Thank you for supporting Partners In Health and our efforts to fight Cholera in Haiti. We’re thrilled to share excerpts from an article recently published on our website about the success of the Cholera vaccination campaign—made possible with the support of generous people like yourself.
When a cholera epidemic exploded in Haiti less than a year after the devastating earthquake in January of 2010, the staff at Partners In Health/Zanmi Lasante responded immediately and aggressively. We mobilized thousands of community health workers, opened cholera treatment wards, ran sanitation and hygiene initiatives, and more. A proposal to administer the new, World Health Organization-approved vaccine Shanchol was also floated.
The idea was doubted and criticized by many, but the community wanted the vaccine, and PIH/ZL was determined to provide the best care available. With the blessing of the Haitian Ministry of Health, PIH/ZL pushed ahead, and after overcoming all sorts of obstacles in distributing the tiny vials—training legions of staff, fighting the axle-gripping mud of rainy season, working around a simultaneous polio vaccination campaign, ensuring 45,417 patients swallowed two doses of the drug two weeks apart—the campaign finished in June 2012.
This past February, Dr. Louise C. Ivers and colleagues published a paper showing exactly how much the vaccine Shanchol slowed the spread of cholera in villages north of St. Marc, Haiti, in 2012. Writing in The Lancet Global Health online, the senior health and policy adviser at Partners In Health finds that Shanchol was widely effective when administered to thousands of adults and children in the region. “We found that there were about 65 percent fewer cholera cases among people that were vaccinated than there were in those that were unvaccinated,” she says.
It’s fantastic news, and not just for the obvious reason that fewer cholera cases means fewer cholera fatalities. ”Effectiveness of reactive oral cholera vaccination in rural Haiti: a case-control study and bias-indicator analysis” also reminds us of the importance of a vaccination campaign that almost never happened. And it paves the way for even stronger efforts to end the epidemic that has killed 8,800 Haitians and infected 20,000 last year alone. “It’s a huge victory,” says Dr. Ralph Ternier, director of community care and support at Partners In Health's (PIH) sister organization Zanmi Lasante (ZL).
“Our study contributes to mounting evidence that oral cholera vaccines have an important role to play as a component of comprehensive, integrated cholera control efforts in Haiti,” the study concludes.
As Dr. Ivers hints, the results of the study aren’t as earth-shattering as might be expected, but rather put a fine point on a cholera-fighting strategy that has become, well, standard. Since the vaccination campaign, the Haitian Ministry of Health, with the support of their partners, administered the vaccine to 300,000 citizens, and the World Health Organization has begun stockpiling the drug for use in future outbreaks.
In 2010, Partners In Health responded to the devastating 7.0 earthquake that struck Haiti, as well as the subsequent cholera outbreak. Above, community health workers conduct public outreach as part of the cholera vaccination campaign.
Thank you for supporting Partners In Health and our work to eradicate cholera in Haiti. Below is a reflection written by PIH/Haiti staff member Ralph Ternier, 5 years after the earthquake and subsequent cholera outbreak. Your support enables us to continue making progress and saving lives in Haiti.
Ralph Ternier is director of community care and support at Zanmi Lasante, Partners In Health’s sister organization in Haiti. Here he reflects on his experiences during the country’s earthquake in 2010—and the five years since.
A few days ago we celebrated the 211th anniversary of the famous Haitian Independence Day. This tiny land of contradiction has witnessed stunning and unfortunate events over the last two centuries. Some people keep saying the nation is damned; others who are attached to the country speak of hope, solidarity, and compassion, especially after having faced one of history’s most destructive and deadly earthquakes.
In a few days we will remind ourselves how fragile and precious life can be. For many years into the future we will tell our grandchildren about that day of sorrow. Some might refuse to believe such a narrative. Even I was incredulous toward what the Dominican taxi driver told me that Tuesday evening five years ago.
I had left Haiti to go to the Dominican Republic at 4:30 p.m. on January 12—20 minutes before my people plunged into the deepest desperation. I returned to Haiti two days later in a small airplane with two Partners In Health colleagues. From the sky I could watch the chaos on the ground—people with their belongings running away from death, an abyss of curse.
