Cholera Outbreak in Haiti Creates Public Health Crisis

The outbreak of cholera, which began in October 2010, is a major public health crisis that is requiring the international community to respond with assistance. Despite efforts to stem the disease, officials are concerned of the epidemic spreading in Haiti and possibly in neighboring countries. As representatives from international groups, governments, and relief agencies respond to the crisis on an immediate level, researchers are urging stockpiling of cholera vaccines to prevent the advance of the disease.  

The challenge

Nigel Fisher, United Nations Deputy Special Representative of the Secretary-General, Ad Interim, for the United Nations Stabilization Mission in Haiti (MINUSTAH), spoke at a UN press conference on  November 23, 2010, saying that the lack of adequate sanitation and clean water created conditions that allowed cholera to spread quickly in Haiti and the number of cases was increasing. He said the response to the epidemic should be “ratcheted up” by providing more adequate water supplies, improved hygiene, and more doctors and nurses. He also said that more drugs, equipment, and human resources were needed as were more treatment centers. The epidemic was expected to continue through the next months or even year, said Fisher. The projection for possible contamination according to a worst-case scenario could be as high as 400,000 people, according to the World Health Organization (WHO) and the Pan American Health Organization (PAHO).

According to information supplied by MINUSTAH, as of Nov. 23, 2010, Haiti’s Department of Public Health and Population reported 1523 deaths and 66,593 cases of infection, including 27,933 persons hospitalized since the discovery of first case of cholera on Oct. 20, 2010. PAHO estimates that more than 350 doctors, 2000 nurses, and  2200 additional support staff are needed for the next several months to deal with the outbreak. Currently, only around 10% of households outside the capital of Port-au-Prince are estimated to be getting access to soap and clean water, according to the UN Office for the Coordination of Humanitarian Affairs. The office added that oral rehydration salts, water-purification tablets, chlorine, body bags, medical supplies, soap, latrines, and other supplies are in short supply. Some 4 million water-purification tablets and 11,000 bars of soap are needed in the capital, Port-au-Prince, for just for two weeks, according to some estimates.  

As of Nov. 23, 2010, 36 cholera treatment centers (CTCs) with a capacity of 2830 beds have been installed in Haiti in addition to 61 units of treatment of the disease already operational, according to MINUSTAH. Four other CTCs with a capacity of 800 beds are planned, noted OCHA. According to a PAHO Nov. 25, 2010 press release, the spreading epidemic has put increased pressure on the newly established CTCs, which are intended to provide medical care for severe cases. PAHO says more work needs to be done at the family and community level to encourage treatment at home with oral rehydration salts or at a local community health center to prevent cases from becoming too severe.

According to the PAHO press release, to stem the spread of the disease, health and relief workers have been working to provide potable water supplies and chlorine tablets to Haitian families and communities. They have also been distributing oral rehydration salts, which can prevent severe illness and death from cholera if administered promptly. In addition, the Haitian government is disseminating prevention messages through the mass media and through public education materials that encourage hand washing, safe food handling, and prompt treatment for people who have symptoms. To further encourage prevention, PAHO and WHO provided 22,000 educational posters for distribution to voting places around the country, which held national elections in late November. The posters, produced in collaboration with Haiti’s Ministry of Health, describe how to prevent cholera and what to do if one becomes ill. Experts are also concerned that official case counts significantly undercount cholera’s toll due to gaps in the surveillance system.

Relief efforts

PAHO/WHO is coordinating with international and NGOs to ensure the prompt acquisition and distribution of medical supplies. Last month, PAHO/WHO, in coordination with Haiti’s Ministry of Health and the World Food Program, distributed 87 tons of essential medicines and supplies via truck and helicopter in nine departments of the country. The supplies were intended to replenish stocks in areas already affected by the epidemic and to prepositioned supplies sufficient to treat about one-third of the expected cases during the coming months. PAHO/WHO and its partners have distributed medical supplies to 23 hospitals and health centers in metropolitan Port-au-Prince. PAHO/WHO also is providing training, technical cooperation and expertise to Haiti’s Ministry of Health and other partners in areas such as epidemiology and surveillance, logistics, case management, laboratory, water and sanitation, and risk communication.

PAHO recently sent an alert to health officials in other member states in Latin America and the Caribbean urging them to take steps to prepare for the possible arrival of cholera. PAHO recommended stepped-up surveillance, preparedness planning, improvements in water and sanitation, and increased public education. PAHO/WHO and about four dozen international and nongovernmental partners issued a joint strategy with detailed plans for how to support efforts to control Haiti’s cholera epidemic and to mitigate its impact. The appeal is based on epidemiological modeling that projects about 200,000 cases during the next six to 12 months. Of these cases 20% of them will require intensive fluid rehydration and possibly antibiotics. These estimates will be re-assessed depending of the results of ongoing field surveys that are being conducted. Other less severe, symptomatic cases would be treated as out-patients or at the community level.

The strategy details how PAHO/WHO and other international partners plan to help Haiti scale up efforts to ensure access to treatment for infected people but also fundamental actions that will break the cycle of infection through improvements in water and sanitation and better hygiene practices by the population. The main framework for the health component of the appeal is Haiti’s National Cholera Response Plan. It aims to protect families at the community level with health promotion and improved case management, and also by reorganizing health services into new Cholera Treatment Centers and Cholera Treatment Units in already existing health facilities. Clean water and sanitation are the main preventive measures that need to be in place to break transmission of cholera. These will require both health and water and sanitation partners to continue to work together to distribute such items as water purification tablets, hygiene kits, and potable water. The strategy will require about $164 million in international funds.

