Geographic Effects on Cholera in Haiti
Response to Cholera
Haiti suffers from poor water and sanitation infrastructure. Before the 2010 earthquake, improved sanitation facilities existed for only 17% of the population (Tappero, 2011). The earthquake damaged an already fragile system. Furthermore, the disaster killed many civil servants and destroyed all but one government ministry building, including the health ministry’s building (Fisher and Kramer, 2014). On October 19, 2010, nine months are the earthquake, the Ministère de la Santé Publique et de la Population (MSPP) was notified of cholera-like cases near the Artibonite River. The presence of V. Cholerae was confirmed on October 21 and the Haitian government announced the outbreak the next day (Tappero, 2011).
Médecin Sans Frontières (MSF), an international NGO, took the lead in the immediate outbreak response. The organization sent health workers to Haiti and set up cholera treatment centers (CTCs). Two months after the outbreak started, MSF had established 40 CTCs. However, MSF’s effort could not match the volume of cholera cases, which turned out to be much higher than expected (Chan et al, 2013).
The MSPP and the Centers for Disease Control and Prevention (CDC) responded by creating a priority list for the response effort:
1) prevent deaths in health facilities by distributing treatment supplies and providing clinical training
2) prevent deaths in communities by supplying oral rehydration solution (ORS) sachets to homes and urging ill persons to seek care quickly
3) prevent disease spread by promoting point-of-use water treatment and safe storage in the home, handwashing, and proper sewage disposal
4) conduct field investigations to define risk factors and guide prevention strategies
5) establish a national cholera surveillance system to monitor spread of disease
(Tappero, 2011).
The CDC, with support from the international community, conducted a training-of-trainers workshop in Port-au-Prince, in which healthcare personnel were briefed on how to treat cholera patients and how to train community health workers (CHWs). These trained staff members then disseminated information to health workers in their respective departments. Training went quickly; by March 2011, more than 10,000 people had been trained (CDC, 2011).
Worried that the public did not understand how cholera spread and how to prevent it, the MSPP turned to education as a way to combat the disease. On October 22, the ministry commenced its campaign by sending out texts and displaying banners with five basic messages:
1) drink only treated water
2) cook food thoroughly (especially seafood)
3) wash hands
4) seek care immediately for diarrheal illness
5) give ORS to anyone with diarrhea
(Tappero, 2011).
President René Préval conducted a four-hour television conference featuring information on cholera prevention and an oral rehydration solution mixing demonstration by comedian Tonton Bichat (Tappero, 2011).
Two cholera surveillance systems were established. The MSPP started its national surveillance system on November 1, publishing daily reports to its website. While the national surveillance system has been effective in reporting information from healthcare facilities, only half of the Haitian population actually has access to these facilities. Identifying the need for a broader surveillance system, the Pan American Health Organization (PAHO), in association with the MSPP, the CDC, NGOS, UN agencies, hospitals, and local officials, launched an Alert & Response (A&R) System in early November. Daily alert messages were sent to those involved in the response and usually reported an increase in cases or deaths and the need for more supplies, human resources or prevention activities. The near real-time reporting of the A&R System allowed health and government officials to geographically track the spread of cholera and respond quickly to alerts, which succeeded in helping control the outbreak (Santa-Olalla, 2013).
Soon after the outbreak, health and government officials began to consider the possibility of vaccinating Haitians against cholera. The international community supported a “limited pilot project” (Cyranoski, 2011) to judge the vaccination’s effectiveness and to decide whether or not to vaccinate the whole population. However, the Haitian government wanted to conduct a large-scale vaccination program in the hopes of eradicating cholera and preventing the public anger of those who were not vaccinated. Health experts were concerned by the massive scale of the vaccination program, the temporary immunity vaccination provided, and the likelihood that some areas would not receive the vaccine. Some experts also thought that money and resources would be better spent toward improved sanitation infrastructure (Cyranoski, 2011).
In April of 2012, the World Health Organization approved a drug called Shanchol for use as a cholera vaccine in Haiti. The Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), a trusted group that has been serving Haiti for thirty years, oversaw the vaccination pilot project of 200,000 doses. They administered the vaccine by going door to door, which proved an effective strategy, as 90.8% of those who received the first dose of Shanchol also received the second dose (Rouzier, 2013). In September of 2014, the MSPP, with help from the U.N., PAHO, and WHO, started a vaccination project aimed at 200,000 people in three high-risk departments (“Haiti Launches Cholera Vaccination Campaign,” 2014).
Cholera continues to plague Haiti and experts believe it will for at least the next decade. The MSPP has confirmed nearly 700,000 cases and 8,500 deaths from cholera as of January 2014 (“U.N. Fact Sheet: Combatting Cholera in Haiti,” 2014). Several factors have hindered the response effort including a weak and unprepared healthcare system, a lack of resources and funding, poor water and sanitation infrastructure, and the post-earthquake state of Haiti. Given the obstacles, many NGOs and health organizations coordinated an effective short-term response to the cholera outbreak (Chan et al, 2013). The response at least lowered the case fatality rate from 4% to below 1%, with some fluctuation (Barzilay, 2013). However, many NGOs have recently left Haiti since they lack the necessary funds. The major wrongdoing in the epidemic is the U.N.’s refusal to acknowledge that its MINASTUH peacekeepers introduced cholera to the region. The U.N. still denies responsibility for the outbreak despite overwhelming scientific evidence and refuses to pay reparations to the victims. Furthermore, in November 2012, the U.N. pledged $2.27 billion to eliminate cholera in Haiti and the Dominican Republic, but as of April 2013 had only secured 1% of the funding (Chan et al, 2013).