A $1 Pill That Could Save Thousands Of Lives: Research Suggests Cheap Way To Avoid U.N.-Caused Cholera

(United Nations Photo/Flickr)

(United Nations Photo/Flickr)

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

Outbreak On Trial: Who’s To Blame For Bringing Disease Into A Country?

Francina Devariste, 3 years old, is one victim of an ongoing cholera outbreak in Haiti that has killed 8,000 people and sickened over 700,000. (2010 photo courtesy of the United Nations)

Francina Devariste, 3 years old, is one victim of an ongoing cholera outbreak in Haiti that has killed 8,000 people and sickened over 700,000. (2010 photo courtesy of the United Nations)

By Richard Knox

If an international agency introduces a devastating disease to a country, should it be held accountable?

That’s the big question at the heart of a court proceeding that gets underway next Thursday. The international agency is the United Nations. The disease is cholera. And the nation is Haiti.

Four years ago this month, thousands of Haitians downstream from a U.N. peacekeeping encampment began falling ill and dying from cholera, a disease not previously seen in Haiti for at least a century.

Since then cholera has sickened one in every 14 Haitians — more than 700,000 people; and over 8,000 have died. That’s nearly twice the official death count from Ebola in West Africa thus far.

A year ago, a Boston-based human rights group sued the U.N. for bringing cholera to Haiti through infected peacekeeping troops from Nepal, where the disease was circulating at the time. The U.N. camp spilled its sewage directly into a tributary of Haiti’s largest river.

There’s little doubt that the U.N. peacekeepers brought the cholera germ to Haiti. Nor is there argument over the poor sanitary conditions at the U.N. camp.

When I visited the scene in 2012, it was plain how untreated sewage from the camp could easily contaminate the Meille River that runs alongside before it spills into the Artibonite — Haiti’s Mississippi — which provides water for drinking, washing and irrigation for a substantial fraction of the country’s population.

The smoking gun, scientifically, is a molecular analysis of the Haitian cholera bug compared to the Nepalese strain from the same time period. It showed the two differ in only one out of 4 million genetic elements.

“That’s considered an exact match, that they’re the same strain of cholera,” Tufts University environmental engineer Daniele Lantagne told me last year. Continue reading

How Twitter, Social Media Helped Detect Cholera In Haiti

Tweets From An Epidemic, Oct. 2010

In October 2010, when cholera was just beginning to spread through earthquake-ravaged Haiti, Tweets, blogs and other Internet-based social media detected and tracked the epidemic faster than traditional methods such as government surveillance reports, according to a new analysis by researchers at Children’s Hospital Boston and Harvard Medical School.

The cholera epidemic has now killed nearly 7,000 people and sickened almost half a million.

The social media study, part of a special Haiti-themed issue of the American Journal of Tropical Medicine and Hygiene, is characterized in a news release as “the first to demonstrate the use of data from “informal” media sources in monitoring an outbreak of a neglected tropical disease in a resource-limited setting,” and it demonstrates that “these sources can yield reliable decision-making data during deadly disease outbreaks almost in real-time, often far earlier than traditional surveillance methods that include surveys of hospitals and health clinics…”

The release quotes Rumi Chunara, Ph.D, of the Informatics Program at Children’s Hospital Boston, Research Fellow at Harvard Medical School, and the lead author of the study:

“When we analyzed news and Twitter feeds from the early days of the epidemic in 2010, we found they could be mined for valuable information on the cholera outbreak that was available up to two weeks ahead of surveillance reports issued by the government health ministry. The techniques we employed eventually could be used around the world as an affordable and efficient way to quickly detect the onset of an epidemic and then intervene with such things as vaccines and antibiotics…” Continue reading

One Year Later: Cholera Keeps Rising In Haiti, Vaccine On The Way

Cholera has killed more people in Haiti in one year than in all other countries in the world combined in 2010

Cholera has killed over 6,500 Haitians in the past year, and nearly half a million people — about 5% of the country’s population — have been treated for the disease since it was detected in 2010, according to the nonprofit, Partners in Health. Indeed, cholera has killed more people in Haiti in one year than it did in all other countries in the world combined in 2010.

