Update: Haiti Travel Precaution

Warning - Level 3, Avoid Nonessential TravelAlert - Level 2, Practice Enhanced PrecautionsWatch - Level 1, Practice Usual Precautions

An outbreak of cholera has been ongoing in Haiti since October 2010. According to the Ministere de la Sante Publique et de la Population (MSPP), as of May 22, 2013, 657,117 cases and 8,096 deaths have been reported since the cholera epidemic began in Haiti. Among the cases reported, 363,740 (55.4%) were hospitalized. Cases have been officially reported in all 10 departments of Haiti. In Port-au-Prince, the country’s capital, 176,935 cases have been reported since the beginning of the outbreak. Cases in Port-au-Prince have been reported from the following neighborhoods: Carrefour, Cite Soleil, Delmas, Kenscoff, Petion Ville, Port-au-Prince and Tabarre.

For more information on cholera cases, see the Health Summary Report from MSPP.

Cholera is a bacterial disease that can cause diarrhea and dehydration. Cholera is most often spread through the ingestion of contaminated food or drinking water. Water may be contaminated by the feces of an infected person or by untreated sewage. Food is often contaminated by water containing cholera bacteria or by being handled by a person ill with cholera.

Since the earthquake, the U.S. Department of State has maintained a travel warning for Haiti urging U.S. citizens to avoid all nonessential travel to Haiti. For more information, see http://travel.state.gov/travel/cis_pa_tw/tw/tw_5541.html.

Most travelers are not at high risk for getting cholera, but people who are traveling to Haiti should still take their own supplies to help prevent the disease and to treat it. Items to pack include

A prescription antibiotic to take in case of diarrheaWater purification tablets*Oral rehydration salts*

*In the United States, these products can be purchased at stores that sell equipment for camping or other outdoor activities.

Although no cholera vaccine is available in the United States, travelers can prevent cholera by following these 5 basic steps:

Bottled water with unbroken seals and canned/bottled carbonated beverages are safe to drink and use.Use safe water to brush your teeth, wash and prepare food, and make ice.Clean food preparation areas and kitchenware with soap and safe water and let dry completely before reuse.

*Piped water sources, drinks sold in cups or bags, or ice may not be safe. All drinking water and water used to make ice should be boiled or treated with chlorine.
To be sure water is safe to drink and use:

Boil it or treat it with water purification tablets, a chlorine product, or household bleach.Bring your water to a complete boil for at least 1 minute.To treat your water, use water purification tablets, if you brought some with you from the United States, or one of the locally available treatment products, and follow the instructions.If a chlorine treatment product is not available, you can treat your water with household bleach. Add 8 drops of household bleach for every 1 gallon of water (or 2 drops of household bleach for every 1 liter of water) and wait 30 minutes before drinkingAlways store your treated water in a clean, covered container.Before you eat or prepare foodBefore feeding your childrenAfter using the latrine or toiletAfter cleaning your child’s bottomAfter taking care of someone ill with diarrhea

*If no soap is available, scrub hands often with ash or sand and rinse with safe water.

Use latrines or other sanitation systems, like chemical toilets, to dispose of feces.Wash hands with soap and safe water after using toilets or latrines.Clean latrines and surfaces contaminated with feces using a solution of 1 part household bleach to 9 parts water.

What if I don’t have a latrine or chemical toilet?

Defecate at least 30 meters away from any body of water and then bury your feces.Dispose of plastic bags containing feces in latrines, at collection points if available, or bury it in the ground. Do not put plastic bags in chemical toilets.Dig new latrines or temporary pit toilets at least a half-meter deep and at least 30 meters away from any body of water.Boil it, cook it, peel it, or leave itBe sure to cook shellfish (like crabs and crayfish) until they are very hot all the way through.Do not bring perishable seafood back to the United States.

*Avoid raw foods other than fruits and vegetables you have peeled yourself.

Wash yourself, your children, diapers, and clothes at least 30 meters away from drinking water sources.

Before departing for Haiti, talk to your doctor about getting a prescription for an antibiotic. If you get sick with diarrhea while you are in Haiti, you can take the antibiotic, as prescribed. Also, remember to drink fluids and use oral rehydration salts (ORS) to prevent dehydration.

If you have severe watery diarrhea, seek medical care right away.

Medical care facilities are strained with the high number of people who are ill. If you will be traveling to Haiti, CDC recommends that you purchase medical evacuation insurance in the event that you become ill while in Haiti. (See the U.S. Department of State list of U.S.-Based Air Ambulance or Medical Evacuation Companies.) If you are in Haiti and need medical care and you do not have access to medical evacuation, you can contact the Embassy of the United States in Port-au-Prince, Haiti, (American Citizens Services Unit office hours are 7:00 a.m. to 3:30 p.m., Monday through Friday. The Consular Section is closed on U.S. and local holidays.):

Boulevard du 15 October, Tabarre 41, Tabarre, Haiti
Telephone: (509) (2) 229-8000
Facsimile: (509) (2) 229-8027
Email: acspap@state.gov

View the original article here

UPDATE: Travelers' Health - Outbreak Notice, Cholera in Haiti

Warning - Level 3, Avoid Nonessential TravelAlert - Level 2, Practice Enhanced PrecautionsWatch - Level 1, Practice Usual Precautions

An outbreak of cholera has been ongoing in Haiti since October 2010. According to the Ministere de la Sante Publique et de la Population (MSPP), as of May 22, 2013, 657,117 cases and 8,096 deaths have been reported since the cholera epidemic began in Haiti. Among the cases reported, 363,740 (55.4%) were hospitalized. Cases have been officially reported in all 10 departments of Haiti. In Port-au-Prince, the country’s capital, 176,935 cases have been reported since the beginning of the outbreak. Cases in Port-au-Prince have been reported from the following neighborhoods: Carrefour, Cite Soleil, Delmas, Kenscoff, Petion Ville, Port-au-Prince and Tabarre.

For more information on cholera cases, see the Health Summary Report from MSPP.

Cholera is a bacterial disease that can cause diarrhea and dehydration. Cholera is most often spread through the ingestion of contaminated food or drinking water. Water may be contaminated by the feces of an infected person or by untreated sewage. Food is often contaminated by water containing cholera bacteria or by being handled by a person ill with cholera.

Since the earthquake, the U.S. Department of State has maintained a travel warning for Haiti urging U.S. citizens to avoid all nonessential travel to Haiti. For more information, see http://travel.state.gov/travel/cis_pa_tw/tw/tw_5541.html.

Most travelers are not at high risk for getting cholera, but people who are traveling to Haiti should still take their own supplies to help prevent the disease and to treat it. Items to pack include

A prescription antibiotic to take in case of diarrheaWater purification tablets*Oral rehydration salts*

*In the United States, these products can be purchased at stores that sell equipment for camping or other outdoor activities.

Although no cholera vaccine is available in the United States, travelers can prevent cholera by following these 5 basic steps:

Bottled water with unbroken seals and canned/bottled carbonated beverages are safe to drink and use.Use safe water to brush your teeth, wash and prepare food, and make ice.Clean food preparation areas and kitchenware with soap and safe water and let dry completely before reuse.

*Piped water sources, drinks sold in cups or bags, or ice may not be safe. All drinking water and water used to make ice should be boiled or treated with chlorine.
To be sure water is safe to drink and use:

Boil it or treat it with water purification tablets, a chlorine product, or household bleach.Bring your water to a complete boil for at least 1 minute.To treat your water, use water purification tablets, if you brought some with you from the United States, or one of the locally available treatment products, and follow the instructions.If a chlorine treatment product is not available, you can treat your water with household bleach. Add 8 drops of household bleach for every 1 gallon of water (or 2 drops of household bleach for every 1 liter of water) and wait 30 minutes before drinkingAlways store your treated water in a clean, covered container.Before you eat or prepare foodBefore feeding your childrenAfter using the latrine or toiletAfter cleaning your child’s bottomAfter taking care of someone ill with diarrhea

*If no soap is available, scrub hands often with ash or sand and rinse with safe water.

Use latrines or other sanitation systems, like chemical toilets, to dispose of feces.Wash hands with soap and safe water after using toilets or latrines.Clean latrines and surfaces contaminated with feces using a solution of 1 part household bleach to 9 parts water.

What if I don’t have a latrine or chemical toilet?

Defecate at least 30 meters away from any body of water and then bury your feces.Dispose of plastic bags containing feces in latrines, at collection points if available, or bury it in the ground. Do not put plastic bags in chemical toilets.Dig new latrines or temporary pit toilets at least a half-meter deep and at least 30 meters away from any body of water.Boil it, cook it, peel it, or leave itBe sure to cook shellfish (like crabs and crayfish) until they are very hot all the way through.Do not bring perishable seafood back to the United States.

*Avoid raw foods other than fruits and vegetables you have peeled yourself.

Wash yourself, your children, diapers, and clothes at least 30 meters away from drinking water sources.

Before departing for Haiti, talk to your doctor about getting a prescription for an antibiotic. If you get sick with diarrhea while you are in Haiti, you can take the antibiotic, as prescribed. Also, remember to drink fluids and use oral rehydration salts (ORS) to prevent dehydration.

If you have severe watery diarrhea, seek medical care right away.

