Help PIH Respond to Cholera Outbreak in Haiti

Photo: Jon Lascher/Partners In Health
Photo: Jon Lascher/Partners In Health

Research on PIH Cholera Vaccination Project Released in Journal

Posted on October 09, 2013

Research reporting the results of Partners In Health’s cholera vaccination project in Haiti was released today in a special section of The American Journal of Tropical Medicine and Hygiene.

The journal’s October issue, released just before the third anniversary of the cholera outbreak on Oct. 19, 2010, features a variety of public health research on cholera in Haiti.

As part of the special section, PIH Senior Health and Policy Advisor Dr. Louise Ivers and colleagues discuss the results of PIH’s rural cholera vaccination campaign in early 2012. The demonstration project was executed in collaboration with Haiti’s Ministry of Health and sought to vaccinate two vulnerable communities in the Artibonite region and build support for using the vaccine more broadly.

“Vaccines should not be viewed as a silver bullet that can subdue cholera in Haiti,” Ivers said. “But wider use of them, such as in campaigns targeting particularly vulnerable populations, can play a meaningful role in protecting people from illness and death.”

The journal article explains the project’s design and successful results. A total of 45,417 people in two communities received at least one dose of the two-dose vaccine, representing 77 to 93 percent of the targeted population. Even more, 91 percent of people who received the first dose also received the second, an excellent completion rate.

Another article reports the results of a similarly successful campaign in Port-au-Prince, conducted by the nonprofit health care organization GHESKIO.

These projects proved that delivering the vaccine in the midst of an epidemic was possible in Haiti. The evidence contributed to the World Health Organization’s recommendation in 2012 to expand access to the vaccine in Haiti and the Dominican Republic.

Ivers said that community involvement was critical to the project’s success. In advance of the vaccination, community health workers conducted a census of the community and registered people to receive the vaccine. PIH and our Haitian sister organization, Zanmi Lasante, also worked with community leaders to ensure support of the campaign. Ivers said it wasn’t hard to convince community members to be vaccinated because they knew the danger through personal experience.

“We interviewed people in focus groups before the vaccination campaign and they had very emotional stories to tell about their experience with cholera,” Ivers said. “So it was not a far-off, distant issue, but a real and immediate threat.”

Photo credit: Bec Rollins
Photo credit: Bec Rollins
CHOLERA IN HAITI: A Look Inside the Epidemic
This spring, 8-year-old Belizaire S. came home from school and started to feel sick. By the following morning, he was so ill with diarrhea and vomiting that he could hardly stand up. His mother, a widow raising six children alone, knew where to go—the PIH cholera treatment center in Mirebalais, in central Haiti. At the center, Dr. Thelisma Heber asked Belizaire a few questions about his symptoms, but there was no doubt he needed IV fluids immediately. "He’s a severe case. You can see his eyes are sunken," Heber said.
With the start of the spring and summer rains, which spread sewage and contaminate water sources, PIH and our Haitian sister organization, Zanmi Lasante, are bracing for more cases of cholera. Because emergency funding has largely ended, many prevention and treatment activities have ceased in other parts of Haiti.
"In most of the areas we serve, it seems that we are the only cholera health care provider, and that puts more pressure on our services," said Dr. Ralph Ternier, PIH/ZL director of community care. Since the epidemic began in late 2010, cholera has killed more than 8,000 people and sickened 650,000, according to Haiti’s Ministry of Health. Thanks to your support, PIH/ZL has treated more than 100,000 patients for cholera and has worked to prevent cholera’s spread since the problem began. PIH/ZL also supported the delivery of Haiti’s first cholera vaccination program. PIH/ZL continues to operate cholera treatment centers in central Haiti, and conduct prevention activities and educational outreach.
At the Mirebalais center, Belizaire wasn’t the only patient Heber and the rest of the staff were treating. Heber admitted a half-dozen patients in less than an hour. He triaged them to either receive oral rehydration solution or, for more severe cases, to be hospitalized and given IV fluids. In different tents designated for men or women, two sisters and their father were also receiving fluid from IVs. Heber said families can become sick when they eat the same contaminated food or water, don’t wash their hands, or take care of a sick relative. "It’s a big battle to combat cholera," he said.

