Prevention of Cholera in Haiti: Proposal

Cholera: Description of the Disease

• Acute infection of the small intestine caused by the gram-negative microorganism Vibrio Cholerae, which secretes a toxin that causes profuse watery diarrhea, leading to dehydration, oliguria, and vascular insufficiency.
• Spread by drinking water, contaminated food (Christian et al., 2017).
• WHO: more than 50 countries worldwide suffer from cholera (Cholera, n.d.)
• Proportion of population infected rises with cases of sanitary and hygienic rules and low sanitary culture of the population (Cholera, 2020).
• Disease spreads usually in epidemics, provoking a rapid loss of fluid in the body and varying degrees of dehydration, causing deaths.

Cholera is an acute infection of the small intestine caused by the gram-negative microorganism Vibrio cholerae, which secretes a toxin that causes profuse watery diarrhea, leading to dehydration, oliguria, and vascular insufficiency. Infection usually occurs through contaminated water or seafood.

Cholera is spread by drinking water, seafood, or other foods contaminated with the feces of people with symptomatic or asymptomatic infection. Domestic cholera patients are at high risk of infection, which is likely through shared sources of contaminated food and water (Christian et al., 2017). Human-to-human transmission is less likely because it requires a large amount of pathogen material. Cholera is endemic to parts of Asia, the Middle East, Africa, South America, Central America, and the northern US Gulf Coast (Cholera, n.d.). In 2010, the outbreak occurred in Haiti and then spread to the Dominican Republic and Cuba. The infection, imported to Europe, Japan, and Australia, caused local outbreaks. According to the World Health Organization (WHO), more than 50 countries around the world suffer from cholera (Cholera, n.d.).

In case of violation of sanitary and hygienic rules and low sanitary culture of the population, it is possible to increase the proportion of those infected by contact and household means up to 60–70% (Cholera, 2020). In the USA, Latin America, India, there are cases with foodborne infection (Fang, 2019). In areas with a high incidence, children are more likely to get sick: the highest incidence occurs at the age of 2-4 years (Christin et al., 2017). Men get sick more often than women, urban dwellers – more often than rural. The peak incidence occurs during the summer months and the rainy season (in the tropics).

The disease spreads, usually in epidemics, provoking a rapid loss of fluid in the body and varying degrees of dehydration, even death.

Cholera in Haiti

• More than 800,000 people were infected in total, up to 200 people per day in peak periods. 10 000 deaths and 10% of the population affected (Agbedahin, 2019).
• The healthcare in Haiti is unfairly underdeveloped and impoverished (Aurelus& Saintil, 2020). Among Latin American and Caribbean countries, Haiti ranks last in healthcare and the provision of medical services to the population (OECD, 2019).
• Lowest life expectancy (61.5 years), worst rates in maternal mortality, healthcare per capita, and drinking water supply.

Cholera: closely linked to these factors, primarily affects and kills the poorest and most disadvantaged without access to clean water and sanitation.

In total, more than 800,000 people were infected, during peak periods, up to 200 people fell ill per day (Agbedahin, 2019). The country is home to 9.8 million people; that is, cholera affected almost 10% of the population and killed 10,000 people (Agbedahin, 2019). Moreover, Vibrio cholerae itself in the first days of the outbreak turned out to be more virulent for people than after a month and a half. Up to 10% of cholera patients admitted to the hospital in the first 48 hours after the onset of the outbreak died, but in early December, this figure dropped to 1.4% (Agbedahin, 2019).

The healthcare in Haiti is unfairly underdeveloped and impoverished (Aurelus & Saintil, 2020). One of the leading indicators of the country’s social well-being is the health authorities’ level and work. While these are not the only characteristics, they largely determine the differences in health care across countries. With this approach in mind, the OECD (2019) assessed the quality of health systems in 20 Latin American and Caribbean countries using 16 objective generally accepted indicators such as infant mortality rates and the number of doctors.

According to the study results, Haiti ranks as one of the last places in terms of the level of healthcare and the provision of medical services to the population. Haiti has the lowest life expectancy at 61.5 years, which is more than 17 years less than in the US (OECD, 2019). It also had the highest infant mortality rate at 64 deaths per 1,000 newborns per year, compared with 14 in the US.

Haiti, where healthcare is most neglected, has the worst rates in other dimensions, such as maternal mortality, the proportion of births attended by qualified doctors, measles vaccination, health care costs per capita, and drinking water supply. The large gap in the healthcare level is a consequence of global structural factors: both at the national policy level and the level of global capitalism (Sell & Williams, 2020). These structural factors result from a harmful combination of unfair policies, economic distress, and incompetent governance.Cholera is a disease that is closely linked to inequality. It primarily affects and kills the poorest and most disadvantaged people without access to clean water and sanitation.