Medical care facilities are strained with the high number of people who are ill. If you will be traveling to Haiti, CDC recommends that you purchase medical evacuation insurance in the event that you become ill while in Haiti. (See the U.S. Department of State list of U.S.-Based Air Ambulance or Medical Evacuation Companies.) If you are in Haiti and need medical care and you do not have access to medical evacuation, you can contact the Embassy of the United States in Port-au-Prince, Haiti, (American Citizens Services Unit office hours are 7:00 a.m. to 3:30 p.m., Monday through Friday. The Consular Section is closed on U.S. and local holidays.):

Boulevard du 15 October, Tabarre 41, Tabarre, Haiti
Telephone: (509) (2) 229-8000
Facsimile: (509) (2) 229-8027
Email: acspap@state.gov

View the original article here

UPDATE: CDC Responds to Cholera Outbreak in Haiti

CDC is working closely with other U.S. government agencies and international partners in support of the Haitian government’s response to the cholera outbreak in that country. CDC is collaborating with the U.S. Agency for International Development, the Pan American Health Organization, the United Nations Children’s Fund, and a host of other organizations to assist the Haiti Ministry of Public Health and Population (MSPP) in a concerted effort to control the outbreak.

For more information about the outbreak in Haiti and about cholera in general, see

View the original article here

UPDATE: CDC Responds to Cholera Outbreak in Haiti

CDC is working closely with other U.S. government agencies and international partners in support of the Haitian government’s response to the cholera outbreak in that country. CDC is collaborating with the U.S. Agency for International Development, the Pan American Health Organization, the United Nations Children’s Fund, and a host of other organizations to assist the Haiti Ministry of Public Health and Population (MSPP) in a concerted effort to control the outbreak.

For more information about the outbreak in Haiti and about cholera in general, see

View the original article here

UPDATE: Frequently Asked Questions About the Haiti Cholera Outbreak

Beginning in mid-May, the Haitian Ministry of Health surveillance and reports from PAHO and other partners indicated an upsurge in cholera cases and deaths in some parts of Haiti. These cases have been primarily seen in the Departments of South-East, Grand-Anse, South and West. As of May 29, 2011, there have been 321,066 cases and 5,337 deaths and the cumulative case fatality rate is 1.6%.

The prevention steps are the same now as they have been since the original outbreak of cholera in Haiti in fall 2010: Drink and use safe water. Wash your hands often with soap and safe water. If no soap is available, scrub hands often with ash or sand and rinse with safe water. Use latrines or bury feces. Do not defecate in any body of water. Cook food well, keep it covered, eat it hot, and peel fruits and vegetables. Clean up safely—in the kitchen and in places where the family bathes and washes clothes. For more information see: Five Basic Cholera Prevention Messages

The outbreak of cholera was confirmed in Haiti on October 21, 2010.

Although we can’t be certain, experience from the Peru outbreak in the early 1990s and from other countries in Latin America suggests that we should expect to identify additional cases for many months to several years.

No, the current outbreak is not a result of the January 2010 earthquake. Outbreaks of epidemic cholera have not been documented in Haiti before or anywhere in the Caribbean since the mid-nineteenth century. For a cholera outbreak to occur, two conditions have to be met: (1) there must be significant breaches in the water, sanitation, and hygiene infrastructure used by groups of people, permitting large-scale exposure to food or water contaminated with Vibrio cholerae organisms; and (2) cholera must be present in the population. While it is unclear how cholera was introduced to Haiti, both of these conditions now exist.

Cholera is an acute, diarrheal illness caused by infection of the intestine with the bacterium Vibrio cholerae. The infection is often mild or without symptoms, but sometimes it can be severe.

Cholera infection is often mild or without symptoms, but can sometimes be severe.  In severe cases, the infected person may experience profuse watery diarrhea, vomiting, and leg cramps, which can cause rapid loss of body fluids and lead to dehydration and shock.  Without treatment, death can occur within hours.

A person can get cholera by drinking water or eating food contaminated with the cholera bacterium. In an epidemic, the source of the contamination is usually the feces of an infected person that contaminates the food and/or water.  The disease can rapidly spread in areas with inadequate treatment of sewage and drinking water, such as Haiti.  However, at this time the origin of this outbreak is unknown and CDC hopes to learn more in the course of its response to this outbreak.

Person-to-person transmission is extremely rare, even to healthcare workers during epidemics. Drinking water and food contaminated with Vibrio cholerae from the feces of an infected person is the most common source of cholera infections.

Cholera can be treated by immediately replacing fluids and salts lost through diarrhea using oral rehydration solution. This solution is used throughout the world to treat diarrhea. Antibiotics may also be used to shorten the course and diminish the severity of the illness. However, they are not as important as receiving oral or intravenous rehydration therapy.

Cholera is found naturally in the environment in many areas around the world and can move from place to place via contaminated water or food, or infected people.

Cholera can be prevented by both visitors and residents of Haiti by following the Five Basic Cholera Prevention Messages:

Drink and use safe water* Bottled water with unbroken seals and canned/bottled carbonated beverages are safe to drink and use Use safe water to brush your teeth, wash and prepare food, and to make ice Clean food preparation areas and kitchenware with soap and safe water and let dry completely before reuse *Piped water sources, drinks sold in cups or bags, or ice may not be safe and should be boiled or treated with chlorine.

To be sure water is safe to drink and use: Boil it or treat it with a chlorine product or household bleach If boiling, bring your water to a complete boil for at least 1 minute To treat your water with chlorine, use one of the locally available treatment products and follow the instructions If a chlorine treatment product is not available, you can treat your water with household bleach. Add 8 drops of household bleach for every 1 gallon of water (or 2 drops of household bleach for every 1 liter of water) and wait 30 minutes before drinking Always store your treated water in a clean, covered container Wash your hands often with soap and safe water* Before you eat or prepare food Before feeding your children After using the latrine or toilet After cleaning your child’s bottom After taking care of someone ill with diarrhea * If no soap is available, scrub hands often with ash or sand and rinse with safe water. Use latrines or bury your feces (poop); do not defecate in any body of water Use latrines or other sanitation systems, like chemical toilets, to dispose of feces Wash hands with soap and safe water after defecating Clean latrines and surfaces contaminated with feces using a solution of 1 part household bleach to 9 parts water What if I don’t have a latrine or chemical toilet? Defecate at least 30 meters away from any body of water and then bury your feces Dispose of plastic bags containing feces in latrines, at collection points if available, or bury it in the ground. Do not put plastic bags in chemical toilets Dig new latrines or temporary pit toilets at least a half-meter deep and at least 30 meters away from any body of water Cook food well (especially seafood), keep it covered, eat it hot, and peel fruits and vegetables* Boil it, Cook it, Peel it, or Leave it Be sure to cook shellfish (like crabs and crayfish) until they are very hot all the way through *Avoid raw foods other than fruits and vegetables you have peeled yourself. Clean up safely—in the kitchen and in places where the family bathes and washes clothes Wash yourself, your children, diapers, and clothes, 30 meters away from drinking water sources

In the United States, cholera was prevalent in the 1800s but water-related spread has been eliminated by modern water and sewage treatment systems.  However, U.S. travelers to areas with epidemic cholera (for example, parts of Africa, Asia, or Latin America) may be exposed to the cholera bacterium.  Additionally, travelers may bring contaminated seafood back to the United States, which can result in foodborne outbreaks of cholera.

At this time, CDC does not recommend cholera vaccines for travelers since their risk of contracting the disease is extremely low. For cholera vaccine to be effective, people need two doses, and it takes time for vaccinated people to become immune. Multiple weeks can elapse before they are protected following vaccination. Since most people travel for a short period of time, the vaccine is not recommended. Basic hygiene precautions should always be taken.

Information can be accessed on CDC’s Travelers’ Health Website as well as the CDC Cholera Website.

CDC, in collaboration with the US government led by USAID, is assisting the government of Haiti, PAHO and several other international health agencies in responding to the cholera outbreak. There are several laboratory tests in progress in CDC labs, including a variety of molecular tests, which will help determine the genetic connections between the bacterial isolates from the Haiti outbreak and other strains around the world. CDC will continue to gather information about outbreak strains for comparison to other known cholera strains. However, the most important goals right now are to save lives and reduce the spread of disease  in Haiti.

View the original article here

UPDATE: Five Basic Cholera Prevention Messages

Page last reviewed: November 4, 2010Page last updated: November 4, 2010Content source: Global Health

View the original article here

UPDATE: CDC Responds to Cholera Outbreak in Haiti

CDC is working closely with other U.S. government agencies and international partners in support of the Haitian government’s response to the cholera outbreak in that country. CDC is collaborating with the U.S. Agency for International Development, the Pan American Health Organization, the United Nations Children’s Fund, and a host of other organizations to assist the Haiti Ministry of Public Health and Population (MSPP) in a concerted effort to control the outbreak.

For more information about the outbreak in Haiti and about cholera in general, see

View the original article here

MMWR: Cholera Outbreak --- Dec 24, 2010 Update: Haiti, Dominican Republic, and Florida

On October 21, 2010, a cholera outbreak was confirmed by the Haitian National Public Health Laboratory (1). By November 19, the outbreak had reached every department of the country, and by December 17, a total of 121,518 cases of cholera, resulting in 63,711 hospitalizations and 2,591 deaths, had been reported. By November 16, additional cases of cholera had been confirmed in the neighboring Dominican Republic and in Florida. Several confirmed cases in the Dominican Republic and all confirmed U.S. cases were among travelers from Haiti. This report describes cases of cholera identified in the Dominican Republic and United States and provides recommendations to physicians regarding management of travel-related cases. Travelers who develop watery diarrhea within 5 days after returning from cholera-affected areas should seek health care and report their travel histories. Clinicians should enquire about recent travel when evaluating patients with diarrhea. When cholera is suspected, rehydration should be initiated immediately, a stool specimen should be collected for culture of Vibrio cholerae, and public health authorities should be notified.

Dominican Republic

In the Dominican Republic, intensive surveillance for cholera-like illness and laboratory testing to confirm cases were initiated by the Ministry of Public Health on October 24, 2010. Suspected cases were defined as profuse watery diarrhea among persons aged =5 years, death in a person with acute watery diarrhea, or diarrhea among persons with an epidemiologic link to a laboratory-confirmed case. Suspected cases were reported to the Ministry's Division of Epidemiology. When possible, rectal swabs were collected from suspected cases, transported in Cary Blair media, and sent to the National Reference Laboratory for confirmation by isolation of V. cholerae and agglutination with V. cholerae O1 antiserum.