On February 28, 2013, Partners In Health's Executive Director Ophelia Dahl sent an email to supporters sharing the powerful words of Dr. Louise Ivers, the clinician who led the cholera vaccination effort in Haiti.  We are excited to share with you Dr. Ivers' op-ed, which was published in the New York Times on February 22nd, prefaced by Ophelia's email: 

Since cholera broke out in Haiti more than two years ago, Partners In Health has worked alongside many others to fight the deadly epidemic. 

With the support of our partners, we have treated tens of thousands of patients. Last year, we delivered Haiti's first cholera vaccination campaign along with our partner in Port-au-Prince, GHESKIO.

On Friday, the clinician who led that vaccination effort, Dr. Louise Ivers, published an op-ed in The New York Times in which she called on the United Nations to make a significant financial contribution to a multilateral plan to eliminate cholera in Haiti.

Partners In Health supporters have stood resolutely by us as we have fought cholera through all the means at our disposal, integrating prevention, treatment, and efforts to increase access to clean water and sanitation. Today, I invite you to read Louise's powerful words:

Published February 22, 2013, in The New York Times:

A Chance to Right a Wrong in Haiti
by Louise C. Ivers

On Thursday, the United Nations secretary general, Ban Ki-moon, rejected a legal claim for compensation filed in 2011 on behalf of cholera victims in Haiti. Through a spokesperson, Mr. Ban said the claims, brought by a nongovernmental organization, were “not receivable” because of the United Nations’ diplomatic immunity.

Regardless of the merits of this argument, the United Nations has a moral, if not legal, obligation to help solve a crisis it inadvertently helped start. The evidence shows that the United Nations was largely, though not wholly, responsible for an outbreak of cholera that has subsequently killed some 8,000 Haitians and sickened 646,000 more since October 2010. The United Nations has not acknowledged its culpability.

Now, as the cholera epidemic appears to worsen, Mr. Ban and the United Nations have an opportunity to save thousands of lives, restore good will — and, yes, fulfill the mandate that brought the organization to Haiti in the first place: stabilizing a fragile country. The United Nations should immediately increase its financial support for the Haitian government’s efforts to control the epidemic. While that may not satisfy everyone, it will go at least some way toward compensating the people of Haiti for the unintentional introduction of the bacteria that caused the epidemic.

Before October 2010, cholera — a diarrheal illness caused by consuming water or food contaminated with the bacterium Vibrio cholerae — had never been reported in the country. In the epidemic’s first year, the striking loss of life attracted international media attention. Even in its third year, the outbreak continues to sicken thousands.

There were 11,220 cases nationwide during the month of December — significantly more than the 8,205 cases seen during December 2011. Our clinic in St. Marc treated more people with the infection last month than in the previous eight months combined.

That soldiers at the United Nations camp were responsible for introducing the bacteria seems apparent. After local and national protests and an Associated Press investigation, Mr. Ban empaneled a group of international experts to determine the disease’s source. Their report stated that evidence “overwhelmingly supports the conclusion that the source of the Haiti cholera outbreak was due to contamination of the Meye Tributary of the Artibonite River with a pathogenic strain of current South Asian type Vibrio cholerae as a result of human activity.” The strain was not indigenous to Haiti.

The report also found that sanitation conditions at the United Nations camp were not sufficient to prevent contamination of the local waterway with human waste. Investigators found that the potential existed for feces to enter the tributary from a drainage canal in the camp and from the open septic disposal pit that was used to handle the waste.

A research study published in January 2011 in The New England Journal of Medicine lent further support to the claim that the cholera came from the United Nations camp, as did an August 2011 study in another scholarly journal.

The interplay of biosocial factors inherently involved in epidemics make it difficult to pinpoint causality. If Haitians had better access to clean water and sanitation, of course, the cholera epidemic would have had a smaller impact and thousands of deaths might have been averted. (By comparison, there were few, if any, deaths from cholera in countries with effective water and sanitation systems where the organism appeared as part of this same epidemic — including the United States.)

