Project #6629

Help PIH Respond to Cholera Outbreak in Haiti

by Partners In Health (PIH)
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.

Thank you for all of your support through GlobalGiving!


Partners In Health Completes Phase Two of the Cholera Vaccine

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

Jon Lascher, PIH – Artibonite Region, Haiti

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:

  • Due to the seasonal rains, water levels in some Artibonite communities are rising. Anecdotally, we are hearing reports that people are busy tending to their farms, mitigating the water levels. Also in some communities the water is so high that people would have to swim to a post to receive the vaccine.
  • We believe many people are waiting at their homes until we change our strategy (again) to vaccinate door-to-door.


May 21, 2012

Vaccine doses 1 and 2 of now delivered to 18,000 Haitians

Jon Lascher, PIH – Artibonite Region, Haiti

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!

Jon Lascher, PIH – Artibonite Region, Haiti

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

Dr. Max Raymond Jr., PIH - Artibonite Region, Haiti

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

Jon Lascher, PIH – Artibonite Region, Haiti


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.


June 19, 2012

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



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Organization Information

Partners In Health (PIH)

Location: Boston, MA - USA
Website: http:/​/​
Project Leader:
Laura Soucy
Annual Giving Coordinator
Boston, MA United States

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