Cholera epidemic driving public health improvements in Haiti

Water and sewage improvements after the 2010 cholera epidemic in Haiti, combined with vaccination efforts, have the potential to avert tens of thousands of deaths and protect against other diseases in the future, public health officials said.

“We’ve struggled to improve Haiti’s overall public health for decades. Now we arrive at a critical juncture where from the depths of a terrible epidemic there is an opportunity for Haiti to rise up to a new level of protection against infectious diseases,” Jon Andrus, MD, deputy director of the Pan American Health Organization (PAHO), reported in a special edition of The American Journal of Tropical Medicine and Hygiene, commemorating the third anniversary of the earthquake and subsequent cholera outbreak in Haiti.

In one study, Isaac Chun-Hai Fung, PhD, of the Center for Emerging and Zoonotic Infectious Diseases at the CDC's Center for Global Health, and colleagues estimated that modest improvements in Haiti’s water, sanitation and hygiene (WASH) conditions from providing more latrines and community water pipes, as well as disinfecting water sources with chlorine, could prevent as many as 78,567 cholera cases during the next 2 decades.

Improved WASH conditions may have the added benefit of preventing other waterborne diarrheal diseases, such as rotavirus and Escherichia coli, the leading cause of death among Haitian children younger than 5 years.

Furthermore, Fung and colleagues estimated that achieving 20% oral cholera vaccine coverage within 5 years could increase the number of cholera cases averted to 88,974.

“The cost of improving WASH conditions and eliminating cholera in Haiti will be significant,” Richard Gelting, PhD, of the Health Systems Reconstruction team in CDC’s Center for Global Health, and colleagues wrote. “The 10 year plan to accomplish these goals provides an estimate of 2.2 billion US dollars, with more than 70% of that investment going to the WASH sector. However, the potential dividend from these investments is apparent.”

Richard Gelting

Two separate studies assessing cholera pilot vaccine programs in both rural and urban settings suggest achieving meaningful vaccine coverage rates is within reach.

A vaccination campaign in the Artibonite Department of rural Haiti achieved 72% vaccine uptake among its target population, with 90% of the 45,417 people vaccinated receiving the second dose in the two-dose regimen, Louise C. Ivers, MD, of the division of global health equity at Brigham and Women’s Hospital, and colleagues reported.

Similar oral cholera vaccine coverage rates were achieved in a separate pilot project undertaken in the urban slums of Port-au-Prince. Overall, 52,357 people in that region received at least one dose of oral cholera vaccine, and 90.8% received the second dose, putting overall coverage at 75%, Jean W. Pape, MD, of Weill Cornell Medical College, and colleagues reported.

Factors contributing to the vaccine campaigns’ success included census efforts undertaken before immunization days, in which participants were given a bar-coded card to present when they went to be vaccinated.

The card contained typical registration information such as name and address and was scanned onto tablet computers at the time of vaccination to keep lines moving quickly. The procedure also helped public health officials keep track of who in the community had yet to be vaccinated.

Other factors contributing to the success of the campaign included involving community leaders in efforts to engage citizens, focus groups, radio shows and trucks outfitted with PA systems.

A separate vaccine policy analysis by public health officials from PAHO and the Sabin Vaccine Institute emphasized that cholera vaccination is just one component of plans to eliminate the disease, with particular benefit in the “short- and medium-terms until significant and sustained advances in infrastructure for sanitation and delivery of potable water are achieved.”

For more information:

Fung IC. Am J Trop Med Hyg. 2013;89(4):633-640.

Gelting R. Am J Trop Med Hyg. 2013;89(4):665-670.

Ivers LC. Am J Trop Med Hyg. 2013;89:617-624.

Rouzier V. Am J Trop Med Hyg. 2013;89:671-681.

Disclosure: The researchers report no relevant financial disclosures.