But all of this is background to the urgent matter at hand. The United Nations recently started a 10-year initiative to eliminate cholera in Haiti and the Dominican Republic, based on a plan that was developed with multiple partners, including the governments of both countries. It is a collaborative and comprehensive approach that aims to eliminate transmission of the disease with substantial investments in water and sanitation infrastructure, as well as through prevention and treatment.

On Feb. 27, Haiti’s minister of health will introduce one important component of this plan — an initiative to expand access to cholera vaccination.

If the United Nations were to finance this initiative, along with the rest of the government’s anti-cholera program, it could have a significant and immediate impact on stemming this epidemic. As of now, however, the United Nations plans to contribute just 1 percent of the cost. That is not enough.

Meanwhile, the organization’s stabilization mission in Haiti is budgeted for $648 million this year — a sum that could more than finance the entire cholera elimination initiative for two years.

It’s time for the United Nations to rethink what true stabilization could be: preventing people from dying of a grueling, painful — and wholly preventable — disease is a good start.

Louise C. Ivers, a senior health and policy adviser at Partners In Health and associate professor at Harvard Medical School, has been leading cholera treatment and prevention activities in Haiti.

Photo by Jon Lascher/Partners In Health
Photo by Jon Lascher/Partners In Health

Fighting Cholera, a Dose at a Time

Published 12/12/12 by Cat Wise in PBS NewsHour

The United Nations announced a $2.2 billion initiative Tuesday aimed at curbing the spread of cholera in Haiti over the next 10 years through improved water and sanitation projects. The plan put forward by U.N. Secretary-General Ban Ki-moon also calls for funding a new tool in health officials' toolkit to combat the disease -- a cholera vaccine.

"The main focus is on the extension of clean drinking water and sanitation systems," Ban said. "But we are also determined to save lives now through the use of an oral cholera vaccine."

"Because global vaccines are in short supply, we will first target high-risk areas: densely populated urban areas and rural areas far removed from health services," Ban added. "As production increases, the vaccine effort will expand its reach."

As NewsHour special correspondent Fred de Sam Lazaro highlighted in his recent report, cholera continues to have a devastating impact on the island nation, nearly three years after the tragic earthquake. Cholera is a waterborne bacterial disease, which causes severe diarrhea and can lead to dehydration and death.

Approximately 7,700 people have been killed and 620,000 have been infected, although some aid groups on the ground believe the actual figures are even higher. Only 17 percent of Haitians have access to improved sanitation and clean water, conditions which fuel the spread of the disease.

Until recently, the use of a widespread cholera vaccine initiative to prevent the disease in Haiti was considered controversial. The Haitian government and some international medical groups such as the Pan American Health Organization were initially skeptical that a massive vaccine rollout would be feasible given the tricky distribution logistics involved. The oral vaccine must be refrigerated and is given in two doses, two weeks apart. Immunity lasts two to three years and the vaccine is about 65 percent effective. There were also concerns that vaccination campaign would pull financial resources away from much-needed water and sanitation projects.

But last year, the Haitian Ministry of Health decided to back a pilot project to vaccinate 100,000 people living in two areas of the country, a slum in Port-au-Prince and a rural, rice-growing area in the Artibonite River Valley. The campaign was a joint effort by the Ministry of Health, Boston-based nonprofit Partners in Health (PIH), and the Haitian nongovernmental organization GHESKIO.

From mid-April to mid-June, teams of community health workers fanned out to reach as many people as possible in the two regions. "We were very pleased with the results," said Dr. Louise Ivers, PIH's senior health and policy advisor.

In the rural areas where PIH teams coordinated the vaccinations, Ivers says they reached about 80 percent of the population. And of the people who received the first dose of vaccination, 90.8 percent received a second dose. Similar results were reported in the urban areas.

"We were particularly interested to see if we would reach a threshold level," said Ivers. "When you reach about 50 percent of the community, the people who haven't been vaccinated become protected. So that means we would be seeing 'herd immunity' in that area."

