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Issue 200 September 3, 2013Sherri L. Porcelain*
Cholera in Cuba:
Notice to Protect U.S. Travelers
The Center for Disease Control and Prevention (CDC) is the leading U.S. government agency with the mission to protect and secure the health of Americans at home and abroad. CDC also functions as a key informational source, for clinicians and travelers, providing up to date facts and advice about health issues both nationally and internationally. Yet, CDC has not posted a notification about cholera in Cuba for summer 2013, even though other countries and the Pan American Health Organization (PAHO) have confirmed the vibrio cholerae bacterium infecting international travelers visiting Cuba this summer.CDC refined their travel announcements on April 5, 2013, with the purpose to clarify both health risks and precautions: (1)
- Level 1: “Watch” is a reminder to use precautions when traveling to a specific destination;
- Level 2: “Alert” to recommend applying enhanced precautions;
- Level 3: “Warning” to avoid any non-essential travel to a specific country.Cholera is one of the oldest reportable diseases along with the plague and yellow fever. Under the International Health Regulations (IHR), the regulatory arm of the World Health Organization, the rapid spread of cholera has a long history. Cuba’s decaying infrastructure of poor water, sewage, sanitation and housing conditions coupled with heavy rains and international medical missions, makes cholera ripe for rapid spread.Recent laboratory evidence confirmed that travelers carried more than their luggage home from Cuba. In the past two weeks:
- August 14, 2013: PAHO reports that Italy, Venezuela and Chile cases support previous rumors and pleas from dissidents that cholera continues to spread in Cuba. (2)
- August 20, 2013: U.S. Interests Section in Havana issued a cholera health warning. (3)
- August 23, 2013: PAHO reports additional information that Spain, Germany and Netherlands confirmed cholera from returning travelers from Cuba, and identified cholera in provinces of Havana, Santiago and Camaguey. (4)
- August 27, 2013: Juan Tamayo, Miami Herald reporter, interviewed a New York teacher hospitalized in Cuba for six days. The Cuban-American was stricken with cholera, along with other family members, after eating at a state-owned restaurant. (5)
- August 29, 2013: European surveillance reports that the 40-year-old male who spent a two-week vacation in Cuba, arrived home to Tieste, Italy in July with cholera and severe renal failure. He was hospitalized for 10 days and has recovered. (6)The latest PAHO surveillance reports 163 cases of cholera in Cuba for the year 2013; however, it is not clear how many cases are linked to this summer outbreak, and little epidemiologic details are presented. The Italian case study provides important epidemiologic evidence, identifying the likelihood of fresh seafood as the infected food source and the Havana waters as a possible point of concern. (7)No one is questioning the active and vigilant epidemiologic surveillance of infectious diseases in Cuba. Conspicuously, it is this evidence- based research that does not mirror the government’s lack of transparency in reporting.We know that cholera re-emerged in Cuba, after a century’s absence, prompting CDC to issue a travel advisory for Cuba in July 2012. Shortly after, the Cuban government reported no more cases of cholera. New scientific and epidemiological evidence this summer revealed European, Latin American, and U.S. travelers visiting Cuba were infected with cholera. Does anyone believe that the recent cholera outbreak started with international visitors from Italy, Venezuela or Chile this summer?Cuban dissidents, independent journalist, and Promed mail (8), working under the auspices of the International Society for Infectious Diseases, have tried to engage the international community- and expose a fact that the 2012 Cuban cholera epidemic did not vanish so quickly. Cholera never does so in countries with poor infrastructure.Unmistakably, we cannot depend upon an early official notification from the Cuban government. Therefore, we must rely on the international scientific evidence and U.S. government’s responsiveness to disseminate travel advisories.The U.S. Interests Section announced a cholera warning for Cuba on August 20, 2013. However, the CDC, whom I highly respect for both their excellent research and up-to date- information sharing about global public health issues, has yet to release a “watch” notification. While on June 19, 2013 CDC announced a cholera watch for Haiti and Dominican Republic. Based upon the evidence, risks and precautions necessary to avoid cholera in Cuba, I would assume a cholera travel health notice is warranted from CDC.
1) Center for Disease Control and Prevention (CDC) Traveler’s Health Notice. http://wwwnc.cdc.gov/travel/notices. Accessed August 31, 2013.
2) Pan American Health Organization (PAHO). Epidemiological Update. Cholera, August 14, 2013. http://www.paho.org/hq/index.php?option=com_docman&task=doc_view&gid=22575&Itemid.
3) U.S. Interests Section, Havana Cuba, Security Message-Cholera Outbreak. August 20, 2013. Accessed August 20, 2013.
4) PAHO, Epidemiological Update, Cholera August 23, 2013. http://www.paho.org/hq/index.php?option=com_docman&task=doc_view&gid=22752.
5) Juan Tamayo. Cuba reports more cholera among foreign visitors. Miami Herald, August 26, 2013. http://www.miamiherald.com/2013/08/26/3587434/cuba-reports-more-cholera-among.html.
6) M Mascarello, M L Deianam C Maurel, C Lucarelli , I Luzzi R Luzzati, Cholera with Severe Renal Failure in An Italian Tourist Returning from Cuba, Eurosurveillance, July 2013. Volume 18, Issue 35, August 29, 2013. http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20572.
8) ProMed mail post. International Society for Infectious Diseases. http://www.promedmail.org._________________________________________________*Sherri Porcelain is Senior Lecturer of Global Public Health in World Affairs & Senior Research Associate at the Institute for Cuban and Cuban-American Studies, University of Miami. Professor Porcelain is currently writing a book on U.S. Foreign Policy and Global Health: The Nexus of Infectious Diseases._________________________________________________
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