Between Life and Death
Fr. Scott Binet MD, MI
CTF-SOS DRS
Sao Paulo, Brazil - October 20, 2011
Inform you about cholera and what the Camillians are
doing to respond to the signs of the times through
disaster relief
Sensitize you to the suffering of those affected by manmade and natural disasters such as cholera
Inspire you to get involved and dialogue amongst
yourselves and with me about how we might collaborate
in disaster relief
Cholera
Between Life and Death
Cholera
Between Life and Death
Presentation Outline
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Summary of Cholera
Introduction to the Camillian Task Force (CTF)
A Convergence – Camillians, Disasters and Risk
Disasters and Cholera - the World , Brazil
Cholera – Cause, Symptoms, Treatment, Prognosis
The Cholera Epidemic in Haiti
Questions/Comments
Cholera - Summary
 Cholera is an infection of the small intestine that is caused by
the bacterium Vibrio cholerae.
 Transmission occurs primarily when drinking water or food is
contaminated by the diarrhea from an infected person or by the feces of
an infected but asymptomatic person.
 The main symptoms are profuse watery diarrhea and vomiting. The
severity of the diarrhea and vomiting can lead to
rapid dehydration and electrolyte imbalance.
 Primary treatment is with oral rehydration solution (ORS) and if this
is not tolerated, intravenous fluids. Antibiotics are beneficial in those
with severe disease.
 Worldwide it is estimated to affect 3–5 million people and causes
100,000–130,000 deaths a year as of 2010. Cholera was one of the earliest
infections to be studied by epidemiological methods.
Camillians and Disasters
Camillian Task Force – A Network
Church and State
Archdiocese of Miami, USA
Caritas Ministers of the Infirm
(Camillians)
Missionaries
CTF Central
of Charity
SOS DRS
*Missionaries of Mercy*
?
Core
CRS
Italian
Episcopal
Conference
?
Archdiocese of Port au Prince, Haiti
Misericordiae
CTF - SOS DRS
A Vision
 To be Jesus’ merciful presence to the neediest of the
needy who are suffering from man-made and natural
disasters.
 To respond globally through a community-based,
Eucharist-centered, Marian-inspired disaster relief
organization.
CTF - SOS DRS
A Mission
 To witness the merciful love of Christ for the poor and
the sick in word, deed, and sacrament
 To serve the medical, pastoral, educational and
humanitarian needs of people affected by man-made
and natural disasters regardless of race, religion, or
ethnicity.
Camillian Task Force
1-
[SOS DRS Office]
3 - Italy [CTF Central/Earthquake]
5
Pakistan [Floods]
2 [Haiti Earthquake, Cholera,
4
Horn
6
Thailand
Hurricane, Slum]
of Africa
[Famine]
A Convergence - Camillians, Disasters, Risk
Camillians – A Family Ready to Respond
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A Convergence - Camillians, Disasters, Risk
People at Risk - Globally
People are Underprepared for Disasters
Urbanization
Increasing Numbers of Slums
Underdeveloped Social Factors
Spiritual, Societal and Family Deterioration – Decreased
Resilience, Man’s Inhumanity to Man
Global Warming - Deteriorating Environment
People Live in Risk by Necessity and By Choice
Lack of Early Warning Signs and Unpredictable Weather
Increasing Number of Refugees and Internally Displaced
The Signs of the Times
People at Risk
Urbanization - “ The United Nations projected that half of
the world's population would live in urban areas or cities
at the end of 2008”
2008 – 50%
The Signs of the Times
People at Risk
Increasing Numbers of Slums - The number of people living out their
days in the squalor of a slum is almost one billion, the United Nations
says - one-sixth of the world's population. By 2050, the UN says, there
may be 3.5 billion slum dwellers, out of a total urban population of
about six billion.
Kibera Slum in Nairobi,
The Signs of the Times
People at Risk
 Underdeveloped Social Factors - The earthquake in Chile
was 1,000 times more powerful than that in Haiti where 230,000
people died, many more than in Chile. Social factors are much more
important than geological when determining the vulnerability of
people to a disaster like an earthquake
.
Haiti - January 12 – Presidential Palace
Chile – February 27, 2010 – Pelluhue
The Signs of the Times
People at Risk
Social factors include:
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The economy of a country
The healthcare infrastructure
Presence of integrated emergency management system
Previous experience of handling disasters
Emergency plan
Educational level of the population
Availability of basic necessities: clean water, housing, etc.
