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01/19/13 - NBCNews.com (blog) - After a century without the disease, Cuba fights to contain cholera

Roberto Leon

Arismael Nieto's job is to pour a diluted bleach solution over the hands
of every commuter at this Havana bus station, and make sure everyone steps
on a cloth soaked with the solution to clean the bottom of their shoes.

Camilo, my 7-year old grandson in Cuba, has never been shy about asking
for presents - especially when he knows I'm heading to Havana from that
big shopping mall 90 miles away. His usual list includes a massive bag of
M&M peanut candy, additions to what's become a pretty pricey collection of
Schleich resin animals, and goofy gags second-grade boys find funny, such
as hand buzzers or that classic snake-in-a-can. When Camilo got on the
phone with me last weekend, he only rattled off one item.

"Aba," (that's what he calls me-short for "abuela", which is "grandma" in
Spanish), "bring me soap."

"Soap? You want soap?" I repeated, convinced I must have heard him wrong.

"Si", he insisted. "Jabon!"

Now he has me worried that I need to make an emergency supply-run for
detergent, shampoo, dishwashing soap and other basics. The last time soap
was in short supply in Cuba was in the 1990s but, if this kid is asking
for soap, the situation must be dire. He's about as germaphobe as your
average stray puppy. Like a lot of little boys, he needs to be reminded
that taking a shower means actually standing under the water.

Camilo, however, didn't want just any soap. He was looking for what he
calls "the soap that melts." He wanted me to bring him an alcohol-based
instant hand sanitizer.

Then he made it clear why. "Aba, there's cholera here," he said.

As it turns out, Camilo had spilled the beans a full 72 hours before the
Cuban Health Ministry issued a formal communiqué on what had been rumored
since the start of the year -- cholera had surfaced in the city of Havana,
home to 2.2 million people.

The announcement explained that 51 new cases of cholera had been diagnosed
in the Cuban capital along with a spike in the number of people suffering
from "diarrheal diseases." The ministry made no mention of any fatalities.
The public was being advised to be more careful with personal hygiene,
boil all drinking water or use purification drops and thoroughly wash all
fruits and vegetables, but to stay assured that Cuba's massive public
health machine was implementing preventive measures meant to "contain" and
"eradicate" the disease.

According to the [1]Centers for Disease Control and Prevention website,
cholera is a bacterial infection in the intestine that can range from mild
to severe. In the latter case, an infected person will experience
"dehydration and shock" that, if left untreated, can lead to death "within
hours." The CDC estimates that every year there are up to 5 million cases
and more than 100,000 deaths from cholera worldwide.

In most cases, the disease takes about a week to run its course, and
during that time, warns the CDC, cholera is highly contagious. Spread hand
to mouth, the bacteria is usually found in water or food sources
contaminated by an infected person's feces.

Contamination
A single food vendor at a baseball game appears to be the cause of the
Havana outbreak. In early January, apparently, contaminated sandwiches or
soda were sold during a packed game in the city's main sports arena, the
Latin American Stadium, located in a neighborhood called Cerro.

"That's why people from different parts of the city tested positive for
cholera at the same time," said a medical source, not authorized to speak
on the record but who claims to have first-hand knowledge of the findings
from the epidemiological task force assigned to trace the origins of the
outbreak.

[2][IMG]

Roberto Leon

Officials from Cuba's Health and Epidemiology department inspected this
pizza parlor located not too far from where the outbreak started in Havana
and closed it down.

At Wednesday's nighttime game between Havana's beloved Industriales and
last year's national champs, Los Tigres de Ciego de Avila, hawkers should
have been making a killing on what had been one of the season's most
sought-after tickets. Instead, 80 percent of the seats remained empty.
Those die-hard fans who did show up were not allowed into the stadium
until they sterilized their shoes and hands. Benches were wiped down with
a disinfectant, and the floors hosed down with the same 0.5 percent bleach
solution. And there was nothing to munch on during the
three-and-a-half-hour game. All food stands have been temporarily shut
down.

The same goes for many mom-and-pop cafeterias across the capital. "Last
week, officials from Health and Epidemiology inspected our place and then
they closed us down," said one owner of a pizza parlor not too far from
where the outbreak started. "They said it's to stop the spread of cholera
but no one's saying how long we have to stay closed." His only consolation
is that this month he doesn't have to pay taxes or his monthly licensing
fee.

Upset about his loss of income, he is also irked by the fact that some
state-run food establishments passed the inspections, so they are being
allowed to stay open. Many though are only authorized to sell bottled
water, canned drinks and commercially packaged food.

Arismael Nieto usually changes the light bulbs and fixes broken chairs at
Havana's Bus Terminal. For the last two weeks, he's been drafted on the
city's anti-cholera campaign. He stands by the one door opened at the
station and his job is to pour a diluted bleach solution over the hands of
every commuter, and make sure everyone steps on a cloth soaked with the
solution to clean the bottom of their shoes. No one gets on a bus or
leaves the building without Nieto's OK.

Now, picture this procedure happening at every school from kindergarten to
college, every public building, factory, lunch room, hospital, health
clinic, department store, train depot and movie theater.

Chlorine a "necessary inconvenience"
Over the summer, two people who live in the Havana neighborhood of
Fontanar thought they had the flu but tested positive for cholera. It was
believed that they were exposed on the bus ride from eastern Cuba, an area
of the country that had an outbreak earlier last year. In late August,
Cuba revealed that cholera had killed three people and infected 417 in
Granma province, some 450 miles east of Havana.

[3][IMG]

Roberto Leon

Signs such as this one are posted everywhere in Havana, alerting people to
go to the hospital as soon as they experience any of the symptoms of
cholera.

Cuba's cholera treatment protocol has doctors knocking on doors and
testing anyone with possible cholera symptoms. A positive test means an
automatic trip to one of the city hospitals for a more comprehensive test.
While most suspected cases go to Havana's Tropical Medicine Institute,
known by its initials IPK, a pediatric hospital and a maternity hospital
have also been designated to admit cholera cases. In addition, the
protocol mandated that all of Havana's 85 neighborhood health clinics set
aside a room with ventilation and a closed door as a place to quarantine
suspected cholera cases until an ambulance arrives to transport the
patient to the hospital.

Once hospitalized, a comprehensive history is taken that focuses on
identifying all the people the patient has come in contact with over the
past weeks. Health workers are dispatched to locate those persons to test
them for cholera and administer a free prophylactic dose of doxycycline.

Although none of the guidelines cited by the CDC recommend using
antibiotics for cholera prevention, the Cuban Health Ministry believes
otherwise. Hundreds of thousands of Doxycycline tablets, apparently
readied in warehouses for just such an emergency, were distributed to
hospitals and health clinics one morning earlier this week-another sign
that Cuba is well-prepared to tackle this outbreak.

Are people complaining? You bet. They hate the chlorine smell. They say
the solution stings but many would agree with Angela Linares, a nurse
raising a 13-year old daughter alone, who said: "It's a necessary
inconvenience."

"No one wants cholera, especially since we know so little about this
disease," she said.

Linares was right. Until last year, the last reported cholera outbreak in
Cuba was recorded almost a century ago.

Upon learning this fact, I became even more baffled that my 7-year-old
grandson mentioned cholera days before the government admitted the
outbreak.

As it turns out, his primary school had been put on alert early last week,
and the kids learned about the intestinal bug and prevention at a school
assembly. Community physicians were dispatched to all of the city's 650
schools to not only give a crash course on cholera but hand out soap to
every classroom.

Still, it wasn't until after the Health Ministry's warning that Cuban
state media began running public service announcements -- considerably
behind the curve of Havana's second graders.

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