Cholera in Haiti: Factors Influencing the Undesirable Situation

• Social factors: low living standards, lack of qualified medical care, living in refugee camps in conditions of high population density, lack of water, and lack of sanitary and hygienic facilities (Guillaume et al., 2018).
• Weather, climatic, and geographical factors.
• Most common in regions with high population densities, poor sanitation, and low water quality.
• Typical risk areas: urban slum areas without basic infrastructure and internally displaced persons, and refugee camps or prisons.

Social factors contributing to cholera’s spread are low living standards, lack of qualified medical care, living in refugee camps in conditions of high population density, lack of water, and lack of sanitary and hygienic facilities (Guillaume et al., 2018). Sanitary and hygienic factors, such as a low level of sanitary culture of the population, lack of necessary hygiene skills (washing hands with soap), lack of full-fledged centralized water supply, and sewerage systems also contribute to the spread of infection (Guillaume et al., 2018). Weather, climatic and geographic factors also play an essential role in developing cholera outbreaks in Haiti.

Cholera is most common in regions with high population densities, poor sanitation, and low water quality. Typical risk areas are urban slum areas that lack even basic infrastructure and internally displaced persons and refugee camps where water quality and sanitation are inadequate. In terms of the climatic conditions that contributed to the emergence of the epidemic in the region, it must be said that the spread of the disease was facilitated by the unsanitary conditions in which a significant part of the population was forced to live after the devastating earthquake.

Implementation Plan

• Two directions: prevention and enhancement of long-term social and sanitary infrastructures and practices.
• Short-term prevention: non-specific measures:
  • compliance with sanitary and hygienic standards on collective and individual level
• specific measures:
  • mass immunization (oral vaccines)
• Long-term prevention:
  • enhancing healthcare system and sanitary infrastructures
  • formation of national systems for surveillance and prevention of cholera, which should have a strictly defined legislative, legal, and methodological basis, as well as meet international requirements and standards.

In the fight against cholera in Haiti, international global control of the disease is essential. The strategy to combat cholera in Haiti should focus on two directions: first, to intensify efforts to prevent cholera cases, and second, to provide material assistance to enhance long-term social and sanitary infrastructures and practices.

Non-specific cholera prevention measures imply compliance with sanitary and hygienic standards in populated areas, at catering establishments, in water intake areas for the needs of the population. Individual prevention consists of maintaining hygiene, boiling the water used, washing food, and cooking them correctly.

The most severe gaps in the system contributing to the spread of the disease are the combination of healthcare system deficiencies and sanitary infrastructures failures. Cholera prevention in this country should be aimed at the whole range of factors contributing to the spread and rooting of cholera (social and sanitary and hygienic in the first place) (Kligerman et al., 2017). In general, the country faces the problems of sustainable economic development, poverty alleviation and the solution of social problems, the improvement of populated areas, the provision of guaranteed drinking water, and an adequate wastewater treatment system.

A critical component is the formation of national systems for the surveillance and prevention of cholera, which should have a strictly defined legislative, legal, and methodological basis (Weill et al., 2017). The basic principles of state epidemiological surveillance should comply with the International Health Regulations (World Health Organization, 2005) and meet international requirements and standards.

• Mass routine immunization (twice a year for a period of at least five years)
  • herd immunization: at least 20% of population.
• Creation of mobile laboratory complexes: visiting the risk populations, control of the activities of the local medical facilities, and help comply with the hygienic standards.
• The construction of an adequate full-fledged centralized water supply and sewage systems.
• Mass education in sanitary culture and necessary hygiene skills.
• Special training of medical personnel and strengthening the medical specialist network

Mass immunization acts as a necessary intermediate between emergency response and broader, long-term efforts such as investing in security, sanitation, and hygiene services. First, global health funders must do their utmost to secure full funding for immunization in the next strategic investment period (Lee et al., 2020). Routine immunization is essential for building strong primary health care systems and achieving universal coverage.

Mass immunization is crucial for achieving the herd immunity against cholera, and large-scale cholera vaccination campaigns would offer the opportunity to achieve near-term population protection (Lee et al., 2020). This is necessary while achieving the long-term control over cholera outbreaks. The latter consists of water and sanitation improvement (Hsiao et al., 2017).

The short term prevention is estimated by five years for the reason that 2020 has become the first year without any cholera cases reported, however, a period of five years is needed to claim Haiti cholera-free (Kushner, 2020). It is essential to prevent the short supply of vaccines, thus, it is crucial to estimate the number of vaccines needed for the population. Vaccines should be done twice a year (Hsiao et al., 2020), and the vaccine coverage should be at least 20% (Lee et al., 2020). Another short-term measure includes the creation of mobile laboratory complexes. It will allow the doctors to visit the risk populations, control the activities of the local medical facilities, and help comply with the hygienic standards.

The long-term measures involve, first, the construction of an adequate full-fledged centralized water supply and sewage systems. Second, it is crucial to conduct mass education in sanitary culture and necessary hygiene skills. Third, the necessary part of the long-term plan is special training of medical personnel and strengthening the medical specialist network.