The government – effectiveness, trustworthiness
The Signs of the Times
People at Risk
People in Risk by Necessity and by Choice [:00-35; 6:15-7:10]
Pakistan Floods – 2010
The Signs of the Times
People at Risk - Increasing Number of Refugees and Internally Displaced
Tent City in the Slum of Solino, Port au Prince, Haiti
A Convergence - Camillians and Disasters
Increasing Incidence and Severity of Disasters
Disaster
A serious disruption of the functioning of a community or a
society causing widespread human, material, economic, or
environmental losses that exceed the ability of the affected
community or society to cope using its own resources.
Disasters – Increasing in Incidence and Severity
Cholera
Between Life and Death
Seven Cholera Pandemics
1.
In the past 200 hundred years, seven cholera pandemics
have killed millions across the globe.
2.
The seventh pandemic is still going on since 1961, but
advancements in medical science have greatly reduced
the number of people who die from it.
3.
Modern-day sewage and water treatment systems have
largely eliminated cholera from developed countries. But
it continues to be a concern in the developing world,
especially in areas ravaged by war and natural disasters
such as earthquakes and hurricanes that leave people
without access to clean drinking water.
Cholera
Between Life and Death
Brazil and Cholera
The first epidemic in Brazil?
Black Death in Brazil - 1855-1856
(Part of the 3rd Cholera Pandemic)
The last epidemic in Brazil?
Cholera Strikes Brazil Again - 1991-1998
(Part
of the 7th Cholera Pandemic)
Cholera – 1st Pandemic
1817-1823
 1817 – First known pandemic of cholera originated in
the Ganges River delta in India. The disease broke out
near Calcutta. Hundreds of thousands died.
Cholera – 2nd Pandemic
1829-1849
 1829 - The 2nd pandemic starts in India and reaches
Russia by 1830 before continuing into Hungary
(100,000 dead), Finland, Poland, Paris (100,000 dead).
 1831 -1849 Epidemic goes from Ireland to Quebec to
the US to Mexico. Hundreds of thousands die.
Cholera – 3nd Pandemic
1852-59
 1852 - The third pandemic, generally considered the most
deadly, originated once again in India. It devastated large
swaths of Asia, Europe, North and South America and
Africa – mainly affecting Russia with over 1 million deaths
(1,000,000).
 1854 - British physician John Snow succeeded in identifying
contaminated water as the transmitter of the disease
 1860 - Deaths in India between 1817 and 1860 are estimated
to have exceeded 15 million people.
3rd Cholera Pandemic
Black Death in Brazil - 1855-1856
 Cholera Epidemic - Black Death in Brazil - 1855-1856
This map represents the movement of the first
terrible cholera epidemic in Brazil as it spread in 1855
and 1856.
2. Red indicates confirmed areas of disease.
1.
Cholera – 4th Pandemic
1863-1879
 1863 - The fourth pandemic began in the Bengal
region of India from which Indian Muslim pilgrims
visiting Mecca spread the disease to the Middle
East, Russia, Europe, Africa and North America
Cholera – 5th Pandemic
1881- 1896
 1881 - The fifth pandemic originated in the Bengal
region of India and swept through Asia [Russia, Japan],
Africa, South America and parts of France and
Germany. US and Britain Spared [Quarantine]
 1892 - Waldemar Haffkine, a Ukrainian bacteriologist
who worked mostly in India, developed a human
vaccine for cholera.
Cholera – 6th Pandemic
1899-1923
 1899- The sixth pandemic killed more than 800,000 in India
before moving into the Middle East, northern Africa, Russia,
parts of Europe and Asia.
 1910 – 11 - The last outbreak in the United States
 1917 – An estimated 23 million people in India died of cholera
between 1865 and 1917. Russian deaths during a similar time
period exceeded 2 million.
 1923 - Cholera had receded from most of the world, although
many cases were still present in India.
Cholera
The 7th Pandemic - 1961 to present
 1961 - The seventh pandemic originates in Indonesia, not
India.
 Vibrio Cholerae Biotype El Tor is the dominant
strain/causative agent [
 El Tor first identified in El Tor, Egypt in 1905 and then
again in 1937, but it does not produce an epidemic until
1961].
 El Tor is distinguished from the classic strain at a genetic
level, although both are in the serogroup O1 and both
contain Inaba, Ogawa and Hikojima serotypes.
