W_
executive committee of worMng party of
the directing council the regional committee
PANAMERICAN
WORLD
HEALTH
HEALTH
ORGANIZATION
ORGANIZATION
107th Meeting Washington, D.C.
June 1991
Provisional Agenda Item 7.1 CE107/25 (Eng.) 21 June 1991 ORIGINAL: ENGLISH
CHOLERA IN THE AMERICAS
For the first time in nearly a century, epidemic cholera struck the Americas in January 1991. During the past five months, over 220,000 cases occurred in Peru, Ecuador and Colombia, with
additional cases in Chile, Brazil and the United States of
America. Other countries can be expected to experience epidemics
in future months and years, and cholera may become endemic in some areas of the Region. Therefore, it is essential that all countries be prepared for the possible introduction of cholera with the development of national plans for cholera control. National plans
should include elements of surveillance, crisis management,
financial planning, case management, epidemiological investigation, environmental sanitation, food safety, health education, laboratory
studies, and information management. PAH0 should support the
development and implementation of national plans, develop a
Regional plan and identify potential external resources for
national and regional prevention and control efforts. The sharing of resources and information about cholera will greatly facilitate control of the disease in the Region. Ultimately, significant resources will have to be provided by the countries and obtained from international donors in order to correct deficiencies in the health and environmental infrastructures that have contributed to
the spread of cholera.
Members of the Executive Committee are asked to review this
document for the purposes of discussion and to decide on policy
suggestions for the Directing Council and guidance for the
CE107/25 (Eng.) C01qTENTS
Page
I. Historical Background ... 1
II. Eptdemiologtcal Situation ... 1
III. Response of the Pan American Health Organization ... 3
CE107/25 (Eng.)
CHOLERA IN THE AMERICAS
I. HISTORICAL BACKGROUND
Most countries of the Americas were affected by the second through
the fifth pandemics of cholera that spread widely between the 1830s and
the 1890s. Fortunately, the Americas were free of epidemic cholera for the first 90 years of this century, which has been attributed, at least in part, to the installation of water treatment in virtually all major cities of the Americas beginning at the turn of the century. Water filtration was widespread by 1870 and chlorination by 1910. The Americas succeeded in being the only region free of cholera during the first 30 years of the seventh pandemic, which began in Indonesia in 1961 and reached much of the world during its first 10 years, including West Africa in 1970. Cholera spread rapidly through Africa from 1970 to 1973 and has remained endemic in several countries since then. Epidemics also occurred in Italy, Portugal and Spain in the 1970's, but cholera was eliminated from these countries after appropriate control measures were implemented. Imported cases were reported by Canada and the United States of America, and since 1973, the United States has also reported occasional autochthonous cases related to the consumption of poorly -cooked seafood caught along the Gulf coast. However, the strains of Vibrio cholerae serogroup O1 isolated from autochthonous cases in the United States were distinct from the pandemic biotype, V. cholerae E1 Tot.
II. EPIDEMIOLOGICAL SITUATION
A. Peru
The first cases of cholera in Peru were reported on 23 January in Chancay, on the coast near Lima, and almost simultaneously in Chimbote, a major port 400 km to the north. V. cholerae, serogroup 01, biotype E1 Tot, serotype Inaba, was isolated and identified by the National Institute of Health in Peru and subsequently confirmed by the U.S. Centers for Disease Control. Over the next week, cases were reported in Lima, Piura
CE107/25 (Eng.) Page 2
management of diarrhea patients through continuous training activities. However, the case-fatality ratio has exceeded 2_ in several interior departments where educational campaigns have been less effective and health care is less readily available (Figures 3 and 4).
Epidemiological investigations in Peru have revealed several mechanisms which are responsible for the spread of cholera. The major
risk factor in the cities has been drinking untreated or unboiled water.
Environmental studies in the earlier stages of the epidemic found high
levels of fecal coliforms and no residual chlorine in several municipal
water systems. Vibrio cholerae was isolated from at least three water
systems, as well as from multiple environmental samples, including river
and coastal waters. Other risk factors include consumption of food and
beverages, especially ice, from street vendors, eating food left for more
than three hours without refrigeration and without reheating, and placing
hands directly into drinking water stored in household containers.
Additional factors considered important in Peru have been raw seafood
consumption, principally as ceviche, and the discharge of untreated waste into rivers and the ocean.
