I
S
T
M
55
BRIEF COMMUNICATION
Diarrheal Illness Among US Residents Providing Medical Services in Haiti During the Cholera Epidemic, 2010 to 2011 Katharine A. Schilling, MPH,∗ Emily J. Cartwright, MD,∗†‡ John Stamper, BA,§ Michael Locke, BBA,|| Douglas H. Esposito, MD,¶ Victor Balaban, PhD,¶ and Eric Mintz, MD∗ ∗ Division
of Foodborne, Waterborne, and Environmental Diseases, Waterborne Disease Prevention Branch, National Center for Emerging and Zoonotic Infectious Diseases, US Centers for Disease Control and Prevention, Atlanta, GA, USA; † Epidemic Intelligence Service, Scientific Education and Professional Development Program Office, OSELS, CDC, Atlanta, GA, USA; ‡ Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA; § Office of the Director, Office of Informatics, National Center for Emerging and Zoonotic Infectious Diseases, US Centers for Disease Control and Prevention, Atlanta, GA, USA; || Office of the Director, Office of Informatics, National Center for Emerging and Zoonotic Infectious Diseases, US Centers for Disease Control and Prevention via Science Applications International Corporation, Atlanta, GA, USA; ¶ Division of Global Migration and Quarantine, Traveler’s Health Branch, National Center for Emerging and Zoonotic Infectious Diseases, US Centers for Disease Control and Prevention, Atlanta, GA, USA DOI: 10.1111/jtm.12075
Although nosocomial transmission of cholera is rare, two US healthcare workers (HCW) became ill with cholera after providing medical services during the Haiti cholera epidemic. To assess the incidence of diarrheal illness and explore preventive health behaviors practiced by US residents who provided medical services in Haiti, we conducted a cross-sectional, anonymous, web-based survey. We e-mailed 896 participants from 50 US-based, health-focused non-governmental organizations (NGOs), of whom 381 (43%) completed the survey. Fifty-six percent of respondents (n = 215) reported providing some care for patients with cholera. Diarrhea was reported by 31 (8%) respondents. One person was diagnosed with cholera by serologic testing. NGOs responding to international emergencies should ensure ample access to basic hygiene supplies and should promote their use to reduce the incidence of diarrheal illness among HCW working overseas.
O
n October 21, 2010, for the first time in history, epidemic cholera caused by toxigenic Vibrio cholerae, serogroup O1, serotype Ogawa, and biotype El Tor was confirmed in Haiti.1 Cholera, a new disease to the Haitian population, introduced many challenges to an already fragile healthcare infrastructure and a population still recovering from a devastating earthquake earlier in the year; people in Haiti were Presented as a poster at the 2012 International Conference of Emerging Infectious Diseases in March 2012 (board 147; pg 104, ICEID 2012 Programs and Abstracts Book). Corresponding Author: Katharine Schilling, MPH, Division of Foodborne, Waterborne, and Environmental Diseases, Waterborne Disease Prevention Branch, National Center for Emerging and Zoonotic Infectious Diseases, US Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop C09, Atlanta, GA 30307, USA. E-mail: [email protected]
not only immunologically susceptible to cholera, but healthcare professionals lacked experience treating cholera and preventing its spread. As of October 20, 2012, 604,634 cholera cases and 7,436 cholera deaths were reported.2 In response to the cholera epidemic, cholera treatment centers (CTCs) were established throughout the country. Many CTCs were run by international non-governmental organizations (NGOs), and staffed by foreign healthcare workers (HCW). Few reports describing the transmission of cholera to HCW while providing medical services exist in the literature, suggesting it is a rare event.3 – 6 Nevertheless, the Centers for Disease Control and Prevention was informed of two US HCW who became ill with cholera after providing medical services in Haiti. Methods To assess the incidence of diarrheal illness and explore preventive health behaviors practiced by US
Published 2013. This article is a U.S. Government work and is in the public domain in the USA. 1195-1982 Journal of Travel Medicine 2014; Volume 21 (Issue 1): 55–57
56