 El Tor is also distinguished from classic biotypes by the
production of hemolysins and the fact that it can remain in
the human system longer allowing for a longer carrier
state.
 1971 - It ravaged populations across Asia and the Middle
East, eventually reaching Africa by 1971. The 7th Pandemic
- Cholera in the World 1970- 2010
Cholera in Brazil (1991-1998) Socioeconomic
Characterization of Affected Areas
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Cholera reappeared in Latin America in January 1991 and spread rapidly.
Vibrio cholerae O1 El Tor caused the disease.
Peru was the first country affected, with an explosive outbreak.
The high incidence of cholera in the Peruvian rain forest area in 1991 was probably
the cause of emergence of cholera in Brazil through this unexpected route.
During this period in Brazil - 161,432 cases and 1,296 deaths from cholera were
reported.
The most severely-affected regions of the country were the North and Northeast
regions, accounting, respectively, for 7.0% and 92.2% of the cases and 6.6% and
90.5% of the deaths. Both the regions presented similar case fatality rates (0.79%
and 0.76% respectively).
In both the regions, the most affected areas were small villages with a
predominantly rural population, characterized by deprivation, low HDI ranking,
poverty, high rates of infant mortality and illiteracy, and lack of sanitation .
During 1991-1996, Latin America reported 1.4 million cases and nearly 10,000
deaths .
Yellow Fever ,Cholera, Small Pox, Bubonic Plague, Influenza…
Cholera
Between Life and Death – The Evolving 7th Pandemic
1980s - in the early 1980s, death rates are believed to have been greater than 3
million a year. [Lancet - Cholera – 2004]
1989 -2010 - Reported Cases - Cholera – Bar Graph – 1989-2010
2010 - It is estimated that cholera affects 3-5 million people worldwide, and
causes 100,000-130,000 deaths a year as of 2010. [2010 WHO position
paper] . This occurs mainly in the developing world.
2010 - Number of reported cases - 317, 534 cholera cases were reported to
WHO in 2010.
2010 Number of reported deaths -7,543 deaths due to cholera were reported
globally in 2010 This represents a 52% increase compared to 2009
2010 Reported case fatality rate - The overall case fatality rate for cholera was
2.38%
Cholera
Cause – Organism –Etymology
 Vibrio \Vib"ri*o\, noun; plural English Vibrios, from Latin
expression Vibriones. [New Latin expression, from the
Latin expression vibrare to vibrate, to move by
undulations.].
 Cholera - The word cholera is
from Greek: χολέρα kholera from χολή kholē "bile". Latin
Cholera means “bilious disease”.
Light Microscopy
Electron Microscopy
Cholera
Cause – Organism – Groups, Strains: Biotypes and Serotypes
Vibrio cholerae is a gram-negative, rod-shaped bacterium with a
single, polar flagellum which renders them motile. and surface O
antigens which form the basis of classifying the bacteria into
more than 130 groups.
Two of the groups, O1 and O139 (‘O’ for O antigen), have been
known to cause epidemics of diarrhea. O1 causes the majority of
outbreaks, while O139 – first identified in Bangladesh in 1992 – is
confined to South-East Asia
O1 strains fall into two biotypes (or biovars), called classical and El
Tor, that are distinguished by their different hemolytic activity,
relative resistance to the antibiotic polymyxin B, and their
different susceptibilities to bacteriophage.
The classical biotype is further divided into two serotypes (or
serovars), based on the antisera that recognize them, and named
after the place where they were first isolated: Inaba and Ogawa.
Thus, any pathogenic strain of Vibrio cholerae has a name that
reflects both the biotype and the serotype; for example, strain
569B has a classical biotype and the Inaba serotype.
Cholera
Susceptibility – Societal and Individual Risk Factors
Societal - Peri-urban slums
Societal - Camps for IDPs or refugees
Societal - Post-disaster disruption of water/sanitation
Individual - Ingestion of 100,000,000 bacteria in healthy adult.
Individual - Lower gastric acidity
Individual - Children two to four years of age
Individual - O blood type
Individual - Lower immunity (AIDS, malnourished children)
Individual - Cholera workers/unprotected
Cholera
Cause - Transmission
 Transmission is primarily due to the fecal contamination of
food and water due to poor sanitation. This bacterium can,
however, live naturally in any environment, particularly
water reservoirs.
