Cholera Vaccination in Haiti

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