Ralph Ternier

Meeting cholera's challenge to Haiti and the world: a joint statement on cholera prevention and care.

Cholera in Haiti: Acute-on-Chronic Long before the devastating earthquake on January 12, 2010, Haiti struggled beneath the burdens of intractable poverty and ill health. The poorest country in the Western Hemisphere, Haiti also faces some of the highest rates of maternal and infant mortality—widely used indicators of the robustness of a health system—in the world ([S1] in Text S1; [2], [3]). The October 2010 cholera outbreak is the most recent of a long series of affronts to the health of Haitis population; it is yet another acute symptom of the chronic weakness of Haitis health, water, and sanitation systems. Water and sanitation conditions highlight these systemic weaknesses. In 2002, Haiti ranked last out of 147 countries for water security [4], [5]. Before the earthquake struck, only half of the population in the capital, Port-au-Prince, had access to latrines or other forms of modern sanitation, and roughly one-third had no access to tap water [6]. Across the country, access to sanitation and clean water is even more limited: only 17% of Haitians had access to adequate sanitation in 2008, and 12% received treated water [7]. Not surprisingly, diarrheal diseases have long been a significant cause of death and disability, especially among children under 5 years of age [6]. The cholera outbreak began less than a year after a 7.0-magnitude earthquake took the lives of more than 300,000 people and left nearly 1.5 million homeless [6]. Almost 1 million Haitians still live in spontaneous settlements known as internally displaced persons (IDP) camps [8]. While post-earthquake conditions in Haiti were ripe for outbreaks of acute diarrheal illness, cholera was deemed “very unlikely to occur” by the United States Centers for Disease Control and Prevention (CDC) and other public health authorities [9]. Cholera had never before been reported in Haiti [S2] [10], [11]; health providers were unprepared for an influx of patients presenting with acute watery diarrhea. The cholera epidemic has been most severe in rural areas and large urban slums. Rural communities were charged with hosting hundreds of thousands of displaced people after the earthquake, placing greater demands on their already-scarce resources, including water. Surface water drawn directly from the source or piped from rivers and streams constitutes the principal supply of drinking water in rural Haiti. The lack of adequate piping, filtration, and water treatment systems (including chlorination) made these rural regions vulnerable to the rapid spread of waterborne disease. While most IDP camps have been supplied with potable water, large urban slums have had to rely on existing water sources—some of them containing Vibrio cholerae—and have therefore been vulnerable to rapid disease spread. Most slums also have poor sanitation infrastructure. Since the first cases were reported in Saint-Marc and Mirebalais, cholera has spread to every department in Haiti, and to other countries, too [S3] [12]–[14]. Public suspicion (ultimately validated by genomic sequence analyses [15]) of the strains link to South Asia, home to a group of United Nations peacekeepers stationed in central Haiti, triggered blame and violence that interfered with response efforts. As we have learned from the global AIDS pandemic and other infectious disease epidemics, cycles of accusation can continue for years, diverting attention and resources from the delivery of care and prevention services [16]. Systemic problems that brought cholera to epidemic levels in Haiti will (unless addressed) continue to facilitate its spread. As a disease of poverty, cholera preys upon the bottom of the social gradient; international trade, migration, and travel—from South Asia or elsewhere—open direct channels for pathogens that follow social fault lines.

Use of Oral Cholera Vaccine in Haiti: A Rural Demonstration Project

A cholera epidemic has claimed the lives of more than 8,000 Haitians and sickened 650,000 since the outbreak began in October 2010. Early intervention in the epidemic focused on case-finding, treatment, and water and sanitation interventions for prevention of transmission. Use of oral cholera vaccine (OCV) as part of a complementary set of control activities was considered but initially rejected by policymakers. In December 2011, the Minister of Health of Haiti called for a demonstration of the acceptability and feasibility of the use of OCV in urban and rural Haiti. This paper describes the collaborative activity that offered OCV to one region of the Artibonite Department of rural Haiti in addition to other ongoing treatment and control measures. Despite logistics and cold chain challenges, 45,417 persons were successfully vaccinated with OCV in the region, and 90.8% of these persons completed their second dose.