Cholera – Prevention
Halting Spread, Surveillance, Vaccination, Preparedness to Respond
 Cholera may be prevented by halting spread (remember diagram):
 Disposal and treatment (fecal waste/contaminated materials)
 Sterilization with bleach/hot water of contaminated materials
 Sterilization of hands (antimicrobial soap, water);
 Antibacterial treatment of sewage before it enters water supply
 Post warnings about possible cholera contamination around
contaminated water sources with directions on how
to decontaminate the water (boiling, chlorination etc.)
 Water purification: Water used for drinking, washing, or cooking
should be sterilized by either boiling, chlorination, ozone water
treatment, ultraviolet light sterilization or antimicrobial filtration.
 Cholera Prevention - Animated Video
Cholera – Prevention
Halting Spread, Surveillance, Vaccination, Preparedness to Respond
Surveillance - Prompt reporting allows for containing epidemics
Surveillance - Cholera is seasonal in many endemic countries (rainy)
Vaccine - Is additional control in cholera-endemic countries
Vaccine - High-risk such as 2-4 year olds, pregnant, HIV-infected, healthcare workers.
Vaccine - Pre-emptive vaccination should be considered
Vaccine - Two types of safe and effective oral vaccines that are whole-cell killed, one
with a recombinant B-sub unit (Dukoral), the other without (Shanchol). Both have
sustained protection of over 50% lasting for two years in endemic settings.
Vaccine – Dukoral is WHO prequalified and licensed in over 60 countries. Dukoral has
been shown to provide short-term protection of 85–90% against V. cholerae O1
among all age groups at 4–6 months following immunization.
Vaccine – Shanchol provides longer-term protection against V. cholerae O1 and O139
in children under five years of age.
Vaccine - Both vaccines are administered in 2 doses given between 7 days and 6
weeks apart. Dukoral is given in 150 ml of safe water.
Vaccine – Immunization should be used in conjunction with the usually
recommended control measures.
Cholera –
Mechanism of Infection
 Vibrio cholera bacteria are ingested and survive the acidity of the stomach.
 The bacteria exit into the small intestine, produce protein flagellin to
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make flagella, Flagella that rotate allow the bacteria to propel themselves
through the mucus of the small intestine.
Upon reaching the intestinal wall, V. cholerae stop producing flagellin and start
producing the toxic proteins that give the infected person a watery diarrhea.
The cholera toxin (CTX or CT) is an oligomeric complex made up of protein
subunits. Upon binding, the complex is taken into the cell via receptormediated endocytosis. This in turn leads to secretion of H2O, Na+, K+, Cl−, and
HCO3− into the lumen of the small intestine and rapid dehydration.
The chloride and sodium ions create a salt-water environment in the small
intestines, which through osmosis can pull up to six liters of water per day
through the intestinal cells, creating the massive amounts of diarrhea.
The diarrhea carries the multiplying new generations of V. cholerae bacteria out
into the drinking water of the next host if proper sanitation measures are not in
place.
Cholera
Diagnosis and Treatment
“Rice Water Stools”
Cholera
Diagnosis and Treatment
 In epidemic situations, history and doing a brief examination are the
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basis for a clinical diagnosis.
Treatment is usually started without or before confirmation by
laboratory analysis.
For laboratory analysis, stool and swab samples of diarrhea
collected in the acute stage of the disease, before antibiotics have been
administered, are the most useful specimens.
A rapid dip-stick test is available to determine the presence of V.
cholerae. In those that test positive, further testing can be done to
determine antibiotic resistance.
A number of special media have been employed for the cultivation for
cholera vibrios: Enrichment media and Plating media.
Direct microscopy of stool is not recommended, as it is unreliable.
Microscopy is preferred only after enrichment, as this process
reveals the characteristic motility of Vibrio and its inhibition by
appropriate antisera.
Diagnosis can be confirmed, as well, as serotyping done by
agglutination with specific sera. If an epidemic of cholera is
suspected, the most common causative agent is Vibrio cholerae O1. If V.
cholerae serogroup O1 is not isolated, the laboratory should test for V.
cholerae O139.