residents who provided medical services in Haiti, we conducted a cross-sectional, anonymous, web-based survey. Respondents were asked questions regarding episodes of diarrhea (≥3 loose stools/24 hours) while in Haiti or within 5 days of returning, hand-washing practices, the availability and use of hand-washing supplies, food and water precautions, travel health preparations, and their level of knowledge about cholera treatment guidelines and recommendations. The Haitian Ministry of Public Health and Population identified 353 health-based NGOs working in Haiti. To recruit respondents, we contacted 172 of these organizations, all of which were US-based and known to provide medical services in Haiti; 181 were excluded because the contact information was not valid, the organization was not based in the United States, or the organization had no US residents as volunteers. We asked NGOs to provide us with contact information for volunteers sent to Haiti who met our survey criteria (inclusion criteria: US resident, ≥18-year old, who provided medical services in Haiti between October 21, 2010 and May 31, 2011). We developed a survey using IBM SPSS Data Collection (IBM SPSS, Armonk, NY, USA) that was available to participants between April 28 and May 31, 2011. Each identified volunteer was sent a unique survey URL. A generic survey URL was sent to NGOs unable to provide individual contact information and was distributed to individuals by the NGO on our behalf. These NGOs were asked to report the number of people who received the URL to allow for calculation of response rates. Reminder e-mails were sent at 2-week intervals until the close of the survey. The results were analyzed using SAS version 9.2 (SAS Institute Inc., Cary, NC, USA). Fisher’s Exact p-values are reported. This inquiry was part of a public health investigation and did not meet the definition of research under 45 CFR 46.102 (d) and therefore, did not require formal ethical review. Results We e-mailed 896 participants from 50 US-based, health-focused NGOs, of whom 381 (43%) completed the survey. The median age of respondents was 47 years (range 19–81 years); 65% were female. Among respondents, 153 (40%) were trained as nurses, 126 (33%) as medical doctors (MD) or physician’s assistants (PA), 48 (13%) as allied health professionals (AHPs), 48 (13%) had no formal medical training, and 6 (2%) were students (Table 1). For 166 respondents (44%) this was their first time providing medical services outside the United States. Eighty-five percent of respondents (n = 322) traveled to Haiti once, while 15% (n = 59) went two or more times. The median trip duration was 8 days (range 3–189 days). While in Haiti, 56% of respondents (n = 215) reported providing some care for patients with cholera. This analysis was conducted using data from the respondents’ first trip to Haiti. Diarrhea was reported by 31 (8%) respondents, of J Travel Med 2014; 21: 55–57
Schilling et al. Table 1 Characteristics and reported hand-washing practices, primary water and food sources, and travel preparations of US residents who traveled to Haiti to provide medical services between October 21, 2010 and May 31, 2011 Characteristic n (%) Medical background (n = 381) Nurses* Medical doctor/physician assistant Allied health professional† No formal medical training Student Hand-washing practices after patient care (n = 381) Always washed hands Usually washed hands Sometimes washed hands Rarely washed hands Never washed hands Do not know Reasons cited for not always washing hands after patient care activities (n = 59) Hand-washing supplies not available No direct patient care Too busy/overwhelmed Not necessary Other Primary water sources (n = 381) Treated water Untreated water Water from unknown source Do not know Primary food sources (n = 381) Privately prepared food (NGO, hospital, and other) Restaurant Brought from home or dehydrated meals Street-vended food Other Travel preparations (n = 381) Received information on staying healthy before traveling to Haiti Visited a healthcare provider before traveling to Haiti
153 (40) 126 (33) 48 (13) 48 (13) 6 (2) 311 (82) 35 (9) 16 (4) 2 (0.5) 9 (2) 8 (2)
30 (51) 13 (22) 8 (14) 6 (10) 2 (3) 362 (95) 4 (1) 2 (0.5) 13 (3) 336 (88) 31 (8) 7 (2) 6 (2) 1 (0.3) 344 (90) 244 (64)
*Includes: nurse anesthetists and nurse practitioners. †Includes: pharmacist, medical technicians/assistants, paramedics, orthotist/prosthetist, public health officials, nutritionists, laboratorians, radiographers, athletic trainers, physical and occupational therapist, and those in the dental field.
