Cholera Vaccination in Haiti

Cholera Vaccination in Haiti

May 12, 2012 Project Director

Shanchol, an oral cholera vaccineCholera is one of those diseases that you really don’t want to get. It begins like any other intestinal illness, with abdominal cramps, nausea, and vomiting. Suddenly, a very profuse, watery diarrhea develops. So much water leaves the body through the diarrhea that the person’s mouth becomes dry. He stops urinating because he has no fluid left. Eyes become sunken, and the sufferer loses his energy.[1] During the course of the disease, a person with cholera may pass as many as 13 US gallons (or 50 liters) of fluid. Left untreated, cholera can kill a person in a matter of hours to days from severe dehydration.[2]

The Americas are relatively cholera-free because of public health successes like hand washing, water treatment, and sewage control. However, any event that disables these measures, combined with the introduction of the cholera bacteria (Vibrio cholerae), could trigger an outbreak of cholera even in the United States.[3] This was the case in Haiti after a major earthquake struck on January 12, 2010. The water supply became contaminated with sewage as water and sewer lines were fractured. The loss of housing placed hundreds of people in close proximity to each other in camps. Then the rainy season came, and the rainwater carried contaminants into streams that were used as drinking water. It is believed that the cholera bacteria were then introduced into Haiti’s water supply from a foreign traveler[4] such as an aid/relief worker or a tourist.  Analysis of the strain circulating in Haiti appears to be related to strains found in Bangladesh (Southeast Asia).[5]

Regardless of its origin or mode of transportation, the cholera bacteria arrived in Haiti and has, at last count, caused more than 470,000 cases and more than 7,000 deaths.[6] Governmental and non-governmental organizations already in Haiti for earthquake relief went to the aid of the victims of the outbreak. They delivered clean water and medicine, set up clinics and mobile hospitals, and distributed educational materials on water sanitation and hand washing. Yet it wasn’t until April 12, 2012, that a vaccination campaign was launched.[7]

A vaccine against cholera has existed since in one form or another since the late 1800s (see our timeline entry on Jaime Ferrán). The vaccine is not currently used in the United States because water and sanitation systems, combined with proper hand washing and a very low number of cases, have kept cholera at bay in this country. The vaccine is recommended for people traveling to areas of the world where cholera is currently active (endemic), although no country requires the vaccination for entry.[8] Because of the degradation of sanitary conditions and the limited availability of clean water, Haiti is the perfect candidate to receive the vaccine in order to control the current outbreak. That is, the vaccine should protect the people while water systems are replaced.

But the project to vaccinate people in Haiti, especially those in very rural and somewhat inaccessible areas, has not been easy to launch. There are issues of maintaining a “cold chain,” meaning that the vaccine must be kept at a low temperature, which is hard to do in rural areas of Haiti. Then there are social concerns associated with the approved vaccine to be used in Haiti. A radio station in Haiti raised a concern that Haitians were being used as “guinea pigs” for the vaccine[9] because the vaccine proposed at the onset of the outbreak had not yet been approved by the World Health Organization (WHO). Those concerns caused the government of Haiti to delay and review the vaccination project. WHO approved the vaccine as safe and effective for use in November 2011, and, once Haitian health authorities agreed that the vaccine needed to be used, the vaccination project got underway. The vaccine being used is an inactivated oral vaccine manufactured in India (Killed Bivalent [O1 and O139] Whole Cell Oral Cholera Vaccine, tradename Shanchol).

Starting in April 2012, 100,000 Haitians of all ages are scheduled to receive the vaccine. Fifty thousand people will receive it in Port-au-Prince, the capital of Haiti, and another 50,000 will get it in the rural, rice-growing areas of the country. If it is shown that the vaccine can be distributed effectively to that number of people, the vaccination project is scheduled to expand to include the whole of the Haitian population in coming months as relief and reconstruction efforts continue.

Additional Reading

Centers for Disease Control and Prevention information on Cholera: http://www.cdc.gov/cholera/index.html

“Controlling Endemic Cholera with Oral Vaccines” http://bit.ly/JrQcVy

 

[1] “Cholera” PubMed Health http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001348/

[2] “Cholera Overview” Doctors Without Borders https://www.doctorswithoutborders.org/news/issue.cfm?id=2390

[3] “Cholera in Disaster Situations” Pan-American Health Organization http://new.paho.org/disasters/index.php?option=com_content&task=view&id=543&Itemid=1

[4] “Where Did Haiti’s Cholera Come From?” National Public Radio https://www.npr.org/blogs/health/2010/10/29/130923065/tracking-the-origins-of-haiti-s-cholera-strain

[5] The Origin of the Haitian Cholera Outbreak Strain. New England Journal of Medicine 364;1 http://www.nejm.org/doi/pdf/10.1056/NEJMoa1012928

[6] “Cholera in Haiti: One Year Later” CDC Global Health http://www.cdc.gov/haiticholera/haiti_cholera.htm

[7] “Vaccination Against Cholera Finally Begins in Haiti” National Public Radio Blog https://www.npr.org/blogs/health/2012/04/12/150493770/vaccination-against-cholera-finally-begins-in-haiti

[8] “ CDC Yellow Book, Chapter 3: Infectious Diseases Related to Travel http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-related-to-travel/cholera.htm

[9] “Fear and Loathing in Haiti: Politics and Distrust Keep Cholera Vaccine in the Cooler” Natural Hazards Center, Disaster Research #585, University of Colorado at Boulder http://www.colorado.edu/hazards/dr/archives/dr585.html#2

Comments

Posted by Kelly Geoghegan (not verified)

Thank you for covering the issue of cholera in Haiti. I work for the Institute for Justice and Democracy in Haiti, which filed a petition against the UN on behalf of 5,000 cholera victims last November.