From that day on, we spent the whole year rescuing, saving, and relieving as many as possible, guided by one label: TNTC (too numerous to count). Then the first cholera epidemic in the country’s history hit, stressing and weakening the health system further.
But always there is opportunity.
We have learned particularly in this last decade that all these unfortunate events and disasters must be a platform to revitalize the health system. Five years after the terrible earthquake, it is important for us to reflect on our major achievements, impediments, and perspectives.
In addition to the roughly 1 million people that received emergency and general health care, we pride ourselves on the legacy of the teaching hospital in Mirebalais that came from all the international support. During 2010, Zanmi Lasante (ZL) understood that this massive contribution to the public health sector wouldn’t be productive without sustaining the community health structure. Therefore we formalized all ZL community activities through the new department of community care and support.
Very often we ask ourselves how we would adequately fight cholera without these tireless workers who still go door to door to raise awareness of the epidemic and ensure that community members are safe and protected. In many narratives we’ll frequently link cholera and the earthquake: they happened the same year, they created panic and chaos, and they took away so many lives.
But we have become stronger in the wake of these disasters. Our network of community health workers has grown to 350 members, and we now have several thousand accompagnateurs—compared to fewer than 100 before 2010.Challenges, however, persist. The earthquake destroyed most of the important public health facilities in several departments, especially in West, where the needs of the surrounding population dramatically increased. To respond to these needs, the community network stepped up to expand services, such as rehab and mental health care in the communities.
A few days ago, I drove into the so-called downtown of Port-au-Prince. At points I felt as if I was living in 2010 as rubbles is still piled on many avenues. One of my friends in the car from the diaspora asked me how I kept morale and stayed in the country. With a beaming smile I responded with what someone had told me the day I came back: “This country cannot be worse; it can only be better.”
After five years, everything that we are doing for the health system, for the patients, must be better, better than what it was before 2010, better than what it was during the cholera outbreak—better for the sake of our beloved lost during these tragedies.
Photo: Carline, 29, received treatment for cholera at a Partners In Health cholera treatment center in Mirebalais, Haiti, in March.
We thank you for supporting Partners In Health and our work to treat and prevent cholera in Haiti. Below is an overview of our work since the outbreak began, as reported by Cate Oswald, Senior Program Manager for Parters In Health in Haiti. Your continued support allows us to address the ongoing needs of patients across Haiti. Often it is a very small amount of money that is required to save the life of someone infected with cholera.
Since cholera was introduced to Haiti in October 2010, it has killed more than 8,500 people, sickened more than 700,000, and become one of the world’s largest epidemics in recent history. To date, Partners In Health (PIH) and our Haitian sister organization Zanmi Lasante (ZL) have treated more than 105,000 cases in the Central Plateau, representing almost one-sixth of total cholera cases in Haiti. PIH/ZL has also worked in partnership with the nonprofit GHESKIO to vaccinate nearly 100,000 people in the first-ever oral cholera vaccine campaign in Haiti.
As it is clear that cholera is in Haiti for the long term, PIH/ZL remains committed to a comprehensive strategy for cholera prevention and treatment. With a main focus on providing high-quality treatment and care, our strategy has incorporated public education; aggressive case finding; oral cholera vaccine implementation; improved access to clean water and proper sanitation; and advocacy of stronger international policies and funding accessibility for cholera treatment and prevention in Haiti.
PIH/ZL is deeply committed to doing whatever it takes to stem the tide of cholera in Haiti. Each day, our community teams distribute chlorine solution so that people can treat their water, and our staff of dedicated doctors, nurses, cooks, cleaners, and infection control specialists work to prevent new infections and deaths from cholera. PIH/ZL maintains a level of preparedness, in the form of clinical staff and treatment supplies, to respond to spikes in cholera cases within our service area and ensure that all new cases are diagnosed and treated. We continue to provide cholera treatment services in the form of acute diarrheal disease units at each of the public hospitals where we work in conjunction with the MSPP.
Truly bringing an end to cholera in Haiti will require a coordinated effort: the government, private sector, and public sector must invest together in a comprehensive response, including long-term improvements in water and sanitation. PIH/ZL is dedicated to continuing advocacy efforts with governments and multilateral organizations to work toward a long-term solution for water security and infrastructure in Haiti, as well as disseminating far and wide the news of our successful efforts to comprehensively combat cholera. Research reporting the resultsof PIH’s cholera vaccination project in Haiti was recently published in The American Journal of Tropical Medicine and Hygiene.
