholera epidemic. cholera epidemic. week Evolution the first casesduring the Haitian of of cholera O1, serotype Ogawa, biotype El Tor[9]." ology andInfectious Diseases al Microbiology andInfe logistsalso observed sanitary deficiencies atthe ction © 2012 European

Accepted Article Second cluster. was first isolated during epidemic an north in Indi El altered Tor anidentical, to but not totally were similar, Haitian isolates that the one study reported In addition, Asia [11-14]. from South probably event or [8], single source Haitiby a to brought havewas likelyto been cholera that showing fewvery polymorphisms exhibited Information in the ispresented analyses review Haiti-only these A of from detailed Haiti. isolates genome sequencingwhole-genome or sequence typing. Most of the published analyseswere done only for partial (MLVA), analysis or Multiple-locusVNTR called also (VNTR) tandem-repeat of variable-number compare them toisolates of other . These tool Severalwere tools used tocharacterize the isolates Evidence Molecular-Genetic [9]. study an epidemiologic event that provokedmassive the contamination Lower of Artibonite could not bedefinitively deduced from holding the dumping aseptic of tank responsible for the epidemic [10].Yet they pointed out that the exact with rumors compatible is that pattern but noted explosive were interpretation, et al. their in cautious whatAsmight to have causedsuch acholera-contaminated sewage plumeArtibonite River, the in Piarroux [8].” Haiti throughout Delta,and eventually, River Artibonite the in downstream outbreak explosive cholera an initiated Artibonite River] of the tributary the [of Meille/Mèyé “This contamination who stated cholera contamination in [9]. river the These findingswere confirmed members also by of UNpanel the new cases and deaths dropped dramatically after only two days, suggesting arapid decrease of the level of the proximity to Mirebalais,would as beexpected fo notto and River Artibonite the to linked was strongly of cholera the spread model that indicated regression the lower Artibonite River occurred simultaneously (see bottom row of Figure 2,Oct. 20-22). Their until after October 19, 2010 [9]. Field investigations showedthat contamination of theseven communes of investigatorswere reportedthat there no cholera cases reported in the lower-Artibonite communes River Society Clinical Microbi of © 2012 The Authors Clinic type Asian South due to contamination of the Meye Tributary ofArtibonite the Riverwith apathogenicstrain of current “the evidence overwhelmingly supports the conclusion thatthe source of outbreak theHaiticholera was when concluded: point they starting epidemic’s on the with investigators agreed and Haitian French the investigation, later their in Panel, UN The [9].” way another there brought been have might strain cholera makeunlikely a that it of incomers other of report Haitiand the absence in central ofremoteness Meille section but briefly summarized here. Overall, the microbial studies of the Haitian isolates isolates Haitian ofmicrobial the the studies here. Overall, summarized section but briefly Regarding explosion the of cases correspondi Vibrio cholerae as aresulthuman of activity [8].” ology andInfectious Diseases al Microbiology andInfe a in 2007[15]. Time-similar isolates from both Haitiand collected duringcollected the Haitia r road-dependent propagation. Theyalso the noted the s were eithers pulse field electrophoresis, oranalysis ngsecondcluster, tothe significant the ction © 2012 European

Vibrio cholerae n epidemic cholera and to Supporting variant which which variant Accepted Article the 24genomes of the Nepal isolates to 10previouslysequenced Laboratory. cases The in occurred Nepal from July 30to November 1,2010. investigatorsThe compared isolatesfrom five different districts in Nepal, provided by officials of the Nepalese National Public Health and provided by NCBI. All six isolateswere almostwith identical, only 1- or2-bp (i.e., base pair) byCDC collected isolates andthree Haitian Nepal), south-central of districts Rupandehi in and the Banke genotypic clusters. such One cluster contained three Nepa closelyfour related into divided were then phylogenetically isolates Nepalese 24 Bangladesh and Haiti. The belonged to asinglemonophyletic (i.e., sharing acommon ancestor) group that contained also isolatesfrom almost picture of complete genetic polymorphisms,showed they all24 that an provides apowerful that tool (WGST), typing whole-genome sequence Using the outbreak. Haitian that has appearedin apeer-reviewed scientif Hendriksen RS etal, 2011. is described by Choi et al [16]. in the used analysis method that the MLVA Hefurther stated not published. Haiti, although fromspecimen acknowledged comparative analysis of a2010cholera specimenfrom Nepal time-linked with a2010 not 2009as stated in the UN (personal report communication, July 19,2011). Hence this represents the first Dr. Kim clarified in histhat email the “perfectmatch” was with strains isolated in Haiti Nepal and in 2010, statement. Kim confirm this Dong Dr. to wrote Wook to us One of (RRF) linked. circulatedmedia, in news the as evidence cholera the that organisms the in two countries were genetically the strains Nepalduring in isolated Haitiand 2009werewasmatch.”widely This information aperfect analysis “Awrote, They (MLVA). careful analysis the of and MLVA results the repeat tandem variable-number multilocus was namely used, method typing genetic asimpler interim in that the however, state, of scientists panel did The “in process.” still is analysis sequences genome werethey being compared toseven Ogawa strains isol O1. In thisgroup of specimens theymentioned twostrains Ogawa isolated in Nepal in 2010,and stated that Society Clinical Microbi of © 2012 The Authors Clinic Vaccine Institute inKoreaon the availabilityin strains Korea of Nepal from 2007-2010 of with the Kim Dong International Dr. of Wook of their correspondence wrote They strains [8].” Nepal of scientists appointed byUnited Nations the included asection “recent entitled preliminary datafrom Cravioto A et al, Kim DW 2011. Haiti and Nepal from Isolates section. wereNepal included in two studies, one published and the other not, and arepresented in the following This is the only analysis of time-related specimens from both Nepal and Haiti Nepal from both specimens of time-related This the analysis is only In their unpublished reporton the 2010Haiticholera epidemic, the panel ology andInfectious Diseases al Microbiology andInfe ic publication [17]. authorsThe analyzed 24 ated inHaiti 2010,butmore the whole definitive lese isolates (collected on August 1,and 30, 2010 V. cholerae ction © 2012 European