Yesterday, Dr. Paul Farmer, co-founder of the group that has been working in Haiti for 25 years, spoke to reporters about the need to greatly intensify efforts to stop the epidemic, and mount a more comprehensive response, including vaccinating about 100,000 Haitians with a cholera vaccine that is “safe, proven, effective.”

(The cholera vaccine, never before used in Haiti, will be rolled out beginning in January, PIH says.)

Here’s a bit of what Farmer said on the call (transcribed by PIH) which you can listen to here.

On the Need for a More Integrated Approach:

“What we’re calling for, a year into the epidemic, is a prompt integration of these prevention and care and treatment measures, including: chlorinated water at the household or village level, hand washing and hygiene measures, building up systems that haven’t previously had them, improved case-finding, treating with oral rehydration salts and finally integration of oral cholera vaccine.”

On Stopping the Water Insecurity:

“Some years ago, PIH and many sister organizations began talking about the right to water. We did so because those of us who are clinicians, we can sit in our clinics and work in our hospitals and wait for people to come in sick with complications of water-borne diseases, or we can work with public authorities and appropriate NGO partners and others to build real water security in Haiti. We’ve been sounding that drum for some years now.”

Continue reading

Paul Farmer’s 5 Fixes To Slow Haiti’s Cholera Epidemic

Dr. Paul Farmer

Cholera has already killed at least 2026 people in Haiti.

Today, the renowned infectious disease doctor and passionate promoter of decent health care for the poor as well as the affluent, Paul Farmer and his colleagues at the nonprofit Partners In Health write in The Lancet that it’s time to get more aggressive in thinking about how to tackle Haiti’s escalating cholera outbreak.

In a nutshell, their five “complementary interventions to slow cholera,” are:

1. Identify and treat everyone with symptoms.
In a news conference today Farmer said there must be “active case finding,” using community health workers to help. “We can’t just wait for people to show up.”

2. Treat the sick with antibiotics and make the oral cholera vaccine available. (The logistics of getting the vaccine to those who need it is explored on NPR today.) “Rehydration without antibiotics is not a good idea,” Farmer said. “We’re arguing for anitbiotics for all comers.”

Farmer said there is resistance from the public health community on this aggressive approach to treatment. “We are seeing resistance,” Farmer said. “I’m not going to be arch about it, the resistance is not coming from patients and their families, it never does. There’s great doubt around logistics and cost. In a battlefield situation, what do you do first?”

Still, he says, there is vaccine available: “Based on our discussions with experts, there are potentially 2 million doses of the cholera vaccine available. In the face of a regional, long-standing epidemic, it does not seem too much to ask to start ramping up that effort to make available significantly more doses of vaccines. I would have expected more engagement on some of these tough logistic questions – how do we have the vaccine, how do we distribute it, make it more available, etc.”

3. Remedy Haiti’s problem with “water security” (i.e. — not having enough clean water) and improve sanitation

4. Make sure all efforts to deal with specific diseases (HIV/AIDS, cholera) include a focus on strengthening the country’s overall health care system, particularly primary care

5. Raise the bar on health care goals in Haiti. “No cholera epidemic is local for long,” they write. “The goals of responding to cholera in Haiti should look the same as the goals of responding to cholera in the Dominican Republic or Florida, to name two settings already touched by what is widely termed the Haitian epidemic.”

Farmer noted: “You don’t make one standard for poor countries, a different one for middle income countries and another one for affluent countries.”

“Although cholera had not been documented in Haiti for many decades,” Farmer and his colleagues write in the Lancet, “it has long been the most feared waterborne disease. Health-care providers working in informal settlements and refugee camps, both especially vulnerable to waterborne diseases, know that cholera’s profuse secretory diarrhoea can shrivel a healthy adult in less than 6 h. Case-fatality rates of untreated severe cholera can reach 50%, while most agree that aggressive case management can drop this figure to under 1%.”

You can listen to the entire news conference here.

Cholera In Haiti: New Cases, Deaths Up Sharply

As cholera spreads through Port-au-Prince, Haitian schoolchildren are taught about the water-bourne illness and how to avoid it

Here’s the latest update from Partners In Health on the recent spike in cholera cases in Haiti. Most troubling is the number of cases now confirmed in the capital, Port-au-Prince, and fears that those living in settlement camps there are particularly vulnerable.