B. Ecuador
The first case of cholera in Ecuador was reported on i March,
approximately one month after the epidemic's onset in Peru, and occurred
in E1 Oro Province among a group of shrimp fishermen who worked in
Peruvian waters. The community probably spread its infection through a
well which was contaminated by a septic tank that overflowed at high tide. Since then, cholera has reached 19 provinces of Ecuador with 20,188 cases and 343 deaths (Table 2). The highest attack rates have been along the coast. While the incidence of cases nationally appears to be reaching a plateau (Figure 5), some areas continue to experience
increased numbers of cases.
C. Colombia
Colombia reported its first case on 10 March, when an adult male living on the Mira River 20 km south of Tumaco, in Narino Province (located on the Pacific coast at the border with Ecuador), was confirmed to have V. cholerae infection. He had no history of travel or apparent connection with Ecuador or Peru. Subsequent cases were reported on and after 26 March from Tumaco and Salahonda. Since then, the infection has spread to five other provinces: Cauca and Valle on the coast and Meta, Amazonas and guaviare in the interior. However, over ?0_ of the 1,780 probable cases reported by 31 May had occurred in Narino Province (Figure 6), while only eight cases were identified in the interior provinces. Colombia has had 28 deaths from cholera (Table 3).
D. Brazil
CE107/25 (Eng.)
Page 3
Benjamin Constant); six of these cases were imported (Table 4). The most
recent case in this area occurred on 28 May. Two additional cases were identified in Pontes-e-Lacerda in Mato Grosso State, but any association with the other cases is unclear.
E. Chile
Chile reported its first case on 12 April in an adult male living in the metropolitan area of Santiago. Since then, Chile has confirmed 40 cases and one death, all in persons 10 years of age and older (Figure 7). Ail but six cases were in the Santiago area, and 35 cases occurred in April (Figure 8). The last case occurred on 27 May (Figure 9). The most
important risk factor has been the consumption of raw vegetables (Figure 10). Measures to restrict the distribution of vegetables irri-gated with sewage-contaminated water have been implemented to control the
cholera epidemic in Chile.
F. United States of America
The first case of cholera in the United States in 1991 occurred on 9 April in an individual who attended a medical conference in Lima. Sub -sequently, 13 additional cases have been confirmed in the United States, one in a person who travelled to South America and 12 in persons who ate meat from two different crabs brought in noncommercially by travelers returning from Ecuador. There has been no evidence of subsequent spread
in the United States.
III. RESPONSE OF THE PAN AMERICAN HEALTH ORGANIZATION
A. Overall Response
When cholera cases were first detected, the PAHO/WHO Representative (PWR) Office in Peru and the Pan American Center for Sanitary Engineering and Environmental Sciences (CEPIS), located in Lima, immediately became involved in assisting Peru confront the epidemic. At PAHO Headquarters, a Cholera Task Force was formed to coordinate the international response, identify human and financial resources to address the emergency and provide essential information to Member Countries and other agencies. The Task Force, which meets several times each week, includes represent-atives from the PAHO Programs dealing with diarrheal diseases, laboratory, emergency preparedness and disaster relief, information, communicable diseases, environmental sanitation, food safety, research, and
eptdem-iology. The focal point is the Health Situation and Trend Assessment
Program.
One of the first concerns of the Organization was to assure that Peru had the means to provide the necessary medical attention for cholera cases. Shipments of additional oral rehydration salts (ORS), intravenous
CE107
/
25
(Eng
.
)
P
age
4
r
e
qu
e
s
t
f
o
r
U
S
$
3
.
8
4
m
ill
i
on,
which
was
pr
e
pared
b
y
the
P
e
ruvian
Hinist
r
y
o
f
Heal
t
h.
PAH0 has
processed
$2.09
million
in
external
assistance
t
o
Peru,
of which
about
half
ha
s
been
for
medical
supplies
and
OR
S
.
Another
i
mm
edi
a
te
concern
w
a
s
the
ec
o
nomic
i
m
p
a
ct
of
the
initial
restric
t
ions
pl
a
ced
on
t
he
imp
o
rtation
of
Peruvi
a
n
products
by
s
o
me
Governments.
A speci
a
l
effort
was m
a
de
t
o
provide
inf
o
r
ma
tion
a
bout
the
l
o
w
level
o
f
risk
a
nd
t
o
cl
a
rify
the
situation,
in
o
rder
to
avoid
o
r
r
e
mov
e
restrictive
p
o
licie
s
and
am
e
liorat
e
t
h
e
ir
impa
c
t.
PAIt0
ha
s
c
o
nt
i
nu
e
d
t
o
ad
v
i
s
e
aga
in
s
t
r
es
t
ric
t
i
on
s
o
n
i
mpor
ted
pro
du
c
ts
as
ot
he
r
c
o
untrie
s
ha
ve
bec
om
e
infe
c
te
d
.
