Persistant plague: Two years after the earthquake Vibrio cholerae is well established in Haiti. Now advocates and policy makers are looking for the best tools to banish it. Image: Wikimedia Commons/Tom Kirn/Ron Taylor/Louisa Howard/Dartmouth Electron Microscope Facility
The cholera epidemic in Haiti has cast a stark light on deep development holes and disagreements about whether a short-term patch—in the form of a cholera vaccine—can help in the long-term fight for better health.
A developing nation, Haiti has long struggled to maintain modern public-health projects. Even before the January 12, 2010 earthquake the country was already falling behind. In 1990 more than a quarter of the population had access to sanitary facilities, but by 2008 only 17 percent of Haitians did. The earthquake brought further destruction to the country's limited infrastructure. Almost before the dust from the devastation settled, however, the international outpouring of support and aid seemed to signal a new opportunity to bring the most basic of health tools—clean water and decent sanitation—to Haitians.
Now, two years after the earthquake, Haiti is backsliding again. In the first half of 2010 about half of people in settlement camps in Port-au-Prince had clean drinking water, but by the end of the year only 7 percent did. And even as the cholera epidemic subsides to a couple hundred cases a day between rainy seasons, experts anticipate a spike in illness and deaths as soon as the rains return, starting next month.
Since the first cases of cholera appeared in October 2010, some 7,000 people have died from the diarrheal disease (caused by the pathogen Vibrio cholerae, which is transmitted via unclean drinking water) and at least 520,000 have suffered symptoms. Treatment is simple (oral rehydration salts), and prevention is basic (clean drinking water and proper sanitation). But for impoverished Haiti, these solutions are still largely out of reach.
That is why many advocates argue for the distribution of the cholera vaccine, which has passed clinical trials and received approval by the World Health Organization (WHO) for global use. But many groups, such as the Pan-American Health Organization (PAHO), are taking a wait-and-see approach and are not yet ready to back a full rollout of the vaccine.
The two existing cholera vaccines, Dukoral and Shanchol, are taken orally in two doses two weeks apart, and immunity takes about a week to kick in, lasting for two to three years. They are about 60 to 90 percent effective.
Those at Partners In Health (PIH), a health care organization, say that imperfect efficacy should not matter in Haiti. "If you have a vaccine that was about 80 percent effective compared to 0 percent effective of drinking stool-laden water, which would you choose?" asks Paul Farmer, co-founder of the organization and a professor at Harvard University. "It's not as good as the polio vaccine, but neither is the flu vaccine." Indeed, the cholera vaccines are roughly as effective as flu vaccine, and are "pretty frickin' good," Farmer says. Shanchol has emerged as the favorite, as unlike Dukoral it does not need to be diluted with water.
PIH is collaborating with the Haitian nongovernmental organization Gheskio to start distributing Shanchol in two locations—in the rural area of Bocozel in the Artibonite River Valley and the more urban Port-au-Prince slum Cité de Dieu. They have 200,000 doses of Shanchol on order from the Indian manufacturer, Shantha Biotechnics, and hope to start the pilot program next month—although Farmer says they had hoped it would start last year.