Cholera
Diagnosis and Treatment
First steps for Managing an Outbreak of Acute Diarrhea – The First Days
THE FIRST TWO QUESTIONS ARE:
1. Is this the beginning of an outbreak?
2. Is the patient suffering from cholera or shigella?
A. Is this the beginning of an outbreak? - You might be facing an
outbreak very soon if you have seen an unusual number of acute
diarrheal cases this week and the patients have the following points in
common:
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They have similar clinical symptoms (watery or bloody diarrhea)
They are living in the same area or location
They have eaten the same food (at a burial ceremony for example)
They are sharing the same water source
There is an outbreak in the neighboring community
You have seen an adult suffering from acute watery diarrhea with
severe dehydration and vomiting
7. If you have some statistical information from previous years or weeks
verify if the actual increase of cases is unusual over the same period of
time.
Cholera
Diagnosis and Treatment
First steps for Managing an Outbreak of Acute Diarrhea – The First Days
2. Is the patient suffering from cholera or shigella? - If
so, it is an emergency
Cholera = acute watery diarrhea
Shigella dysentery = acute bloody diarrhea
1. Both transmitted by contaminated water, unsafe food, dirty
hands and vomit or stools of sick people.
2. Cholera and shigella produce outbreaks which represent an
immediate threat to the community.
3. Symptoms/Signs differentiate them (stool [amount/character];
fever; abdominal cramps; vomiting; rectal pain]
4. Establish clinical diagnosis for patient, family members with
acute diarrhea, take stool samples/send for analysis or
refrigeration; Don’t wait for lab to start treatment; estimate
supplies needed; protect community; collect patient data
Cholera
Diagnosis and Treatment
First steps for Managing an Outbreak of Acute Diarrhea – The First Days
What are the next 3 questions to ask if you suspect an outbreak?
■ Who do I inform and ask for help from?
■ How do I protect the community?
■ How do I treat the patients?
What 3 things not to forget?
1. PROTECT YOURSELF FROM CONTAMINATION
■ Wash your hands with soap before and after taking care of the patient
■ Cut your nails
2. ISOLATE CHOLERA PATIENTS
■ Stools, vomit and soiled clothes of patients are highly contagious
■ Latrines and patients’ buckets need to be washed and disinfected with chlorine
■ Cholera patients have to be in a special ward, isolated from other patients
3. CONTINUOUS PROVISION OF NUTRITIOUS FOOD is important for all patients,
especially for those with shigella dysentery
■ Provide frequent small meals with known foods during the first 2 days
■ Provide food as soon as the patient is able to take it
■ Breastfeeding of infants and young children should continue
Cholera
Diagnosis and Treatment
First steps for Managing an Outbreak of Acute Diarrhea – The First Days
Check the supplies you have and record available quantities
➥ IV fluids (Ringer Lactate is the best)
➥ Drips
➥ Nasogastric tubes
➥ Oral Rehydration Salt (ORS)
➥ Antibiotics (see Table 2)
➥ Soap
➥ Chlorine or bleaching powder
➥ Rectal swabs and transport medium
(Cary Blair or TCBS) for stool samples
➥ Safe water is needed to rehydrate
patients and to wash
Cholera
Diagnosis and Treatment
First steps for Managing an Outbreak of Acute Diarrhea – The First Days
PROTECT THE COMMUNITY: Stool and vomit are highly contagious
■ Isolate the severe cases ■ Provide information on how to avoid cholera through
simple messages and on the outbreak ■ Disinfect water sources with chlorine ■
Promote water disinfection at home using chlorine ■ Avoid gatherings
PRECAUTIONS FOR FUNERALS
■ Disinfect corpses with chlorine solution (2%) ■ Fill mouth and anus with cotton
wool soaked with chlorine solution ■ Wash hands with soap after touching the
corpse ■ Disinfect the clothing and bedding of the deceased by stirring them in
boiling water or by drying them thoroughly in the sun
GIVE SIMPLE MESSAGES TO AVOID CHOLERA/SHIGELLA
■ Wash your hands with soap: after using toilets and latrines; before preparing
food; before eating ■ Boil or disinfect the water with chlorine solution ■ Only
eat freshly cooked food ■ Do not defecate near the water sources ■ Use latrines
and keep them clean
In case of acute diarrhea
■ Start oral rehydration with ORS before going to the health centre
■ Go to the health centre as soon as possible
Cholera
Diagnosis and Treatment
First steps for Managing an Outbreak of Acute Diarrhea – The First Days
Summary of the treatment
Rehydrate with ORS or IV solution depending on the severity
2. Maintain hydration and monitor the hydration status
3. Give antibiotics for severe cholera cases and for shigella cases
1.