V. cholerae isolates, includingfrom three ctxB gene indicated that gene isolatesNepal from Vibrio cholerae Vibrio cholerae

Accepted Article peacekeepers from source Nepalas of the reinforces previous the epidemiological investiga infectious disease epidemiology [17].”Asstated for anew standard setting imaginable … molecular approach “most the using powerful confirmed and Nepal during 2010 were perfectmatch.” a Neverthelessthese preliminary resultswerefurther After correcting thetypographic dateerror, the reportfr results. and clear Haitigave from Nepal both obtained comparing specimens analyses laboratory-based The wascampfound waste toallow fluids toseep downnearby into the river. (see the usual location company disposalwaste responsible for atthewaswaste UNcamp seen truckfrom dumping its outside the Haitian thewaste and the river, into fecal from leaked thepipes camp that journalists to complained cholera appearedin next the village UNca tothe cholera, either before theyleft Nepalorwhen arriving Afew Haiti. in days after they cases arrived, of soldiers camewhere fromacholera Nepal outbreak had strong, based on background events and published epidemiologicmolecular-genetic and investigations. The evidenceThe that UNpeacekeeping Nepalese the troops morespecific conclusions. Society Clinical Microbi of © 2012 The Authors Clinic type Asian South strain of current with apathogenic River Artibonite of the Meye of Tributary the contamination due to was report, “the evidence overwhelminglysupports the conclusion that the source of the Haiti cholera outbreak UNPanel assignedThe toinvestigate the origincholera ofwrote epidemic Haiti the May their in 2011 Discussion of source cholera in Haiti. astheUN peacekeepers initial Nepalese to pointing all others, and journalists by provided information background with along [9], exists highly are suggestiveused WGST together [17].”As Nepal is the of source the cholera Haitian outbreak bereached can only if both classical epidemiology and based upon alone requires WGST comprehensive geographic strain collections. current The conclusion that of words some offered the authors with said, Yet that the outbreak. Haitian of origin with asthe consistent Nepal are method, WGST powerful differences [17]. investigatorsThe emphasized that thes Vibrio cholerae Supporting Information as aresulthuman of activity [8].”Weagree, but feel our findings support ology andInfectious Diseases al Microbiology andInfe the epidemic cholera Haitian [17].” section). Finally, a waste septic pit on a hilltop near the UN hilltop onwaste a Finally, section). pit septic a mphousingthe Nepalese new troops. Local peoplehad by Hendriksen RS et al, “this molecular phylogeny phylogeny molecular “this al, et RS Hendriksen by tion [of Piarroux et al [9 presented here, such“classical epidemiology” now caution. Theycaution. “Attribution stated, outbreak of sources om the UN panel reads, “the strains isolated in Haiti in Haiti isolated “thestrains om reads, UNpanel the e findings,first thee isolates of Haiti-Nepal using the just occurred. None ofwere the soldiers for tested brought toHaitiappears cholera particularly ction © 2012 European ] that pointed towards UN

