nej mp 1013771

7/25/2019 Nej Mp 1013771

1/3

n engl j med 364;1 nejm.org january 6, 2011

PERSPECTIVE

5

camps listed by the United Na-tions camp-management clusterreportedly have no water or sani-tation agency, and most are farfrom reaching the establishedguidelines for sanitation in hu-manitarian emergencies.3The liv-

ing conditions of most of Haitispoor, whether theyre living incamps or communities, are equal-ly miserable in terms of the riskof diarrheal disease.

The reported numbers of casesand deaths, though shocking, rep-resent only a fraction of the epi-demics true toll. We have seenscores of patients die at the gatesof the hospital or within minutesafter admission. Through our net-

work of community health work-ers, we have learned of hundredsof patients who died at home oren route to the hospital. In thefirst 48 hours, the case fatalityrate at our facilities was as highas 10%. Though it dropped to lessthan 2% in the ensuing days asthe health system was rein-forced locally and patients be-gan to present earlier in the

course of disease, mortality willmost likely climb as the diseasespreads and Haitis fragile healthsystem falters.

This most recent crisis in Haitihas reinforced certain lessonsregarding the provision of ser-

vices to the poor. Complemen-tary prevention and care shouldbe the primary focus of the re-lief effort. Vaccination must beconsidered as an adjunct for con-trolling the epidemic, and anti-biotics should be used in thetreatment of all hospitalized pa-tients. These endeavors shouldproceed in concert with much-needed improvements to sanita-tion and accessibility of potable

water. More generally, reliablepartnerships are essential, espe-cially if local partners are depend-able and have practical experi-ence and complementary assets.Long-term reinforcement of thepublic-sector health system is awise investment, permitting pro-vision of a basic minimum set ofservices that can be built upon intimes of crisis. And community

health workers who can be rap-idly mobilized as educators, dis-tributors of supplies, and firstresponders are a reliable back-bone of health care. In Haiti,such workers can bring the time-sensitive lifesaving therapy of

oral rehydration right to the pa-tients door.

Disclosure forms provided by the au-thors are available with the full tex t of thisarticle at NEJM.org.

From the Department of Global Health andSocial Medicine, Harvard Medical School;the Division of Global Health Equity,Brigham and Womens Hospital; and Part-ners in Health all in Boston.

This article (10.1056/NEJMp1012997) waspublished on December 9, 2010, at NEJM.org.

1. Sullivan CA, Meigh JR, Giacomello AM.The Water Poverty Index: development andapplication at the community scale. Nat Re-sour Forum 2003;27:189-99.2. Ministre de la Sant Publique et de laPopulation, Haiti. Enqute mortalit, mor-bidit et utilisation des services (EMMUS-IV): Haiti, 2005-2006. (ht tp://new.paho.org/hai/index.php?option=com_docman&task=doc_download&gid=25&Itemid=.)3. 101112 WASH Cluster situation report.November 12, 2010. (http://haiti.humanitarianresponse.info/Default.aspx?tabid=83.)Copyright 2010 Massachusetts Medical Society.

Responding to Cholera in Post-Earthquake Haiti

Antibiotics for Both Moderate and Severe CholeraEric J. Nelson, M.D., Ph.D., Danielle S. Nelson, M.D., M.P.H., Mohammed A. Salam, M.B., B.S., and David A. Sack, M.D.

Related article, p. 33

The 2010 Haitian cholera out-break has pressed local andinternational experts into rapidaction against a disease that is

new to many health care provid-ers in Haiti. The World HealthOrganization (WHO) has time-tested management protocols foremerging cholera outbreaks. Theseprotocols have been used by theHaitian government to fight anepidemic that is merely one ofseveral recent tragedies in Haiti.The use of these protocols has

allowed for a high standard ofcare in this complex and evolv-ing medical landscape. But where-as the current WHO cholera-

treatment protocol (www.who.int/mediacentre/factsheets/fs107/en/index.html) recommends anti-biotics for only severe cases, theapproach of the InternationalCentre for Diarrhoeal Disease Re-search, Bangladesh (ICDDR,B),recommends antibiotics for bothsevere and moderate cases.

Several antibiotics are effec-

tive in the treatment of cholera,including doxycycline, ciproflox-acin, and azithromycin, assumingthat the cholera strain is sensi-

tive. Currently, the epidemic strainin Haiti is susceptible to tetracy-cline (a proxy for doxycycline) andazithromycin but is resistant tonalidixic acid, sulfisoxazole, andtrimethoprimsulfamethoxazole.The WHO advocates giving anti-biotics to patients with choleraonly when their illness is judgedto be severe. This recommen-

The New England Journal of Medicine

Downloaded from nejm.org on May 27, 2013. For personal use only. No other uses without permission.