Through December 18, a total of 399 suspected cases were reported; laboratory testing was performed for at least 327 of these cases. V. cholerae O1 serotype Ogawa was identified in 59 cases; the majority of negative test results were attributed to other enteric pathogens for which testing is not performed routinely. Three confirmed cases were attributed to importation from Haiti, one each in the provinces of La Altagracia, Independencia and Monte Cristi. The remaining 56 confirmed cases occurred in the provinces of Santiago (19), San Juan (11), Elías Piña (10), Santo Domingo (10), Dajabón (two), Valverde (two), Independencia (one), and Monte Cristi (one). These 56 cases, with no known association with travel from Haiti, were attributed to local transmission (Figure). Of the 59 confirmed cases, 46 (78%) resulted in hospitalization; no fatalities have been confirmed.

Three separate outbreaks of cholera, involving 19 of the 59 confirmed cases, were identified and investigated in the Dominican Republic. In El Dique, a resource-poor neighborhood in the capital city of Santo Domingo, eight cases of cholera-like illness, including six confirmed cholera cases, were identified in two households; investigation suggested household transmission, although the vehicle of transmission was not determined. In a second outbreak in Navarrete, Santiago Province, preliminary investigation suggested that contaminated canal water was the source of infection for 29 cases of cholera-like illness (six confirmed). A third outbreak in Bánica, Elías Piña Province, occurred in a community along the banks of the Artibonite River near the Haitian border and resulted in nine cases (seven confirmed); drinking untreated river water was considered the most likely source of infection.

United States

In the United States, cholera is a nationally notifiable disease. A confirmed case of cholera is defined by the Council of State and Territorial Epidemiologists as a clinically compatible illness in a person from whom toxigenic V. cholerae O1 or O139 has been isolated from stool or vomitus, or who has serologic evidence of recent infection.* After the outbreak was confirmed in Haiti, to encourage early reporting of suspected cholera cases without waiting for laboratory confirmation, the Florida Department of Health created two working case classifications for surveillance purposes.† A probable case was defined as a clinically compatible illness in a person with a stool culture that yielded Vibrio species and who recently traveled to Haiti or another affected area or who was linked epidemiologically to a confirmed case. A suspected case was defined as a clinically compatible illness in a person who recently traveled to Haiti or another affected area or who was linked epidemiologically to a confirmed case, but whose stool culture or serology results were pending. Case reporting guidelines were distributed to county health departments, and clinician advisories were developed and distributed.

As of December 18, a total of 13 cases had been investigated by the Florida Department of Health. V. cholerae O1 serotype Ogawa was isolated from stool specimens of five patients at Florida laboratories. All five developed symptoms during October 23--November 29, either while in Haiti or on the day of arrival in Florida from Haiti. The five patients with confirmed cases ranged in age from 9 to 84 years; four were female. One patient reported using community well water in Haiti for drinking and bathing, one had eaten several meals in family homes in Haiti, and one was a physician who had treated cholera patients in Haiti but might have had other exposures. In addition to diarrhea, reported symptoms included abdominal pain or cramping, vomiting, and lethargy or weakness.

Four of the five patients were hospitalized, including two who had been evaluated in an emergency department, discharged the same day, and readmitted 2--3 days later. A history of recent travel from Haiti had not been elicited on the first emergency department visit for one of those patients. All five patients with confirmed cholera received intravenous rehydration and oral antibiotics, including single doses of doxycycline or ciprofloxacin or multiday courses of doxycycline, tetracycline, azithromycin, or ciprofloxacin; three patients received two different antibiotics. Some treatment regimens were not consistent with recommendations. No secondary transmission was identified.

Characterization of Isolates

Isolates from four confirmed cases in the Dominican Republic and all five Florida cases were sent to CDC for confirmation and additional characterization. All were confirmed as toxigenic V. cholerae O1, serotype Ogawa, biotype El Tor, and matched the Haiti outbreak strain by pulsed-field gel electrophoresis (2). Those isolates from Florida cases had the same antimicrobial susceptibility pattern as the Haiti outbreak strain (pending for Dominican Republic isolates). CDC's laboratory assessment of 380 cholera isolates subtyped since 2005 has indicated that isolates from the cases in Haiti, the Dominican Republic, and Florida are most similar to a strain previously characterized from South Asia and elsewhere.

PH Jenkins, MPH, HJ Montejano, MS, Broward County Health Dept; MJ Abbasi, MD, MS Crowley, MS, MG O'Brien, Collier County Health Dept; V Conte, MD, M Etienne, MPH, E Rico, MPH, Miami-Dade County Health Dept; DG Rea, MPH, Orange County Health Dept; RM Baker, MS, EA Burden, LD Gillis, PhD, JJ Hamilton, MPH, RS Hopkins, MD, AC Kite-Powell, MS, E Merlo, Florida Dept of Health. Ministry of Public Health, Dominican Republic. Ministry of Public Health and Population, Haiti. Pan American Health Organization. CDC.

Less than 4 weeks after the Haitian National Public Health Laboratory first confirmed cholera in Haiti and before cholera had been identified in all 10 Haitian departments, confirmed cases were reported in the neighboring Dominican Republic and in a resident of Florida who had traveled to Haiti. Transnational spread of cholera is not uncommon. In late January 1991, an outbreak of cholera began in Peru and, by 1992, had spread to most other countries in Central and South America and to the United States (3). During 2000--2008, of 51 cholera cases in the United States reported to CDC, 29 (57%) were associated with international travel.§

Although transnational spread of cholera is caused most commonly by importation by travelers, it also has been associated with contaminated food that was imported commercially (4) or transported by travelers (5). Toxigenic V. cholerae also can be transported by ships' ballast water (6).

Travel between Haiti and other countries predominantly involves those countries where most expatriate Haitians reside (7). In November, of approximately 60,000 airline passenger seats available on direct flights from Haiti, 76% were on flights to the United States and U.S. territories, 17% to the Dominican Republic and other Caribbean islands, 4% to France, 2% to Canada, and 2% to Panama.¶ Substantial travel also occurs across the border between Haiti and the Dominican Republic.

More cholera cases associated with the current outbreak in Haiti are expected. In preparation for an anticipated increase in holiday travel, public health authorities in countries receiving travelers from Haiti should consider the need to heighten surveillance for cholera and educate clinicians to be vigilant for cholera-like illness in patients who have traveled from cholera-affected areas. CDC is distributing Travel Health Alert Notices to travelers from Haiti to the United States, advising them to seek health care promptly if they develop diarrhea within 5 days after arrival.

Although the risk for acquiring cholera during travel is low (8), travelers can reduce their risk for cholera and other enteric infections by drinking and using water that has been boiled or treated or is supplied in cans or bottles, eating only food that has been cooked and served hot, paying vigorous attention to handwashing with soap, and avoiding swimming or bathing in rivers. Health-care providers and persons traveling to Haiti or other cholera-affected countries should consult CDC,** World Health Organization (WHO),†† or Pan American Health Organization (PAHO)§§ websites for general information about international travel and for specific information related to cholera. Neither cholera vaccine nor chemoprophylaxis is indicated for U.S. travelers to Haiti. CDC, the Haitian Ministry of Public Health and Population, PAHO, and other organizations are evaluating the potential role of cholera vaccines for populations in Haiti and other countries.

Physicians evaluating patients with diarrhea should obtain a travel history. If cholera is suspected, clinicians should initiate rehydration, treat hospitalized patients with antibiotics, obtain a stool specimen for culture before starting antibiotic treatment (if indicated), and report the case to public health authorities. The risk for person-to-person transmission is low, and isolation of cholera patients or quarantine of asymptomatic travelers from affected areas is not warranted. However, persons in sensitive occupations, such as food preparation, child care or health care, should not work while they have diarrhea.

The mainstay of cholera treatment is vigorous oral or intravenous rehydration. Antibiotics can reduce the volume and duration of diarrhea and should be given to hospitalized patients. A single dose of doxycycline by mouth (300 mg for nonpregnant adults; 2--4 mg/kg for children, not to exceed 300 mg) is the preferred regimen. A single dose of azithromycin (1 g by mouth) is recommended for pregnant women. Alternative therapies and additional guidance for clinicians are available from CDC¶¶ and PAHO.

The Florida Department of Health provided advisories to clinicians, prompting correct referral of specimens to clinical laboratories. Because Vibrio species require special media for isolation, the laboratory should be notified to suspect cholera. Specific information on V. cholerae culture methods and specimen transport can be found at CDC's cholera website.*** In the United States, all suspected cholera isolates should be sent to state public health laboratories and from there to CDC for confirmation and additional characterization.

The potential for secondary transmission of cholera is low in countries where sanitation, water, and food production systems minimize the risk for fecal contamination. Only two instances of secondary transmission in the United States have been reported since 1965 (8,9). Spread within the Dominican Republic has been limited to date, as is typical in countries with improved water and sanitation infrastructure.††† Nonetheless, the risk for secondary and ongoing transmission of cholera remains high in populations with limited access to improved water sources and sanitation.

An increase in reported cases of cholera associated with holiday travel to cholera-affected areas is anticipated in the United States and other countries. Travelers are encouraged to take precautions, and providers should suspect cholera in patients with diarrhea and recent travel to cholera-affected areas. All suspected cases should be reported to public health authorities, and stool samples should be collected under appropriate conditions to increase the yield of V. cholerae. In 2009, 45 countries reported 221,226 cases of cholera to WHO (10). The persistence of cholera in any country puts other countries at risk. Until cholera is controlled around the world, importations to other countries probably will continue, and areas with poor water and sanitation infrastructure will be at risk for transmission. Public health authorities in unaffected countries should be vigilant in monitoring for cholera introductions and take public health actions to prevent its spread.

