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I. Context
of the Epidemic
II. About Ecuador
III. About Cholera
IV. Epidemiology of the Outbreak
V. Status of Efforts
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Case
Study:
Cholera Comes
to Guayaquil, Ecuador
Scenario Date: March, 1992
Class Scenario Instructions
I. Context of Epidemic
Before the outbreak began in January, 1991, it was commonly thought that
Cholera in Latin America was eradicated at the start of the 20th century.
However, by the beginning of this year (1992), over 400,000 cases had occurred
in Peru, Ecuador, and Colombia. In addition, there have been reports of
over 1,000 cases each in Brazil, Mexico, Guatemala, Bolivia, El Salvador,
and Panama. Cases have also been reported in the United States, Chile, Honduras,
Nicaragua, Venezuela, Costa Rica, Belize, French Guyana, and Argentina.
Cholera will certainly spread to other countries in the region, making it
endemic in the Americas. This outbreak in Latin America has been the largest
recorded in the history of cholera outbreaks.
The primary cause for the spread of cholera is inadequate (or nonexistent)
water and sanitation systems. PAHO (the Pan American Health Organization)
estimates that 95% of all waste water sewage in the Latin America region
is discharged, untreated, into rivers, streams, and other bodies of water.
Estimates for the construction and renovation of the existing sanitation
systems range from $80 billion (from the World Bank) to $200 billion (from
PAHO). Included in these estimates are the construction of new potable water
and sanitation systems for previously unserved populations. However, the
money simply is not available for such projects. Furthermore, the institutional
policy infrastructure required to manage funds for building, operating and
maintaining effective water and sanitation systems is absent or inadequate.
II. About Ecuador
Population:
In a 1990 census, excluding indigenous nomadic groups of Indians, the population
was estimated to be 9,648,000. Slightly over half (50.3%) of the total population
lives in coastal region of the country. The remainder of the population
inhabits the country's mountainous regions (45.6%), eastern region (4.1%),
and island region (0.1%). Education is compulsory for 6 years. In 1990,
12.7% of the population was illiterate.
In the population, there is a dramatic excess of physicians, however, medical
schools continue to keep the levels of enrollment the same. In 1990, there
were two strikes by physicians lasting a total of three months.
Government
A series of rulers, in rapid succession, has characterizing the constantly
changing political environment of Ecuador. Paramilitary groups are active,
as is the drug trade, both of which continue to be a source of political
unrest.
At this time, the Ecuadorian government is in a state of flux, with two
national events in its near future: the presidential elections in April,
1992 (with a change of government in August) and a movement toward an Andean
Common Market (consisting of Bolivia, Colombia, Peru, Venezuela and Ecuador)
which is supposed to begin in July.
Under the leadership of Dr. Plutarco Naranjo, the Ministry of Public Health
has for the past four years remained relatively stable. However, he will
be leaving office when the government changes in August. The Ministry is
organized with three main units: one subsecretariate for environmental health,
one for the Quito region, and a third for Guayaquil, including seven other
provinces.
Economy
Ecuador's shaky political setting has historically been accompanied by a
similarly shaky economy. Much of the political unrest in Ecuador has stemmed
from uncertain economic conditions within the nation. The economy is strongest
in fishing and agriculture, with some production in mining and oil refining.
Principal cash crops are bananas, coffee and cocoa. Tourism plays an important
economic role as well.
Just about the time of the outbreak, the government had recently introduced
new austerity measures in order to control inflation in the lagging economy.
In late January, 1991, following widespread opposition to the government's
economic measures, there were violent demonstrations in the nation's capital,
Quito. Inflation has fluctuated between 30-100% per year for the past four
years.
Guayaquil
Guayaquil is the capital of the Guayas province. It is the country's most
populous city, with more than a million inhabitants. Many of them live in
conditions of deprivation and chronic unemployment, which has forced a large
portion of the population into the informal economy.