whom 13 were trained as MD/PA, 12 as nurses, 4 had no medical training, and 2 were trained as AHP. Of the 31 respondents who reported having diarrhea, 27 (87%) had mild-to-moderate diarrhea (3–12 stools/24 hours) and 4 (13%) had severe diarrhea (≥12 stools/24 hours). One person with severe diarrhea was diagnosed with cholera by serologic testing. Among those with diarrhea, 17 (55%) took antibiotics, 4 (13%) sought medical care, 2 (6%) received intravenous fluids, and 1 (3%) was medically evacuated. Overall, 311 respondents (82%) reported always washing their hands after patient care activities. Among those who did not always wash their hands (n = 59), 51% reported a lack of hand-washing supplies as the primary
57
Diarrhea in HCW During the Haiti Cholera Epidemic
reason (Table 1). While most respondents reported drinking water and eating food from what would be considered safe sources, 1% of respondents consumed untreated water and 2% ate street-vended foods (Table 1). Before traveling, 90% of respondents obtained information about how to stay healthy in Haiti, and 64% reported visiting a healthcare provider in preparation for their trip (Table 1). HCW who developed diarrheal illness were more likely to report not always washing their hands (32% vs 17%, p = 0.05) as compared with those who did not develop diarrheal illness; however, those who developed diarrheal illness were not more likely to have any particular medical background (nurses: 39% vs 40%, p = 1.00; MD/PA: 42% vs 32%, p = 0.32; AHP: 7% vs 13%, p = 0.40; no formal medical training: 13% vs. 13%, p = 1.00; student: 0% vs 2%, p = 1.00), consume untreated drinking water (0 vs 1%, p = 1.00) or street-vended foods (3% vs 4%, p = 1.00), or have obtained pre-travel health information (61% vs 64%, p = 0.70) or visited a healthcare provider before traveling (94% vs 90%, p = 0.75) (data not shown). Discussion Many US residents responded to the medical needs of the Haitian population during the Haiti cholera epidemic. Some HCW who provided medical services during this time became ill with diarrhea, and one HCW had serologically confirmed cholera. Our survey found lower rates of diarrheal illness as compared with previous studies examining diarrhea in travelers.7 – 10 We suspect this is in part due to lower consumption of risky food and water which could be attributed to heightened food safety and hygiene precautions during the cholera epidemic and less recall of diarrheal illness due to time elapsed between travel and the administration of our survey. Our survey was subject to response bias as it is impossible to determine whether significant differences exist between those who completed the survey and those who did not. Cholera and other diarrheal illnesses are largely preventable through consuming safe foods and beverages and practicing recommended hygiene and sanitation practices.11 Cholera is not typically transmitted through person-to-person contact.11 Our survey found that many US HCW took precautions to protect themselves against cholera. It also suggested that many survey respondents lacked experience working in an international, emergency epidemic situation such as the one in Haiti, and had little experience treating cholera patients. This, along with inadequate handwashing supplies, may have led to diarrheal illnesses experienced by some HCW. To protect HCW from becoming ill during future emergency response efforts, it will be important