Earlier today, Partners In Health’s Chief of Mission in Haiti Dr. Louise Ivers spoke to reporters on the status of the ongoing outbreak and PIH’s response. She said that the situation has taken a dramatic turn for the worse, with clear signs that the outbreak has spread to the crowded slums and settlement camps in Port-au-Prince. According to the latest report from the Haitian Ministry of Public Health and Population, a total of 12,303 people have been hospitalized and 796 have died since the outbreak began.

The number of new cholera cases and the death toll have both risen sharply in recent days. Roughly 1,000 new cases have been reported each day this week. The disease has been confirmed among nearly 200 people in Port-au-Prince, and there is great concern that the disease will spread rapidly among more than a million people who have been living in overcrowded settlement camps with limited access to clean water and sanitation since the January earthquake. More than 700 people have died and more than 11,000 have fallen ill since the epidemic first began in October.

PIH has seen dozens of cases in Parc Jean-Marie Vincent, the largest of the four settlement camps where we work in Port-au-Prince. Our teams are carrying out intensive education and prevention campaigns with camp residents and have set up a separate Cholera Treatment Unit (CTU) to provide care for patients. Outside the capital, PIH is rapidly strengthening cholera treatment capacity at all of our sites, as the number of new cases is increasing in the Artibonite and Central Plateau.

Other highlights of recent updates from PIH staff in Haiti include:

• In Port-au-Prince, we are seeing a steady stream of cases with classic clinical symptoms of cholera. Of the first 32 patients seen at the CTU in Parc Jean-Marie Vincent, many had come from outside the camp. PIH is directing medical operations at the CTU. The British Red Cross is taking responsibility for water and sanitation.

• In the Central Plateau, a Cholera Treatment Center has been established in Mirebalais and is being operated jointly by the Haitian Ministry of Public Health and Population (MSPP), Partners In Health, and a Cuban medical team, with support from Medishare and J/P HRO (Jenkins Penn Haitian Relief Organization.)

• In the Artibonite Valley, an increasing number of cases is being reported from communities in the Upper Artibonite, outside the area around St.-Marc where the outbreak began in October. PIH operates the hospital in St.-Marc and two other facilities in the Lower Artibonite in partnership with the MSPP.

Daily Rounds: The Bush Miscarriage; Demanding Dr. Famous; Cholera Hits Port-Au-Prince; Romney’s Repudiation

Bush Recollection Puts Spotlight on Miscarriage – NYTimes.com “The image of a mother handing her teenage son a jar containing the remains of her just-miscarried fetus may be a disturbing one. But the scene, described by former President George W. Bush in his interview with Matt Lauer of NBC News on Monday night, has started a national conversation — both about his mother, Barbara Bush, and about the complex psychological fallout from miscarriage.” (The New York Times)

Running a hospital: I'm sorry, Doctor Famous is busy Beth Israel Deaconess Medical Center CEO Paul Levy writes: “What happens when a referring doctor insists that "Doctor Famous" see his or her patient, even when other physicians on the staff can do the job just as well? In Lean terms, waste is introduced into the system. As diagnosed below: The minute an additional seemingly unnecessary step is added to the flow it adds a huge delay.” (Running A Hospital)

Cholera Is Found in Port-au-Prince, Haiti – NYTimes.com “Medical officials say they believe that there are at least 73 cases here in the capital and, based on outbreaks in other countries, they fear that cholera may become a way of life that could afflict as many as 270,000 people over the next several years.” (The New York Times)

Rick Perry Calls On Mitt Romney To 'Repudiate' His Health Care Plan (VIDEO) “PERRY: I think it's a problem to go — if he were to stand up and say "You know what, this was a program that didn't work, and I wish I hadn't tried it" — I think that would help him substantially. But the fact is: they are so similar that it is going to be a major anchor unless he stands up and repudiates that approach.” (Huffington Post)

Cholera In Haiti: Cases Stabilize But Conditions Remain Desperate

A young Haitian girl with cholera symptoms

In a conference call with reporters today, Parters In Health Haiti Chief of Mission, Dr. Louise Ivers said while the number of cholera cases appears to have leveled off, the conditions in the capital, Port-au-Prince remain dire. For instance, she said, people still lack access to clean water, and unsanitary conditions are rampant. “People are in desperate situations,” she said, with up to 1.2-1.5 million people living on the streets in camps in the capital, displaced after January’s massive earthquake. Dr. Ivers confirmed the total number of cholera patients is over 3,000, with 253 deaths. Five cases have been confirmed in Port-au-Prince.