As
e
ff
o
r
t
s
to
c
o
ntr
o
l
th
e
ep
id
em
ic
br
oade
n
e
d
,
app
r
o
xim
ate
ly
$1 milli
o
n
o
f
ext
e
rnal
funds
has
been
us
ed
f
or
envir
o
nmental
s
a
nit
a
ti
o
n,
health
educa
t
ion,
l
a
bor
ato
ry
su
ppo
rt
and
related
int
e
rventions.
T
he
PWR
Office
has
been
extremely
a
c
t
ive
in
su
ppo
rting
the
loc
a
l
p
urchase
and
dis
t
ribu
t
i
o
n
of
su
pp
lies
and
ac
q
uiring
needed
technic
a
l
ex
p
ertise.
All
PAH0
o
ffices
h
a
ve
been
involved
in
dissemin
a
ti
o
n
of
he
a
l
t
h
inform
a
ti
o
n
t
hr
o
ugh
television
and
news
p
a
p
ers,
includi
n
g
sp
ecial
su
pp
le
m
en
t
s
on
choler
a
p
reven
t
ion.
It
should
be
mentioned
t
h
at
c
o
nsiderable
assistance,
bo
t
h
in
m
at
eri
a
l
a
nd
p
ersonnel,
has
been
p
rovided
t
o
Peru
by
other
Hember
Co
u
ntries,
and
PAH0
has
reg
a
rded
t
his
a
s
an
excellent
exa
mp
le
of
technic
a
l
c
oop
er
a
ti
o
n
a
nd
coll
a
b
o
ration.
Th
e
PWR Office
has
a
ctively
co
o
rdin
a
ted
much of
t
he
bil
a
ter
a
l
a
ssis
t
ance
t
o Peru.
In
t
he
o
t
her
L
a
tin
A
m
erican
c
o
untries
a
ffec
t
ed
by
cholera,
the
res
p
onse
of
t
he
PAH0
/
_t0
Offices
has
been
a
s
p
r
omp
t
a
nd
com
p
rehensive
a
s
in
Peru.
PAH0 e
p
ide
m
iol
o
gis
t
s
and
o
t
her
staff
have
been
inv
o
lved
in
field
inves
t
iga
t
ions
and
have
a
ssisted
the
g
o
vernment
s
to
institute
control
me
a
sures.
Headqu
a
r
t
ers-based
st
a
ff
h
a
ve
p
rovided
technic
a
l
a
ssistance
in
many
are
a
s,
including
case
man
a
gement,
environ
m
en
ta
l
s
a
ntit
a
tion,
f
oo
d
safety
and
o
thers.
B.
Emergency
Resp
onse
and Resource
Mobilization
C
r
isis
m
an
a
ge
m
ent
is
app
licable
t
o
large-scale
emergencies.
In
a
ddition
t
o
t
he
e
p
idemiologic
a
l
inf
o
rm
a
tion
p
rovid
e
d
by
PAH0
t
o
a
ll
member
coun
t
ries,
information
on emergency
health
needs
has
been
ch
a
nnel-led
regul
ar
ly
t
o
t
he
Office
of
the
Uni
t
ed
Na
t
ions
Dis
a
s
t
er
Relief
Coordi-nat
o
r
(UNDR0).
UNDR0's
situ
a
tio
n
re
po
rts
h
a
ve
been
distributed
worldwid
e
a
mong
U.N.
m
ember
countries
a
nd
have
been
an
effective
mechanism
for
securing
and
c
oo
rdina
t
ing
in
t
ern
at
i
o
n
a
l
a
ssis
t
ance.
Funds
were
al
s
o
s
o
ught
a
nd
ob
ta
ined
from
bilat
e
ral
and
multilateral
a
gencies,
including
the
Eur
op
ean
C
o
mmunity
and
the
G
o
vern
m
ents
of
Can
a
da,
Germany,
the
Netherland
s
,
the
Uni
t
ed
Kingd
o
m
and
Ireland.
A gran
t
for
$1 million
by
CE107/25 (Eng.) Page 5
d
The strengthening of national capacities in rapid resource
mobilization, intercountry and intersectoral cooperation, emergency
logistics and communication have been promoted by PAH0 as important
components of the emergency phase of the cholera prevention and control strategy in the Region. At the country level, health disaster coordi-nators have been deeply involved in the daily management of the emergency,
in cooperation with other agencies, such as the civil defence units, the Red Cross and various nongovernmental organizations.