Effectiveness of reactive oral cholera vaccination in rural Haiti: a case-control study and bias-indicator analysis

BACKGROUND Between April and June, 2012, a reactive cholera vaccination campaign was done in Haiti with an oral inactivated bivalent whole-cell vaccine. We aimed to assess the effectiveness of the vaccine in a case-control study and to assess the likelihood of bias in that study in a bias-indicator study. METHODS Residents of Bocozel or Grand Saline who were eligible for the vaccination campaign (ie, age ≥12 months, not pregnant, and living in the region at the time of the vaccine campaign) were included. In the primary case-control study, cases had acute watery diarrhoea, sought treatment at one of three participating cholera treatment units, and had a stool sample positive for cholera by culture. For each case, four control individuals who did not seek treatment for acute watery diarrhoea were matched by location of residence, enrolment time (within 2 weeks of the case), and age (1-4 years, 5-15 years, and >15 years). Cases in the bias-indicator study were individuals with acute watery diarrhoea with a negative stool sample for cholera. Controls were selected in the same manner as in the primary case-control study. Trained staff used standard laboratory procedures to do rapid tests and stool cultures from study cases. Participants were interviewed to collect data on sociodemographic characteristics, risk factors for cholera, and self-reported vaccination. Data were analysed by conditional logistic regression, adjusting for matching factors. FINDINGS From Oct 24, 2012, to March 9, 2014, 114 eligible individuals presented with acute watery diarrhoea and were enrolled, 25 of whom were subsequently excluded. 47 participants were analysed as cases in the vaccine effectiveness case-control study and 42 as cases in the bias-indicator study. 33 (70%) of 47 cholera cases self-reported vaccination versus 167 (89%) of 188 controls (vaccine effectiveness 63%, 95% CI 8-85). 27 (57%) of 47 cases had certified vaccination versus 147 (78%) of 188 controls (vaccine effectiveness 58%, 13-80). Neither self-reported nor verified vaccination was significantly associated with non-cholera diarrhoea (vaccine effectiveness 18%, 95% CI -208 to 78 by self-report and -21%, -238 to 57 by verified vaccination). INTERPRETATION Bivalent whole-cell oral cholera vaccine effectively protected against cholera in Haiti from 4 months to 24 months after vaccination. Vaccination is an important component of efforts to control cholera epidemics. FUNDING National Institutes of Health, Delivering Oral Vaccines Effectively project, and Department of Global Health and Social Medicine at Harvard Medical School.

5-SPICE: the application of an original framework for community health worker program design, quality improvement and research agenda setting

Introduction Despite decades of experience with community health workers (CHWs) in a wide variety of global health projects, there is no established conceptual framework that structures how implementers and researchers can understand, study and improve their respective programs based on lessons learned by other CHW programs. Objective To apply an original, non-linear framework and case study method, 5-SPICE, to multiple sister projects of a large, international non-governmental organization (NGO), and other CHW projects. Design Engaging a large group of implementers, researchers and the best available literature, the 5-SPICE framework was refined and then applied to a selection of CHW programs. Insights gleaned from the case study method were summarized in a tabular format named the ‘5×5-SPICE chart’. This format graphically lists the ways in which essential CHW program elements interact, both positively and negatively, in the implementation field. Results The 5×5-SPICE charts reveal a variety of insights that come from a more complex understanding of how essential CHW projects interact and influence each other in their unique context. Some have been well described in the literature previously, while others are exclusive to this article. An analysis of how best to compensate CHWs is also offered as an example of the type of insights that this method may yield. Conclusions The 5-SPICE framework is a novel instrument that can be used to guide discussions about CHW projects. Insights from this process can help guide quality improvement efforts, or be used as hypothesis that will form the basis of a programs research agenda. Recent experience with research protocols embedded into successfully implemented projects demonstrates how such hypothesis can be rigorously tested. This paper is part of the thematic cluster Global Health Beyond 2015 - more papers from this cluster can be found at http://www.globalhealthaction.net

Comparison of two control groups for estimation of oral cholera vaccine effectiveness using a case-control study design

BACKGROUND Case-control studies to quantify oral cholera vaccine effectiveness (VE) often rely on neighbors without diarrhea as community controls. Test-negative controls can be easily recruited and may minimize bias due to differential health-seeking behavior and recall. We compared VE estimates derived from community and test-negative controls and conducted bias-indicator analyses to assess potential bias with community controls. METHODS From October 2012 through November 2016, patients with acute watery diarrhea were recruited from cholera treatment centers in rural Haiti. Cholera cases had a positive stool culture. Non-cholera diarrhea cases (test-negative controls and non-cholera diarrhea cases for bias-indicator analyses) had a negative culture and rapid test. Up to four community controls were matched to diarrhea cases by age group, time, and neighborhood. RESULTS Primary analyses included 181 cholera cases, 157 non-cholera diarrhea cases, 716 VE community controls and 625 bias-indicator community controls. VE for self-reported vaccination with two doses was consistent across the two control groups, with statistically significant VE estimates ranging from 72 to 74%. Sensitivity analyses revealed similar, though somewhat attenuated estimates for self-reported two dose VE. Bias-indicator estimates were consistently less than one, with VE estimates ranging from 19 to 43%, some of which were statistically significant. CONCLUSIONS OCV estimates from case-control analyses using community and test-negative controls were similar. While bias-indicator analyses suggested possible over-estimation of VE estimates using community controls, test-negative analyses suggested this bias, if present, was minimal. Test-negative controls can be a valid low-cost and time-efficient alternative to community controls for OCV effectiveness estimation and may be especially relevant in emergency situations.