CDC. Update: outbreak of cholera---Haiti, 2010. MMWR 2010;59:1586--90.CDC. Update: cholera outbreak---Haiti, 2010. MMWR 2010;59;1473--9.CDC. Update: Vibrio cholerae O1---Western Hemisphere, 1991--1994, and V. cholerae O139---Asia, 1994. MMWR 1995;44:215--9. Taylor JL, Tuttle J, Pramukul T, et al. An outbreak of cholera in Maryland associated with imported commercial frozen fresh coconut milk. J Infect Dis 1993;167:1330--5.Finelli L, Swerdlow D, Mertz K, Ragazzoni H, Spitalny K. Outbreak of cholera associated with crab brought from an area with epidemic disease. J Infect Dis 1992;166:1433--5.McCarthy SA, Khambaty FM. International dissemination of epidemic Vibrio cholerae by cargo ship ballast and other nonpotable waters. Appl Environ Microbiol 1994;60:2597--601.Pan American Health Organization. Haiti. In: Health in the Americas. Volume II-countries. Pan American Health Organization; 2007:412--29. Available at http://www.paho.org/hia/archivosvol2/paisesing/haiti%20english.pdf.Weber JT, Levine WC, Hopkins DP, Tauxe RV. Cholera in the United States, 1965--1991. Risks at home and abroad. Arch Intern Med 1994;154:551--6.Ackers M, Pagaduan R, Hart G, et al. Cholera and sliced fruit: probable secondary transmission from an asymptomatic carrier in the United States. Int J Infect Dis 1997;1:212--4.World Health Organization. Cholera, 2009. Wkly Epidemiol Rec 2010;85:293--308.

What is already known on this topic?

A cholera outbreak has spread rapidly through Haiti since October 2010. Transnational spread of cholera is not uncommon.

What is added by this report?

Cholera has now been confirmed in the Dominican Republic and Florida, and the strains are indistinguishable from the strain causing the outbreak in Haiti. Secondary spread in the Dominican Republic has been limited to date; in the United States, no transmission to household contacts has been reported.

What are the implications for public health practice?

Additional cases of cholera in travelers from Haiti are likely to occur in the United States, the Dominican Republic, and elsewhere. Clinicians should ask patients with diarrhea about their travel history. If cholera is suspected, clinicians should initiate rehydration, treat hospitalized patients with antibiotics, obtain a stool specimen for culture before starting antibiotic treatment (if indicated), and report the case to public health authorities.

FIGURE. Confirmed cholera cases (N = 59), by province --- Dominican Republic, 2010*

Alternate Text: The figure above shows confirmed cholera cases (N = 59), by province in the Dominican Republic in 2010. Three confirmed cases were attributed to importation from Haiti, one each in the provinces of La Altagracia, Independencia and Monte Cristi. The remaining 56 confirmed cases, with no known association with travel from Haiti, have been attributed to local transmission.

Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.

References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of pages found at these sites. URL addresses listed in MMWR were current as of the date of publication.

All MMWR HTML versions of articles are electronic conversions from typeset documents. This conversion might result in character translation or format errors in the HTML version. Users are referred to the electronic PDF version (http://www.cdc.gov/mmwr) and/or the original MMWR paper copy for printable versions of official text, figures, and tables. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Government Printing Office (GPO), Washington, DC 20402-9371; telephone: (202) 512-1800. Contact GPO for current prices.

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Update: Defeating Cholera: Clinical Presentation and Management for Haiti Cholera Outbreak, 2010

Rapid high-volume rehydration will save livesMany patients can be rehydrated entirely with oral rehydration solution (ORS)Even if the patient gets intravenous (IV) rehydration, he/she should start drinking ORS as soon as he/she is able

Most persons infected with the cholera bacterium have mild diarrhea or no symptoms at all. Only about 7% of persons infected with Vibrio cholerae O1 have illness requiring treatment at a health center.

Cholera patients should be evaluated and treated quickly. With proper treatment, even severely ill patients can be saved. Prompt restoration of lost fluids and salts is the primary goal of treatment.

Watch "Defeating Cholera" video.

Symptoms of Moderate or Severe CholeraProfuse, watery diarrheaVomitingLeg crampsSigns and Symptoms of DehydrationSome dehydrationSevere dehydrationRestlessness and irritabilitySunken eyesDry mouth and tongueIncreased thirstSkin goes back slowly when pinchedDecreased urineInfants: decreased tears, depressed fontanelsLethargy or unconsciousnessVery dry mouth and tongueSkin goes back very slowly when pinched (“tenting”)Weak or absent pulseLow blood pressureMinimal or no urine

Dehydrated patients who can sit up and drink should be given oral rehydration salts
(ORS) solution immediately and be encouraged to drink. It is important to offer ORS
solution frequently, measure the amount drunk, and measure the fluid lost as diarrhea
and vomitus. Patients who vomit should be given small, frequent sips of ORS solution,
or ORS solution by nasogastric tube. ORS solution should be made with safe water. Safe
water means the water has been boiled or treated with a chlorine product or household
bleach.

Guidelines for treating patients with some dehydration Approximate amount of ORS solution to give in the first 4 hours to patients with some dehydration. Use the patient’s age only when you do not know the weight:The approximate amount of ORS (in milliliters) can also be calculated by multiplying the patient’s weight in kg by 75.A rough estimate of oral rehydration rate for older children and adults is 100 ml ORS every five minutes, until the patient stabilizes. If the patient requests more than the prescribed ORS solution, give more.For Infants: Encourage the mother to continue breast-feeding.

1. The volumes and time shown are guidelines based on usual needs. If necessary, amount and frequency can be increased, or the ORS solution can be given at the same rate for a longer period to achieve adequate rehydration. Similarly, the amount of fluid can be decreased if hydration is achieved earlier than expected.
2. During the initial stages of therapy, while still dehydrated, adults can consume as much as 1000 ml of ORS solution per hour, if necessary, and children as much as 20 ml/kg body weight per hour.
3. Reassess the patient after 1 hour of therapy and then every 1 to 2 hours until rehydration is complete.
4. Resume feeding with a normal diet when vomiting has stopped.

Patients with severe dehydration, stupor, coma, uncontrollable vomiting, or extreme fatigue that prevents drinking should be rehydrated intravenously.

Plain glucose (dextrose) solution

*Acceptable in emergency, but does not correct acidosis and may worsen electrolyte imbalance.

Guidelines for treating patients
with severe dehydration
Start intravenous fluids (IV) immediately. If the patient can drink,
give ORS solution by mouth while the IV drip is set up.
Give 100 ml/kg Ringer’s Lactate Solution divided as follows:AgeFirst give 30 ml/kg IV in:Then give 70 ml/kg IV in:

* Repeat once if radial pulse is still very weak or not detectable.

Reassess the patient every 1-2 hours and continue hydrating. If hydration is not improving, give the IV drip more rapidly. 200ml/kg or more may be needed during the first 24 hours of treatment.Also give ORS solution (about 5 ml/kg per hour) as soon as the patient can drink.After 6 hours (infants) or 3 hours (older patients), perform a full reassessment. Switch to ORS solution if hydration is improved and the patient can drink.Skin goes back normally when pinchedThirst has subsidedUrine has been passedPulse is strong

An antibiotic given orally will reduce the volume and duration of diarrhea. Treatment with antibiotics is recommended for moderately and severely ill patients, particularly for those patients who continue to pass large volume of stools during rehydration treatment, and including all patients who are hospitalized.  Do not give antibiotics to asymptomatic persons. Zinc given orally can reduce the duration of most infectious diarrhea in children. No drugs should be given for treatment of diarrhea or vomiting besides antibiotics and zinc.

Appropriate oral antibiotics (give one of these) ** ALL BY MOUTH** These recommendations are based on the antibiotic resistance profile of V. cholerae isolates from the Haiti cholera outbreak, as reported on December 14, 2010, and local drug availability. Multiple first choice and second choice options are presented. Selection of antibiotics should be based on individual case consideration and available medications.Patient classificationFirst choiceSecond choiceDoxycycline: 300 mg by mouth in one doseAzithromycin:1 gram in a single dose

Tetracycline: 500 mg 4 times a day for 3 days

Erythromycin: 500 mg 4 times a day for 3 days

Azithromycin: 1 gram in one doseErythromycin: 500 mg 4 times a day for 3 daysChildren =12 months old and capable of swallowing pills and/or tablesAzithromycin: 20 mg/kg in one dose

Erythromycin: 12.5 mg/kg 4 times a day for 3 days

Doxycycline: 2-4 mg/kg in one dose*

Tetracycline: 12.5 mg/kg 4 times a day for 3 daysChildren <12 months old and others unable to swallow pills and/or tabletsAzithromycin oral suspension: 20 mg/kg in one dose

Erythromycin oral suspension: 12.5 mg/kg 4 times a day for 3 days

Doxycycline oral suspension: 2-4 mg/kg in one dose*

Tetracycline oral suspension: 12.5mg/kg 4 times a day for 3 days

* Doxycycline is safe for treatment of cholera in children at the recommended dose. The Pan American Health Organization recommends doxycycline as a second-line choice because of limited regional availability and to avoid future overuse in children.

Zinc supplementation significantly reduces the severity and duration of most childhood diarrhea caused by infection. When available, supplementation (10-20 mg zinc per day) should be started immediately.