Despite the fact that international funding for cholera prevention and treatment has diminished, we anticipate that health facilities will continue to see more cases and more deaths from cholera, particularly in rural areas. PIH/ZL continues to seek dedicated funding to ensure that we are able to maintain our comprehensive approach, prevent unnecessary deaths, and build on the progress Haiti has made in combating the cholera epidemic.
We are so grateful for your support of Partners In Health and our work to prevent and treat cholera in Haiti. We are pleased to share a brief update around some of the current successes and challenges that our colleagues are seeing on the ground in Haiti.
Since January, the number of cholera cases and fatalities have decreased across PIH's 11 facilities in Haiti, but the epidemic continues to sicken thousands across the country, hitting the most vulnerable populations the hardest--like malnourished children who have low immunity. With rainy season quickly approaching, the need for basic treatment and prevention tools has never been greater.
Below is an excerpt from a New York Times article authored by Randal C. Archibold and Somini Sengupta, discussing the current situation in Haiti, and citing examples of how PIH's approach is working:
The United Nations raised barely a fourth of the $38 million it needed last year to provide lifesaving supplies, including the most basic, like water purification tablets. Clinics have run short of oral rehydration salts to treat the debilitating diarrhea that accompanies the disease. Some treatment centers in the countryside have shut down as the aid groups that ran them have moved on to other crises. And a growing share of patients are dying after they finally reach hospitals, according to the United Nations’ own assessments.
Josilia Fils-Aime, 11, who lives in this village on an isolated spit of land near the Artibonite River, where the epidemic first began, knows these shortcomings all too well. Her family had run out of water purification tablets, and she drank water from what must have been a polluted stream nearby.
“I felt dizzy and sick,” the girl said. She was struck by sudden vomiting and diarrhea. Doctors diagnosed cholera.
Her predicament has multiplied across Haiti, which has had the most cholera cases in the world for three years in a row.
The United Nations has yet to raise the $5 million necessary to vaccinate 600,000 vulnerable people right away — as the rainy season approaches and the threat of waterborne illnesses like cholera looms — let alone the $2 billion that it promised to raise from rich countries to build Haiti’s water and sanitation infrastructure, which public health experts say is vital to ridding the country of cholera.
Pedro Medrano Rojas, the United Nations secretary general’s newly appointed envoy for the cholera outbreak, attributed the shortfall to global “donor fatigue” in the face of other humanitarian crises.
“Had we had the resources it would have been different,” Mr. Medrano said. “It’s not expensive. No one should be dying from cholera.”
Since the outbreak began in October 2010, 8,562 people in Haiti have died of cholera. New infections have declined, following the typical trajectory of an epidemic, from a peak of more than 350,000 reported cases in 2011 to a little more than 50,000 cases in 2013.
The United Nations is essential to solving the problem because, like many of the country’s institutions since the January 2010 earthquake, Haiti’s own health care system remains in shambles. Clean drinking water and sanitation remain as scarce as when the epidemic began. And where international nonprofit groups, along with the government, once operated 120 cholera treatment centers across the nation, the number has shrunk to barely 40 as aid groups have pulled out.
Perhaps that most troubling measure of all is the rising percentage of cholera patients who die in the treatment facilities that remain. As the United Nations mission said in its report to the Security Council in March, “That reflects weaknesses in the capacity of health centers to provide timely and adequate health services to patients affected by cholera and the longer travel time required for treatment as a result of the closure of many cholera treatment centers.”
Josilia Fils-Aime, for instance, most likely survived because Partners in Health, a nonprofit that has worked in Haiti for years, opened a satellite clinic near her home. The next closest cholera treatment center would have required a two-hour trek, including a boat ride.
“In any other country, you would declare it a humanitarian disaster,” said Dr. Louise Ivers, a health policy adviser for Partners in Health. “What’s going to happen when the rainy season starts?”
By Mr. Medrano’s estimates, as many as 40,000 people could become infected once the clouds break and the rivers swell.