Haiti's progress in achieving its 10-year plan to eliminate cholera: hidden sickness cannot be cured

Since the beginning of the cholera epidemic in Haiti 5 years ago, the prevalence of this deadly water-borne disease has fallen far below the initial rates registered during its explosive outset. However, cholera continues to cause extensive suffering and needless deaths across the country, particularly among the poor. The urgent need to eliminate transmission of cholera persists: compared to the same period in 2014, the first 4 months of 2015 saw three times the number of cholera cases. Drawing upon epidemiology, clinical work (and clinical knowledge), policy, ecology, and political economy, and informed by ethnographic data collected in a rural area of Haiti called Bocozel, this paper evaluates the progress of the nation’s 10-year Plan for the Elimination of Cholera. Bocozel is a rice-producing region where most people live in extreme poverty. The irrigation network is decrepit, the land is prone to environmental shocks, fertilizer is not affordable, and the government’s capacity to assist farmers is undermined by resource constraints. When peasants do have rice to sell, the price of domestically grown rice is twice that of US-imported rice. Canal water is not only used to irrigate thousands of acres of rice paddies and sustain livestock, but also to bathe, wash, and play, while water from wells, hand pumps, and the river is used for drinking, cooking, and bathing. Only one out of the three government-sponsored water treatment stations in the research area is still functional and utilized by those who can afford it. Latrines are scarce and often shared by up to 30 people; open defecation remains common. Structural vulnerabilities cut across all sectors – not just water, sanitation, health care, and education, but agriculture, environment, (global and local) commerce, transportation, and governance as well. These are among the hidden sicknesses that impede Haiti and its partners’ capacity to eliminate cholera.

Long-term effectiveness of one and two doses of a killed, bivalent, whole-cell oral cholera vaccine in Haiti: an extended case-control study

Summary Background No study of long-term protection following killed oral cholera vaccination has been done outside of the historically cholera-endemic areas of south Asia, or has examined protection after a single-dose vaccination regimen. To address this, we examined the duration of protection of the standard two-dose regimen and an incomplete regimen of one dose up to 4 years after vaccination in Haiti. Methods In the setting of two-dose vaccination campaigns with a killed, bivalent, whole-cell oral cholera vaccination, we did a case-control study from October, 2012 through November, 2016. Eligible participants were required to be resident in the vaccine catchment area (Artibonite Department or Central Department) where they were recruited at the start of the study; and be eligible for the vaccination campaign (ie, aged ≥12 months, not pregnant, and living in the region at the time of the vaccine campaign). Patients with cholera had a positive stool culture and were recruited from cholera treatment centres. Community controls were matched to people with cholera by age group, time, and neighbourhood. We did adjusted matched regression analyses to calculate vaccine effectiveness and examine heterogeneity in effectiveness over time. The primary outcome was the effectiveness of one and two oral cholera doses as compared with zero doses from 2 months to 48 months after vaccination, measured by self reporting. Findings Among 178 people assigned to the case group and 706 people assigned to the control group, we found no evidence that two-dose effectiveness decreased during follow-up. In adjusted analyses, the average cumulative 4 year effectiveness for two doses was 76% (95% CI 59–86). In contrast, single-dose effectiveness decreased over time in a log-linear fashion, with a predicted vaccine effectiveness of 79% at the end of 12 months (95% CI 43–93), which declined to zero before the end of the second year. Interpretation In a setting of epidemic and newly endemic cholera in Haiti, single-dose vaccination with killed, bivalent, whole-cell oral cholera vaccination provided short-term protection; however, vaccination with two doses was required for long-term protection, which lasted up to 4 years after vaccination. These results add to the evidence in support of the use of killed, bivalent, whole-cell oral cholera vaccination as part of comprehensive cholera control plans. Funding US National Institute of Allergy and Infectious Diseases of the National Institutes of Health and the Bill & Melinda Gates Foundation.