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UPDATE: Cholera: Diagnosis and Treatment in Haiti

Laboratory Test Results of Cholera Outbreak Strain in Haiti Announced

Growth of V. cholerae on thiosulphate citrate bile salt sucrose agar  (TCBS)
Photo Credit: Centers for Disease Control and Prevention Atlanta, Georgia 1999

Culture: Vibrio cholerae (V. cholerae) is confirmed through culture from stool or rectal swabs. For isolation and identification, a selective medium, thiosulfate citrate bile salts (TCBS) agar is used and the serogroup and serotype is confirmed using V. cholerae specific antisera.

Antibiotic Susceptibility Testing: Many bacteria, including V.  cholerae, show resistance to some antibiotics used to treat illnesses. It is important for clinicians to understand what drugs various bacteria are typically resistant to in order to prescribe effective treatment regimens. In addition, related bacteria usually show similar resistance patterns. Bacterial drug resistance can be tested in the laboratory. Bacteria are exposed to various concentrations of multiple antibiotics. Bacteria that grow are considered resistant whereas bacteria that do not grow are considered susceptible.

Antibiotic susceptibility testing requires several days to perform. Antibiotic susceptibility testing of selected isolates provides information that helps inform recommended antibiotic therapy for treating a population. However, it is not recommended for guiding care for individual patients.

The V. cholerae isolates from people with cholera in Haiti have undergone antimicrobial susceptibility testing.

Scanning electron micrograph of V. cholerae bacteria
Photo Credit: Centers for Disease Control and Prevention Atlanta, Georgia 2005

Current antibiotic testing results show*:

*Susceptibility testing of selected isolates from ill patients in Haiti will continue, and clinicians should be alert for changes in antibiotic treatment recommendations based on clinical experience in Haiti.
**Susceptibility inferred based on tetracycline testing.

Rapid Tests:  Commercially available rapid immunochromatographic test kits for stool antigen are useful in epidemic settings but do not yield an isolate for antimicrobial susceptibility testing and subtyping, and should not be used for routine diagnosis.

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MMWR: Cholera Outbreak --- Dec 10, 2010 Update: Haiti

On December 8, 2010, this report was posted as an MMWR Dispatch on the MMWR website (http://www.cdc.gov/mmwr).

The first cholera outbreak in Haiti in at least a century was confirmed by the Haitian National Public Health Laboratory on October 21, 2010 (1). Surveillance data through December 3, provided by the Haitian Ministry of Public Health and Population (MSPP), indicated that the outbreak had spread nationwide and that cases of cholera and cholera-associated hospitalizations and deaths had climbed rapidly in November. As of December 3, MSPP reported 91,770 cases of cholera from all 10 departments and the capital city of Port-au-Prince; 43,243 (47.1%) patients had been hospitalized, and 2,071 (2.3%) had died. A rapid mortality assessment in Artibonite Department found that deaths occurred as rapidly as 2 hours after symptom onset and identified important gaps in access to life-saving treatments, including oral rehydration solution (ORS). Urgent activities are under way, and additional efforts are imperative to reduce cholera mortality by expanding access to cholera treatment and to reduce cholera transmission by improving access to safe water and adequate sanitation.

A nationwide cholera surveillance system has been established in Haiti. Hospitals and clinics send daily case counts to local MSPP officials; aggregate data are sent on to department-level officials and then to central government officials. A case of cholera is defined as profuse, acute, watery diarrhea in a resident of a department in which at least one case of cholera has been laboratory-confirmed by isolation of Vibrio cholerae from culture of a stool specimen. A hospitalized case occurs in a patient admitted to a health facility (i.e., a hospital or cholera treatment site) for at least one night. A cholera death is the death of a person with illness that meets the case definition for cholera. Any cholera death that occurs in a health facility, regardless of whether the decedent was admitted overnight, is considered a cholera hospital death. MSPP posts daily and cumulative tallies of cholera reports on a public website; tallies are stratified by department and age group (aged <5 years and all ages).* Since November 16, nonhospitalized cases have been posted in addition to hospitalized cases.

All 10 departments and the capital city of Port-au-Prince have reported laboratory-confirmed cases of cholera. As of December 3, a total of 91,770 cases had been reported nationwide, and 43,243 (47.1%) patients had been hospitalized (Figure 1). The largest number of cases (42,596 [46.4%]) were reported from Artibonite Department, which comprises approximately 16% of the Haiti population (2) and is the department where cases were first laboratory-confirmed (Figure 2). As of December 3, of 2,071 deaths, 1,437 (69.4%) had occurred in hospitals. A total of 82,599 (90.0%) cases, 39,435 (91.2%) hospitalizations, and 1,908 (92.1%) deaths had occurred among persons aged =5 years.

Nationwide, during November 27--December 3, the median daily number of deaths was 41 (range: 18--64). As of December 3, the overall case-fatality ratio (CFR) (cumulative deaths divided by cumulative cases) was 2.3%. The hospital CFR (cumulative hospital deaths divided by cumulative hospitalized cases) was 3.3%. The daily nationwide hospital CFR has varied; however, simple linear regression indicates decreases in the rolling 7-day hospital CFR in Artibonite (p<0.001) and in all other departments combined (p<0.001) (Figure 3). In Artibonite Department, the rolling 7-day hospital CFR decreased from a high of 4.2% on November 9 to a low of 1.4% on December 1 (Figure 3).

A rapid assessment of mortality from cholera among persons aged =5 years was conducted in Artibonite Department during November 12--16. Teams visited homes of 22 cholera decedents identified through records in two hospitals. Family members were interviewed about decedents' use of ORS and other health-care services. Family and community members were asked about other cholera deaths in the community, resulting in identification of an additional 65 decedents, whose families also were interviewed. Among the total of 87 cholera decedents identified, 58 (67%) were male; eight (9.2%) were aged 5--18 years, and 79 (90.8%) were aged 19--100 years. Of the 87 deaths, 48 (55%) occurred in a hospital or other health facility, and 39 (45%) occurred in the community. For those who died in the community, median time to death from onset of symptoms was 12 hours (range: 2 hours--8 days). Only nine (23%) of the 39 persons who died in the community received ORS. Sixteen (41%) of the 39 had sought health care; eight died en route to a health facility, and eight died after discharge. When asked to cite reasons for not seeking health care, family members in 10 cases did not think the ill person had cholera; family members in seven cases reported difficulty getting to a health facility (including transport at night), and family members in six cases did not see the need to seek care.

Ministry of Public Health and Population, Haiti. Pan American Health Organization. CDC.

Surveillance data show that from October 21 to December 3, cholera spread rapidly across Haiti. Although decreasing, the hospital CFR of 3.3% remains high. Improvements in receipt of appropriate care in health facilities might be reflected in the decreasing hospital CFR. However, when cholera is recognized early and appropriate rehydration treatment is initiated rapidly, a CFR <1% can be achieved among patients who have sought care (3). The outbreak strain of cholera has been identified as a "hybrid" strain of the El Tor biotype and the classic toxin type; the classic toxin might be associated with more severe illness, and the El Tor biotype is associated with longer persistence in the environment (4,5).† Underlying poor nutritional status and other comorbidities also are likely to contribute to disease severity in Haiti (6,7). In 2008, only 63% of Haiti's population had access to an improved drinking water source,§ and only 17% had access to adequate sanitation (8). The lack of safe water and sanitation infrastructure in Haiti and the devastation caused by the January 2010 earthquake have created conditions favorable for the rapid spread of cholera across the country.

A cholera epidemic in the Western Hemisphere began in 1991 and lasted for nearly a decade, spreading across Central and South America in countries that, like Haiti, were previously unexposed to cholera and thus lacked population immunity (9). Peru experienced the highest cholera incidence and mortality among affected countries. During the first 6 full epidemiologic weeks of the cholera epidemic in Peru, 19,431 hospitalizations (87.5 per 100,000 population) and 368 cholera deaths (1.7 per 100,000) were reported (10). By comparison, during the first 6 full weeks of the Haiti outbreak, 39,010 hospitalizations (393 per 100,000 population) and 1,882 cholera deaths (19.0 per 100,000) were reported. Thus, early rates of reported hospitalizations and deaths in Haiti were substantially higher than those in Peru (rate ratios: 4.5 and 11.5, respectively). In fact, the death rate during 6 weeks of the outbreak in Haiti (19.0 per 100,000) exceeded the death rate observed during the first 48 weeks of the Peru epidemic (13.1 per 100,000).¶

Urgent measures are being taken to expand access to treatment that will mitigate cholera morbidity and mortality; improvements in water quality and sanitation also are necessary to reduce transmission. Because cholera can progress quickly to severe dehydration, shock, and death, rapid rehydration is the mainstay of cholera treatment. In the mortality assessment presented in this report, only nine of 39 cholera decedents who died outside of health facilities had received ORS, and eight died en route to care. Early access to ORS in homes, in communities (e.g., at specially designated ORS sites), and at health facilities can slow disease progression, reduce the need for hospitalization, and reduce mortality. Because cholera can lead to death rapidly, ideally all persons at risk for cholera should be within 1 hour of a location where they can receive ORS and should have access to more advanced care at specially designated cholera treatment centers.

MSPP, the U.S. government, and multiple other governmental and nongovernmental entities have worked rapidly under challenging circumstances to establish, staff, and supply cholera treatment sites. To expand treatment options further, the United States is developing cholera treatment sites within health facilities supported by the President's Emergency Plan for AIDS Relief (PEPFAR). In addition, CDC, MSPP, and the International Centre for Diarrhoeal Disease Research, Bangladesh, have developed a train-the-trainer program** in which health workers educated in cholera treatment and clinical management techniques are providing clinical training to health workers across the country. Ensuring sufficient supplies and staffing for cholera treatment sites during the evolving cholera outbreak will be challenging, and ensuring appropriate care will require systematic assessments of cholera treatment sites.