C. Diarrheal Disease Control
Together with USAID and UNICEF, PAHO has assisted all Member
Countries with and without cholera to develop a highly effective
diarrheal disease control program. During the epidemic, support for this
program has continued, and PAHO has sought to strengthen the local
production of ORS. Emphasis also has been placed on appropriate case
management, including vigorous rehydration and the preferential use of
ORS rather than intravenous fluids whenever possible. Technical guide -lines for cholera case management have been produced and distributed for adaptation at country level. A training module on cholera, describing
the eptdemiological and clinical characteristics and laboratory and control procedures, was also prepared and distributed to all countries.
D. Epidemiolo_¥
Investigations to document the distribution of cholera and factors involved in its transmission were begun as soon as the first cases were
reported. Several of these studies were done by the Peruvian Field
Epidemiology Training Program. Because of the size of the epidemic, epidemiological assistance was requested from the Centers for Disease Control, and several other countries sent epidemiologists. Eventually, the investigations broadened to include environmental and food
contami-nation studies, also supported by expert consultants. As a result, a fairly complete picture of the epidemiology of cholera in Peru has been developed, allowing the implementation of specific control measures.
PAHO epidemiologists have provided technical assistance to Ecuador and Colombia and have been closely involved in several field investi-gations. In Chile, epidemiological information has permitted the
success-ful implementation of specific interventions. Investigations in Brazil
have defined the extent of disease, which up to this time has been
limited.
It has been important to provide information about cholera preven-tion and control to all countries, so that they could take measures to prepare for the possible introduction of cholera. Within days of the first reports from Peru, the draft lggl revision of the WHO Guidelines for Cholera Control was sent to all countries. The Guidelines were
C
E
107
/
25
(Eng.)
Pa
g
e
6
A
mee
ting
att
en
d
e
d
by
r
e
pr
e
s
en
tativ
e
s
fr
om
17
Lati
n
Am
e
rican
c
o
untri
e
s
was
held
at
the
end
o
f
April
t
o
review
ch
o
lera
preventi
o
n
and
c
o
ntr
o
l
measu
r
es
and
assist
t
he
c
o
untries
t
o
prepare
comprehensive
nati
o
nal
plans.
S
i
m
ilar
meetings
were
held
at
the
Caribbean
Epidemi
o
l
o
gy
Cente
r
for
the
English-speaking
Caribbean
c
o
un
t
ries
and
in
S
an
J
o
s_,
Cos
t
a
Rica,
f
o
r
Central
America
and
Panama.
All
c
o
unties
o
f
the
Regi
o
n
have
initiated
plans
f
o
r
ch
o
lera
su
r
veillance,
preventi
o
n
and
c
o
ntr
o
l,
and
many
have
actively
put
their
plans
int
o
effect.
E
.
Environ
mental
He
alth
Co
nsiderable
eff
o
rt
has
been
made t
o
identify
environmental
fact
o
rs
tha
t
have
cont
r
ibuted
t
o
the
spread
o
f
ch
o
lera
in
P
e
r
u
and,
p
ot
en
t
ially,
in
o
ther
c
o
untries.
Emergency
meas
u
res
have
been
implemented
t
o
improve
drinking
wa
t
e
r
quality
,
princip
a
lly
by
assuring
adequate
chl
o
rinati
o
n
where
piped-water
systems
exis
t
and
by pr
o
viding
practical
means
o
f
disin-fecti
o
n
where
syste
m
s
do n
o
t
exist
o
r
are
inadequate.
Emphasis
has
als
o
been
placed
o
n intensified
m
o
nit
o
ring
o
f
water
quantity
and
water
quality
c
o
ntrol.
Efforts
are
being
made
t
o
i
m
pr
o
ve
human
waste
disp
o
sal
in
c
o
mmunities
and h
o
spitals.
F.
F
ood Safety
The
majority
of
cholera
o
utbreaks
worldwide
have
been
ass
o
ciated
with
c
o
ntaminated
food
pr
o
ducts,
such
as
raw molluscan
shellfish
harvested
in
waters
contaminated
with
raw
o
r
p
oo
rly
treated
human
sewage.
There-f
o
re,
e
d
uca
t
i
o
n
a
l
campaign
s
have s
o
ugh
t
to
ins
t
ruct
pe
o
ple h
o
w
to
prepare
a
nd handle
f
oo
d
s
in
o
rder
t
o
av
o
id
c
o
ntaminati
on
with
and
t
r
ansmissi
o
n
o
f
V. ch
olerae.
The presence
o
f
ch
o
ler
a
in
o
ne
c
o
unt
r
y
has
o
ften
gener
a
ted
fear
in
o
ther
c
o
untries
,
which
have
s
o
metimes
attempted
t
o
prevent
the
intr
o
duc-ti
o
n
o
f
ch
o
lera
b
y
b
a
n
n
ing
imp
o
rts
fr
om
infected
c
o
untries.