to ensure adequate hygiene supplies. Those with limited experience working in international, public health emergency situations or working with unfamiliar diseases should consider participating in additional preparatory activities, such as on-line training or short, topic-specific courses. Importantly, NGOs responding to international emergencies should ensure ample access to basic hygiene supplies and should promote their use to reduce the incidence of diarrheal illness among HCW working in Haiti. Declaration of Interests The authors state they have no conflicts of interest to declare. References 1. Centers for Disease Control and Prevention. Cholera outbreak—Haiti, 2010. Morb Mortal Wkly Rep 2010; 59:1411. 2. Ministry of Public Health and Population. Rapport du 20 Octobre 2012. Port-au-Prince, Haiti; October 2012. Available at: http://mspp.gouv.ht/newsite/docu mentation.php. (Accessed 2012 Nov 17) 3. Cliff J, Zinkin P, Martelli A. A hospital outbreak of cholera in Maputo, Mozambique. Trans R Soc Trop Med Hyg 1986; 80:473–476. 4. Oladele D, Oyedeji K, Niemogha M, et al. An assessment of the emergency response among health workers involved in the 2010 cholera outbreak in northern Nigeria. J Infect Public Health 2012; 5:346–353. 5. Haus-Cheymol R, Theodose R, Quilici M, et al. A cluster of acute diarrhea suspected to be cholera in French travelers in Haiti, December 2010. J Travel Med 2012; 19:189–191. 6. Malangu N, Legothoane A. Analysis of occupational infections among health care workers in Limpopo Province of South Africa. Glob J Health Sci 2013; 5:44–51. 7. Castelli F, Pezzoli C, Tomasoni L. Epidmiology of travelers’ diarrhea. J Travel Med 2001; 8:S26–S30. 8. Hill D. Occurrence and self-treatment of diarrhea in a large cohort of Americans traveling to developing countries. Am J Trop Med Hyg 2000; 62:585–589. 9. von Sonnenburg F, Tornieporth N, Waiyaki P, et al. Risk and aetiology of diarrhoea at various tourist destinations. Lancet 2000; 356:133–134. 10. Steffen R, van def Linde F, Gyr K, Sch¨ar M. Epidemiology of diarrhea in travelers. JAMA 1983; 249:1176–1180. 11. Centers for Disease Control and Prevention. Cholera prevention and control. Atlanta, GA; 21 May 2010. Available at: http://www.cdc.gov/cholera/prevention. html. (Accessed 2012 Jun 27)
J Travel Med 2014; 21: 55–57
S
T
M
55
BRIEF COMMUNICATION
Diarrheal Illness Among US Residents Providing Medical Services in Haiti During the Cholera Epidemic, 2010 to 2011 Katharine A. Schilling, MPH,∗ Emily J. Cartwright, MD,∗†‡ John Stamper, BA,§ Michael Locke, BBA,|| Douglas H. Esposito, MD,¶ Victor Balaban, PhD,¶ and Eric Mintz, MD∗ ∗ Division
of Foodborne, Waterborne, and Environmental Diseases, Waterborne Disease Prevention Branch, National Center for Emerging and Zoonotic Infectious Diseases, US Centers for Disease Control and Prevention, Atlanta, GA, USA; † Epidemic Intelligence Service, Scientific Education and Professional Development Program Office, OSELS, CDC, Atlanta, GA, USA; ‡ Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA; § Office of the Director, Office of Informatics, National Center for Emerging and Zoonotic Infectious Diseases, US Centers for Disease Control and Prevention, Atlanta, GA, USA; || Office of the Director, Office of Informatics, National Center for Emerging and Zoonotic Infectious Diseases, US Centers for Disease Control and Prevention via Science Applications International Corporation, Atlanta, GA, USA; ¶ Division of Global Migration and Quarantine, Traveler’s Health Branch, National Center for Emerging and Zoonotic Infectious Diseases, US Centers for Disease Control and Prevention, Atlanta, GA, USA DOI: 10.1111/jtm.12075
Although nosocomial transmission of cholera is rare, two US healthcare workers (HCW) became ill with cholera after providing medical services during the Haiti cholera epidemic. To assess the incidence of diarrheal illness and explore preventive health behaviors practiced by US residents who provided medical services in Haiti, we conducted a cross-sectional, anonymous, web-based survey. We e-mailed 896 participants from 50 US-based, health-focused non-governmental organizations (NGOs), of whom 381 (43%) completed the survey. Fifty-six percent of respondents (n = 215) reported providing some care for patients with cholera. Diarrhea was reported by 31 (8%) respondents. One person was diagnosed with cholera by serologic testing. NGOs responding to international emergencies should ensure ample access to basic hygiene supplies and should promote their use to reduce the incidence of diarrheal illness among HCW working overseas.
