Cholera in Haiti: Vaccine plan readied; group sues UN

Nov 9, 2011 (CIDRAP News) – Two medical aid groups in cholera-stricken Haiti are planning a pilot campaign to administer a cholera vaccine to about 1% of the population, but some public health experts are questioning whether the effort is the most cost-effective way to fight the disease, according to press reports.

Meanwhile, a Boston-based human-rights group is suing the United Nations on behalf of the families of the more than 5,000 Haitians who have died of the disease, according to an Associated Press (AP) report. The cholera epidemic, which began in the fall of 2010, is believed to have been started by waste from a camp housing UN soldiers from Nepal.

Cholera has killed more than 6,500 Haitians and sickened nearly 500,000 since the epidemic began in October 2010, according to Haitian Health Ministry numbers cited by the AP.

Vaccine plan targets 100,000
The vaccination drive is being planned by Partners in Health, based in Boston, and the Gheskio Center, a nonprofit organization in Port-au-Prince, Haiti, that has historically focused on AIDS. The effort is expected to cost $870,000, which has not yet been secured, but it has the support of Haiti's newly elected leaders, President Michel Martelly and Prime Minister Dr. Garry Conille, the AP reported.

In an Oct 24 statement, Partners in Health said the plan calls for vaccinating about 100,000 vulnerable people in Port-au-Prince, the capital, and rural communities along the Artibonite River near St. Marc, where the epidemic began. It said 200,000 doses of the Shanchol vaccine are available at $1.85 apiece. The vaccine, which requires two doses given 2 weeks apart, is about 70% effective and provides protection for "upwards of 36 months," the group said.

The AP said some public health experts question the wisdom of the plan because it will reach only 1% of the population and could deplete global stocks of cholera vaccine. They argue that the money could be better spent improving water supplies and sanitation in Haiti.

"There are bigger-bang-for-the buck activities out there," Richard Garfield, a professor of public health and nursing at Columbia University, told the AP.

In a recent statement, Doctors Without Borders (Medecins Sans Frontieres, or MSF), another medical aid group, suggested it sees a very limited role for vaccines in fighting Haiti's epidemic. Dr. David Olson, MSF medical adviser for diarrheal diseases, wrote that the lack of clean water and sanitation puts nearly everyone in Haiti at risk for cholera and that vaccinating everyone would be very difficult.

Such a campaign would take 20 million doses, which is far beyond the capacity of the two companies that make cholera vaccines, Olson said. That amount of vaccine would cost $40 million, and the immunity begins wearing off after 2 or 3 years, he added. "Money spent on vaccines should not come at the expense of money spent on permanent water and sanitation measures," he wrote.

Olson said vaccination could have a role in rural and mountainous areas where it's hard to provide soap, water, and treatment, but the decision to vaccinate requires government involvement.

The Partners in Health statement said the vaccination campaign will be part of a "comprehensive package of prevention and treatment" efforts. Dr. Paul Farmer, co-founder of the group and a longtime health worker in Haiti, insists that the vaccine should be provided for Haiti's poor regardless of the cost, according to the AP.

The story noted that vaccination has become a more practical option in recent months because of the availability of a second oral vaccine. In September the World Health Organization authorized UN agencies to use Shanchol, made by Sanofi Pasteur. Previously the only available oral vaccine was Dukoral, made by Crucell and sold for about $6 a dose.

Last December, as reported previously, a group of experts assembled by the Pan American Health Organization (PAHO) suggested that a vaccination pilot project in Haiti could yield valuable lessons about how to use cholera vaccines in response to outbreaks and natural disasters. PAHO officials said at the time that the supply of vaccine was improving.

The AP report said public health experts discussed using vaccination early in Haiti's epidemic, but former President Rene Preval didn't want to go that route unless everyone could be vaccinated. Dukoral was the only vaccine available at the time, and the supply was limited to about 250,000 doses, the report said.

Seeking payments for cholera victims
In the lawsuit, the Boston-based Institute for Justice and Democracy in Haiti argues that the UN and its peacekeeping force are liable for damages for failing to adequately screen peacekeeping soldiers, the AP reported in a separate story. The institute is seeking at least $100,000 for each bereaved family and $50,000 for cholera survivors.

The suit cites studies indicating that infected Nepalese soldiers sparked the outbreak when untreated waste from their base was dumped into a tributary of the Artibonite River, the story said.

Brian Concannon, an attorney who directs the institute, said the petition was filed Nov 3 with the UN Office of the Secretary-General in New York and with the claims unit for the UN mission in Port-au-Prince, the report said..

Ruth Wedgwood, a professor of international law and diplomacy at the Paul H. Nitze School of Advanced International Studies at Johns Hopkins University, said the UN has immunity from national courts, but "one would hope that the Secretary General would address this with great moral seriousness," according to the AP.

See also:

Oct 20 MSF statement

Oct 24 Partners in Health

Dec 20, 2010, CIDRAP News story on PAHO discussion of using cholera vaccine in Haiti

Jan 26 CIDRAP News story about studies supporting reactive cholera vaccination

WHO information
on cholera vaccines

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