Possibility of Population-Wide Cholera Vaccination in Haiti

After a devastating earthquake in Haiti in 2010, an epidemic of cholera quickly

spread. Within 2 years, roughly 600,000 reported people had contracted cholera (Barilay
et al. 599). After the two trips that I took to Haiti, I saw parts of the impact of this
epidemic and became concerned with the large numbers of people with the diseases, as
well as the inability of the government to protect its people against it. Haiti is the poorest
country in the Western Hemisphere. This has left the government crippled against
widespread prevention or treatment. Someday I hope to become a doctor in Haiti and
other impoverished nations to help those without the resources to battle diseases like
cholera. Through research of studies done in Haiti and other locations where cholera has
become an issue, I have found that there are options that can be taken against this disease.
Even with the large presence of cholera in Haiti, widespread treatment at reasonable,
realistic costs are tangible methods for relief from cholera.
Cholera is a bacterial disease caused by the bacteria Vibrio cholerae . Cholera is
easily transferred by the bacteria through ingestion of infected food or water. Often times,
an epidemic of cholera is due to its transfer through contamination of food or water with
feces. Though most patients show little to no symptoms, those with more serious cases
experience severe dehydration due to vomiting and watery diarrhea. Dehydration can lead
to coma and possibly death. Patients diagnosed with cholera are often given an oral
rehydration solution or an IV. Tetracycline and erythromycin are common antibiotics
given to aid in the treatment of cholera. Although cholera is not always seriously
threatening to health, its ease of transfer causes concern that can create epidemics in
locations without strong health codes or sanitary practices.

After the 2010 earthquake, much of Haiti was in ruin. Destroyed buildings and
houses left many out on the street. The Haitians were forced to sleep on the streets or in
tents grouped together (tent villages/cities). As a nation with a tropical climate, Haiti
receives rain in very large, torrential, downpours. This leads to a lot of water flowing on
the ground, often through the tent villages. Due to poor sanitary conditions, this running
water often carried feces, leading to the transfer of the bacteria that causes cholera. Food
also contributed to the transfer of the bacteria. With no regulations or laws being enforced
with the sale or distribution of food, bacteria was quickly spread. According to Page, two
years after the first diagnosed case there were a reported 600,000 Haitians with cholera
and 7,000 deaths because of it (e3605). Many cases were probably not reported due to
limited access to healthcare facilities in the rural regions of Haiti and the unwillingness of
some to travel to nearby cities. In fact, the rural regions presented a large numbers of
cases. A study performed in rural Haiti from November 2010 to March 2011 found, The
attack rate of watery diarrhea on the area during the recall period was 12% (95% Cl:
10.8-13.2) (Page et al. e3605). 12% of the area translated to an estimated 21,681
Haitians with cholera. Of the 12% in the study performed by Page, 68.9% reported
vomiting in addition to other symptoms. Within the sample from the study, the
outcome of the episode was death in 224, for a [case-fatality rate] of 11.0%... (Page et
al.3605). With so much of the population being infected by cholera, and over ten percent
resulting in death, there is a clear need for some form of mass help for the Haitians.
With cholera being so widespread, it is clear that the government of Haiti needs to
step in to solve this problem in its entirety. As individuals, Haitians do not have the
resources to receive treatment or options for prevention. Those that do receive treatment

may not benefit from it because of the rate at which cholera spreads. A population-wide
prevention through vaccination and treatment campaign would be most effective in
ending the cholera epidemic. Though canvassing an entire population is nearly
impossible, reaching enough people would help prevent others who are able to receive
vaccinations.
Though it has been shown that a vaccination even in small groups of people
would be effective, the argument can be made that with Haitis crumbled economy, costs
of vaccinations would be too expensive. To vaccinate mass amounts of people, it would
not only take the vaccination, but delivery systems, shipping costs, doctors to administer
the vaccinations, and locations central enough that it would reach a majority of the
population. All of these factors combined could put large stress on the Haitian
government. Outside organizations could offer to fund such vaccinations but none have
so yet for the entire country. Fortunately, a study done in India has found that there are
highly cost effective ways of treating mass amounts of people. The study in India sought
to discover the cost of vaccination for a large population where cholera is present. The
study found that, The total cost of the vaccination program wasUS $2.7 per dose
delivered to the target population (Kar et al. e2629). The study used a drug called
Shanchol, which at market price is around, US $1.85 per dose (Kar et al. e2629). Each
person needed to receive two doses for the full vaccination. This study took into account
many different costs and factors, some were omitted because the cost was irrelevant due
to existing conditions that took care of them. Factors that were excluded were: staff time
spent on program planning, costs of vaccine storage equipment and utilities, and costs of
unused vaccines. Similarly, rental costs for training rooms and vaccination booths were

excluded because the campaign employed the existing government infrastructure. Cost of
waste management was excluded as it was absorbed within existing government waste
management system (Kar et al. e2629).
Through resourcefulness and utilizing existing infrastructures, the high costs of a
widespread vaccination can be kept to a minimum, allowing for greater coverage and
results.
The question then arises, How effective can such an inexpensive oral vaccination
like Shanchol be against an epidemic like cholera? Often, lower costs imply a lower
quality product in order to achieve such mass volumes in production. A study on a
smaller scale was performed to test the effectiveness of a whole-cell oral vaccination, one
similar to Shanchol. The World Health Organization often provides or prescribes
Shanchol, as well as another medication similar in cases of an epidemic. The study
performed says in their introduction of oral vaccinations, they are not routinely used
in cholera outbreaks (Ivers et al. e162- e168.). Ivers then goes on to say on the same
page that this is due to limited information considering that real world data is more
difficult to come by (e162- e168). Though the study conducted omitted many people due
to several factors, results were positive. Though many facets of the lives of those
involved in the study were examined, the final conclusion was that, The bivalent wholecell vaccine was effective in reducing the rate of cholera among vaccine recipients in
rural Haiti between 4 months and 24 months (i.e., from April, 2012, to March, 2014) after
vaccination began (Ivers et al. e162- e168). Though the range of effective time is
broad in terms of a vaccine that spreads as quickly as cholera, results inspire hope.
Hypothetically speaking, if every vaccination proved effective for 2 years, there would be