Accepted Article Society Clinical Microbi of © 2012 The Authors Clinic 6. 5. 4. 3. 2. 1. References authorsThe declareno conflict of interest of any nature. Transparency Declaration authorsThe wish tothankPiarroux Martine for creating Figures 1and 2. Acknowledgement [18]. their devastation cholera to lead events that the understand to Haitians triggered the is epidemic important for preventingfuture occurrences, acknowledges and right the of from acountr travelling ofby soldiers acontingent consequence of the January earthquake.All 2010 ofwas the scientific evidence shows that cholera brought direct not thewas and factors climatic not due to was in Haiti of cholera onset the In conclusion, examine soldiers. the notwas allowed to health team cholera, but the public of Haitian symptoms of the showed peacekeepers none them UNcamp by of Meille.Hetold the that met the doctor health team theoutbreak, public Haitian Mirebalais of the was their During 2010, investigation butunsuccessful. initial made 21, onwas October been cholera tests the of Nepalese UN troops at the onset the of epidemic.An attempt such to do testing have would findings missing only The gleaned. be to evidence scientific more no is there juncture, At this

cholera-outbreak.html) (Accessed 11/15/11 at:http://www.thejakartapost. UNprobesKatz JM. base as source of HaiticholeraAssociated outbreak. Press, Oct.28,2010. http://english.aljazeera.net/programmes/aljazeer 11/15/11 at: Walker S.UNInvestigatesCholera Spreadin Haiti.Al English, Jazeera Oct.27,2010. (Accessed www.npr.org), October 26, 2010. (NPR, Radio National Public blame Haiti. R. Earthquake not for cholera outbreak in to Knox (http://www.circleofblue.org/waternews/), November 11,2010. of Blue Waternews Circle Connection. Climate The -- AA. in Haiti Parker Cholera and other Caribbean regions,19th century. Emerg Infect Dis 2011;17:2130-5. in Haiti Cholera Team. Research Student Laboratory HaitiHumanities FHI V,DukeJenson D,Szabo human-driven dissemination.Clin Microbiol Infect 2012Mar;18(3):231-8. Piarroux R, Faucher B.Cholera epidemics in 2010: respective roles of environment, strainchanges and ology andInfectious Diseases al Microbiology andInfe y experiencing acholerawhat epidemic. Understanding acorrespondent/2011/09/2011913144553324479.html com/news/2010/10/28/un-probes-base-source-haiti- ction © 2012 European

Accepted Article 18. 17. 16. 15. Society Clinical Microbi of © 2012 The Authors Clinic 14. 13. 12. 11. 10. 9. 8. 7.

scientific curiosity? Clin Microbiol Infect 2011;17:479-80. of matter a only itsorigin for issearching epidemic: Haitian Piarroux cholera R.The B, Faucher 2010: evidence on the origin of outbreak. the Haitian 2011;2:e00157-11. MBio HendriksenRS, Price LB, Schupp JM,et al. Population genetics of Vibrio cholerae from in Nepal cholerae analysis tandem of repeat variable-number YS,etal.Multilocus Lee Jeon Choi JH, SY, Haiti. Lancet Infect 2011;11:262. Dis Ceccarelli D, Spagnoletti M, Cappuccinelli P, Cappuccinelli M, Ceccarelli D,Spagnoletti Asia,. and Emerg Infect Dis 2011;17:2113-21. Reimer AR, G,Stroika Van S,etal.Comparative Domselaar genomics of 2011;17:699-701. in Infect Dis Haiti.Emerg cholera al.Recent of JA, clonal origin et Chen Y,Johnson A,Ali 2011;364:33-42. ChinC, Sorenson origin etal.The Harris J, J, of cholera the outbreak Haitian strain. Med J NEngl Update: Cholera outbreak - 2010. Haiti, MMW outbreak.html) (Accessed 11/15/11 at:http://www.miamiherald.c Tasker F, Robles F. Source of cholera outbreakmay never beknown. Miami Herald, Nov. 20,2010. 2011;17,1161-8. Infect Dis Haiti.Emerg etal.Understanding epidemic, B, cholera the R,Faucher R,Barrais Piarroux at:http://www.un.org/News/dh/infocus/haiti/UN-cholera-report-final.pdf) 11/15/11 United Nations (Cravioto A. (Chair), LanataCF,Lantagne DS, Nair May GB), 4,2011. (Accessed NY: in outbreak York, Haiti.New cholera of panel on the experts of the independent Final report +Cholera+beliefs+and+perceptions.pdf&tabid=77&mid=860&language=en-US). http://haiti.humanitarianresponse.info/LinkClick.aspx?link=HRC+PSP+- at: Available at: outbreak: note onbeliefs,feelings community RedHaitian Cross International and FederationRed of Cross, Psychosocial Support Program. Cholera O1 El strainsTor harbouring classical toxin B.JMed Microbiol 2010;59:763-9. ology andInfectious Diseases al Microbiology andInfe Burrus V, Colombo MM.Origin Burrus of V,Colombo and perceptions. December 2010.(Accessed 12/27/11 R MorbMortal WklyRep 2010;59:1586-90. om/2010/11/20/ ction © 2012 European 1934870/source-of-haitis-cholera-

Vibrio cholerae Vibrio cholerae Vibrio from Haiti, in