O
n October 21, 2010, for the first time in history, epidemic cholera caused by toxigenic Vibrio cholerae, serogroup O1, serotype Ogawa, and biotype El Tor was confirmed in Haiti.1 Cholera, a new disease to the Haitian population, introduced many challenges to an already fragile healthcare infrastructure and a population still recovering from a devastating earthquake earlier in the year; people in Haiti were Presented as a poster at the 2012 International Conference of Emerging Infectious Diseases in March 2012 (board 147; pg 104, ICEID 2012 Programs and Abstracts Book). Corresponding Author: Katharine Schilling, MPH, Division of Foodborne, Waterborne, and Environmental Diseases, Waterborne Disease Prevention Branch, National Center for Emerging and Zoonotic Infectious Diseases, US Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop C09, Atlanta, GA 30307, USA. E-mail: [email protected]
not only immunologically susceptible to cholera, but healthcare professionals lacked experience treating cholera and preventing its spread. As of October 20, 2012, 604,634 cholera cases and 7,436 cholera deaths were reported.2 In response to the cholera epidemic, cholera treatment centers (CTCs) were established throughout the country. Many CTCs were run by international non-governmental organizations (NGOs), and staffed by foreign healthcare workers (HCW). Few reports describing the transmission of cholera to HCW while providing medical services exist in the literature, suggesting it is a rare event.3 – 6 Nevertheless, the Centers for Disease Control and Prevention was informed of two US HCW who became ill with cholera after providing medical services in Haiti. Methods To assess the incidence of diarrheal illness and explore preventive health behaviors practiced by US
Published 2013. This article is a U.S. Government work and is in the public domain in the USA. 1195-1982 Journal of Travel Medicine 2014; Volume 21 (Issue 1): 55–57
56
residents who provided medical services in Haiti, we conducted a cross-sectional, anonymous, web-based survey. Respondents were asked questions regarding episodes of diarrhea (≥3 loose stools/24 hours) while in Haiti or within 5 days of returning, hand-washing practices, the availability and use of hand-washing supplies, food and water precautions, travel health preparations, and their level of knowledge about cholera treatment guidelines and recommendations. The Haitian Ministry of Public Health and Population identified 353 health-based NGOs working in Haiti. To recruit respondents, we contacted 172 of these organizations, all of which were US-based and known to provide medical services in Haiti; 181 were excluded because the contact information was not valid, the organization was not based in the United States, or the organization had no US residents as volunteers. We asked NGOs to provide us with contact information for volunteers sent to Haiti who met our survey criteria (inclusion criteria: US resident, ≥18-year old, who provided medical services in Haiti between October 21, 2010 and May 31, 2011). We developed a survey using IBM SPSS Data Collection (IBM SPSS, Armonk, NY, USA) that was available to participants between April 28 and May 31, 2011. Each identified volunteer was sent a unique survey URL. A generic survey URL was sent to NGOs unable to provide individual contact information and was distributed to individuals by the NGO on our behalf. These NGOs were asked to report the number of people who received the URL to allow for calculation of response rates. Reminder e-mails were sent at 2-week intervals until the close of the survey. The results were analyzed using SAS version 9.2 (SAS Institute Inc., Cary, NC, USA). Fisher’s Exact p-values are reported. This inquiry was part of a public health investigation and did not meet the definition of research under 45 CFR 46.102 (d) and therefore, did not require formal ethical review. Results We e-mailed 896 participants from 50 US-based, health-focused NGOs, of whom 381 (43%) completed the survey. The median age of respondents was 47 years (range 19–81 years); 65% were