Additional support

On Nov. 24, 2010, the World Bank announced a $10-million emergency grant to address the epidemic. The emergency funding is expected to be formally submitted for approval to the World Bank board of directors in December 2010, but bank emergency-operation procedures allow for up to 40% of the grant to be used to reimburse eligible expenditures already incurred as part of the emergency response. As much as $8 million will go towards funding the response capacity of the largest NGOs, which are already taking up much of the health work in Haiti.

The problem in Haiti is compounded by the loss of infrastructure and expertise as a result of the earthquake that struck the country on Jan. 12, 2010. The earthquake crippled the country's public infrastructure, killing up to 30% of Haiti's senior public officials, while destroying or putting out of commission water and sanitation systems. Many of the 1.3 million people displaced by the earthquake live in temporary camps, with unsafe water and sanitation, a breeding ground for cholera. The proposed grant will strengthen the monitoring capacity of the Ministry of Public Health and Population and the Haitian National Directorate of Water Supply and Sanitation.

The American Red Cross announced on Nov. 29, 2010, that it is committing an additional $2 million to combat the cholera epidemic in Haiti. The funds will be used to purchase supplies, including 40 million chlorine tabs, 3 million pieces of soap, and 140,000 oral rehydration solution sachets, as well as tens of thousands of buckets, jerry cans, and water-purification sachets. The new contribution increases the total American Red Cross support for the cholera response to date to more than $3.3 million.

Since the cholera outbreak began in October, the American Red Cross has provided 5000 cots for use in health centers operated by Partners in Health, Project Medishare, and the Haitian Ministry of Health. At the request of the Haitian Ministry of Health, the American Red Cross has purchased 250,000 sachets of oral rehydration solution. During the response, the Red Cross has also been providing safe, chlorinated water each day to an estimated 280,000 displaced survivors throughout Port-au-Prince.

In response to the rapid spread of cholera in Haiti, the humanitarian-relief effort, Direct Relief International has expanded its medical-supply efforts to support more than 100 hospitals and health facilities throughout the country and has furnished 157 tons of medical essentials and hygiene materials to health facilities. Direct Relief is working in collaboration with Haiti’s National Ministry of Health and its departmental directors, as well as directly with individual health facilities caring for cholera patients throughout the country.

Abbott (Abbott Park, IL) reported in October that it is providing $180,000 in support to help address the recent cholera outbreak in central Haiti. This donation includes a $25,000 grant from the Abbott Fund to Partners in Health and $155,000 in donated Abbott rehydration solutions and antibiotics. Donated products are being distributed through AmeriCares, Catholic Medical Mission Board, Direct Relief International, and Partners in Health.

Cholera vaccine

In the wake of the cholera outbreaks in  Haiti, a group of leading experts from Harvard Medical School, George Washington University, and the International Vaccine Institute (IVI) have urged the United States to create an emergency stockpile of cholera vaccines for future humanitarian use.

“The costs to the US of creating and maintaining a stockpile of several million doses of cholera vaccine would be low,” said the experts in an article published online on Nov. 24, 2010 in The New England Journal of Medicine (NEJM), according to a Nov. 24, 2010 IVI press release. “But the humanitarian benefits of rapid deployment of cholera vaccines to areas at high risk for major cholera outbreaks such as earthquake-wracked Port-au-Prince, the Haitian capital where 1.3 million people live in unsanitary refugee camps could be enormous,” according to the release.

 “Outbreaks of cholera and other diarrheal diseases impede recovery from natural and man-made disasters,” said Peter Hotez, president of the Sabin Vaccine Institute and a coauthor of the NEJM article, in the IVI release. “They also destabilize poor communities, promoting poverty by interfering with agricultural productivity and adversely affecting food security, and thereby potentially igniting new conflicts or exacerbating existing ones. If the vaccine were available now, it could still be delivered to as-yet-unaffected parts of Haiti in time to stabilize the country.”

Cholera is a diarrheal disease caused by the bacterium Vibrio cholerae. It can be fatal because the pathogen elicits secretion of large quantities of bacteria-laden fluid from the intestine, resulting in extreme dehydration. It is transmitted through the fecal-oral route, and if the drinking water or food supply becomes contaminated with V. cholerae, the disease can spread through a population very rapidly. It is estimated that the annual global burden of cholera is 3 million to 5 million cases and 100,000 to 130,000 deaths, according to IVI. A recent analysis of the global burden of cholera conducted by the IVI estimates that approximately 1.5 billion people are at risk for cholera globally.

Treatment of cholera involves replacement of lost fluid with oral or intravenous rehydration solution and antibiotics, but can be difficult to administer when healthcare infrastructure is poor or damaged because of a crisis. One way to prevent the spread of the disease is to administer a vaccine. According to IVI, three oral cholera vaccines currently are available. Dukora, produced by Crucell (Leiden, The Netherlands), consists of killed V. cholerae cells and recombinant cholera toxin B. Dukoral is licensed in more than 60 countries and is prequalified by WHO for purchase by UN  agencies. The two other vaccines, Shanchol produced by Shantha Biotechnics of India, and mORC-VAX made by VaBiotech in Vietnam, consist of killed V. cholerae cells without the added toxin. Both vaccines were licensed in 2009, and Shanchol is currently awaiting prequalification by the WHO. All three vaccines are administered in a two-dose regimen. Shanchol was originally developed by IVI, and does not require administration with a buffer, thereby simplifying its use under field conditions, including refugee camps and other post-crisis situations, according to IVI. According to IVI, fewer than 500,000 total doses of oral cholera vaccines (Dukoral or Shanchol) are presently available for shipment from their manufacturers. Stockpiling the vaccine is considered an important strategy for the situation in Haiti but also to address the problem in neighboring countries, said IVI.