Short-term and long-term efforts also are needed to prevent cholera transmission. In the short-term, products for household water chlorination and safe water storage must be made available to all households and health facilities, including in communities not yet affected by cholera. Hand washing with soap and safe sanitation behaviors, including latrine use, need to be reinforced, and soap should be made more widely available. Safe food-handling practices, in homes and in open markets, ought to be encouraged. Although much work has been done by MSPP and its partners to improve access to safe drinking water and adequate sanitation in the areas of Haiti hardest hit by the January 2010 earthquake, additional activities are needed to ensure long-term access. In the coming months, certain efforts will be critical for reducing cholera transmission and mortality: 1) sustaining and improving drinking water chlorination; 2) improving access to safe drinking water sources; 3) enhancing water, sanitation, and hygiene education activities; and 4) ensuring appropriate sanitation measures in cholera treatment centers to prevent contamination of the environment.

The findings in this report are subject to at least four limitations. First, cholera cases and deaths, particularly those not evaluated or occurring in health facilities, likely are underreported, and how reporting might differ among facilities and age groups is not well understood. Second, the mortality assessment was conducted in one area of Artibonite Department, and sampling was not systematic; as such, demographic characteristics, circumstances of illness, and location of death might not be representative of all deaths in the country. Third, family member responses in the mortality assessment might not have provided an accurate account of the decedent's perceptions or experiences. Finally, population estimates used to calculate rates for cholera morbidity and mortality are uncertain, particularly because of the mortality caused by the earthquake in Haiti.

Despite strong responses from MSPP and governments and nongovernmental agencies, the size and speed of this cholera outbreak, combined with the lack of safe water and sanitation infrastructure in Haiti, indicate that further action is urgently needed to reduce cholera transmission and mortality. All parties should extend their periods of involvement and redouble their efforts to support efforts in Haiti to reduce the burden of this disease.

CDC. Update: cholera outbreak---Haiti, 2010. MMWR 2010;59:1473--9.Direction des Statistique Demographiques et Sociales of the Institut Haitien de Statistique et d'Informatique. Population totale, population de 18 ans et plus menages et densites estimes en 2009 [French]. March 2009. Available at http://www.ihsi.ht/pdf/projection/poptotal&menagdens_estim2009.pdf. Accessed December 6, 2010.World Health Organization. Cholera. Fact sheet no. 107. Geneva, Switzerland: World Health Organization; June 2010. Available at http://www.who.int/mediacentre/factsheets/fs107/en/index.html. Accessed on December 8, 2010.Siddique A, Nair G, Alam M, et al. El Tor cholera with severe disease: a new threat to Asia and beyond. Epidemiol Infect 2010;138:347--52.Gangarosa E. The epidemiology of cholera: past and present. Bull NY Acad Med 1971;47:1140--51.Palmer D, Koster F, Alam A, Islam M. Nutritional status: a determinant of severity of diarrhea in patients with cholera. J Infect Dis 1976;134:8--14. Von Seidlein L, Wang X, Macuamule A, et al. Is HIV infection associated with an increased risk for cholera? Findings from a case-control study in Mozambique. Trop Med Int Health 2008;13:683--8.World Health Organization and UNICEF. Progress on sanitation and drinking water: 2010 update. Geneva, Switzerland: WHO Press; 2010. Available at http://www.who.int/water_sanitation_health/publications/9789241563956/en/index.html. Accessed December 6, 2010.Swerdlow DL, Mintz ED, Rodriguez M, et al. Waterborne transmission of epidemic cholera in Trujillo, Peru: lessons for a continent at risk. Lancet 1992;340:28--32.Ministry of Health, Peru. Cholera epidemic in Peru. Epidemiological Bulletin no. 11, 1991.

What is already known on this topic?

Cholera is marked by profuse, acute, watery diarrhea that can lead to rapid dehydration and death; case-fatality ratios can be reduced to <1% with early recognition and appropriate rehydration. For at least a century, no cholera outbreak had occurred in Haiti.

What is added by this report?

As of December 3, a total of 91,770 cases of cholera had been reported in Haiti from all 10 departments and the city of Port-au-Prince, including 43,243 hospitalizations and 2,071 deaths; the case-fatality ratio was 2.3% overall and 3.3% among persons hospitalized. A mortality assessment of 87 decedents indicated that some deaths occurred within 2 hours after symptom onset and important gaps exist in access to life-saving rehydration.

What are the implications for public health practice?

The potential exists to prevent many cholera deaths in Haiti; to do so, urgent efforts are needed to recognize affected patients early, provide ready access to oral rehydration solution, and provide access to more advanced care at cholera treatment centers as needed. Short-term and long-term measures to improve water and sanitation in Haiti also are necessary.

FIGURE 1. Reported number of new cases of cholera (N = 91,770), by hospitalization status --- Haiti, October 20--December 3, 2010*

Alternate Text: The figure above shows the daily reported number of new cholera cases in Haiti, including hospitalized and nonhospitalized cases, during October 20-December 3, 2010.

FIGURE 2. Cumulative number of cases of cholera reported overall* and date of first laboratory-confirmed case, by department and in Port-au-Prince†--- National Cholera Monitoring System, Haiti, December 3, 2010

* Artibonite 42,596; Port-au-Prince 12,566; Nord 10,436; Nord' Ouest 9,735; Centre 9,527; Ouest 4,899; Sud 419; Nord' Est 341; Grande Anse 205; Sud' Est 76; Nippes 34.

† Includes the following communes: Carrefour, Cite Soleil, Delmas, Kenscoff, Petion Ville, Port-au-Prince, and Tabarre.

Alternate Text: The figure above is a map showing the cumulative number of cases of cholera in Haiti's 10 departments and the capital, Port-au-Prince, as of December 3, 2010. The largest number of cases (42,596) were reported from Artibonite Department, which comprises approximately 16% of the Haitian population and is the department where cases were first laboratory-confirmed.

FIGURE 3. Rolling 7-day hospital case-fatality ratio* for Artibonite and all other departments --- Haiti, October 31--
December 3, 2010

Alternate Text: The figure above shows the rolling 7-day cholera hospital case-fatality ratio for Artibonite Department and all other departments combined in Haiti during October 31-December 3. In Artibonite Department, the rolling 7-day hospital CFR decreased from a high of 4.2% on November 9 to a low of 1.4% on December 1.

Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.

References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of pages found at these sites. URL addresses listed in MMWR were current as of the date of publication.

All MMWR HTML versions of articles are electronic conversions from typeset documents. This conversion might result in character translation or format errors in the HTML version. Users are referred to the electronic PDF version (http://www.cdc.gov/mmwr) and/or the original MMWR paper copy for printable versions of official text, figures, and tables. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Government Printing Office (GPO), Washington, DC 20402-9371; telephone: (202) 512-1800. Contact GPO for current prices.

**Questions or messages regarding errors in formatting should be addressed to mmwrq@cdc.gov.

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Scientists measure reaction rates of second key atmospheric component (Update)

Researchers at Sandia National Laboratories' Combustion Research Facility, the University of Manchester, Bristol University, University of Southampton and Hong Kong Polytechnic have successfully measured reaction rates of a second Criegee intermediate, CH3CHOO, and proven that the reactivity of the atmospheric chemical depends strongly on which way the molecule is twisted.

The measurements will provide further insight into hydrocarbon combustion and atmospheric chemistry. A paper describing the research findings titled "Direct Measurements of Conformer-Dependent Reactivity of the Criegee Intermediate CH3CHOO" is featured in the April 12 edition of Science magazine.

Criegee intermediates—carbonyl oxides—are considered to be pivotal atmospheric reactants, but only indirect knowledge of their reaction kinetics had previously been available. Last year, Sandia and its UK-based partners reported, for the first time, direct measurements of reactions of the smallest gas-phase Criegee intermediate using photoionization mass spectrometry. That research was featured in the January 13, 2012, edition of Science. A short video featuring two Sandia researchers describing the work can be seen below:

This video is not supported by your browser at this time.

New findings include confirmed fast reactions, first-time measurements with water

Sandia combustion chemist Craig Taatjes, the lead author on the Science papers, said there are several significant aspects about the new research findings.

In particular, the measurements show that the reaction rate depends dramatically on whether the CH3CHOO is bent, with the CH3– and –OO ends pointing toward the same side, a conformation called "syn–" or more straightened, with the CH3– and –OO ends pointing away from each other, called "anti–".

"Observing conformer-dependent reactivity represents the first direct experimental test of theoretical predictions," said Taatjes. "The work will be of tremendous importance in validating the theoretical methods that are needed to accurately predict the kinetics for reactions of Criegee intermediates that still cannot be measured directly."

In fact, said Taatjes, the latest results supply one of the most critical targets for such validation. Because of the large concentration of water in Earth's atmosphere, Criegee concentrations—and, hence, the tropospheric implications of all Criegee intermediate reactions—depend on knowing the rate constant for reaction with water.

Although the reactions for most Criegee intermediates, including the syn- conformer of CH3CHOO, with water may simply be too slow to be measured by the research team's methods, anti-CH3CHOO has been predicted to have a vastly enhanced reactivity with water. Taatjes and his colleagues confirmed this prediction and made the first experimental determination of the reaction rate of a Criegee intermediate with water. "A Criegee intermediate's reaction with water determines what the concentration of these intermediates in the atmosphere is going to be. This is a significant benchmark," he said.

Taatjes said one of the questions remaining after the first direct measurement of Criegee reactions was whether the remarkably fast reaction of CH2OO with SO2 was representative of other Criegee intermediates.

"This measurement of a second intermediate—which we found to react just about as fast with sulfur dioxide as the intermediate we measured last year—supports the notion that the reactions of all Criegee intermediates with SO2 will occur easily," said Taatjes "It also confirms that Criegee intermediate reactions are likely to make a contribution to sulfate and nitrate chemistry in the troposphere." This increase in reactivity, he said, provides additional evidence that Criegee intermediates will play a significant role in the oxidation of sulfur dioxide in the atmosphere.

