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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The Haiti team has successfully completed phase two of the Cholera Vaccine Project, reaching over 90% of people who received dose one, an incredible accomplishment. Once again, we have proven the cynics wrong, showing the world that we can treat sickness in poor places with the same tools we’d use to fight the disease in our own country. Below, you will find excerpts from their blog during the final phases of the project, as they administered the two-dose vaccine to nearly 50,000 people living in the most vulnerable, rural communities in Haiti.
April 23, 2012
Dose # 1 given to more than 20,000...and counting
Jon Lascher, PIH – Artibonite Region, Haiti
We've finished our first full week and have vaccinated over 20,000 people ages 10 and older. For the first four days teams set up fixed vaccination posts across 54 localities. After four days the number of people showing up at the posts decreased, so our strategy changed from maintaining fixed posts to teams traveling door-to-door in search of people that had been pre-registered.
The teams have walked, ridden motorcycles, donkeys, and horses to spread the word about the vaccine and find people to vaccinate.
May 09, 2012
First phase of vaccine delivery is complete!
Dr. Max Raymond Jr., PIH - Artibonite Region, Haiti
Phase 1, dose 1 of the project is completed and may be considered a success.
Phase 1, dose 2 will begin on Sunday 13th and run through until May 20-22th. Then we'll double back to vaccinate children.
We will start vaccinating children 9 years old and under starting on May 27th. The timeline for all of this has changed a bit because the national government is running a National Polio Vaccine Campaign in the Artibonite region right now. The vaccines cannot be delivered at the same time, so we've had to adjust our schedule. I am keeping in close contact with government health officials about the timing of all vaccine administration to avoid overlap.
May 14, 2012
Second dose of vaccine delivery begins
We are pleased to report that during the first two days of delivering the second dose of Shanchol, we vaccinated over 8,000 people. Thanks to Amanda, Jessica and the Majella team for working on a fast solution to a few problems we had yesterday with the tablets.
Some challenges faced today:
May 21, 2012
Vaccine doses 1 and 2 of now delivered to 18,000 Haitians
It rained most of the day today limiting our ability to vaccinate large numbers of people. Teams were deployed at different intervals throughout the day in the hopes of vaccinating farmers returning home from the fields in the evening.
Tomorrow teams will be going door-to-door again.
May 24, 2012
Initial phase completed!
We've completed the planned vaccination -- doses 1 and 2 -- for the current phase of the project.
We are very pleased with the results thus far, but we know there are still people we can reach.
We proposed to the teams today that we continue vaccinating for 1-2 days of “attrapage” or continued case finding. We are sensitive to the long hours the teams have already been working and we want to ensure that they have enough rest for the next leg -- dosing children 9 and under -- but given the option this evening, they said they wanted to continue working.
June 8, 2012
Haitian children vaccinated against cholera
We will soon be finishing up the vaccine campaign with the final dose for children 9 and under. So far, even with delays and the rainy season well upon us, we've reached more than 40,000 people... that's pretty good!
Maybe someday soon we will be here together scaling up the cholera vaccination to the national level with the Haiti Ministry of Health.
June 19, 2012
An incredible accomplishment
I am pleased to report that we have completed phase 2 and have reached over 90% of people who received dose 1! An incredible accomplishment that would not have been possible without the perseverance of this incredible team.
This team did what “they” said was impossible.
Dr. Louise Ivers - Senior Health and Policy Advisor for PIH
Well done everyone.
This project started in November of 2010 when we wrote that cholera vaccine should be included as one of 5 complementary pieces of cholera control. It then got its wings at TAG meeting in Buenos Aires in July last year and a running start in December when the Minister gave the green light. You all made it fly and I'm really proud of the project and to be part of this team that did what "they" said was impossible.
Aba Kolera!!Chapo ba ekip solid
Below is an email from our Senior Health and Policy Advisor in Haiti, Dr. Louise Ivers, sent to Partners In Health supporters on April 3, 2012. In addition to the brief update on the status of PIH's Haiti Cholera Vaccine Project, you will see a video highlighting the crucial work of our volunteers, who played a key role in vaccine preparations.
For a year and a half, I've watched cholera devastate an entire country, wishing, as a doctor, that I could do more to save lives. Just this weekend, the New York Times wrote about the need to do more. It's a simple bacterial infection, and yet our tools to fight this disease in Haiti simply haven't been enough. That's why I'm thrilled to introduce you to the newest weapon in our arsenal: the Haiti Cholera Vaccine Project. Volunteers helped get the vaccine delivery rolling at Partners In Health in Boston by preparing the registration cards -- a crucial part of the project that will ensure each patient gets the required two doses. We made a video of that big day. http://act.pih.org/phase-one-watch
This vaccine will save lives -- both in the short term and in the long term. In the short term, it will help us protect the lives of the 50,000 people we vaccinate. In the long term, it will help contribute to ending cholera in Haiti entirely -- by demonstrating that cholera vaccination is both feasible and effective in Haiti. I'll send more updates as the project continues. Thank you, Dr. Louise Ivers Senior Health and Policy Advisor Partners In Health
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.
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