Ending cholera in Haiti – a work in progress

Since 1 January 2015 it is estimated that cholera has killed 185 people in Haiti* – children, women and men whose deaths could have been avoided. Close to 9,000 children, women and men have died since the epidemic began in October 2010. The structural causes of their death are the same as those that allowed Ebola to kill 10,200 people over the course of last year in Africa. Besides numbers and causes, both epidemics share another feature, they require continued global attention and vigilance. After the spotlight has moved on and the initial emergency response is over, there is always a danger that the initial international drive and determination to respond to the crisis diminishes. We cannot allow that to happen with cholera in Haiti.

Little has been written about cholera in Haiti in recent months. The fight, while progressing, well is far from over. Since 2010, we have seen the numbers of suspected cholera cases fall from 351,839 to 27,388 last year. So far (until 19th September) in 2015 there have been 22,511 suspected cases. The number of suspected deaths due to cholera has also fallen from 3,951 in 2010 to 178 this year. But even one death is too many for such a preventable and treatable disease!

At the end of 2014 we saw heavy rainfall after the June monsoon season. A direct consequence was a resurgence in the number of cases from September, reaching 7,400 cases for November 2014 only, and a higher number of cases at the beginning of 2015 compared to the previous year with 4,000 cases in January 2015. It was a warning not to let complacency creep in!

Still, the situation could have been worse. The surveillance mechanism and the rapid response teams that were put in place in 2014 under the leadership of the Minister of Health, had by May, brought the number of cases back down to under 2,000 a month, and less than 1,500 in August, very close to where we were a year before despite this disastrous year start. UNICEF partners have made impressive efforts to control each cholera spike and cut the transmission as early as possible. An innovative chlorination control operation has been put in place in the Port au Prince area which so far allowed to annihilate the role rains played last year in triggering cholera spikes.

Rainfall and the contamination of water sources is an important factor in the spread of cholera, yet even during periods of heavy rainfall, the risk of cholera outbreaks is not the same for everyone. Cholera generally affects the most vulnerable. Most often those families affected by cholera live in underprivileged neighborhoods. As seen in the spike in suspected cases registered in Port au Prince towards the end of November 2014, those areas most affected were neighborhoods where the population density is high and access to water and sanitation and health care low. When the cholera vibrio contaminates places such as markets bus stations or even festivals as it did, the risk of the spread elsewhere in the country becomes more acute and more difficult to control.

Today more than ever before it is crucial to maintain and increase our efforts to move towards the control and elimination of cholera in Haiti. In collaboration with the Haitian Ministry of Health, PAHO and several NGO partners, UNICEF works hard throughout the country to respond to the epidemic, while at the same time supporting improved access to water and sanitation – those structural conditions that are necessary to interrupt the chain of transmission. Achieving this dual objective of maintaining a rapid response while improving prevention and a long-term prevention campaign is critical.

An outreach worker explains the use of Aquatabs to residents of d'Artibonite.
©UNICEF Haiti/Cornelia WaltherAn outreach worker explains the use of Aquatabs to residents of d’Artibonite.

What needs to be done?
An integrated strategy aims firstly to ensure a prompt and effective response to outbreaks of cholera and secondly to make long-term investments to reduce the vulnerability of families to cholera, thanks to solid health services, clean water and functional and affordable sanitation for all.

The rapid response is a network of international NGOs working with MSPP emergency response teams who, upon notification of a cholera case arrive on the scene within 48 hours, disinfect the immediate household as well as neighbouring households, distribute water purification, conduct awareness campaigns, and provide oral rehydration salts. The teams also take patients to nearby health care services when necessary. From January 1st to the end of July, UNICEF’s WASH and PAHO Health NGO partners provided more than 5,252 interventions, 75% of which occurred within the first 48 hours (81% ≤72 hours). UNICEF funded interventions account for 67% of the interventions reported. More than 1.86 million people were sensitized through various communication methods (door-to-door, group discussions etc.). Some 23,400 cholera kits** were distributed plus over 20.6 million household water treatment products (Aquatab tablets and bottles of chlorine or AquaJiff/Dlo Lavi), over 227,000 soaps, 11,120 buckets and over 370,000 sachets of oral rehydration salts. At least 29,958 houses were disinfected and 418 water points put in place or received rehabilitation.

The mechanism is for now supported by the European Commission Humanitarian Office, the United Kingdom Aid Agency, the Central Emergency Funds of the United Nations, and UNICEF’s own resources. It is imperative that a rapid response system remains in place until cholera is eliminated. The system can only function if a strong epidemiological surveillance system is present. The latter is the core of an efficient alert and rapid response mechanism, but it is also crucial for the targeting of priority areas in which service-related investments are needed.

Parallel to this, a long-term approach is needed to ensure long-term access to clean water and sanitation. Last year a 5-year “National Sanitation Campaign” was officially launched by the Prime Minister in Los Palmas, Central Department. The National Sanitation Campaign with DINEPA and MSPP and the support of Canada and Japan, aims to increase access to improved sanitation in both rural and disadvantaged urban areas in 16 of the priority communes (first phase). The Community Approach to Total Sanitation (ACAT), an essential element of this campaign, accompanies local villages and families in the priority communes to eliminate open defecation.

So far, ACAT has been implemented in 33 localities and is already producing favourable results with; 293 self-built household toilets and 652 in progress, one community is already close to being certified open defecation free (ODF) and 224 tippy-taps (hand washing system) have been installed. Today following the experience of last year in Martissant, implementing the same approach in urban and semi-urban areas is a priority. Both the short term rapid response and long-term improvements to clear water and sanitation must remain in place.

The UN in Haiti last month launched an emergency appeal to cover the most urgent requirements for cholera– for UNICEF Cholera is on top of the list. UNICEF is also involved in the Transition Call (TAP) launched by the UN in collaboration with the Haitian Government in February 2015 which seeks to mobilize the financial support also for long term improvement to access to water and sanitation in high-risk areas. However in times of global changes and the recurrence of crises across the world we must be innovative to make the best use of funding mechanisms. Integrating the rapid response into long-term development will enable sustainability. Strengthening local capacities for surveillance, investigation and rapid response is a long-term investment in a country facing multiple risks as Haiti.

Collaboration and coordination of all the involved players is the key to success in defeating Cholera in Haiti. Only an approach that combines curative and preventive action can break the chain of transmission – and protect children at risk. Today more than ever our collective challenge is to give all children the same opportunities to survive and thrive, whether they live in disadvantaged neighborhoods or in affluent areas. It’s up to us to make a difference!

Marc Vincent is the UNICEF Representative in Haiti.

* Until 19th Septmeber 2015. Source: Department of Epidemiology, Laboratory and Research MSPP (DELR / MSPP)

** A UNICEF cholera kit includes 1 bucket, 12 soap, 5 sachets of oral rehydration salts and 200 Aquatabs. Some partners will distribute components separately or in addition to the cholera kit.

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