A young girl receiving an IV in her home. The best way to treat cholera is to rehydrate the patient.
On October 20, 2011, NPR published the following article written by Richard Knox about PIH's response to the Cholera Outbreak in Haiti:
A year after cholera burst upon earthquake-weary Haiti, plans are afoot to begin vaccinating people against the highly contagious disease.
Nearly half a million Haitians — about 5 percent of the population — have already been afflicted and more than 6,500 have died.
But the goal of the vaccinators isn't to stop cholera in its tracks. They can't do that in Haiti with just 200,000 doses — enough for only 100,000 people — that's all the manufacturer can offer.
The aim is to show the world that vaccination against the illness can be done.
"We believe we can do it. I have no doubt we can do it," says Dr. Louise Ivers of Boston-based Partners in Health, which has negotiated the purchase of cholera vaccine from Shantha, an Indian manufacturer, at $1.85 per dose, or $3.70 per person. (The other cholera vaccine, called Dukarol, costs almost twice as much, she says.)
"I believe the first step is to get started," Ivers says. "As we show success, we can use that experience not just to show it's possible but do it while strengthening the Haitian health care system."
Meanwhile, Dr. David Olson of Doctors Without Borders tells Shots that his group is considering its own cholera vaccination project in Haiti. It would involve several hundred thousand people in northern villages too remote for life-saving treatment to reach. "We think it's a good idea," Olson says.
Ivers says Partners in Health will start vaccinating early next year in two areas — an urban neighborhood in Port-au-Prince, in cooperation with a group called GHESKIO, and a rural village near St. Marc, in the region where the cholera outbreak began last October.
Skeptics abound, but their numbers appear to be dwindling.
Haiti's new president, former bad-boy pop singer Michel Martelly, is for cholera vaccination. His predecessor feared it would incite riots because there wouldn't be enough vaccine to go around. But now the Haitian Ministry of Health says it will soon vaccinate 100 people in a pilot test.
The World Health Organization and the Pan American Health Organization have apparently abandoned their earlier opposition. Ivers says the U.S. Centers for Disease Control and Prevention, formerly reluctant to support cholera vaccination in Haiti, may be having a change of heart.
The WHO quietly took one big step toward making it possible earlier this month by "pre-qualifying" an oral cholera vaccine called Shanchol, the one that Partners in Health will use. That long-awaited seal of approval opens the door to purchase of the vaccine by international agencies. It also makes governments willing to allow importation, and encourages the manufacturer to ratchet up production.
But this doesn't mean all is smooth sailing for cholera vaccination in Haiti. For one thing, there's the matter of who will pay for it.
You'd think a few hundred thousand dollars to launch a vaccination campaign against a big and growing disease threat wouldn't be a problem. After all, donor nations pledged $4.6 billion to help Haiti recover from the calamitous earthquake of January 12, 2010 – the biggest international relief effort ever.
Donna Barry of Partners in Health says nearly 60 percent of those funds, or $2.6 billion, remains to be disbursed.
But yesterday the group's founder Dr. Paul Farmer was in California beating the bushes to raise money for the vaccination campaign, "which I regard as somewhat ridiculous," he says. "We're not entirely pleased that we're going out on a limb, looking for funding that should have been made available very quickly."
Farmer, who is U.N. deputy special envoy to Haiti, pointedly noted that the "so-called international community is associated with the introduction of cholera" to Haiti. All evidence points to U.N. peacekeeping forces from Nepal as the likely source of cholera in Haiti, which had been free of the disease for a century even as it colonized the rest of the hemisphere.
Apart from funding, there's a lot else that's uncertain about vaccinating Haitians against cholera.
For starters, there may be resentment among those who can't get the vaccine. Ivers says this will take careful explanation so that people understand there just isn't enough vaccine for everyone yet. And everybody (vaccinated or not) needs to keep taking precautions against cholera infection.
Then there's the big question of whether and how fast the maker of Shanchol will gear up to make more.
"What I'm afraid of now is there will be competition for the limited amount of vaccine available in the next six months," says Olson of Doctors Without Borders.
The WHO estimates there are up to 5 million annual cases of cholera worldwide, and maybe 130,000 deaths. And currently cholera epidemics are raging in Angola and Zimbabwe as well as Haiti. Still, there's no global stockpile of cholera vaccine — something Farmer and other advocates are pushing for.
Meanwhile, the augurs are not good for Haiti's ability to control cholera anytime soon.
Partners in Health's Barry says new figures from the U.N. Office for Coordination of Humanitarian Affairs show an alarming backslide in access to clean drinking water and sanitation in the displaced persons camps in Port-au-Prince.