III. About Cholera
Members of the genus Vibrio, are natural inhabitants of water environments.
Discovered in 1884 by Robert Koch, Vibrio cholerae, the bacteria known to
cause cholera, was previously thought to be highly adaptive to the host
only with little chance of outside survival. However, since the 1970's,
it is commonly believed that V. cholerae can survive for extended periods
of time in water, both fresh and salt water environments through a variety
of environmental conditions.
Cholera, only one of many diarrheal diseases, is spread because of contaminated
sources of food and water by human feces. Although this can be prevented
through the installation of effective sanitation, and safe hygienic practices,
instances of cholera are general indicators of the sanitary conditions in
a population.
Historically, cholera epidemics hit in Southeast Asia until the start of
the 19th century. The locations of epidemics changed from 1820-1920, through
a series of six pandemics which struck much of the world, including Africa
and the Americas. This deadly series sparked improvements in the poor living
conditions in large cities of newly industrializing countries throughout
the world. Cholera was thought to be irradiated after the sixth pandemic,
however, the latest discovery of a new strain of cholera is the seventh
pandemic in recorded history.
Named El Tor, after the site of discovery, a new strain of cholera distinguished
itself from its predecessors for its ability to survive for long periods
of time in the environment and the fact that a many who have developed the
infection show little or no immediate symptoms. El Tor cholera can better
survive in inadequate conditions of sanitation, hygiene or water.
The key to managing cholera is through oral rehydration therapy (ORT), a
simple but critical method of treatment which allows for the restoration
of basic sugars and salts. This method of treatment has been successful
throughout the world for treatment of this and other acute diarrhea illnesses.
IV. Epidemiology of the
Outbreak
The first cases in Ecuador were reported in El Oro Province, along the Peruvian
border in the south of the country and spread north. Those most affected
by the outbreak were various disadvantaged neighborhoods with poor sanitation.
In the overall case numbers for the country, seasonal patterns have been
established. The highest numbers have occurred in the early months of both
years (refer to graph 1), during the rainy season of the country. According
to the PAHO Epidemiological Bulletin, by mid-June of last year, the cumulative
incidence of infection reached an approximate amount of 259.1 cases per
100,000 inhabitants, with greater incidence of occurrence in the coastal
and island areas of the country. Approximately 78 out of every 100 cases
registered were hospitalized in the country with a case fatality ration
of 1.6%.
The province of the Guayas, the region most affected by the outbreak, reported
cases from the beginning of outbreak in late February, 1991 until the 5th
of October of the same year. They totaled 13,060, or about 1600 cases per
month. By the 29th of December, 1991 until the 22nd of February, 1992, the
total reports in the province was 1611.
V.
Status of Country Efforts
USAID and other international organizations assess the major problems Ecuador
currently has in confronting and coping with the epidemic. Some of the major
problems identified are:
Surveillance (with little to no community based investigation of deaths)
Case management (including proper diagnosis and treatment)
Water quality
Food safety
Health education and hygiene behavior
Health personnel training
Provision and distribution of commodities (ORT, IV therapy, Antibiotics)*
Improving local production
*case management of cholera is seen as a problem, with rehydration taking
too long and not being done properly.
Ecuador, cognizant of this outbreak as well as the lack of sanitary conditions,
wants to work with international organizations to confront and end this
epidemic. The stated objective from the Ministry of Public Health is to:
lessen the cases of cholera in Ecuador and to reduce the numbers of deaths
from cholera. Furthermore, in order to achieve their objectives, the Ministry,
with the help of international organizations, intends to target the locations
which are at the greatest risk of further outbreak to improve the basic
sanitation, the accessibility of quality health care for patients, and the
communication of epidemiological information.
Various international aid organizations have said that Ecuador's efforts
to combat this outbreak having mostly been in hospitals. Epidemiological
surveillance tends to be too centralized and needs to be dispersed further
in the regions. |