Vaccinating the at-risk Haitian population with Sanchol is an important measure that will undoubtedly save lives over the coming years. As you note, however, vaccination is an at-best temporary solution. Sanchol will protect Haitians for approximately 3 years before mutations in the cholera strain overcome immunity. The only effective long-term solution for stopping cholera is improved water and sanitation.

As for the source of the cholera, your information is inaccurate. A "mountain" of evidence shows that untreated waste from a UN Peacekeeping base in the rural Artibonite region of Haiti was the source of the outbreak, rather than waste from an unidentified aid/relief worker or tourist. Genetic studies precisely link the strain of cholera in Haiti to that in Nepal. Other evidence shows that a unit of troops from Nepal, where cholera is endemic, arrived in Haiti, their wastes were haphazardly handled at the Mirebalais peacekeeping base contaminating a nearby stream, and the epidemic began near the base and traveled quickly and fatally downstream, killing thousands among the populations that relied on the Artibonite river for water.

I refer you to a plethora of scientific studies and news publications that all converge on this conclusion:

- Final Report of the Inde­pen­dent Panel of Experts on the Cholera Out­break in Haiti (U.N. Inde­pen­dent Panel) — May 4, 2011 http://ijdh.org/wordpress/wp-content/uploads/2011/11/UN-cholera-report-final.pdf

- Nepalese Origin of Cholera Epidemic in Haiti (Clinical Microbiology and Infection) - April 17, 2012. http://onlinelibrary.wiley.com/doi/10.1111/j.1469-0691.2012.03841.x/abstract

- The Ori­gin of the Hait­ian Cholera Out­break Strain (The New Eng­land Jour­nal of Med­i­cine) — Jan­u­ary 6, 2011 http://ijdh.org/wordpress/wp-content/uploads/2011/11/NEJM-Origin-of-the-Haitian-Cholera-Strain.pdf

- Sci­en­tists: UN Sol­diers Brought Deadly Super­bug to Amer­i­cas ( By Matthew Mosk, Brian Ross and Rym Mom­taz, abcnews.go.com) — Jan­u­ary 12, 2012. http://abcnews.go.com/Blotter/scientists-soldiers-brought-deadly-superbug-americas/story?id=15341129#.T7EjFBwgozP

- In Haiti, Global Fail­ures on a Cholera Epi­demic (By The New York Times) — March 31, 2012 http://www.nytimes.com/2012/04/01/world/americas/haitis-cholera-outraced-the-experts-and-tainted-the-un.html?pagewanted=1&_r=1

Why does the source matter since, as you say, cholera is already in Haiti and is killing thousands? Three reasons:

1) The UN should have come forward immediately to claim responsibility. Quickly identifying the disease as cholera and knowing the precise Nepalese source of the strain could have saved lives in the early, high-fatality days of the epidemic;

2) The United Nations is under numerous obligations to protect the environment surrounding their bases, but their negligent actions triggered the outbreak that has killed and sickened so many. “It was like throw­ing a lighted match into a gasoline-filled room,” said Dr. Paul S. Keim, a micro­bial geneti­cist whose lab­o­ra­tory deter­mined that the Hait­ian and Nepalese cholera strains were vir­tu­ally identical.

3) Most importantly, now that cholera is in Haiti, the UN has a legal and moral obligation to undo the damage, install life-saving water and sanitation infrastructures, and compensate the victims who were harmed and killed by the disease. Providing comprehensive clean water in Haiti will prevent deaths from cholera, and other water-borne diseases, saving tens of thousands of Haitian lives over the next decade.

I invite anyone with questions or comments to contact me, Kelly Geoghegan, at Kelly@ijdh.org.

Posted by Project Director

From the blog post author: Thank you for your comment. In my research for this piece, I came across conflicting evidence as to the original source of the infection. Because it is a controversial matter at the moment (as evidenced in your comments), I chose not to point the finger at one group over another. My main aim of the blog post was to say that Haiti had a devastating earthquake which crippled the infrastructure (including manpower), that cholera arrived and triggered an outbreak, and, that among other solutions I mention in the post (e.g. water sanitation) vaccination is now underway to help bring the outbreak under control. I wish you the best of luck in your efforts in Haiti, and thank you for your comments.

Posted by Dr. Richard A… (not verified)

Prior field studies of the effects of Shanchol vaccine on cholera have yielded mixed results depending on whether the studies were conducted by the developers of the vaccine or its producers or by independent scientists who were not biased in their interpretation of the results. One good thing is that it is generally agreed that it is harmless. Actually, the composition of this vaccine is irrational. It contains two serotypes of V. cholerae, O1 and O139, killed in enormous numbers by various arbitrary methods. The inclusion of O139 is useless in Haiti because that serotype is not present in the current epidemic. The O1 strains used were isolated in Egypt in the 1940s and maintained in the laboratories in Sweden which created the present concoction. How closely they are related to the El Tor biotype of V. cholerae causing the present outbreak has not been established nor is there any method of comparing different lots of vaccine with a standard in the laboratory. This could account, at least in part, for the variable results obtained in previous field studies of different lots of vaccine. Further, as far as I can determine, the vaccine is to be given indiscriminately. No mention has been made of a double blind study with a placebo as a control so there will, in reality, be no way of determining scientifically whether the vaccine actually prevents cholera in Haiti. A different vaccine produced by the company that manufactures Shanchol was previously condemned by WHO. Shanchol should be evaluated in a smaller number of people in a cholera-infected area against a placebo control in a double blind study conducted by scientists who
have no connection and do not profit from the sales of this vaccine before it is used blindly without control in larger numbers of people. The dollars which could be wasted in a large scale uncontrolled vaccine campaign could better be used to provide sanitary toilets and purified water.

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