In March, about half the camp residents had access to safe water. Now only 7 percent do
In response to reports showing that cholera will continue to spread in Haiti, and to evidence that even a limited vaccination campaign could save thousands of lives, Partners In Health continues to advocate that the international community must step up vaccination and efforts to provide clean potable water to all Haitians.
Drs. David Walton, Arjun Suri, and Paul Farmer write that the international community should not be arguing the “value of competing interventions when in fact complementary ones are needed.”
In “Cholera in Haiti: Fully Integrating Prevention and Care,” published in the March 7 edition of Annals of Internal Medicine, the team of PIH physicians contend that: “Because cholera is part of a vicious cycle of poverty, poor sanitation, water contamination, and a weak health system, we argue for an approach that combines prevention and care at every step.”
PIH’s Drs. Walton, Suri, and Farmer argue three points in their article:
Morbidity and mortality rates during the epidemic phase of cholera is likely to last well into 2011… [C]holera may become endemic in Haiti.
Since October, 2010, at least 215,936 cases of cholera have been reported across all 10 of Haiti's geographic departments, and among these, at least 4,131 patients (or 1.9 percent of those infected) have died. These numbers very likely underestimate the actual scope of infection and death.
[Evidence supports our] initiating and expanding cholera vaccination in Haiti as soon as possible. Although vaccines can be effective even with limited use, broader and earlier intervention leads to greater risk reduction, highlighting the need for a global stockpile of cholera vaccine to respond rapidly to epidemics.
[W]idespread rapid vaccination in previous epidemics in the last decade may have averted 40 percent of cases and deaths… even a “reactive” cholera vaccination campaign with 50 percent coverage could have prevented more than 10,000 cases of the disease in Zimbabwe in 2008 and 2009.
The dual approach of vaccination and clean water illustrates the positive synergies of a comprehensive strategy that combines multiple interventions.
The challenge of cholera in Haiti reveals the biosocial complexity before us. A comprehensive strategy that ranges from oral and intravenous rehydration and antibiotic therapy to strengthening Haiti's public water and sanitation systems, while also including vaccination, is the best way to limit the spread of cholera in Haiti.
To read the full article, click the link below:
Partners In Health/Zanmi Lasante's response to the outbreak of cholera in Haiti
A. Treatment of Cholera Cases in the Lower Artibonite and Central Plateau
In the Lower Artibonite, the epicenter of the epidemic, PIH has established ten cholera stabilization/rehydration posts, two larger-scale isolation outpatient cholera treatment units (CTU), and two cholera treatment centers (CTCs). In the Central Plateau, PIH has established a CTC in Mirebalais and is supporting cholera care at three additional facilities (Lascohabas, Hinche, and Boucan Carre).
At the district hospital in St. Marc, PIH has strengthened infrastructure, staffing and systems in order to establish a cholera treatment center, with help from Medecins Sans Frontieres Spain. The hospital was triaging an average of 600 new patients each day until October 26 when a slight decrease in new patients occurred; now there is a regular load of 200-250 hospitalized cholera patients at St. Marc. PIH has established an emergency health center unit, particularly to care for non-diarrhea related illnesses running 24 hours/day at the outpatient clinic in St. Marc. PIH is providing administrative, supply chain and logistics support as well as coordination, food, lodging and transport of non-PIH volunteer medical staff at the hospital.
In addition to PIH’s three health facilities in the Lower Artibonite, PIH is also providing supplies to eight additional community centers surrounding St. Marc. In remote areas, PIH has set up oral rehydration posts to supply patients with clean water and oral rehydration. For patients with more serious cases, who may be unable to be treated orally, stabilization posts are also being established.
To support this clinical care, PIH will hire additional clinical and support staff for up to six months. An estimated ten additional doctors and 29 nurses are needed to reinforce the medical teams in St. Marc, Petite Riviere, Brocozel, Grand Saline, Desdunes and Mirebelais and to establish oral rehydration stations and cholera stabilization stations in the surrounding areas. The cholera transition/stabilization tents will require additional clinical staff; the rehydration stations will be staffed by community health workers (CHWs) and auxiliary nurses. In addition to current staff, PIH anticipates hiring an additional 97 nurse auxiliaries and 125 CHWs. Because of the surge in inpatient care, PIH will expand our patient feeding program as well as purchase substantially more essential medicines and medical supplies. The following list depicts the number of hospitalized cholera cases at PIH facilities as of November 10, 2010.
