By Richard Knox
Here’s a way to get a big bang for a buck:
If a few hundred United Nations peacekeeping troops had taken a $1 antibiotic pill five years ago before they were deployed to Haiti, it may well have prevented a cholera outbreak that has so far sickened 753,000 Haitians and killed more than 9,000.
That’s the takeaway of a new study by Yale University researchers in the journal PLoS.
The authors believe their evidence should prompt the U.N. to adopt a simple and incredibly cost-effective strategy: Make sure all the 150,000 peacekeepers it sends out into the world each year from cholera-afflicted countries get preventive doses of antibiotics before deployment.
It’s not the first time the U.N. has gotten that advice. It was first suggested by a panel of outside experts the agency appointed back in 2011 to investigate the Haitian epidemic. But so far the U.N. has rejected the panel’s recommendation on preventive antibiotics.
It’s not clear whether that will change. The U.N.’s chief medical officer, Dr. Jillian Farmer, said in an interview Friday that she welcomes the new study. But she noted it does not address “the biggest barrier to implementing the antibiotic recommendation” — a concern that what she calls “mass administration” of antibiotics would give rise to antibiotic-resistant strains of cholera.
“It may be we will be able to do this [administer pre-deployment antibiotics to U.N. peacekeepers],” Farmer said. “I don’t have a closed mind.”
The Yale researchers and others argue that the concern about generating resistant cholera strains is overblown because the antibiotics would be targeted — not administered massively. They further argue that the U.N. should sponsor research to answer that question, given the urgency of the question.
“When we have a case as extreme as Haiti showing the status quo doesn’t work, we should be working to build evidence for a solution that does, not using a lack of proven solutions as an excuse not to act,” said Adam Houston, who works with the Boston-based Institute for Justice and Democracy in Haiti.
The new study is the latest chapter in a tragic story that’s been unfolding since mid-October of 2010, when, researchers say, a single U.N. peacekeeper from Nepal most likely introduced cholera to Haiti, touching off the most explosive cholera epidemic in modern times. Before the outbreak. Haiti had been cholera-free for at least a century; thus, its citizens had no immunity to the disease.
“Based on DNA evidence, this outbreak was probably started by one or very few infected, asymptomatic individuals — I would guess one,” said Daniele Lantagne, a Tufts University environmental engineer who was one of four independent experts appointed by the U.N. in 2011 to investigate the outbreak.
Since none of the 454 Nepalese peacekeeping troops deployed to Haiti in late 2010 showed any symptoms of cholera, all of them would have had to take a prophylactic dose of antibiotic to prevent any one of them from starting the outbreak. That would have cost around $500 — a tiny price to pay to avoid a devastating epidemic that — absent the investment of billions of dollars in clean water and sanitation — will continue into Haiti’s indefinite future.
The new analysis finds that prophylactic antibiotics would have reduced the chances of the Haitian epidemic by 91 percent. When antibiotics are combined with cholera vaccination, the risk of an outbreak goes down by 98 percent.
The U.N. began requiring cholera vaccination of all its field personnel late last year. But the new study says vaccination by itself isn’t very effective; it reduces the risk of an outbreak by only 60 percent at best.
That’s because vaccination can prevent someone from falling ill from cholera, but it doesn’t prevent infection — so a vaccinated person can still carry the cholera bacterium and pass it on to others.
“Vaccination alone is not enough,” said Virginia Pitzer, who led the Yale research team. “Vaccination plus antibiotic prophylaxis would be best.”
“Antibiotics are far and away the most effective and the least expensive,” added epidemiologist Joseph Lewnard, the study’s first author. “It hits the problem from two angles. It not only prevents those exposed to cholera from experiencing an infection, but if they do get infected it shortens the duration of shedding the bacteria. So once they arrive [at their deployment destination] they would no longer have bacteria in their stools.” Continue reading