1. Nutrition Components of the Cholera response in Haiti H A I T I

2. Very fertile Ground for a Cholera Epidemic  Extreme poverty,  Weak governance  Weak Healthcare system  Poor access to safe water, hygiene and sanitation  Political violence and unrest  Still recovering from Earthquake of January 2010  Vulnerable to other natural disasters

3. Temporal-spatial evolution of cholera from 19/10/10 to 20/11/10 Centre d’Operation d’Urgence Nationale (COUN)

4. From Epidemic to Endemic:  No population immunity.  Highly virulent Vibrio Cholerae strain.  First reports of 40 diarrhoeal deaths on 20 th October, by 29 th 4714 cases and 330 deaths and within 5 weeks (21 st November) 61,825 cases and 1426 deaths.  Cholera rapidly became endemic and is likely to have further peaks during the next cyclonic season.  As of 1st March 252,640 cases, 136,275 hospitalisations and 4,672 deaths with still 7000 new cases a week.  Approximately 10% of cases are under 5.  Estimated that only 60% of cases get reported.

5. Initial difficulties of Cholera Response:  The Haiti Cholera Treatment protocol did not make provision for severely malnourished children, breastfeeding or use of Zinc with RO ORS.  Initial key messages issued by MoH did not include nutrition.  Heath system including external support overwhelmed for many weeks.  Not always good implication of sectors besides Health and Wash in the response coordination.

6. More initial difficulties…  Impossibility to assist with safe water and sanitation at such a large scale.  Initial delay by MoH in approval of Zinc with RO ORS for cholera.  Difficulty in adopting the Nutrition components of cholera response in a Health setting.  Several nutrition centres were converted to CTCs and stigmatisation of all health/nutrition facilities.

7. Key messages developed and diffused:  Development of key IYCF messages for diffusion.  Poster on use of Zinc and RO ORS for under 5.  Poster on breastfeeding and cholera.  Decisional Flowchart of breastfeeding in a CTC context.  Posters of screening of SAM in children with cholera and rehydration protocol  Addendum to National Nutrition Protocol to include SAM rehydration in a cholera context.  Guidelines for management of SAM and IYCF in CTC and IYCF in the community.

8. Key Nutrition components of cholera care more easily implemented: To be included in revised National Cholera Protocol:  Rapid screening of SAM children on admission for application of rehydration protocol for SAM children with cholera.  Use of Zinc with RO ORS for U5. Then:  Food provision once a patient is able to eat.  Supplementary or therapeutic feeding (mainly in CTCs run by Nutrition partners).  MAM/SAM take home ration of RUSF/RUTF upon discharge (mainly in CTCs run by Nutrition partners).

9. Coverage of Nutrition components in CTC/CTUs Key activitiesPartners Centers Screening of children < 5 yrs Zinc administration with ORS Food rations Therapeutic food Referral to PTA/PNS/USN 12/ 16 11 / 16 7/ 16 16 / 16 62 / 67 58 / 67 42 / 67 37 / 67 67 / 67  By February 2011, 101 CTCs, 165CTUs and 786 ORPs, # keep changing according to needs and NGO presence.  Only 16 partners have reported on Nutrition activities covering 67 CTC/CTUs: WVI, SC, MDM-F, MDM-Ch, MDM-E, Gheskio, Healing Art Mission, Merlin, ALIMA, IMC, MSF-F, MSF-E, MSF-Ch, Jap. RC, FSB, MDM-Can

10. Components care more difficult to implement:  Record of nutrition activities in CTC.  Screening on discharge and referral for SAM/MAM or IYCF follow up (coverage low).  Identification of breastfeeding mothers with cholera separated from their children and reunification.  No requests of RUIF from CTC/CTUs.  Plumpy Doz on discharge to assist recovery of non- malnourished.  Advice on adequate IYCF after discharge to assist recovery.

11. lessons learned:  Need for advocacy at all levels for inclusion of Nutrition Components in cholera treatment protocols.  Rapid and early response at scale is essential  Better Preparedness (scenarios, protocols and messages)  Easier to change the health approach if it is not seen as a Nutrition action  Better Surveillance and M&E  Is a MUAC of 115mm the best SAM threshold for a young child with cholera?  Breastfeeding promoted as an effective cholera prevention strategy.

12. Mesi Anpil