Fighting Cholera in Haiti With Vaccines

Cholera epidemic has taken a toll on individuals, communities, and the health system in Haiti


Excerpts from an article written by: Louise Catherine Ivers, MD, MPH

When Hurricane Matthew struck Haiti in 2016, it left over one million people in need of urgent humanitarian assistance to combat cholera.

Cholera had not been reported in Haiti until it was introduced in 2010.

The introduction of Vibrio cholerae into a population that had never been exposed to cholera and that had extremely limited access to safe water and sanitation had a predictable effect.

An explosive cholera epidemic in Haiti has killed at least 10,000 people and caused nearly 800,000 reported cases throughout the country.

Now in its seventh year, the cholera epidemic has taken an immeasurable toll on individuals, communities, and the health system in Haiti.

In 2015, Haiti reported more cases of cholera per population than any other country.

In 2016, there were 29,000 cases of cholera in the first 9 months of the year, already a disaster before the hurricane hit.

New approaches are needed to address the ongoing problem and mitigate suffering from cholera in Haiti.

There is a simultaneous need to ensure that cholera treatment centers and oral rehydration posts are functional. After the hurricane, many of these facilities will have to be rebuilt; resupplied with rehydration fluids, antibiotics, and zinc for children; and supported with staff to perform effective case finding in the community and rapid treatment of the sick.

These strategies have not changed since the beginning of the cholera epidemic in 2010, although in recent years resources to implement them have dwindled.

When the cholera epidemic began in Haiti, and for some years afterward, there was a lack of consensus on the role that oral cholera vaccine (OCV) could play in the response.

One clear issue, however, was that the supply of vaccine was very limited, and there was limited experience in using OCVs in response to outbreaks.

Furthermore, the fact that the most affordable vaccine had not yet met prequalification requirements of the World Health Organization (WHO). The products are essentially the same vaccine, made by different manufacturers.

Shanchol (Shantha Biotechnics, India) was prequalified in 2011. Other OCVs are available (VaxChora, PaxVax, United States; Dukoral, Valneva, Sweden) but at this time are not considered practical for major public health use in resource-poor settings.

Finally, a series of studies with OCVs in Haiti have demonstrated the efficacy of the Shanchol vaccine in both urban and rural settings, the feasibility of achieving high coverage rates, and the low cost of delivering this vaccine to the population.

This information fundamentally changes the way health authorities should now consider the use of OCV in controlling cholera.

Mass vaccination in Haiti would save lives, and modeling suggests that such an intervention, coupled with targeted, effective water, sanitation, and hygiene interventions, could substantially control, if not eliminate, the disease within a few years of the program’s introduction, at an affordable cost.

Over the past six decades, several public health programs in Haiti (e.g., those focused on HIV care and treatment and control of neglected tropical diseases) have provided models for the world.

The increased availability of OCVs and their rollout in a national program could provide an opportunity for the government of Haiti and the international community to demonstrate another successful strategy: comprehensive national OCV coverage combined with targeted water, sanitation, and hygiene interventions could eliminate the transmission of cholera in Haiti over the next 3 to 5 years at an affordable cost (some estimates suggest approximately $66 million).

This goal is surely one to aspire to, given the human cost of maintaining the status quo.