November 29, 2010 Liz Borkowski, MPH 0Comment

Given that Haiti is suffering from the devastation of a major earthquake and a cholera epidemic, it’s not surprising that voters yesterday encountered disorganized polling places where many were told their names weren’t on the rolls. But there were also reports of violence and intimidation, polling places being ransacked and ballot boxes ripped open, and ballot-stuffing. In the afternoon, 12 of the 19 candiates for president joined together and called for the election to be canceled.

Meanwhile, the cholera epidemic continues. Haitian authorities report that more than 1,600 people have died from the disease, and the Pan-American Health Organization estimates that the country has seen 50,000 cholera cases.

The World Bank has announced a $10 million emergency grant to boost Haiti’s response to the cholera epidemic; as much as $8 million of that will go to large NGOs that are already doing health work in the country. Haiti’s ministry of public health and its Directorate of Water Supply and Sanitation will also receive funding to improve early detection and monitoring of outbreaks.

Money alone won’t be enough, though. PAHO estimates that the response effort needs an additional 350 doctors, 2,000 nurses, and 2,200 support staff over the next three months.

On a previous post about the cholera outbreak, one of our commenters asked whether the cholera vaccine should be given to Haitians. NPR’s Richard Knox looked into the issue shortly after the outbreak erupted.

PAHO’s Dr. Jon Andrus explained to NPR that vaccination wouldn’t be the best strategy in Haiti because 80% of the people who carry the disease are asymptommatic – so the approach of vaccinating the uninfected to stop cholera’s spread would be unlikely to work. And, Knox explains, there are other reasons not to promote vaccination when a cholera outbreak’s already in progress:

It requires two doses in most people, and three in young children. Keeping track of who’s been vaccinated and getting them back for a second and third dose presents enormous logistical problems and a lot of personnel. And even with all that effort, it still takes three weeks at the least for immunity to build in the body, Andrus says.

The effort to mount a crash vaccination campaign would also surely detract from other public health measures known to be effective, like educating people about hand-washing and handing out safe water, soap and oral rehydration. Such measures prevent infections and reduce fatality rates to around 1 percent.

“Measures to prevent and treat this disease are so effective…that we don’t vaccinate our own staff on the ground or staff we’re sending there,” Andrus says.

Having said all that, though, Andrus says PAHO is discussing whether to vaccinate some populations beyond the current reach of the outbreak.

Knox also notes that the small global supply of cholera vaccine is a problem. That supply issue is the focus of an editorial piece in the November 24th issue of the New England Journal of Medicine. Drs. Matthew Waldor, Peter Hotez, and John Clemens urge the US to create a vaccine cholera stockpile:

Even though there is no imminent threat of cholera in the United States, we believe that our country should stockpile cholera vaccines for rapid deployment to parts of the world that suddenly find themselves at high risk for this disease. Until recently, Latin America and the Caribbean region were considered to have a negligible risk of a cholera epidemic. Recent events in Haiti, however, force us to reconsider this belief (see map). Other areas of the world where populations are at great risk include sub-Saharan Africa and South and Southeast Asia (see map). A recent analysis of the global burden of cholera undertaken by the International Vaccine Institute suggests that approximately 1.5 billion people are at risk for cholera globally.

The costs to the United States of creating and maintaining a stockpile of several million doses of cholera vaccine would be low. (The current price of Shanchol to public-sector programs in developing countries is under $2 per dose.) But the humanitarian benefits of rapid deployment of cholera vaccines to areas at high risk for major cholera outbreaks — such as earthquake-wracked Port-au-Prince, the Haitian capital where 1.3 million people live in unsanitary refugee camps, or the neighboring country of the Dominican Republic, where the epidemic could potentially spread to the slums of Santo Domingo, or flood-ravaged areas of Pakistan, where cholera emerged this past spring — could be enormous. Remarkably, there are fewer than 400,000 total doses of oral cholera vaccines (either Dukoral or Shanchol) available at present for shipment from their manufacturers, making it impossible to consider large-scale vaccination of at-risk populations with the recommended two- or three-dose regimens of either product. The global shortage of cholera vaccine reinforces the urgency of creating a stockpile.

The authors point out that deploying cholera vaccines to places struck by disasters can help stabilize areas where conflicts might ignite and earn goodwill in countries with whom we have troubled relationships. If a cholera-vaccine stockpile could avert the kind of compounded disaster we’re seeing in Haiti right now, it sounds like a worthwhile plan.

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