Hi, my name is Doctor Eric Mintz and I am an epidemiologist at the CDC, the Centers for Disease Control and Prevention in Atlanta. Today I'm going to talk about a real life example of how diarrheal diseases surveillance was implemented in a complex humanitarian emergency. On January 12th 2010, Haiti experienced a magnitude 7.0 earthquake. The earthquake caused massive destruction of almost all infrastructure. Within days over 200,000 persons had died and over 1.4 million person were displaced. The epicenter of the earthquake was near the capital Port-au-Prince. The US embassy in Port-au-Prince where the CDC country office was located immediately became the headquarters for all US government supported relief efforts. And CDC work closely with the Ministry of Health and NGOs to initiate disease surveillance and sent into health facilities around the country. And in camps, for internally displaced persons in the Port-au-Prince area. Our team was asked to help lead the surveillance effort for diarrhea and other infectious diseases. Before boarding the CDC jet to Port Au Prince, we learned that rates of malnutrition and HIV were high. Vaccine coverage was low and 11% of the population was under 5 years old. We also learned that typhoid fever and shigella were endemic in Haiti, but that cholera had never been reported. Despite the fact that coverage with safe water and sanitation was very low. Unfortunately, there was no information available on baseline disease rates. However, we knew that oral rehydration solution was widely used for diarrheal treatment. Disease surveillance through sentinel health facility sites began on January 25th for all of the diseases listed here. Each day, the sentinel sites reported the numbers of patients seen with each of the 13 conditions shown here in white, including acute watery diarrhea and acute bloody diarrhea. Nationwide, all health providers were immediately told to report any of the top six conditions in gray and suspected outbreaks of any of the remaining of 13 conditions. Sentinel surveillance was extended to the 21 major IDP camps in Port-au-Prince on February 18th. The disease surveillance form included information on age group and on the number of deaths attributed to each disease. Graphs like this one allowed us to follow trends in disease occurrence and maps allowed us to visualize where reported diseases and deaths were most prevalent. We even followed the number of newly constructed latrines and showers in the camps for displaced persons. To have a sense for whether diarrheal disease prevention efforts were on track. As all this was getting started, we trained and equipped the laboratory with everything they needed. To perform rapid test for cholera ,typhoid fever and shiga toxin-producing bacteria, such as Shigella dysenteriae. And to isolate and identify these pathogens from stool culture and to test the isolates for antimicrobial resistance. And then the unthinkable occurred. On October 20th, ten months after the earthquake surveillance was launched, a cluster of adult patients with acute watery diarrhea and death was reported. Stool samples from ten surviving patients were brought to the National Public Health laboratory. Rapid tests for cholera were performed and eight of the ten tested positive for cholera. By the next evening, the diagnosis of cholera was confirmed by stool culture. The following day, antimicrobial susceptibility testing was initiated and isolates were sent to CDC for further testing. By October 23rd, we had returned to Haiti. Despite the early detection of cholera, we were too late to prevent the epidemic from spreading throughout the country. And causing over 750,000 cases of whom over 400,000 were hospitalized and over 8,000 died. The epidemic continues today and reminds us of the need to re-double our efforts at prevention of diarrheal diseases. Thank you and for more information on diarrheal diseases, please visit the CDC website.