a hope of killing off enough of the bacteria and containing it to a limited number of cases.
Conducting another mass vaccination may prove to be too costly. In contrast, if the
county of Haiti could rally enough support through private organizations and help from
the UN. Two rounds of a mass, public vaccination could prove effective enough to stop
the entire epidemic in its tracks.
A similar study performed prior to the one mentioned above, also sought to test
the effectiveness of the Shanchol, specifically the homogeneity of it. The study conducted
was clustered by age groups due to the varying response levels of the immune system
common at different physical developments of life. The immune responses found were: A
4-fold increase in vibriocidal antibody titer against V. cholerae O1 Ogawa was
observed in 91% of adults, 74% of older children, and 73% of younger children after two
doses of Shanchol; similar responses were observed against the Inaba serotype. A 2fold increase in serum O-antigen specific polysaccharide IgA antibody levels against V.
cholerae O1 Ogawa was observed in 59% of adults, 45% of older children, and 61% of
younger children; similar responses were observed against the Inaba serotype (Charles et
al. e2828). The study ultimately found that the oral vaccination produced an immune
response in the majority of participants across all age levels. Shanchol is physiologically
effective and cost effective.
Across all studies a common method can be examined: exclusions. In any given
experiment or observational study certain factors must be excluded in order to properly
test a specific aspect or to be given consistent and reliable results. In terms of a cost
effective, oral vaccination used to subdue an epidemic, this is not always practical. Those
admitted from a study will still be present in a population. This leaves gaps in the ability

to predict the outcome of the vaccination for an entire population. Another common flaw,
though not entirely statistically significant, is the sample size for some studies. Smaller
sample sizes are sometimes the only available option and may be needed to satisfy the
10% condition necessary to perform most statistical tests, but they may create unrealistic
numbers and lead to extrapolation. Nonetheless, most data was objectively acquired and
as random as the current conditions allowed.
These studies confirm that though the nation of Haiti may be financially unstable
and lacking, tangible hope is a very real option. It has been concluded that mass
vaccinations, with an oral drug, can be administered at a lowered expense if costs of the
medication are kept lower and delivery methods use existing infrastructures. Going
forward for Haiti, it will be crucial to reach as many people as possible in hopes of
completely removing cholera. As someone who wants to dedicate their life to countries in
financial situations similar to Haiti, the takeaway is this: though resources may be
limited, options exist if one thinks outside the box. Utilizing existing resources,
especially working with existing government entities, can prove to be effective in battling
widespread physical and health? disaster. Hopefully, as I continue down the road to
aiding those without the ability to help themselves, I will be able to seek out help where I
am the one who is lacking .

Works Cited
Barizilay, Erza J., Schaad, N., Maglorie, R., Mung, K. S., Boncy, J., Dahourou, G. A.,
Mintz, E. D., Steenland, M. W., Vertefeuille, J. F., and Tappero, J. W. "Cholera
Surveillance during the Haiti Epidemic - The First 2 Years." New England Journal of
Medicine (2013): 599-609.
Charles, Richelle C, Hilaire, I. J., Mayo-Smith, L. M., Teng, J. E., Jerome, J. G.,
Franke, M. F., Saha, A., Ya, Y., Kovac, P., Calderwood, S. B., Ryan, E. T., LaRocqu,
R. C., Almazor, C. P., Qadri, F., Ivers, L. C., and Harris, J. B. "Immunogenicity of a
Killed Bivalent (O1 and O139) Whole Cell Oral Cholera Vaccine, Scanchol, in Haiti."
PloS Neglected Tropical diseases (2014): e2828.
Ivers, Louise C, Hilaire, I. J., Teng, J. E., Almazor, C. P., Jerome, J. G., Ternier, R.,
Boncy, J., Buteau, J., Murray, M. B., Harris, J. B., and Franke, M., F. "Effectivness of
reactive oral cholera vaccination in a rural Haiti: a case-control study of the biasindicator analysis." The Lancet Goblet Health 3.3 (2015): e162- e168.
Kar, Shantanu K, Sah, B., Patnaik, B., Kim, Y. H., Kerketta, A. S., Shin, S., Rath, S.
B., Ali, M., Mogasale, V., Khuntia, H. K., Bhattachan, A., You, Y. A., Puri, M. K.,
Lopez, A. L., Maskery, B., Nair, G. B., Clemens, J. D., and Wierzba, T. F. "Mass
Vaccination with a New, Less Expensive Oral Cholera Vaccine Using Public Health
Infrastructure in India; The Odisha Model." PLoS Neglected Tropical Diseases
(2014): e2629.
Page, Anna-Laure, Ciglenecki, I., Jasmin, E. R., Desvignes, L., Grandesso, F.,
Polonsky, J., Nicholas, S., Alberti, K. P., Porten, K. and Luquero, F. J. "Geographic
Distribution and Morality Risk Factors during the Cholera Outbreak in a Rural Region
of Haiti, 2010-2011." PLoS Neglected Tropical Diseases (2105): e3605.