H
o
wever
,
there
has
bee
n
n
o do
cu
m
ented
instance
o
f
the
intro
d
uction
o
f
ch
o
ler
a
f
rom
c
o
m
m
e
r
cial
f
o
od
pr
o
ducts
,
and
such
a
n
intr
od
ucti
o
n
is
unlikely
t
o
o
ccur.
S
ince
all
o
f
affected
c
o
untries
in
So
uth
A
m
erica
export
f
ood
pr
o
ducts
t
o
o
ther
c
o
untries
within
a
nd
o
utside
the
Regi
o
n
,
PAH
O
has
a
dvised
c
o
untries
o
f
the
li
m
ited
risk
ass
o
ciate
d
with
these
pr
o
ducts
and
sought
t
o
insure
that
thei
r
imp
o
rtati
o
n
is
n
o
t
u
nn
ecessarily
restricte
d
o
r
b
anned.
H
o
wever
,
a
few
c
o
untries
,
including
s
om
e
i
n
Latin
America
,
continue
t
o
res
t
rict
i
m
p
o
r
t
s
fr
om
c
o
un
t
ries
rep
o
rting
ch
o
lera.
G.
Lab
oratory
Th
e
a
b
ility
t
o isolat
e
and
c
onfirm V
. eholerae
is essential in all
CE107
/
25
(Eng
.
)
P
a
ge
7
H.
Vaccines
P
AH0 a
nd
WHO hav
e
rec
omm
e
n
de
d
t
hat
c
h
o
lera
v
a
c
c
i
n
e
sh
o
ul
d
n
o
t
be
used
f
o
r
c
o
ntr
o
l
o
f
epide
m
ics
because
t
h
e
existing
paren
t
eral
vaccine
has
limited
p
rotective
efficacy
and
d
o
es
not
p
revent
trans
m
issi
o
n
o
f
V
.
ch
olerae
.
New
ch
o
ler
a
v
a
ccines
hav
e
been
investigated
in
ot
h
e
r
Regi
o
ns
,
a
nd PAH0 conven
e
d
a meeting
of
ch
o
lera
vaccine
experts
o
n 2
6 a
nd
27 April
to
f
o
r
m
ulate
rec
o
mmendations
on th
e
approach
to
v
a
ccines
in
t
his
hemis
p
here
.
The
experts
reaffirmed
that
the
existing
paren
t
er
a
l
v
a
ccine
should
not
be
used
for
prev
e
ntion
o
r
c
o
ntrol
.
They
did
r
ec
o
mmend
t
h
a
t
s
t
udies
o
f
both
the
ora
l
whole
cell
,
B subuntt
killed
vaccine
a
nd
t
he
o
ral
live
at
t
enuated
vaccin
e
be
ini
t
ia
t
ed
in
several
La
t
in
Americ
a
n
countries
during
1991
and
t
hat
,
should
the
results
be pr
o
mising
,
larger-scale
field
trials
be
c
o
nduc
t
ed
in
1992
.
P
AH0
/
A
E
R
0
should
c
oor
dinate
th
e
se
studies
f
o
r
Member
Count
r
ies
,
in
conjucti
o
n
with
the
Diarrheal
D
i
sease
Co
ntr
o
l
Pr
o
gr
a
m
at
WHOHeadquart
e
rs
.
I
.
Information
The
demand
for
inf
o
rma
t
ion
on
ch
o
lera
f
r
om
the
public
,
the
p
ress
and
heal
t
h
communi
t
ies
has
g
ro
wn
exp
o
nentially
since
the
o
u
tbre
a
k
in
t
he
Americas
was
firs
t
repor
t
ed.
PAH0 has
t
a
ken
an
a
ctive
role
in
repondtng
to
inquiries
,
believing
it
essential
t
o
pr
ovide
inf
o
rm
a
ti
o
n
to
all
conce
r
ned
c
o
mmunities
and
that
a
full
understanding
of
the
situati
o
n
will
lead
t
o
more
r
a
ti
o
nal
and
effective
responses
.
Television
and
r
a
di
o
interviews
have
been
a
r
r
a
nged
,
and
mate
r
ials
describing
the
ch
o
ler
a
situati
o
n
,
history
,
environment
a
l
health
m
e
a
sures
,
epidemiol
o
gy
and
t
he
li
m
ited
risk
of
transmissi
o
n
thr
o
ugh
commercial
f
oo
d
p
ro
ducts
have
been
dis
t
ributed
widely
.