At PIH’s medical facilities, she said, there has been, on average, a steady population of 400 patients a day requiring hospitalization. But, she added, “the number (of patients) has been about the same for the past few days. “There hasn’t been a dramatic increase or decrease,” she said, and the organization is “seeing slightly less severe cases; more people are going to hospital for services when they are more ambulatory.”

She said PIH is working with community health workers, the Haitian Ministry of Health and Doctors Without Borders to conduct a widespread community education and mobilization effort to get the message out about hand-washing and using clean water and toilet facilities. The groups are also distributing water purification packets and oral rehydration salts. But with “no plan to truck in clean water,” there is still the potential for the epidemic to worsen, she said.

She said the Ministry of Health has a three-part plan to deal with sick patients. It will:

— Set up a post where people have have quick, easy access to oral hydration solution
–Establish a center for intravenous hydration
–Send patients with more severe diarrea and dehydration symptoms to treatment centers

When asked what the chances are that the epidemic could hit Port-au-Prince and spiral out of control, Dr. Ivers said it is still possible that the epidemic could be contained. “I don’t think it’s inevitable there will be a more widespread outbreak in the capital,” she said. “But I think it is inevitable there will be more cases.”

Still, with so many transient families living in the densely packed camps, with limited access to soap, clean water and proper toilets, at this point, public health officials tell NPR, they are preparing for the worst.

Cholera Outbreak In Haiti: An Update From Partners In Health

A Haitian child suffers from cholera symptoms

Boston-based Parters In Health Haiti Chief of Mission Dr. Louise Ivers and PIH Chief Medical Officer Dr. Joia Mukherjee will be on a conference call today at 3 pm to discuss the cholera epidemic that has broken out in the Lower Artibonite region of Haiti, where the organization operates three hospitals in partnership with the Haitian Ministry of Health. PIH is now mobilizing in the camps in Port au Prince, where five cases of cholera have been confirmed so far.

CommonHealth will post an update following the conference call this afternoon.

PIH reports: “As of Sunday more than 3,000 cases and over 250 deaths had been reported. Hôpital Saint Nicolas in St. Marc, which PIH operates in partnership with the Haitian Ministry of Health hospitalized 300 patients on Sunday. Every day hospital patient management improves. PIH and its partners have rushed clinical reinforcements and supplies to the region and have mounted a massive community education and mobilization campaign. Community health workers are fanning out throughout the area to distribute oral rehydration salts and soap and to warn people of the need to drink only clean or purified water and wash their hands frequently—the two keys to preventing further spread of the disease.”

Aftershocks: Deadly Cholera Outbreak In Haiti

Update: As of Sunday night, The New York Times reports: “Imogen Wall, a spokeswoman for the United Nations Office for the Coordination of Humanitarian Affairs, confirmed that as of Sunday, 253 had died of the disease, with 3,015 reported cases. On Saturday, Haitian officials had reported 208 dead and 2,674 cases.”

Partners In Health says cholera has killed 160 people in Haiti with 2000 cases confirmed.

Haiti hasn’t had a documented case of cholera since the 1960s but the chaotic conditions following January’s earthquake have left the tragically fragile country even more vulnerable. The Boston-based aid group, Partners In Health, with its long history helping to build up Haiti’s medical infrastructure, is now trying to grapple with the latest outbreak. PIH’s Chief Medical Officer, Joia Mukherjee, explains what’s going on:

An outbreak of cholera has been documented in the area surrounding the lower Artibonite region of Haiti by the staff of PIH’s sister organization Zanmi Lasante (ZL,) working with the Haitian Ministry of Health and other partners. As of Friday morning October 22, 2010; there have been more than 2000 cases of acute watery diarrhea and 160 deaths reported at the facilities in St. Marc, Petite Riviere d’Artibonite, Mirebalais, Lascahobas, and Verretes; the death rate since Tuesday night, October 19, 2010, has been approximately 10 percent.

NPR reports that officials are worried that the outbreak might spread to the tens of thousands of people living in unsanitary conditions in camps around the capital.