Copyright 2011 Massachusetts Medical Society. All rights reserved.

7/25/2019 Nej Mp 1013771

2/3

PERSPECTIVE


dation is interpreted to mean thatonly patients who present withsevere dehydration (10% de-hydration) should be given anti-biotics. By contrast, the ICDDR,Brecommends antibiotics for pa-tients with cholera who have se-

vere dehydration as well as forthose with some dehydration(5 to 10%) who continue to passlarge volumes of diarrheal stoolduring their treatment. Theserecommendations apply only topatients who have symptomstypical of cholera that is, lessthan 24 hours of acute waterydiarrhea with dehydration andusually vomiting. It is crucial intriage to rapidly assess dehydra-

tion, rule out alternative causesof diarrhea that are common inareas with poor sanitation andcoexisting infections, and rehy-drate aggressively according tothe WHO protocols.

With effective antibiotic thera-py, the purging rate is lessened byabout 50%, the illness is short-ened by about 50%, and the dura-tion of excretion of Vibrio choleraein the stool is shortened to 1 or2 days. Without effectiveantibi-otic therapy, patients continue toexcrete V. cholerae for 5 or moredays and shed for a longer periodat home.1-3If antibiotics are used,patients recover more quickly andrequire less rehydration fluid.Nursing care is lessened, and pa-tients are able to leave the treat-ment center earlier, as demon-strated in a study that showed

dramatic resolution of diarrhea at24 hours with azithromycin.1Thisapproach maximizes the effec-tiveness of limited resourceswhile optimizing patient care.

Regarding transmission, rice-water stools contain 1011to 1012V. choleraeorganisms per liter. Aninfectious dose is 105to 108or-

ganisms. These numbers mightexplain why 50% of householdcontacts of a patient who is theindex case in Bangladesh developdiarrhea about 2 days after theindex case occurs.4 Althoughsome of these household con-

tacts may have been infected fromthe same source as the index pa-tient, many others are likely to betrue secondary cases. Direct dataare not available to determinewhether household contacts areprotected when the index case istreated with antibiotics. However,given the liter volumes of diar-rhea, antibiotics will decreasecontamination in the household.

We do not, however, recom-

mend antibiotic prophylaxis forhousehold contacts because of theprogrammatic difficulty in re-stricting the use of such prophy-laxis only to those persons in theimmediate family who are athighest risk5 and because doingso would almost certainly driveantibiotic resistance. Since fami-lies of patients with cholera areat high risk for cholera them-selves, they need targeted educa-tion about safe water and sanita-tion, appropriate home use oforal rehydration solution, and in-formation about the availabilityof treatment facilities in case ill-ness does occur.

Some may argue that empha-sizing the importance of anti-biotic therapy may lead to themisguided belief that this is themost important component in

the overall management of pa-tients with cholera. With carefultraining in instituting appropri-ate and aggressive rehydrationfollowed by effective antibiotictherapy, this misunderstandingneed not occur.

A practical reason for hesitancyregarding administering antibiot-

ics to patients with cholera re-lates to the severe vomiting thatusually accompanies infection.Vomiting generally stops withina few hours after patients arerehydrated; thus, the administra-tion of the antibiotic should be

delayed until the patient is ableto take food and drink withoutvomiting. Doxycycline can be as-sociated with nausea and shouldbe taken with food and plenty offluids.

In summary, the use of anti-biotics is an urgent issue for allstakeholders, because effectiveantibiotic therapy shortens theduration of illness and reducesthe shedding of thousands of

infectious doses. Our goal is topromote more effective care forlarge numbers of patients withcholera while maximizing limitedresources to keep patients whoare discharged early from dying,reduce the number of repeat hos-pital admissions, and limit at-home shedding of V. cholerae. Toachieve these aims, we believethat patients with moderate andsevere cholera should be treatedwith antibiotics especially inHaiti, and especially now.

Disclosure forms provided by the authorsare available with the full text of this arti-cle at NEJM.org.

From the Lucile Packard Childrens Hospi-tal, Stanford University, Palo Alto, CA(E.J.N.); the Santa Clara Valley Medical Cen-ter, Milpitas, CA (D.S.N.); the InternationalCentre for Diarrhoeal Disease Research,Bangladesh, Dhaka, Bangladesh (M.A.S.);and the Johns Hopkins Bloomberg Schoolof Public Health, Baltimore, MD (D.A.S.).