Haiti’s cholera outbreak has spread to three countries across the region: the Dominican Republic, Cuba and Mexico. The fatality rates have been much lower in those countries, which have far better public health systems; it is a measure of how easy it can be to treat the disease.
Three years since cholera broke out in Haiti, prevention and treatment efforts have helped control the epidemic, but the disease is far from gone.
An infectious disease that causes vomiting and diarrhea, cholera can lead to deadly dehydration in as little as 24 hours. In Haiti, where most people lack access to clean water and sanitation, cholera spread rapidly through waterways, accelerated by heavy rains and flooding. Since it appeared on Oct. 19, 2010, it has killed more than 8,000 people and caused about 650,000 cases, sickening approximately one in 15 Haitians.
Haiti’s Ministry of Health and aid groups responded quickly to help control the epidemic. Partners In Health, with our Haitian sister organization, Zanmi Lasante (PIH/ZL), has treated more than 105,000 cases in the Central Plateau, representing almost one-sixth of total cholera cases in Haiti. Cholera has declined since the peak of the epidemic, but persists: Last month, PIH providers treated more than 1,700 cases in clinics and hospitals. Meanwhile, funding for cholera prevention and treatment has diminished since the initial emergency.
“We’re making progress, and we know what we’re doing,” said Dr. Louise Ivers, senior health and policy advisor for Partners In Health, who reported some of the earliest cases of cholera in Haiti. “We need funds to keep a sustained response going.”
The governments of Haiti and the Dominican Republic have created a 10-year strategy to eliminate cholera from the island of Hispaniola, which they share. Haiti, which has seen the vast majority of cases, has called for a comprehensive response, including short-term measures such as vaccination, to stay the disease during the long-term work of building latrines and piped water systems.
Still, funding to put the plans into action has come up short. Donors have committed only about $30 million of the proposed $2.2 billion plan.
“We have the opportunity now, as cholera is decreasing, to invest in building water and sanitation systems to prevent the kind of outbreak that we had in 2010,” said Dr. Ralph Ternier, director of community care and support for PIH/ZL. “Cholera has killed so many people these past three years. We shouldn’t forget that.”
Cholera cases have continued to spike throughout the epidemic with increases in rainfall, both during the spring rainy season and in the tropical weather season in the late summer and fall. Just a few weeks ago, heavy rains caused severe flooding in a community near Mirebalais in the Central Plateau. About 120 families lost their homes and crops in the floods. A PIH/ZL team responded the following morning, distributing chlorine and buckets to disinfect drinking water, oral rehydration solution to treat dehydration from cholera, and materials to improve hygiene.
Ternier said the PIH/ZL clinic in Lascahobas has been overwhelmed by cases lately. Many people in that area don’t have latrines, which creates conditions ripe for transmission.
“That shows you the fight is really not behind us,” Ternier said.
Over the course of the epidemic, PIH has monitored cholera cases and deaths to improve care and target vulnerable communities with additional prevention and treatment. Data have shown a decrease in the number of cholera patients who died. In the first two and a half years, about 1 percent of cholera patients that came to PIH clinics died. In the last year, that figure dropped by half to .6 percent, demonstrating that it’s possible to manage cholera with a very low fatality rate in Haiti. PIH’s work to monitor cholera data and use it to improve care will be presented at the annual meeting of the American Public Health Association in November.
Partners In Health has advocated for a comprehensive response to the epidemic since its start, including the use of vaccination, publishing these views in The Lancet. In early 2012, in partnership with the Haitian Ministry of Health, PIH delivered the vaccine to two rural communities hard-hit by cholera in the Artibonite region. The successful results of this project were recently published inThe American Journal of Tropical Medicine and Hygiene.
With evidence from PIH’s vaccination project, the World Health Organization recommended in 2012 to expand access to the vaccine in Haiti and the Dominican Republic. The Haitian Ministry of Health has also conducted targeted vaccination campaigns in the Central Plateau and the north of Haiti.
Vaccination is just one part of a comprehensive response that also includes improvements to water and sanitation systems and health care facilities where people can receive treatment.
“We have to take care of cholera, and we also have to take care of other diarrheal diseases,” Ivers said. “We need to ensure that funding to support cholera treatment and prevention is also used to strengthen the health system as a whole. Only a strong health system is going to be able to deal with cases of cholera as they come.”
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