PAH0 h
a
s
p
rovided
full
sup
po
rt
to
c
o
untry-level
health
educati
o
n
efforts
,
sending
a vid
eo
and
p
hot
o
g
r
a
p
hy
crew
t
o
Peru
to
obtain
m
a
t
erials
for
educ
a
t
i
on
a
nd
informa
t
ion
campaigns.
PA
H
0 has
als
o
worked
cl
o
s
e
ly
wi
t
h
PW
R
Off
i
ces
to
disseminate
ra
p
idly
inf
o
rma
t
ion
o
n h
o
w
to
p
revent
cholera
,
es
p
eci
a
lly
t
o
those
a
t
highest
r
isk
of
inf
e
cti
o
n
.
Because
of
the
u
r
gent
need
t
o
inf
o
rm
p
e
op
le
in
all
sect
o
rs
,
sev
e
ral
elements
of
education
a
l
c
a
m
pa
igns
were
developed
simult
a
neously
,
whil
e
formulating
a
larger
,
long-
t
erm
project
and
seeking
funding
to
su
pp
ort
t
he
c
o
un
t
ries
in
their
eff
o
r
t
s
t
o
inform
and
educ
a
t
e
the
public
.
P
A
H0
has
already
developed
a
n
inf
o
rmation
kit
,
t
o
be
disse
m
in
a
ted
t
hr
o
ugh
P
UR
Offices
,
cont
a
ining
instructi
o
nal
manuals
o
n how t
o
o
rganize
a
nd
op
er
at
e
a public
health
information
campaign
;
vide
o
s
of
TV commercials
sup
p
orting
nation
a
l
cam
p
aigns
and
documen
t
aries
on
cholera
;
radi
o
s
p
o
t
s
;
m
aterials
f
o
r
press
releases
;
fac
t
sheets
on cholera
and
its
p
reven
t
ion
;
a
nd phot
o
graphs
a
nd drawings.
I
V
.
P
L
ANN
I
N
G
F
O
R
THE FUTU
R
E
F
o
r
p
lanning
and
oper
a
ti
o
n
a
l
p
u
rpo
ses
,
the
r
esponse
t
o
the
choler
a
epidemic
can
be
divided
int
o
emergency
and
l
o
ng-term
p
h
a
ses
.
The
emergency
p
h
a
se
will
include
th
o
se
me
a
sures
which
a
re
needed
t
o
c
o
ntrol
the
p
resent
e
p
idemic
,
reduce
the
i
m
m
edi
a
te
thre
a
t
of
future
e
p
idemics
a
nd
i
CE107
/
25
(
E
ng.)
P
a
ge
8
phase
is
d
irected
at
i
m
p
ro
ving
the
inf
r
as
tr
uc
t
u
r
e
of
health,
f
oo
d
safe
t
y
and
envir
o
nmental
services
s
o
that
the
threat
o
f
ch
o
lera
is
eliminated
f
ro
m
t
he
Regi
o
n
during
the
next
10 years.
A.
Em
er2enc¥ Phase
A Regi
o
nal
Plan
f
o
r
Cholera
P
r
eventi
o
n
and
C
o
ntr
o
l
has
been
devel-o
ped
as
the
basis
for
Regi
o
n
-
wide
activi
t
ies
du
r
ing
the
next
2 to
3 years,
which
will
c
o
m
p
l
e
m
e
nt
acti
o
n
s
taken
within
the
_emb
e
r G
0
unt
r
_e
s.
Th
e
Regional
Plan
has
three
gene
r
al
o
bjectives
:
i)
Reduce
the
risk
o
f
the
spread
of
chole
r
a;
ii
)
Reduce
morbidity
and mo
rt
ality
associa
t
ed
wi
t
h
chole
r
a;
and
iii)
Reduce
the
s
o
cial
and
economic
impact
of
cholera
.
There
are
five
components
o
f
the
plan
:
-
The
fi
r
st
c
o
mp
o
nent
is
support
o
f
nati
o
nal
plans
,
which
itself
includes
five
priori
t
y
areas
f
o
r
acti
o
n:
a)
nati
o
nal
cholera
commissi
o
ns
should
be
established
and
s
t
rengthen
e
d
t
o
c
oo
rdinate
devel
o
pment
and
implementa
t
i
o
n
of
nati
o
nal
plans
and
prepa
r
e
o
perational
pr
o
cedures
f
o
r
obtaining
and
distributing
materials
and supplies;
b)
active
surveil-lance
for
cholera
should
be
implemented
to
promptly
iden
t
ify
and
report
the
epidemi
o
logic
characteristics
o
f
any
cases
t
ha
t
occur;
c)
p
ro
per
case
management
should
be
taught
to health
care
providers
and sufficient
supplies
f
o
r
t
r
eatment
should
be
available
in
l
o
cal
health
systems;
d)
in
t
e
r
ven
t
i
o
ns
t
o
impr
o
ve
water
quality
and
f
oo
d
safe
t
y
and
t
o
disp
o
se
safely
o
f
human
waste
from
selected
l
o
cations
(e.g
.