This article (10.1056/NEJMp1013771) waspublished on December 9, 2010, at NEJM.org.

1. Saha D, Karim MM, Khan WA, Ahmed S,Salam MA, Bennish ML. Single-dose azithro-mycin for the treatment of cholera in adults.N Engl J Med 2006;354:2452-62.2. Lindenbaum J, Greenough WB, IslamMR. Antibiotic therapy of cholera. Bull WorldHealth Organ 1967;36:871-83.

Antibiotics for both Moderate and Severe Cholera




7/25/2019 Nej Mp 1013771

3/3


PERSPECTIVE

7

3. Rahaman MM, Majid MA, Alam A, IslamMR. Effects of doxycycline in actively purgingcholera patients: a double-blind clinicaltrial. Antimicrob Agents Chemother 1976;10:610-2.

4. Weil AA, Khan AI, Chowdhury F, et al.Clinical outcomes in household contacts ofpatients with cholera in Bangladesh. Clin In-fect Dis 2009;49:1473-9.5. Khan MU. Efficacy of short course antibi-

otic prophylaxis in controlling cholera in con-tacts during epidemic. J Trop Med Hyg 1982;85:27-9.Copyright 2010 Massachusetts Medical Society.

Antibiotics for both Moderate and Severe Cholera

Rethinking Safety-Net Access for the UninsuredMark A. Hall, J.D.

Now that health insurancereform has begun, safety-netprograms throughout the UnitedStates are struggling to adapttheir missions to suit the post-reform composition of the unin-sured population. Most such pro-grams are organized at the locallevel, with funding largely pre-

mised on their serving low-incomeuninsured residents. Examplesinclude well-structured compre-hensive care programs in somemajor cities, more than 1000limited-service free clinics, anddozens of volunteer physician-referral programs.

When the Affordable Care Act(ACA) is fully implemented, 8% ofthe U.S. population is projected toremain uninsured. Other thanundocumented immigrants, how-ever, most such people will beeligible for Medicaid or highlysubsidized private insurance andwill be subject to tax penalties ifthey dont obtain coverage. Sobeginning in 2014, most peoplewho are currently served by ac-cess programs for the uninsuredwill have insurance, be eligiblefor insurance, or be undocument-

ed immigrants.Some people will remain un-insured because their income istoo high for a subsidy but lowenough to make insurance unaf-fordable (costing more than 8%of their household income). Butsubsidies will be available to peo-ple with family incomes up to

400% of the federal poverty level,which currently calculates to$88,200 for a family of four well above the countrys medianhousehold income of about$50,000.

Access programs for the un-insured usually serve people withhousehold incomes below about

twice the federal poverty level.They may therefore be hardpressed to adapt their missionsto the new uninsured popula-tion in ways that will maintaintheir fragile support from fundersand volunteers. Since safety-netsystems are already on life sup-port,1 any major shock maythreaten their very existence.Therefore, access programs mustconsider carefully how best torefocus and justify their func-tion and mission.

First, health care reformschickens should not be counteduntil theyve hatched. Duringthe 3 years before full imple-mentation begins, constitutionalchallenges and conservative pol-iticians threaten to upend theACA.2Safety-net programs mustremain intact at least until re-

form takes effect and just incase it never does. Second, evenafter reform, the newly insuredwill face barriers to access aris-ing from provider shortages,transportation difficulties, andlanguage differences all ofwhich safety-net organizationscan help to overcome.

Third, the future uninsuredpopulation will probably deservemore safety-net support than onemight imagine. Some people willbe uninsured temporarily whentheir economic circumstanceschange. New workers may earnenough to lose their subsidy forindividual insurance but remain

ineligible for group insurance dur-ing the 3-month probationaryperiod that employers may im-pose. People without good jobswhose income increases justenough to nudge them over138% of the poverty level will bedisqualified from Medicaid andbe required to purchase subsi-dized private insurance. It maybe difficult to make this public-to-private transition smoothly.Medicaid enrollment can startinstantaneously, sometimes evenretroactively, but private coveragetypically begins on the first dayof the month after all formshave been completed and theinitial check has cleared.

If the experience in Massachu-setts is any guide, these wrin-kles will probably cause short-term coverage gaps for many

people (see table). Coverage dis-continuity will also occur withinhouseholds, when different fam-ily members qualify for coveragefrom different sources, depend-ing on their citizenship and em-ployment status. Safety-net pro-grams can therefore serve acritical function in maintaining




nej mp 1013771

Documents