Risk Factors for Self-Reported Cholera Within HIV-Affected Households in Rural Haiti

Abstract Background Cholera continues to be a major cause of morbidity and mortality worldwide and is now endemic in Haiti since first being introduced in 2010. Cholera and HIV have significant geographic overlap globally, but little is known about the clinical features and risk of cholera among HIV-infected people and their households. Methods We assessed HIV-affected households originally recruited for a randomized controlled trial of food supplements. We assessed for correlation between household and individual factors and reported history of cholera since 2010 using univariable and multivariable analyses. Results There were 352 HIV-infected household members, 32 with reported history of medically attended cholera, and 1968 other household members, 55 with reported history of medically attended cholera. Among HIV-infected individuals in this study, no variables correlated with reported history of cholera in univariable analyses. Among all household members, known HIV infection (adjusted odds ratio [AOR], 3.75; 95% CI, 2.43–5.79; P < .0001), source of income in the household (AOR, 1.82; 95% CI, 1.05–3.15; P = .034), time required to fetch water (AOR, 1.07 per 5-minute increase; 95% CI, 1.01–1.12; P = .015), and severe household food insecurity (AOR, 3.23; 95% CI, 1.25–8.34; P = .016) were correlated with reported history of cholera in a multivariable analysis. Conclusions Known HIV infection, source of household income, time required to fetch water, and severe household food insecurity were independently associated with reported history of medically attended cholera in HIV-affected households in rural Haiti. Further research is required to better understand the interactions between HIV and cholera.

Responding to Cholera in Haiti: Implications for the National Plan to Eliminate Cholera by 2022

Haiti is confronting an 8-year-long cholera epidemic, which until 2017 caused at least 27 000 cases annually, with over half of them being severe enough to require hospitalization. Since its emergence in October 2010, the disease has cumulatively sickened more than 810 000 Haitians, killed nearly 10 000, and become endemic [1]. Other estimates indicate a considerably higher burden, uncaptured by official numbers due to the underreporting of infections and deaths managed outside the healthcare system [2, 3]. Still, between 2010 and 2011, the country accounted for 57% of all cholera incidents and 45% of all related fatalities registered globally, making this epidemic one of the largest in recent history [4]. The explosive spread of cholera was linked to several biosocial factors, not least of which was the population’s initial immunological naïveté to toxigenic Vibrio cholerae, having no prior documented exposure to the disease before 2010 [5]. Cholera was inadvertently introduced into Haiti’s longest river through the improper disposal of untreated sewage from a United Nations peacekeeping base in Mirebalais in the Central Plateau and would subsequently propagate to all other regional departments [6]. The bacterial strain (serogroup O1, serotype Ogawa, biotype El Tor) causing the epidemic also contained a classical type of cholera toxin associated with more severe diarrhea and protracted outbreaks [7, 8]. Further exacerbating the situation were Haiti’s pre-existing deficiencies in water, sanitation, hygiene (WASH), and healthcare infrastructure. At the start of the epidemic, only an estimated 54% of Haitians had access to healthcare [9], 62% to an improved water source near their homes, 26% to an improved, nonshared sanitation facility, and 24% to a handwashing station with water and soap [10]. In the Artibonite and Central Plateau departments, where the nonprofit organization Partners In Health and its sister organization in Haiti, Zanmi Lasante (PIH/ZL) operate and have assisted with the cholera response, only 60% and 40% of the population had access to an improved water source, respectively. In both regions, which are 2 of the most cholera-affected departments in Haiti, less than 3% owned an improved toilet [11]. Such conditions facilitated epidemic spread and still continue to play a role in ongoing transmission.

Exploring the use of labor and delivery services by women of Haitian nationality in a Dominican Republic border town

Purpose Women of Haitian nationality comprise a sizeable proportion of all women seeking labor and delivery services in a public hospital in Dominican Republic (DR), along the central border of Haiti. The purpose of this paper is to better understand and address the needs of Haitian women receiving labor and delivery services in this border region. Design/methodology/approach The authors conducted a mixed-methods study to identify personal motivations, demographic characteristics, and migration history of women seeking labor and delivery services at a public hospital. Findings The majority of women (83 percent) were born in Haiti but spoke Spanish (74 percent) and were long-term residents of the DR (mean 7.8 years). While many women reported they felt they had a positive experience delivering at the public hospital, some described feeling unwelcome or resented. Research limitations/implications The study sample was small and from one hospital. Future studies could explore the differences in experiences among Haitian women who are long-term residents of the DR and those whose presence is more transient. Practical implications Women residing on both sides of the border would likely benefit from coordinated efforts by the Haitian and DR Ministries of Health to strengthen referral services to and from either country. Social implications Hospital staff and services in the DR should consider the unique needs of this population, which makes critical contributions to workforce and culture in the DR. Originality/value This study is the first to assess labor and delivery service seeking practices and experiences within this population.