,
h
o
spitals)
are
pri
o
rities,
with
emphasis
being
placed
o
n
r
apid,
practical
measures
in
the
emergency
phase;
and,
e)
community
pa
rt
icipati
o
n
must
be
strengthened
if
the
proposed
inte
r
ventions
are
to be
implemen
t
ed
succ
e
ssfully
.
- The
second
c
o
mp
o
nent
o
f
t
he
Regi
o
nal
Plan
is
the
dissemination
of
info
r
mation
ab
o
ut
effec
t
ive
preventi
o
n
and
con
t
r
o
l
m
easures,
financial
and
human
resources
,
laborat
or
y
procedures
,
and
o
the
r
matters
which
will
be
important
f
o
r
effective
acti
o
n
in
the
c
o
untries
and
regi
o
nally
.
- The
third
c
o
mponent
is
the
initia
t
i
o
n
and
supp
o
rt
of
r
esearch
on
o
ral
ch
o
lera
vaccines
(whole
ce11
/
B
subunit
and
live
-
a
t
tenuated),
evaluation
of
interventi
o
n
stra
t
egies
,
and
assessmen
t
of
r
apid
diagnos
t
ic
meth
o
ds
.
- The
f
o
urth
c
o
mponen
t
is
th
e
mo
bilizati
o
n
o
f
technical
and
financial
resources
t
o
complement
nati
o
nal
resources.
All
o
cation
o
f
r
es
o
urces
should
be
co
o
rdinated
between
g
o
vernments,
interna
t
i
o
nal
agencies,
universi
t
ies,
the
private
sector,
n
o
ng
o
vernmental
organizati
o
ns
and
o
the
r
expert
gr
o
ups
and
individuals
.
CE107/25 (Eng.) Page g
The objectives of emergency measures in the Member Countries are a) to limit the extent of the cholera epidemic and b) to reduce the im-pact from cholera where the disease is present. Measures to be instituted
or continued in the countries include the purchase and distribution of additional materials and supplies, enhanced surveillance, proper case management, improved food safety, health education, improved water
quality, monitoring of water quality and proper disposal of waste from selected locations (especially hospitals). Ail of these measures have been initiated by countries affected by cholera and have been included in national plans developed by other countries. The Organization has
estimated that $600 million will be needed to put the measures into effect in all countries and continue them during the emergency phase. Half of this amount will have to come from external sources, with the remainder being provided by the countries themselves.
B. Long-Term Interventions: Strategies for the lgg0s
The cholera epidemic is the most obvious and dramatic health
consequence of the economic crisis of the lg80s. More than $200 billion
has been transferred abroad since lg82 to pay the interest on private and
public debt. The resulting gap between existing resources and needs has
meant deteriorating capital stock in all sectors. Economies in the Region
have been stifled by the absence of capital for new investment in every
area of physical infrastructure. Studies undertaken by PAH0 and by the
Inter-American Development Bank (IDB) have shown a drastically reduced
level of investment in health, water and sanitation in contrast to the
level of need.
Beyond the emergency phase, a major investment program is needed
to respond to three critical gaps in environment and health in the
Americas:
- First, the repair and full protection of existing water and
sanitation systems. Currently, water systems barely reach 7g% of the
population in Latin America and the Caribbean, and sanitation systems
reach only 66% of the population. Many existing systems have not been
properly maintained or operated;
- Second, the extension of potable water, sewage treatment and garbage disposal systems to those without services.
- Third, the strengthening of national and local health systems
and the extension of the health services network, within the primary
health care strategy, to the 40_ of the Region's population which
continues to be without access to adequate care.
These actions are essential long-term steps to prevent the spread
of cholera and other diarrheal diseases as well as to reduce overall
morbidity and mortality in the Americas from diseases which are
prevent-able or readily treatable. Nearly 700,000 people die each year in the
Americas from those diseases. These objectives must be realized if the
health needs of the people of the Americas are to be met. They also
represent the bare minimum for fulfilling the goals set during the lg80s
CE107/25 (Eng.) Page l0
PAH0, the World Bank, IDB and USAID participated in an evaluation of the Decade and found that approximately one third of the needed
invest-ment in water and sanitation had been made during that period, half
of those funds coming from external sources. Thus, the countries were
$20 billion short of the original $30 billion investment target (expressed in 1980 US dollars).
