As Haiti’s cholera epidemic enters its ninth month, the country’s rainy season has begun, further stressing and disrupting the country’s woefully inadequate water and sewage systems. According to the World Health Organization (WHO) and Haiti’s Ministry of Health, increasing numbers of people are falling ill and dying from the illness.
Debate about the public health response to the crisis has also been underway, with some experts arguing that a vaccination campaign in Haiti would be neither feasible, nor cost-effective. But a coalition of medical and public health researchers, policymakers, and practitioners, led by PIH co-founder Paul Farmer, argue that a universal vaccination campaign is essential to ending the crisis in an article published in the May 31 issue of the open-access journal PLoS Neglected Tropical Diseases.
“Vaccination has a significant role to play in Haiti given the vulnerability of the post-earthquake health, water, and sanitation systems and the observed virulence of the El Tor strain,” write the 44 authors of Meeting Cholera’s Challenge to Haiti and the World: A Joint Statement on Cholera Prevention and Care. “The MSPP (Haitian Ministry of Health) has called for nothing less than a universal vaccination campaign — an end goal this document endorses.”
In addition to universal vaccination, the statement endorses three primary goals: aggressive case finding and scaling up of all treatment efforts; strengthening Haiti’s water and sanitation infrastructures; and linking prevention to care by bolstering surveillance, education campaigns, and water, sanitation and hygiene (WASH) efforts. “n the face of cholera’s challenge to Haiti and the world, we can accept nothing less than complementary and comprehensive prevention and care,” writes Farmer, who is also the Kolokotrones University Professor and Chair of the Department of Global Health and Social Medicine at Harvard Medical School, and his coauthors.
There are currently fewer than 400,000 vaccine doses ready for shipment, but the PLoS consensus statement asserts that advance purchase commitments could significantly increase availability, perhaps to several million doses. In the past, bulk purchases have expanded vaccine access by boosting production and lowering prices. Economies of scale contribute to lower production costs, as observed during the scale-up of antiretroviral therapy for HIV/AIDS.
Furthermore, scaling up efforts in Haiti would also create momentum to prevent similar vaccine shortages during future outbreaks. For example, Farmer and his coauthors say that neighboring countries in the Caribbean and Latin America also lack strong public health, water, and sanitation systems, so the threat of a multi-country epidemic is real.
Farmer and some of his coauthors drafted a vaccination proposal to present at the World Health Organization (WHO) meeting ("Integrated Response to Cholera Outbreaks in Large Scale Humanitarian Crises") in May. As a first step in a Haitian vaccination campaign, they called for the WHO to endorse the development of a two-million dose stockpile for Haiti, coupled with a large-scale pilot in Haiti comparing the effectiveness of cholera control efforts with — and without — mass vaccination. If this pilot were successful, they would suggest that production be ramped up so a global stockpile of 10 million doses could be developed.
Before last October, cholera had never been reported in Haiti. Largely because Haiti’s population was “immunologically naïve,” initially the outbreak exhibited a 7 percent case-fatality rate — among the highest recorded in recent history. In just 40 days, there were over 2,000 reported cholera-related deaths — nearly half the number of total deaths registered in Zimbabwe’s yearlong epidemic, which started in 2008, and the Haitian figures are likely underreported in many rural areas.
Another factor that has exacerbated the Haitian epidemic includes the large number of people left homeless and displaced by the 2010 earthquake who have been living in rural areas or large rural slums, where the epidemic has been most severe. “These communities were charged with hosting hundreds of thousands of displaced people after the earthquake, placing greater demands on their already-scarce resources, including water,” write Farmer and his coauthors.
A cholera vaccination campaign could leverage existing health worker networks without taking doctors and nurses away from providing more acute care. Unlike more complex medical interventions, community health workers can quickly and effectively administer oral vaccines. And existing vaccination and treatment delivery infrastructure — such as the cholera treatment units (CTUs) and cholera treatment centers (CTCs) created during the crisis — may provide sites for vaccine administration.
Paul Farmer is the United Nations Deputy Special Envoy to Haiti, and Chief of the Division of Global Health Equity at Brigham and Women's Hospital. The other coauthors of the article represent organizations including the Haitian Medical Association, GHESKIO Centre, the Earth Institute at Columbia University, the Global Health Program or the Bill & Melinda Gates Foundation, the International Vaccine Institute, the American Society of Tropical Medicine & Hygiene, and the International Centre for Diarrhoeal Disease Research in Bangladesh.
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