female. Among respondents, 153 (40%) were trained as nurses, 126 (33%) as medical doctors (MD) or physician’s assistants (PA), 48 (13%) as allied health professionals (AHPs), 48 (13%) had no formal medical training, and 6 (2%) were students (Table 1). For 166 respondents (44%) this was their first time providing medical services outside the United States. Eighty-five percent of respondents (n = 322) traveled to Haiti once, while 15% (n = 59) went two or more times. The median trip duration was 8 days (range 3–189 days). While in Haiti, 56% of respondents (n = 215) reported providing some care for patients with cholera. This analysis was conducted using data from the respondents’ first trip to Haiti. Diarrhea was reported by 31 (8%) respondents, of J Travel Med 2014; 21: 55–57
Schilling et al. Table 1 Characteristics and reported hand-washing practices, primary water and food sources, and travel preparations of US residents who traveled to Haiti to provide medical services between October 21, 2010 and May 31, 2011 Characteristic n (%) Medical background (n = 381) Nurses* Medical doctor/physician assistant Allied health professional† No formal medical training Student Hand-washing practices after patient care (n = 381) Always washed hands Usually washed hands Sometimes washed hands Rarely washed hands Never washed hands Do not know Reasons cited for not always washing hands after patient care activities (n = 59) Hand-washing supplies not available No direct patient care Too busy/overwhelmed Not necessary Other Primary water sources (n = 381) Treated water Untreated water Water from unknown source Do not know Primary food sources (n = 381) Privately prepared food (NGO, hospital, and other) Restaurant Brought from home or dehydrated meals Street-vended food Other Travel preparations (n = 381) Received information on staying healthy before traveling to Haiti Visited a healthcare provider before traveling to Haiti
153 (40) 126 (33) 48 (13) 48 (13) 6 (2) 311 (82) 35 (9) 16 (4) 2 (0.5) 9 (2) 8 (2)
30 (51) 13 (22) 8 (14) 6 (10) 2 (3) 362 (95) 4 (1) 2 (0.5) 13 (3) 336 (88) 31 (8) 7 (2) 6 (2) 1 (0.3) 344 (90) 244 (64)
*Includes: nurse anesthetists and nurse practitioners. †Includes: pharmacist, medical technicians/assistants, paramedics, orthotist/prosthetist, public health officials, nutritionists, laboratorians, radiographers, athletic trainers, physical and occupational therapist, and those in the dental field.
whom 13 were trained as MD/PA, 12 as nurses, 4 had no medical training, and 2 were trained as AHP. Of the 31 respondents who reported having diarrhea, 27 (87%) had mild-to-moderate diarrhea (3–12 stools/24 hours) and 4 (13%) had severe diarrhea (≥12 stools/24 hours). One person with severe diarrhea was diagnosed with cholera by serologic testing. Among those with diarrhea, 17 (55%) took antibiotics, 4 (13%) sought medical care, 2 (6%) received intravenous fluids, and 1 (3%) was medically evacuated. Overall, 311 respondents (82%) reported always washing their hands after patient care activities. Among those who did not always wash their hands (n = 59), 51% reported a lack of hand-washing supplies as the primary
57
Diarrhea in HCW During the Haiti Cholera Epidemic
reason (Table 1). While most respondents reported drinking water and eating food from what would be considered safe sources, 1% of respondents consumed untreated water and 2% ate street-vended foods (Table 1). Before traveling, 90% of respondents obtained information about how to stay healthy in Haiti, and 64% reported visiting a healthcare provider in preparation for their trip (Table 1). HCW who developed diarrheal illness were more likely to report not always washing their hands (32% vs 17%, p = 0.05) as compared with those who did not develop diarrheal illness; however, those who developed diarrheal illness were not more likely to have any particular medical background (nurses: 39% vs 40%, p = 1.00; MD/PA: 42% vs 32%, p = 0.32; AHP: 7% vs 13%, p = 0.40; no formal medical training: 13% vs. 13%, p = 1.00; student: 0% vs 2%, p = 1.00), consume untreated drinking water (0 vs 1%, p = 1.00) or street-vended foods (3% vs 4%, p = 1.00), or have obtained pre-travel health information (61% vs 64%, p = 0.70) or visited a healthcare provider before traveling (94% vs 90%, p = 0.75) (data not shown). Discussion Many US residents responded to the medical needs of the Haitian population during the Haiti cholera epidemic. Some HCW who provided medical services during this time became ill with diarrhea, and one HCW had serologically confirmed cholera. Our survey found lower rates of diarrheal illness as compared with previous studies examining diarrhea in travelers.7 – 10 We suspect this is in part due to lower consumption of risky food and water which could be attributed to heightened food safety and hygiene precautions during the cholera epidemic and less recall of diarrheal illness due to time elapsed between travel and the administration of our survey. Our survey was subject to response bias as it is impossible to determine whether significant differences exist between those who completed the survey and those who did not. Cholera and other diarrheal illnesses are largely preventable through consuming safe foods and beverages and practicing recommended hygiene and sanitation practices.11 Cholera is not typically transmitted through person-to-person contact.11 Our survey found that many US HCW took precautions to protect themselves against cholera. It also suggested that many survey respondents lacked experience working in an international, emergency epidemic situation such as the one in Haiti, and had little experience treating cholera patients. This, along with inadequate handwashing supplies, may have led to diarrheal illnesses experienced by some HCW. To protect HCW from becoming ill during future emergency response efforts, it will be important
to ensure adequate hygiene supplies. Those with limited experience working in international, public health emergency situations or working with unfamiliar diseases should consider participating in additional preparatory activities, such as on-line training or short, topic-specific courses. Importantly, NGOs responding to international emergencies should ensure ample access to basic hygiene supplies and should promote their use to reduce the incidence of diarrheal illness among HCW working in Haiti. Declaration of Interests The authors state they have no conflicts of interest to declare. References 1. Centers for Disease Control and Prevention. Cholera outbreak—Haiti, 2010. Morb Mortal Wkly Rep 2010; 59:1411. 2. Ministry of Public Health and Population. Rapport du 20 Octobre 2012. Port-au-Prince, Haiti; October 2012. Available at: http://mspp.gouv.ht/newsite/docu mentation.php. (Accessed 2012 Nov 17) 3. Cliff J, Zinkin P, Martelli A. A hospital outbreak of cholera in Maputo, Mozambique. Trans R Soc Trop Med Hyg 1986; 80:473–476. 4. Oladele D, Oyedeji K, Niemogha M, et al. An assessment of the emergency response among health workers involved in the 2010 cholera outbreak in northern Nigeria. J Infect Public Health 2012; 5:346–353. 5. Haus-Cheymol R, Theodose R, Quilici M, et al. A cluster of acute diarrhea suspected to be cholera in French travelers in Haiti, December 2010. J Travel Med 2012; 19:189–191. 6. Malangu N, Legothoane A. Analysis of occupational infections among health care workers in Limpopo Province of South Africa. Glob J Health Sci 2013; 5:44–51. 7. Castelli F, Pezzoli C, Tomasoni L. Epidmiology of travelers’ diarrhea. J Travel Med 2001; 8:S26–S30. 8. Hill D. Occurrence and self-treatment of diarrhea in a large cohort of Americans traveling to developing countries. Am J Trop Med Hyg 2000; 62:585–589. 9. von Sonnenburg F, Tornieporth N, Waiyaki P, et al. Risk and aetiology of diarrhoea at various tourist destinations. Lancet 2000; 356:133–134. 10. Steffen R, van def Linde F, Gyr K, Sch¨ar M. Epidemiology of diarrhea in travelers. JAMA 1983; 249:1176–1180. 11. Centers for Disease Control and Prevention. Cholera prevention and control. Atlanta, GA; 21 May 2010. Available at: http://www.cdc.gov/cholera/prevention. html. (Accessed 2012 Jun 27)
J Travel Med 2014; 21: 55–57