At the same time, international cooperation is needed to support long-term prevention interventions, including major investments in sustainable water supply, sanitation, hygiene services, improved surveillance, and strengthening of health systems. Funds are also needed to support groups and organizations operating in Haiti. This calls for increased UN support to reduce and ultimately halt the spread of cholera, improve the availability of hospital care and treatment, and address the longer-term challenges of water, sanitation, and health care in Haiti

Budget: Short-Term Period

Mass immunization

1.85 per dose x 2 (twice a year) x 5 (five years to sustain the herd immunity and total elimination for the long-term plan come into action) x 1.95 mln (approx. 20% of population) = 36,075 mln total for five years, 7,215 mln per year

• The creation of mobile laboratory complexes:
  • 2 x 10 (number of departments in Haiti) x 10 000 $ (the provision with necessary equipment and materials) x 5 years = 1 mln total, 200,000 per year
  • + 5 (people per a hospital) x 2 x 10 x 10000 $ per year (medical professionals’ salary) x 5 years = 1 mln total, 200,000 per year
• TOTAL, 5 YEARS: 38,075 mln, 7,615 mln per year

According to Mogasale et al. (2016), the price of the cholera vaccine on the public market worldwide is $1.85 per dose.

Monitoring and Evaluation

• Case Reported: KPI = 0
• Vaccination:
  • number of people vaccinated: KPI = 20% of population twice a year
  • socio-demographic characteristics of population vaccinated (target: risk regions and dense populations)
• Mobile Laboratory Complexes:
  • facilities visited (target: risk populations and hard-to-reach facilities, e.g., prisons), KPI = 5 monthly
  • activity individually planned for each facility and population
  • reports’ compliance with international medical standards

Milestones to Assess Progress and Success

Reporting to the Stakeholders

• The key information about the improvements in the area.
• KPIs included
• The comparative perspective with the focus on the factual improvements
• Evidence based criteria

It is important to structure the reports in such a way that gives the stakeholder the key information about the improvements in the area. First, it is important to include all the mentioned KPIs in the report. The information reported should be presented in the comparative perspective with the focus on the factual improvements. It is also essential to base the evaluation on the evidence-based criteria.

References

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Christian, K. A., Iuliano, A. D., Uyeki, T. M., Mintz, E. D., Nichol, S. T., Rollin, P., Staples, J. E., & Arthur, R. R. (2017). What We Are Watching-Top Global Infectious Disease Threats, 2013-2016: An Update from CDC’s Global Disease Detection Operations Center. Health security, 15(5), 453–462. Web.

Cholera. (2020). Centers for Disease Control and Prevention. Web.

Cholera. (n.d.). World Health Organization. Web.

Fang, L., Ginn, A. M., Harper, J., Kane, A. S., & Wright, A. C. (2019). Survey and genetic characterization of Vibrio cholerae in Apalachicola Bay, Florida (2012–2014). Journal of applied microbiology, 126(4), 1265-1277.

Guillaume, Y., Ternier, R., Vissieres, K., Casseus, A., Chery, M. J., & Ivers, L. C. (2018). Responding to cholera in Haiti: Implications for the national plan to eliminate cholera by 2022. The Journal of infectious diseases, 218(3), 167-170.

Hsiao, A., Desai, S. N., Mogasale, V., Excler, J. L., & Digilio, L. (2017). Lessons learnt from 12 oral cholera vaccine campaigns in resource-poor settings. Bulletin of the World Health Organization, 95(4), 303–312. Web.

Kligerman, M., Walmer, D., & Bereknyei Merrell, S. (2017). The socio-economic impact of international aid: a qualitative study of healthcare recovery in post-earthquake Haiti and implications for future disaster relief. Global public health, 12(5), 531-544.

Kushner, J. (2020). ‘It became part of life’: How Haiti curbed cholera. The Guardian. Web.

Lee, E. C., Chao, D. L., Lemaitre, J. C., Matrajt, L., Pasetto, D., Perez-Saez, J.,… & Longini Jr, I. M. (2020). Achieving coordinated national immunity and cholera elimination in Haiti through vaccination: a modelling study. The Lancet Global Health, 8(8), e1081-e1089.

Mogasale, V., Ramani, E., Wee, H., & Kim, J. H. (2016). Oral Cholera Vaccination Delivery Cost in Low- and Middle-Income Countries: An Analysis Based on Systematic Review. PLoS neglected tropical diseases, 10(12), e0005124. Web.

OECD (2019). Health systems characteristics: A survey of 21 Latin American and Caribbean countries. Organization for Economic Co-operation and Development.

Peak, C. M., Reilly, A. L., Azman, A. S., & Buckee, C. O. (2018). Prolonging herd immunity to cholera via vaccination: Accounting for human mobility and waning vaccine effects. PLoS neglected tropical diseases, 12(2), e0006257. Web.

Sell, S. K., & Williams, O. D. (2020). Health under capitalism: a global political economy of structural pathogenesis. Review of International Political Economy, 27(1), 1-25.

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World Health Organization. (2005). International health regulations. Web.