Cumulative number of hospitalized cases: 5,968
Cumulative number of hospitalized deaths: 76
Average number of hospitalized cases per day: more than 200
Cumulative number of hospitalized cases: 3,183
Cumulative number of hospitalized deaths: 42
Average number of hospitalized cases per day: 150
Cumulative number of hospitalized cases: 407
Cumulative number of hospitalized deaths: 10
Average number of hospitalized cases per day: 20
Cumulative number of hospitalized cases: 2,734
Cumulative number of hospitalized deaths: 13
Average number of hospitalized cases per day: 30
Cumulative number of hospitalized cases: 546
Cumulative number of hospitalized deaths: 5
Cumulative number of hospitalized cases: 256
Cumulative number of hospitalized deaths: 11
Average number of hospitalized cases per day: 50
Cumulative number of hospitalized cases: 33
Cumulative number of hospitalized deaths: 4
Average number of hospitalized cases per day: 8
B. Community Outreach and Prevention of Future Cholera Cases
Community Outreach: Over the course of the six-month response, 2,000 CHWs will be trained to perform outreach in their communities in order to prevent future cases of cholera and refer those who need care for treatment. Already, hundreds of PIH community health workers and social workers have been mobilized to educate their communities and to distribute water purification tablets and oral rehydration salts. The areas where PIH has concentrated these efforts are those most affected by the outbreak: Desdunnes, Villard, Sanoi, Pisto 2, Danache, L’Esther, Delandes, Savan Nan Woch, Labadie, Cannot, Gimel, and Bouji. PIH staff began training over 600 community health workers on community prevention of cholera today using a Creole training module developed by PIH. Topics include: helping cholera patients get care they need, preventing the transmission of cholera, decontaminating homes and properly disposing the bodies of those who have died of cholera.
PIH will continue to carry out community messaging in order to reinforce infection prevention, control, and mitigation measures throughout the Lower Artibonite and Central Plateau. To date, nine mass mobilization campaigns have been organized by PIH in collaboration with MSPP to quickly inform the population of the emergency. PIH has produced nine different radio messages in collaboration with MSPP, which are now being played on as many radio stations as possible. By driving trucks with loudspeakers playing community education campaigns about cholera, and tireless outreach to individual homes, schools, churches, and community gathering places, the team continues to spread the word of how to prevent cholera. PIH will mobilize existing CHWs and staff to use flyers, community meetings, and trucks with loudspeakers to inform the residents of the Lower Artibonite and Central Plateau about how to prevent and treat cholera.
Finally, PIH will conduct 200 “washing schools” to demonstrate to community leaders and school teachers who can teach others how to wash hands, purify water, and care for those who get sick. PIH will also distribute a simple version of cholera training manual for community leaders, school teachers and others who can provide training to larger numbers of people.
Distribution of Water and Cholera Prevention Kits: In October and early November, forty-two water trucks, each holding 1,200 gallons of potable water, have reached 15 communities in the region most affected by the outbreak. Permanent water filters have been installed at three communities, in partnership with Operation Blessing. The communities that have been reached by water trucks are: Bocozel, Pisto 1, Sanoi, Duvalon, Lacolline, Mirebalais, Verrettes, Petite Riviere Hospital (CCMC), Lamou, Robuis, Savan Nan Woch, Ditrijette, Preval, Carrefour Lavil, and Jean Denis.
However, trucking in water is not a sustainable response and so PIH has transitioned our efforts to training communities on how to treat water locally. We will establish 2,000 distribution centers in the homes of community health workers. These distribution centers will be stocked with “cholera” kits that each include 100 sachets of ORS, 216 Pur sachets, 250 aquatabs, 12 pairs of gloves, 21 bars of soap, 15 mosquito nets for pregnant women, many bottles of bleach and one body bag. These distribution centers will be located in communities along the river and its tributaries as the highest priority zones. PIH will establish an additional 500 distribution points at schools, churches or other community centers.
C. Treatment and Prevention in Port-au-Prince
PIH supports health care in three camps of Internally Displaced Persons (IDP) in Port-au-Prince and provides care through a daily mobile clinic that travels to different sites in the city. Following the November 7 storm (Hurricane Tomas), living conditions at the camps have deteriorated. Standing water, mud, lack of garbage collection, and limited sanitation availability make the camps a potential flashpoint for cholera outbreak. To date, 529 cholera cases have been confirmed in Port-au-Price. In response, PIH continued its prevention campaign and set up two CTUs with 50 beds each in PJMV and Carradeax. PIH teams are carrying out intensive education and prevention campaigns with camp residents in the three camps where we have fixed health posts and are making preparations to manage and control any outbreaks that might occur.
PIH is doing whatever it takes to contain the cholera outbreak and treat those who have been infected. We expect that this emergency response will ultimately cost just over $3 million; of this the USAID Office For Disaster Assistance will provide $1.5M million in emergency relief funds. However, many critical items from medicines to water filters are not covered by this funding and therefore a formidable gap remains. To date, PIH has received $832,974 in foundation grants and individual support to support our emergency response to the cholera outbreak.
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