Medical Director Musings: Water Contamination

Diseases from contaminated water kill more people every year than all forms of violence, including war ( of those deaths are children under five years old.
Haiti is the poorest country in the western hemisphere. Subsequently, they have many problems with infectious disease and especially with waterborne disease. In 2011 alone, 6,000 people died in Haiti due to waterborne disease.  Haiti has the lowest improved water and sanitation coverage in the Western Hemisphere by a significant margin and is currently suffering from the largest cholera epidemic on record. One tenth of the disease in the world could be prevented by improving the hygiene, sanitation, and management of water. Only one tenth of Haitians have appropriate toilet facilities and this lack of sewage systems in Haiti means that much of the water problems are caused by human waste contaminating water that Haitians use to cook, clean, and drink. One of the biggest problems is that children don’t properly wash their hands or don’t wash them at all.  Many children also don’t know what water is safe to drink in Haiti and what water isn’t.  Because of this, of the 3.5 million deaths worldwide that occur each year from waterborne diseases, like Cholera, 80% are children.  Five thousand of the six thousand deaths from waterborne disease in Haiti in 2011 were due to an outbreak of the infectious disease Cholera.  This is where the population’s inadequate education on self-hygiene becomes most dangerous.  Because there is a ratio of only 1 doctor to every 11,000 people in Haiti, educating Haitians on how to prevent outbreaks like this is the only simple and cost-effective way of preventing outbreaks of water borne disease. Of course all the education in the world is worthless if there is not clean water available for drinking cooking and cleaning.
Most waterborne illnesses cause common symptoms making them clinically difficult to differentiate. There is usually abdominal discomfort or cramping, fever, vomiting and diarrhea. Loss of weight and fatigue may accompany several of the viral illnesses.
Cholera is an infection of the small intestine by some strains of the bacterium Vibrio cholerae. It is the most deadly waterborne disease in Haiti. Because death can occur a few hours after the disease has been contracted, 50% of people who have a severe case will die.  If treated right away, only 1% of people will die from it.  Unfortunately, Haitians usually do not have access to immediate treatment for this disease, which is one reason why it is such a big problem in Haiti. The major transmission is through poor sanitation of water and food by a fecal oral route (meaning water or food is contaminated with infected feces.) Symptoms may range from none, to mild, to severe. The classic symptom is large amounts of watery diarrhea that lasts a few days. Vomiting and muscle cramps may also occur. Diarrhea can be so severe that it leads within hours to severe dehydration and electrolyte imbalance. This may result in sunken eyes, cold skin, decreased skin elasticity, and wrinkling of the hands and feet. Dehydration can cause the skin to turn bluish. Symptoms start two hours to five days after exposure. In 2018 there were 3,786 suspected cases and 41 deaths from cholera in Haiti. This represents a 73% decrease from the year prior and thought to be due to improved surveillance and treatment. Prevention through clean water and avoidance of contaminated food remain the best approach. (It should be noted that cholera was not known in Haiti until the earthquake of 2010. It is thought that the vibrio bacteria might have been brought to Haiti by NGO health workers from Nepal where vibrio is epidemic.)
Typhoid fever is a bacterial disease caused by a specific type of Salmonella and spread through contact with food or water contaminated by fecal matter or sewage. Affected individuals exhibit sustained high fevers and if left untreated, mortality rates can reach 20%. These organisms are shed in both the urine and stool of infected individuals thus when I saw Haitian men pull down their pants and urinate against a wall some of them are contaminating the area with Salmonella typhi. There is both an oral and injectable vaccine but these are only about 50% effective. There are no good data on the incidence of Typhoid in Haiti as most victims never present to a clinic. The most famous typhoid carrier (a person who was exposed to Salmonella typhi but did not contract the disease and who can pass the disease on to others) was Typhoid Mary an early 20th century Irish American cook who transmitted typhoid to innumerable people including 50 who died.
Hepatitis A is a viral disease that interferes with the functioning of the liver. It is spread through consumption of food or water contaminated with fecal matter, principally in areas of poor sanitation. Victims exhibit fever, jaundice, and diarrhea. 15% of victims will experience prolonged symptoms over 6-9 months. A vaccine is available.
Amoebic dysentery is caused by the parasite known as Entamoeba histolitica and it can cause abdominal pain, vomiting and bloody diarrhea. Because the disease can be mild and chronic it can be very difficult to diagnose causing chronic symptoms. It is known to be the third leading cause of death among intestinal infections worldwide. There is effective antibiotic treatment.
Escheria coli enteritis is an abdominal infection caused by the E coli bacteria which is normally found in the gut of healthy people. It is an intestinal disease spread by fecal oral contact and is caused by the ingestion of infested water and poorly cooked beef. Clinical course is self-limiting however infection with the enteroinvasive strains can cause life threatening disease. Most of us in America remember the Jack in the Box scare many years ago which caused many illnesses and deaths due to poorly cooked and infested hamburgers.
Leptospirosis is a bacterial disease that affects animals and humans. Infection occurs through contact with water, food, or soil contaminated by animal urine. Unlike those above, this infection is spread by contact with the skin and the virus will find any microscopic opening in the skin to gain access to the victim. Symptoms include high fever, severe headache, vomiting, jaundice, and diarrhea and untreated, the disease can result in kidney damage, liver failure, meningitis, and respiratory distress. While in Puero Rico after Hurricane Maria we encountered a family whose patriarch died from Leptospirosis after walking in muddy fields. Leptospirosis is known to be endemic in Haiti. The Haitian System of Sanitary Information reported between 6,500 and 11,000 cases of leptospirosis annually between 2005 and 2008. Lesson – Don’t walk barefoot!
Intestinal parasites infect more than a third of the global population. The highest infection rates occur amongst school aged children. The transmission typically occurs through soil, vegetation, food and water contaminated by parasite eggs. The life cycle generally involves ingestion of eggs or spores, hatching of the eggs in the gut followed by the excretion of eggs in the feces with repeating cycle. The most common soil transmitted helminthes in Haiti are Ascaris lumbricoides, Trichuris trichiura (whipworm) and Necator americanus (hookworm). Infection with these organisms results in malnutrition and impaired growth.
In summary, there are multiple organisms which can cause severe waterborne illness. The path to infection can include drinking contaminated water but can also occur from cleaning and bathing in contaminated water as well as walking barefoot through muddy fields. While there are some medications for some of these diseases, they remain a treatment of last resort. Rather, the treatment should be prevention by the safe use of clean water for drinking, cooking, and cleaning.
Unfortunately, in Haiti, and especially on the remote island of Gonave, there is scant fresh and clean water. This is why GR3 has partnered with our friends from SOS (Sustainable Ocean Systems) on a project to provide fresh water to the people of Gonave. This is an incredible project involving not only GR3 and SOS but also the local island government, the central government of Haiti, international financiers and many others. Once we are successful on Gonave, we hope to provide clean water to all of Haiti. ‘
As always, I hope that you will post comments and questions.
See you in a couple weeks

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