Fighting Cholera, A Dose at a Time

December 12, 2012

Photo by Jon Lascher/Partners in Health.

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.

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