Unraveling the mysteries, complexities of Criegee intermediates

Hydrocarbons that are emitted into Earth's troposphere, either naturally or by humans, are removed by many reactive atmospheric species. For unsaturated hydrocarbons—molecules with at least one C=C double bond—a prominent removal mechanism is reaction with ozone, called ozonolysis. It is accepted that ozonolysis produces other reactive species, including carbonyl oxides, which are known as Criegee intermediates. Rudolf Criegee, a German chemist, first proposed the mechanism of ozonolysis in the 1950s.

Because so much ozonolysis happens in the atmosphere, the reactions of Criegee intermediates are thought to be very important in a wide range of tropospheric processes like secondary organic aerosol formation and nighttime production of highly reactive OH radicals. As a result, the chemistry of these reactive Criegee intermediates has been the subject of intense investigation for decades, but without any direct measurement of their reaction rates until last year's published work by Sandia and its collaborators.

More information: "Infrared Absorption Spectrum of the Simplest Criegee Intermediate CH2OO," by Y.-T. Su, Science, 2013. www.sciencemag.org/content/335/6065/204

Journal reference: Science

Provided by Sandia National Laboratories

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UPDATE 3-Telecom Italia directors to consider Hutchison tie-up

* Chairman, committee of four directors to assess deal proposal-sources

* Formal negotiations have not started-sources

* Telco shareholders divided - sources

* Shares up 1.7 pct

By Lisa Jucca and Danilo Masoni

MILAN, April 11 (Reuters) - Telecom Italia has appointed a panel of directors to consider a proposed tie-up with Hutchison Whampoa which would make the Hong Kong group Telecom Italia's top shareholder in return for merging their local mobile businesses.

After a six-hour board meeting Telecom Italia issued a statement on Thursday saying it has asked its chairman Franco Bernabe and four other board members to examine Hutchison's proposal "in a short period of time" and see whether it is in its interest to pursue negotiations.

According to sources familiar with the situation Hutchison would be willing to take a near 30 percent stake in Italy's biggest telecoms operator by folding its 3 Italia business into Telecom and buying out controlling Telecom shareholders who are sitting on big losses on the value of their holdings.

3 Italia is the smallest of the four operators in the Italian mobile market, vying with Telecom Italia, Vodafone and Wind, but analysts reckon it could still be worth 1.5 to 2 billion euros.

Under the proposals Hutchison would get shares in exchange for selling 3 Italia but Telecom Italia said Hutchison had also set as a condition for the tie-up the purchase of an additional stake in the enlarged group that would make it the leading shareholder.

According to sources close to the situation Hutchison would buy that additional stake from Telco, the consortium of shareholders which owns 22.4 percent of Telecom Italia and comprises Spain's Telefonica and Italy's Generali , Intesa Sanpaolo and Mediobanca.

The sources have said Hutchison is prepared to buy Telecom Italia's shares from Telco for 1.2 euros per share - the valuation which Telco holds in its books after repeated writedowns which is twice the current market value.

However, sources close to Telco told Reuters on Thursday that a majority of the consortium's shareholders were sceptical about the tie-up proposal, with Telefonica taking a particularly critical stance. Telefonica is the largest shareholder in Telco and has a right of first refusal over Telecom Italia's shares owned by Telco.

One of the sources said it was difficult to see the business logic for such a deal and that a tie-up could create antitrust concerns as the combined group would have a 46 percent market share in Italy's mobile market.

However, another senior source said there were divisions among the Telco shareholders.

FIXED LINE NETWORK

Also, it was unclear whether the enlarged group would still include Telecom Italia's politically-sensitive fixed line business, valued at between 12-15 billion euros.

Telecom said in its statement that its management would also consider the feasibility of spinning-off the network, although it made no direct link between this and the Hutchison proposal.

The company has been in talks for months with Italian state-backed fund Cassa Depositi e Prestiti over such a spin-off, which could remove a potential hurdle to any deal with Hutchison.

Any decision on a deal and on the network separation is further complicated by Italy's political stalemate following an inconclusive election in February. The Italian treasury holds a golden share in Telecom Italia that gives it veto powers over new shareholders and other strategic decisions.

But by merging its Italian unit into Telecom Hutchison would ease competition pressure in the Italian market, and the combined group could reap synergies worth 500 million euros, according to analysts.

And Bernabe is under pressure to find a way to improve returns for his debt-laden group, which is now struggling against falling margins in its crisis-hit home market as well as a cooling in its other main market, Brazil, where it competes with Telefonica.

Telecom said Bernabe will be joined on the panel exploring a possible deal with Hutchison by directors Gabriele Galateri di Genola, Elio Catania and Julio Linares - representing Telco - along with independent director Luigi Zingales.

A source close to Telco said the panel was expected to report back in two to three weeks.

Shares in Telecom Italia closed 1.7 percent higher at 0.6125 euros.

View the original article here

UPDATE 3-Telecom Italia directors to consider Hutchison tie-up

* Chairman, committee of four directors to assess deal proposal-sources

* Formal negotiations have not started-sources

* Telco shareholders divided - sources

* Shares up 1.7 pct

By Lisa Jucca and Danilo Masoni

MILAN, April 11 (Reuters) - Telecom Italia has appointed a panel of directors to consider a proposed tie-up with Hutchison Whampoa which would make the Hong Kong group Telecom Italia's top shareholder in return for merging their local mobile businesses.

After a six-hour board meeting Telecom Italia issued a statement on Thursday saying it has asked its chairman Franco Bernabe and four other board members to examine Hutchison's proposal "in a short period of time" and see whether it is in its interest to pursue negotiations.

According to sources familiar with the situation Hutchison would be willing to take a near 30 percent stake in Italy's biggest telecoms operator by folding its 3 Italia business into Telecom and buying out controlling Telecom shareholders who are sitting on big losses on the value of their holdings.

3 Italia is the smallest of the four operators in the Italian mobile market, vying with Telecom Italia, Vodafone and Wind, but analysts reckon it could still be worth 1.5 to 2 billion euros.

Under the proposals Hutchison would get shares in exchange for selling 3 Italia but Telecom Italia said Hutchison had also set as a condition for the tie-up the purchase of an additional stake in the enlarged group that would make it the leading shareholder.

According to sources close to the situation Hutchison would buy that additional stake from Telco, the consortium of shareholders which owns 22.4 percent of Telecom Italia and comprises Spain's Telefonica and Italy's Generali , Intesa Sanpaolo and Mediobanca.

The sources have said Hutchison is prepared to buy Telecom Italia's shares from Telco for 1.2 euros per share - the valuation which Telco holds in its books after repeated writedowns which is twice the current market value.

However, sources close to Telco told Reuters on Thursday that a majority of the consortium's shareholders were sceptical about the tie-up proposal, with Telefonica taking a particularly critical stance. Telefonica is the largest shareholder in Telco and has a right of first refusal over Telecom Italia's shares owned by Telco.

One of the sources said it was difficult to see the business logic for such a deal and that a tie-up could create antitrust concerns as the combined group would have a 46 percent market share in Italy's mobile market.

However, another senior source said there were divisions among the Telco shareholders.

FIXED LINE NETWORK

Also, it was unclear whether the enlarged group would still include Telecom Italia's politically-sensitive fixed line business, valued at between 12-15 billion euros.

Telecom said in its statement that its management would also consider the feasibility of spinning-off the network, although it made no direct link between this and the Hutchison proposal.

The company has been in talks for months with Italian state-backed fund Cassa Depositi e Prestiti over such a spin-off, which could remove a potential hurdle to any deal with Hutchison.

Any decision on a deal and on the network separation is further complicated by Italy's political stalemate following an inconclusive election in February. The Italian treasury holds a golden share in Telecom Italia that gives it veto powers over new shareholders and other strategic decisions.

But by merging its Italian unit into Telecom Hutchison would ease competition pressure in the Italian market, and the combined group could reap synergies worth 500 million euros, according to analysts.

And Bernabe is under pressure to find a way to improve returns for his debt-laden group, which is now struggling against falling margins in its crisis-hit home market as well as a cooling in its other main market, Brazil, where it competes with Telefonica.

Telecom said Bernabe will be joined on the panel exploring a possible deal with Hutchison by directors Gabriele Galateri di Genola, Elio Catania and Julio Linares - representing Telco - along with independent director Luigi Zingales.

A source close to Telco said the panel was expected to report back in two to three weeks.

Shares in Telecom Italia closed 1.7 percent higher at 0.6125 euros.

View the original article here

UPDATE 3-Telecom Italia directors to consider Hutchison tie-up

* Chairman, committee of four directors to assess deal proposal-sources

* Formal negotiations have not started-sources

* Telco shareholders divided - sources

* Shares up 1.7 pct

By Lisa Jucca and Danilo Masoni

MILAN, April 11 (Reuters) - Telecom Italia has appointed a panel of directors to consider a proposed tie-up with Hutchison Whampoa which would make the Hong Kong group Telecom Italia's top shareholder in return for merging their local mobile businesses.

After a six-hour board meeting Telecom Italia issued a statement on Thursday saying it has asked its chairman Franco Bernabe and four other board members to examine Hutchison's proposal "in a short period of time" and see whether it is in its interest to pursue negotiations.

According to sources familiar with the situation Hutchison would be willing to take a near 30 percent stake in Italy's biggest telecoms operator by folding its 3 Italia business into Telecom and buying out controlling Telecom shareholders who are sitting on big losses on the value of their holdings.

3 Italia is the smallest of the four operators in the Italian mobile market, vying with Telecom Italia, Vodafone and Wind, but analysts reckon it could still be worth 1.5 to 2 billion euros.