Cholera
Diagnosis and Treatment
First steps for Managing an Outbreak of Acute Diarrhea – The First Days
BOX 1. HOW TO PREPARE HOME-MADE ORS SOLUTION
• If ORS sachets are available: dilute 1 sachet in 1 liter of safe water
• Otherwise: Add to 1 liter of safe water:
— Salt 1/2 small spoon (3.5 grams)
— Sugar 4 big spoons (40 grams)
And try to compensate for loss of potassium - for example, eat bananas or
drink green coconut water
Cholera
Diagnosis and Treatment
First steps for Managing an Outbreak of Acute Diarrhea – The First Days
When is it useful to give antibiotics?
➥ For cholera cases with severe dehydration only.
➥ Ideally for all of Shigella dysenteriae cases, but as
a priority for the most vulnerable patients:
children under five, elderly, malnourished,
patients with convulsions.
Cholera
Diagnosis and Treatment
First steps for Managing an Outbreak of Acute Diarrhea – The First Days
Which antibiotics?
Cholera
Adults – doxycycline - 1 dose 300 mg or tetracycline 12.5 mg/kg 4
times a day for 3 days;
Young children: erythromycin liquid 12.5 mg/kg 4 times a day for 3 days
Shigella
Adults: ciprofloxacin 500 mg twice a day for 3 days
Children: ciprofloxacin 250 mg/15kg twice a day for 3 days
For children below 6 months of age: add zinc 10 mg daily for 2 weeks
For children 6 months to 5 years of age: add zinc 20 mg daily for 2 weeks
Cholera
Prognosis – Between Life and Death
 About 75% of people infected with V. cholerae do not
develop any symptoms, although the bacteria are
present in their feces for 7–14 days.
 Among people who develop symptoms, 80% have mild
or moderate symptoms that can be treated with ORS;
while around 20% develop acute watery diarrhea with
severe dehydration. With untreated cholera, the
mortality rate rises to 50–60%. In an outbreak, the
fatality rate should be around 1%
 For certain genetic strains of cholera, such as the one
present during the 2010 epidemic in Haiti and the
2004 outbreak in India, death can occur within two
hours of the first sign of symptoms.
A Case Study of Convergence - Haiti
Camillians, Signs of the Times, Disasters
Earthquake - Moments After – The Cathedral [1:30] [January 2010]
Cholera is a New Threat [October 2010]
Hurricane Thomas [November 2010]
Haiti Epidemic - Summary
1. The epidemic is ongoing and has a history:
2 On October 21, 2010 the US Centers for Disease Control and
Prevention (CDC) confirmed that the cases of diarrheal illness
first seen at hospitals in the Artibonite region had been
receiving had been identified as cholera.
3. The rural Artibonite Department of Haiti,[3] about 100
kilometers (62 mi) north of the capital, Port-au-Prince,
Artibonite (Gonaïves) – 1
Centre (Hinche)
Grand'Anse (Jérémie) – 3
Nippes (Miragoâne)
Nord (Cap-Haïtien)
Nord-Est (Fort-Liberté)
Nord-Ouest (Port-de-Paix)
Ouest (Port-au-Prince) -8
Sud-Est (Jacmel)
Sud (Les Cayes)
Haiti Epidemic - Summary
By November 2010 the epidemic spread to the Dominican
Republic and there was a single case in Florida, United
States;
2. By the first 10 weeks of the epidemic to all of Haiti's 10
departments or provinces (December 2011).
3. By January 2011 a few cases were reported in Venezuela.
1.
4. By March 2011 the epidemic had killed 4672 people and
hospitalized thousands more. Some 252,640 cases had
been reported by March 2011.
5. By late September 2011, some 6,435 deaths have been
reported and this number is expected to increase
Interactive Map of Cholera Epidemic in Haiti
First Mission – Artibonite – October, 2010
Second Mission – Grand Anse – December- February, 2010
Cholera Bed
Most Recent News
 jedi, 20 oktòb 2011
 Ayiti: Depatman Sante Piblik ak Popilasyon Pral
Lanse yon Kanpay Vaksinasyon kont Kolera
 madi, 11 oktòb 2011
 20 Moun Mouri anba Maladi Kolera nan
Depatman Grand' Ans
Camillian Task Force
1-
[SOS DRS Office]
3 - Italy [CTF Central/Earthquake]
5
Pakistan [Floods]
2 [Haiti Earthquake, Cholera,
4
Horn
6
Thailand
Hurricane, Slum]
of Africa
[Famine]
Obrigado! Many Thanks