Ivers says one of their biggest challenges was a six-week delay in the rollout caused by an erroneous local radio report that said an experimental vaccine was being used. After everything was cleared up, and Ministry of Health gave the green light, the rainy season had started and health workers had a difficult time reaching some of the rural areas.

To further complicate matters, the delay caused the cholera vaccine distribution to overlap with a pre-planned national polio vaccine campaign. Because much is unknown about cholera and polio vaccine interactions, health officials decided to wait to give children the cholera vaccine one week after they had received a polio vaccine. Ivers says that meant every area targeted had to be visited four times, instead of just twice.

Despite all the challenges, Ivers says the pilot project was a success and showed what could be possible with a vaccination campaign targeting the entire country.

"We found that there was a huge interest in the vaccine," said Ivers. "There was not any built-in fear or skepticism from communities once we engaged them and explained what we were doing and asked them if this is something they wanted. I think the fact that so many people have been personally impacted by cholera, there was a strong desire to take any tools that might be available to prevent it from happening again."

Ivers believes the battle against cholera in Haiti must be fought on multiple fronts. "We are completely behind the issues of water and sanitation. Those are the gold standard ways to fix the problem," said Ivers. "But investments in public water and sanitation projects take years and billions of dollars. So this is a bridge to that. There's no reason why you can't use the cholera vaccine for a limited time and then make progress on sanitation projects."

Currently, PIH is distributing several thousand remaining doses from the pilot project to another small community. And they are working with the country's Ministry of Health to figure out next steps, while providing ongoing treatment for those who are ill. The United Nations endorsement this week should provide a boost for a larger rollout of the vaccine throughout Haiti in the coming years.


Djencia Eresa Augustin, Community Health Worker
Djencia Eresa Augustin, Community Health Worker

For Djencia Eresa Augustin, helping to administer the oral cholera vaccine this spring was one thing she could do to fight the cholera epidemic raging through her country. Thanks to her efforts—and the partnership of hundreds of other community health workers, Haiti’s ministry of health, and the nonprofit organization GHESKIO—nearly 100,000 people received the vaccination earlier this year.

“From everything I’ve seen, there is no one who was eligible for the vaccine who didn’t want it,” Augustin said.

For her and others on the front line of cholera epidemics—in Haiti and around the world—the announcement last week from a working group of the World Health Organization (WHO) comes as a welcome affirmation of their efforts. The Pan American Health Organization’s Technical Advisory Group on Vaccine-Preventable Diseases (PAHO TAG) recommended expanding the use of the oral cholera vaccine in Haiti, based in part on data that Dr. Louise Ivers, PIH’s senior health and policy advisor, presented on behalf of PIH and its sister organization Zanmi Lasante. Dr. Bill Pape presented data from GHESKIO’s portion of the campaign.

“An important part of our campaign was to ensure that our experience informed the control of cholera in Haiti and in other countries,” Ivers said. “While cholera vaccines aren’t ‘golden tickets,’ we must move quickly to save as many lives as we can with the tools we have now.”

During last week’s meeting in Washington, DC, Ivers presented data from the successful vaccine campaign, which began in April and finished in June. For example, in a rural area near St. Marc, 45,368 people were vaccinated, and 90.8 percent were confirmed to have received the second dose—a very high completion rate.

In another piece of good news, the World Health Organization also endorsed a recommendation that a global stockpile of 2 million oral cholera doses be created to respond to outbreaks around the world—a major policy shift on the emergency use of cholera vaccines.

In Haiti, the work that PIH, the government, and other partners are doing to improve the country’s water and sanitation infrastructure continues—and is critical. But vaccines are a necessary component of a comprehensive strategy to fight an epidemic that has killed more than 7,000 Haitians, sickened half a million, and continues to claim lives.

“The PAHO TAG recommendations to scale up use of the vaccine in Haiti and the WHO endorsement of a stockpile of cholera vaccines are both great strides forward for those at risk of cholera in Haiti and worldwide,” said Ivers.

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