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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 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.

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.

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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