a temporary isolated cholera treatment area was set up in the hospital s courtyard , and routine hospital services were relocated to prevent nosocomial spread .
mspp , with the help of international organizations , established cholera treatment centers ( ctcs ) at 2 nearby public hospitals , while has acted as a referral hospital to treat immunosuppressed patients and patients with complicated cases .
however , patients with cholera continued to seek care at has , which required the hospital to develop a longer term plan to manage cholera patients .
the medical director implemented the world health organization cholera treatment protocols , which included oral rehydration solution for patients with moderate dehydration and intravenous ringer s lactate solution and antimicrobial drugs for the patients with severe dehydration ( 2 ) .
cases were defined as persons > 5 years of age who were admitted to has with acute watery diarrhea , with or without vomiting .
beds were removed and disinfected after each patient was discharged . with a limited number of nurses ,
family members were trained to be the primary caregivers for patients in the ctc ; training included proper hygiene .
sanitation staff supervised handwashing stations , disinfected all buckets used for waste collection , disinfected the floors and walls , and sprayed the shoes of everyone exiting the facility with chlorinated water . although the initial cases were among men working in the rice fields ,
cholera quickly spread among persons of all age groups , both sexes , and residing in valley and mountain regions .
a complicated disease course often developed in the elderly and those patients with underlying medical conditions .
older patients experienced renal failure , pulmonary edema , and heart failure ; hypoglycemia developed in young children who were malnourished .
severe dehydration among pregnant women caused many to have miscarriages , a known side effect of cholera ( 3 ) .
these complications were challenging because patients could not be transferred from the ctc to the hospital for specialized care because of cholera s contagiousness . because medical records were incomplete for almost half of the patients with cholera , an accurate overall case - fatality rate
could not be calculated . among the 2,359 patients for whom outcome data were available , the case - fatality rate at the hospital was 0.8% . as the number of cases continued to rise in november 2010 , has opened a permanent ctc adjacent to the hospital . by january 2011 , there were only on average 6 new admissions per day to the ctc , so staffing was considerably reduced . at the same time , ctcs run by international organizations in neighboring towns were reducing operations and shifting management responsibilities to mspp . in
late may 2011 , the number of ctc admissions increased rapidly with the beginning of the rainy season ; by june 29 , 2011 , the number of ctc admissions peaked at 132 new cases per day , a rate even greater than that during the initial outbreak ( figure 1 ) . with no other ctcs nearby operating 24 hours a day and able to treat persons with severe dehydration , has served a large geographic area .
cholera treatment center admissions , patients > 5 years of age , hpital albert schweitzer , artibonite department , haiti , october 17 , 2010july 31 , 2011 .
patients were treated in 6 tents organized by severity of dehydration ( figure 2 ) . as the outside temperature was > 90f , the temperature inside the tents was much higher , posing a threat to already severely dehydrated patients . patients were closely monitored by nurses and family members to ensure adequate hydration .
visiting teams of doctors and nurses supported the permanent staff in dealing with the patient surge .
tents where patients with cholera were treated at hpital albert schweitzer , artibonite department , haiti , october 17 , 2010july 31 , 2011 .
after initial reports that severe diarrhea was being treated with traditional remedies of guava leaves and rum and that persons were dying of  supernatural causes ,  has staff began meeting with influential community members such as traditional healers , teachers , and religious and local leaders .
community health workers , trained by has , educated the community on cholera signs and symptoms and disseminated prevention messages on proper hygiene while also distributing oral rehydration solution and water treatment products .
poor sanitary conditions were present in the community long before the cholera outbreak ( 4 ) . although an informal survey of ctc patients from january 2011may 2011 showed that most knew to drink treated water and wash their hands , only slightly more than half had access to a latrine .
soap and water - treatment products distribution addressed the acute but not chronic need for latrines .
after site visits that included hygiene education and latrine assessments , has constructed 266 latrines .
point - of - use water treatment has proven to be a more complicated intervention ; powdered chlorine to add to water and charcoal for boiling water are expensive , and water purification tablets are donor driven and lack standardization across organizations .
different types of tablets treat different amounts of water , and low literacy rates and language comprehension make ensuring proper use of the tablets challenging . after the surge in cholera cases in june 2011 with the start of the rainy season ,
has is prepared to address the clinical consequences of this disease , but more needs to be done to reduce illness and death .
the rise in cases signaled that the mspp hospital infrastructure was not capable of addressing the disease independently . without a regional plan that incorporated private and public institutions ,
the lack of preparedness across the artibonite region for the resurgence of cholera during the rainy season proved that a unified system must be fully equipped to manage future outbreaks .
such a system should be developed by mspp in collaboration with private institutions and international organizations .
to reduce the effects of cholera in rural haiti , all households should have access to latrines and clean water ( 5 ) . to reduce cholera illness and death
, private and public hospitals must work closely with the government and international organizations to standardize a nationwide plan of action .
 in october 2010 , hpital albert schweitzer haiti treated some of the first patients with cholera in haiti . over the following 10 months , a strategic plan was developed and implemented to improve the management of cases at the hospital level and to address the underlying risk factors at the community level . 
Management Strategies
Conclusions