Under the proposals Hutchison would get shares in exchange for selling 3 Italia but Telecom Italia said Hutchison had also set as a condition for the tie-up the purchase of an additional stake in the enlarged group that would make it the leading shareholder.

According to sources close to the situation Hutchison would buy that additional stake from Telco, the consortium of shareholders which owns 22.4 percent of Telecom Italia and comprises Spain's Telefonica and Italy's Generali , Intesa Sanpaolo and Mediobanca.

The sources have said Hutchison is prepared to buy Telecom Italia's shares from Telco for 1.2 euros per share - the valuation which Telco holds in its books after repeated writedowns which is twice the current market value.

However, sources close to Telco told Reuters on Thursday that a majority of the consortium's shareholders were sceptical about the tie-up proposal, with Telefonica taking a particularly critical stance. Telefonica is the largest shareholder in Telco and has a right of first refusal over Telecom Italia's shares owned by Telco.

One of the sources said it was difficult to see the business logic for such a deal and that a tie-up could create antitrust concerns as the combined group would have a 46 percent market share in Italy's mobile market.

However, another senior source said there were divisions among the Telco shareholders.

FIXED LINE NETWORK

Also, it was unclear whether the enlarged group would still include Telecom Italia's politically-sensitive fixed line business, valued at between 12-15 billion euros.

Telecom said in its statement that its management would also consider the feasibility of spinning-off the network, although it made no direct link between this and the Hutchison proposal.

The company has been in talks for months with Italian state-backed fund Cassa Depositi e Prestiti over such a spin-off, which could remove a potential hurdle to any deal with Hutchison.

Any decision on a deal and on the network separation is further complicated by Italy's political stalemate following an inconclusive election in February. The Italian treasury holds a golden share in Telecom Italia that gives it veto powers over new shareholders and other strategic decisions.

But by merging its Italian unit into Telecom Hutchison would ease competition pressure in the Italian market, and the combined group could reap synergies worth 500 million euros, according to analysts.

And Bernabe is under pressure to find a way to improve returns for his debt-laden group, which is now struggling against falling margins in its crisis-hit home market as well as a cooling in its other main market, Brazil, where it competes with Telefonica.

Telecom said Bernabe will be joined on the panel exploring a possible deal with Hutchison by directors Gabriele Galateri di Genola, Elio Catania and Julio Linares - representing Telco - along with independent director Luigi Zingales.

A source close to Telco said the panel was expected to report back in two to three weeks.

Shares in Telecom Italia closed 1.7 percent higher at 0.6125 euros.

View the original article here

UPDATE 3-Telecom Italia directors to consider Hutchison tie-up

* Chairman, committee of four directors to assess deal proposal-sources

* Formal negotiations have not started-sources

* Telco shareholders divided - sources

* Shares up 1.7 pct

By Lisa Jucca and Danilo Masoni

MILAN, April 11 (Reuters) - Telecom Italia has appointed a panel of directors to consider a proposed tie-up with Hutchison Whampoa which would make the Hong Kong group Telecom Italia's top shareholder in return for merging their local mobile businesses.

After a six-hour board meeting Telecom Italia issued a statement on Thursday saying it has asked its chairman Franco Bernabe and four other board members to examine Hutchison's proposal "in a short period of time" and see whether it is in its interest to pursue negotiations.

According to sources familiar with the situation Hutchison would be willing to take a near 30 percent stake in Italy's biggest telecoms operator by folding its 3 Italia business into Telecom and buying out controlling Telecom shareholders who are sitting on big losses on the value of their holdings.

3 Italia is the smallest of the four operators in the Italian mobile market, vying with Telecom Italia, Vodafone and Wind, but analysts reckon it could still be worth 1.5 to 2 billion euros.

Under the proposals Hutchison would get shares in exchange for selling 3 Italia but Telecom Italia said Hutchison had also set as a condition for the tie-up the purchase of an additional stake in the enlarged group that would make it the leading shareholder.

According to sources close to the situation Hutchison would buy that additional stake from Telco, the consortium of shareholders which owns 22.4 percent of Telecom Italia and comprises Spain's Telefonica and Italy's Generali , Intesa Sanpaolo and Mediobanca.

The sources have said Hutchison is prepared to buy Telecom Italia's shares from Telco for 1.2 euros per share - the valuation which Telco holds in its books after repeated writedowns which is twice the current market value.

However, sources close to Telco told Reuters on Thursday that a majority of the consortium's shareholders were sceptical about the tie-up proposal, with Telefonica taking a particularly critical stance. Telefonica is the largest shareholder in Telco and has a right of first refusal over Telecom Italia's shares owned by Telco.

One of the sources said it was difficult to see the business logic for such a deal and that a tie-up could create antitrust concerns as the combined group would have a 46 percent market share in Italy's mobile market.

However, another senior source said there were divisions among the Telco shareholders.

FIXED LINE NETWORK

Also, it was unclear whether the enlarged group would still include Telecom Italia's politically-sensitive fixed line business, valued at between 12-15 billion euros.

Telecom said in its statement that its management would also consider the feasibility of spinning-off the network, although it made no direct link between this and the Hutchison proposal.

The company has been in talks for months with Italian state-backed fund Cassa Depositi e Prestiti over such a spin-off, which could remove a potential hurdle to any deal with Hutchison.

Any decision on a deal and on the network separation is further complicated by Italy's political stalemate following an inconclusive election in February. The Italian treasury holds a golden share in Telecom Italia that gives it veto powers over new shareholders and other strategic decisions.

But by merging its Italian unit into Telecom Hutchison would ease competition pressure in the Italian market, and the combined group could reap synergies worth 500 million euros, according to analysts.

And Bernabe is under pressure to find a way to improve returns for his debt-laden group, which is now struggling against falling margins in its crisis-hit home market as well as a cooling in its other main market, Brazil, where it competes with Telefonica.

Telecom said Bernabe will be joined on the panel exploring a possible deal with Hutchison by directors Gabriele Galateri di Genola, Elio Catania and Julio Linares - representing Telco - along with independent director Luigi Zingales.

A source close to Telco said the panel was expected to report back in two to three weeks.

Shares in Telecom Italia closed 1.7 percent higher at 0.6125 euros.

View the original article here

UPDATE 3-Telecom Italia directors to consider Hutchison tie-up

* Chairman, committee of four directors to assess deal proposal-sources

* Formal negotiations have not started-sources

* Telco shareholders divided - sources

* Shares up 1.7 pct

By Lisa Jucca and Danilo Masoni

MILAN, April 11 (Reuters) - Telecom Italia has appointed a panel of directors to consider a proposed tie-up with Hutchison Whampoa which would make the Hong Kong group Telecom Italia's top shareholder in return for merging their local mobile businesses.

After a six-hour board meeting Telecom Italia issued a statement on Thursday saying it has asked its chairman Franco Bernabe and four other board members to examine Hutchison's proposal "in a short period of time" and see whether it is in its interest to pursue negotiations.

According to sources familiar with the situation Hutchison would be willing to take a near 30 percent stake in Italy's biggest telecoms operator by folding its 3 Italia business into Telecom and buying out controlling Telecom shareholders who are sitting on big losses on the value of their holdings.

3 Italia is the smallest of the four operators in the Italian mobile market, vying with Telecom Italia, Vodafone and Wind, but analysts reckon it could still be worth 1.5 to 2 billion euros.

Under the proposals Hutchison would get shares in exchange for selling 3 Italia but Telecom Italia said Hutchison had also set as a condition for the tie-up the purchase of an additional stake in the enlarged group that would make it the leading shareholder.

According to sources close to the situation Hutchison would buy that additional stake from Telco, the consortium of shareholders which owns 22.4 percent of Telecom Italia and comprises Spain's Telefonica and Italy's Generali , Intesa Sanpaolo and Mediobanca.

The sources have said Hutchison is prepared to buy Telecom Italia's shares from Telco for 1.2 euros per share - the valuation which Telco holds in its books after repeated writedowns which is twice the current market value.

However, sources close to Telco told Reuters on Thursday that a majority of the consortium's shareholders were sceptical about the tie-up proposal, with Telefonica taking a particularly critical stance. Telefonica is the largest shareholder in Telco and has a right of first refusal over Telecom Italia's shares owned by Telco.

One of the sources said it was difficult to see the business logic for such a deal and that a tie-up could create antitrust concerns as the combined group would have a 46 percent market share in Italy's mobile market.

However, another senior source said there were divisions among the Telco shareholders.

FIXED LINE NETWORK

Also, it was unclear whether the enlarged group would still include Telecom Italia's politically-sensitive fixed line business, valued at between 12-15 billion euros.

Telecom said in its statement that its management would also consider the feasibility of spinning-off the network, although it made no direct link between this and the Hutchison proposal.

The company has been in talks for months with Italian state-backed fund Cassa Depositi e Prestiti over such a spin-off, which could remove a potential hurdle to any deal with Hutchison.

Any decision on a deal and on the network separation is further complicated by Italy's political stalemate following an inconclusive election in February. The Italian treasury holds a golden share in Telecom Italia that gives it veto powers over new shareholders and other strategic decisions.

But by merging its Italian unit into Telecom Hutchison would ease competition pressure in the Italian market, and the combined group could reap synergies worth 500 million euros, according to analysts.

And Bernabe is under pressure to find a way to improve returns for his debt-laden group, which is now struggling against falling margins in its crisis-hit home market as well as a cooling in its other main market, Brazil, where it competes with Telefonica.

Telecom said Bernabe will be joined on the panel exploring a possible deal with Hutchison by directors Gabriele Galateri di Genola, Elio Catania and Julio Linares - representing Telco - along with independent director Luigi Zingales.

A source close to Telco said the panel was expected to report back in two to three weeks.

Shares in Telecom Italia closed 1.7 percent higher at 0.6125 euros.

View the original article here