Eff ectiveness 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 eff ectiveness 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 eff ectiveness 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 eff ectiveness 63%, 95% CI 8–85). 27 (57%) of 47 cases had certifi ed vaccination versus 147 (78%) of 188 controls (vaccine eff ectiveness 58%, 13–80). Neither self-reported nor verifi ed vaccination was signifi cantly associated with non-cholera diarrhoea (vaccine eff ectiveness 18%, 95% CI –208 to 78 by self-report and –21%, –238 to 57 by verifi ed vaccination). Interpretation Bivalent whole-cell oral cholera vaccine eff ectively protected against cholera in Haiti from 4 months to 24 months after vaccination. Vaccination is an important component of eff orts to control cholera epidemics

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

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

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 program's research agenda. Recent experience with research protocols embedded into successfully implemented projects demonstrates how such hypothesis can be rigorously tested

Achieving coordinated national immunity and cholera elimination in Haiti through vaccination: a modelling study

Summary: Background: Cholera was introduced into Haiti in 2010. Since then, more than 820 000 cases and nearly 10 000 deaths have been reported. Oral cholera vaccine (OCV) is safe and effective, but has not been seen as a primary tool for cholera elimination due to a limited period of protection and constrained supplies. Regionally, epidemic cholera is contained to the island of Hispaniola, and the lowest numbers of cases since the epidemic began were reported in 2019. Hence, Haiti may represent a unique opportunity to eliminate cholera with OCV. Methods: In this modelling study, we assessed the probability of elimination, time to elimination, and percentage of cases averted with OCV campaign scenarios in Haiti through simulations from four modelling teams. For a 10-year period from January 19, 2019, to Jan 13, 2029, we compared a no vaccination scenario with five OCV campaign scenarios that differed in geographical scope, coverage, and rollout duration. Teams used weekly department-level reports of suspected cholera cases from the Haiti Ministry of Public Health and Population to calibrate the models and used common vaccine-related assumptions, but other model features were determined independently. Findings: Among campaigns with the same vaccination coverage (70% fully vaccinated), the median probability of elimination after 5 years was 0–18% for no vaccination, 0–33% for 2-year campaigns focused in the two departments with the highest historical incidence, 0–72% for three-department campaigns, and 35–100% for nationwide campaigns. Two-department campaigns averted a median of 12–58% of infections, three-department campaigns averted 29–80% of infections, and national campaigns averted 58–95% of infections. Extending the national campaign to a 5-year rollout (compared to a 2-year rollout), reduced the probability of elimination to 0–95% and the proportion of cases averted to 37–86%. Interpretation: Models suggest that the probability of achieving zero transmission of Vibrio cholerae in Haiti with current methods of control is low, and that bolder action is needed to promote elimination of cholera from the region. Large-scale cholera vaccination campaigns in Haiti would offer the opportunity to synchronise nationwide immunity, providing near-term population protection while improvements to water and sanitation promote long-term cholera elimination. Funding: Bill & Melinda Gates Foundation, Global Good Fund, Institute for Disease Modeling, Swiss National Science Foundation, and US National Institutes of Health

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

Eternally restarting or a branch line of continuity ? Exploring consequences of external shocks on community health systems in Haiti

Background: Community health systems (CHS) are integral in promoting well-being in humanitarian settings, like Haiti, a country plagued by disruptive socio-political and environmental shocks over the past two decades. Haiti’s community health workers (CHWs) as critical intermediaries have persisted throughout these contextual shocks. This study explores how shocks influence CHS functionality and resilience in Haiti. Methods: We applied an inductive and deductive qualitative approach to understand the lived experience of CHS actors. A desk review of peer-review and grey literature searched 393 and identified 25 relevant documents on community health policies, guidelines, and strategies implemented over the last fifteen years in Haiti. In-depth interviews with policy and program stakeholders (n = 12), CHWs (n = 24), and CHW supervisors and community health auxiliary nurses (n = 15) were conducted. Results: Various shocks – political transitions, natural disasters, and disease outbreaks – describe Haiti’s protracted complex humanitarian setting and reveal distinct influences on CHS functionality (challenges and enablers), resilience, and mediating factors (eg, policy, financing, governance, parallel systems). Consequences of civil unrest and lockdowns (political transitions), internal displacement and infrastructural damage (natural disasters), and livelihood depletion and food insecurity (natural disasters and disease outbreaks) affect CHS functioning. CHW resilience is rooted in their generalized scope of work, intrinsic motivation, history in the community, trusting relationships, self-regulatory capacity, and adaptability. Mental health and safety among CHS actors and communities they serve pose challenges to CHS functionality and resilience, while reinforcing collaborations that promote CHW coverage and support and sustain CHS. Participants recommended government support for CHWs, collaborations stewarded by the government and complemented by partners, sub-national autonomy, and integration of disaster preparedness for all CHWs. Conclusions: Political transitions, natural disasters, and disease outbreaks in Haiti continue to profoundly influence CHS functioning, despite mitigating policy and programming efforts. This study documents the relevance of CHS in maintaining primary health care for a country in protracted crises and suggests that propositions of CHW resilience can be explored in complex humanitarian settings globally

Seroprevalence of Vibrio cholerae in Adults, Haiti, 2017

In Haiti in 2017, the prevalence of serum vibriocidal antibody titers against Vibrio cholerae serogroup O1 among adults was 12.4% in Cerca-la-Source and 9.54% in Mirebalais, suggesting a high recent prevalence of infection. Improved surveillance programs to monitor cholera and guide public health interventions in Haiti are necessary

Establishing and utilizing strategic partnerships for vaccine-preventable diseases: Best practices in Haiti

On March 10 to 11, 2016, the Ministère de la Santé Publique et de la Population (Ministry of Health of Haiti) and the Global Health Initiative at Henry Ford Health System hosted their Second Annual Scientific Conference entitled, “Best Practices for Establishing and Utilizing Partnerships for Vaccine-Preventable Diseases in Haiti,” at the National Laboratory in Port-au-Prince, Haiti. The conference brought together Ministry of Health officials, researchers, clinicians, academics, public health professionals, and other stakeholders to discuss vaccine programs and policies in Haiti. This forum provides a learning and discussion space to fuel strategies and public health research responding to priority areas identified by the Ministry of Health, and consequently, this forum serves as counsel for the Ministry of Health in its decision making on strategies to prevent and control infectious diseases in Haiti. The following article summarizes the presentations and conclusions of the March 2016 conference and covers a variety of important issues relating to vaccines and vaccine-preventable diseases in Haiti, including Haiti\u27s Expanded Program on Immunization, surveillance, logistical and funding challenges, and community approaches, as well as case studies detailing introduction of the pentavalent, rotavirus, oral cholera, and human papillomavirus vaccines in Haiti. Most importantly, this article highlights a model for effective partnerships for vaccines, a model that can transcend response to specific diseases and apply to all global health partnerships

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