The fact that barely 5_ of all municipal water systems in the Americas treat sewage before it is discharged into rivers, bays and ult i-mately the sea is another indicator of unmet need. The current PAH0 and World Bank estimate of the costs for investment in water and sanitation infrastructure in the Americas to make up the shortfall remaining from the 1980s and to cover anticipated population growth through the year 2000 is approximately $77 billion (in 1985 US dollars).
It is estimated now that about US$140 billion will be necessary to achieve the goals in regard to environmental health during the next 12 years.
With respect to the third element in the long-term strategy for responding to the cholera crisis, the provision of health services, the countries in Latin America and the Caribbean currently are expending approximately US$40-$45 billion per year for health. To extend basic services to those lacking them and to improve the utilization of the existing capacity will mean increasing the level of investments by $5-6 billion per year during the next decade. With utilization of the primary health care strategy and full implementation of SILOS, adequate access to
services would be achievable with the lower amount.
In summary, it is estimated that some $200 billion in investment over the next 12 years will be necessary to achieve the extension of health, water and sanitation services. Approximately 70% of the amount will be provided by the countries themselves, but 30% will be required
from external sources.
Achieving those flows of resources to health is clearly within the capacity of the countries and the international community. It will mean:
- First, directing 1.5 to 2.0% of GNP annually from the countries of the Region to capital investment in water and sanitation systems as well as in health infrastructure.
- Second, the allocation at least of 20% of the official, external bilateral and multilateral financial assistance to health, water and
environmental sanitation.
- Third, the use of debt swaps for increased investment in health, water and environmental sanitation.
CE107/25 (Eng.) Page 11
Figure 1
Cumulative Cases of C
h
olera in Peru, by Department
30 May 1991.
PIUJ
LAMBAYEQUE
ANCASH
LIMA-CALLAO
Not reported
...
< 1
0
.._
10 < 100
1O0< 1000
1000 <10,000
10,000+
Source:Figure
2
C
h
olera Cases an
d H
ospitalizations in Peru
b
y epi
d
e
m
iological
w
ee
k
, as of 10 June 1991.
Cases
14,000
12
,0
00
...
10
,
000
...
8
,000
6,0
00
"--
-
-4
,0
00
--2
,
0
00
0 __L__
L
__
--_
1 2
3
4
5
6
7
8
9
10 11 12 1
3 1
4 15 16
17
1
8
19 20
21 2
2 23 24
Epi
d
emiological Week
Hosp
i
t
a
l
i
za
ti
ons
_
C
a
ses
Source:
Ministry of
Health, Peru
3
Reported
Deaths From Cholera
in Peru
by epidemiological
week,
1991
Dea
t
hs
2
5
0
200
-150
100
5O
0
i
f
i -_ [[_
_i
_i
_i
J
,
i
i
2 3 4 5
0
7 8 9 I0 11 12 13 14 15 16 17 10 19 20 21 2223 24 25
epidemiological
week
Source: Ministry of Ilealth, Department of Epldemlology.Figure
4
Cholera E
p
idemic Case Fatality Rate in Peru,
by Department,
as of 10 June 1991.
I
f
C
u
sco
I
I
M
a
dre de D
ies
L
a
L
i
bert
a
d _
BB
Ay
ac
u
c
h
o
Pa
sco _
BB
[]
Lore
t
o
_
BB
Caja
m
a
rc
a
_
BB
Am
a
z
o
n
as
__
U
cayali
Sa
n
Martin
__
J
u
n
i
n __
P
u
n
o
__
H
u,
_n
uco
__
Ica
__
T
ac
n
a
__
Hua
n
ca
v
elica
_11
La
m
ba
y
eque
P
iu
r
a
mm
T
u
mbe
s
mm
Ar
eq
u
ipa
[]
A
ncash
L
i
_
m
a
_
Me
a
n
(1.
0
)
Callao
·
A
puri
m
ac I!
I I I I
0
5
10
15
2
0
De
a
th
s p
er
1
00 C
a
ses
Fi 5
Cholera. Cases in
E
cuador
by epldemlologlcal
week,
as of 23 May, 1991.
C
ases
35
00
3000
-2500
-2
00
0
-
1500-
1000-500
-0
8
9
10
11
12
13
14
15
16
1
7
18
19
20
21
E
pidemio
l
ogi
c
al
W
eeks
·
C
a
s
es
I
R
eg
r
e
ssi
on
l
i
ne
Source:
N
atio
n
al
D
epartment
of Epi
d
e
m
iology
Figure 6
