World Wide Med: Bringing Cholera Vaccine to Haiti

In the wake of a cholera outbreak in Haiti in 2010, Partners in Health, the Boston-based nonprofit advocacy and global health organization, developed an ambitious pilot program to vaccinate against cholera, with Dr. Max Raymond in charge of the implementation. Dr. Raymond was born in Haiti and earned his medical degree there in 2004, at the Université Notre Dame d’Haiti, Port-au-Prince.

He first became involved with PIH (and its sister organization in Haiti, Zanmi Lasante) shortly after completing his medical studies, when he was invited to manage a program to combat sexually transmitted infections, tuberculosis, and HIV/AIDS in a commune of the Artibonite Valley.

Courtesy Dr. Max Raymond

"I accepted this position because I knew about the high quality work that PIH/ZL was doing in another region of the country, particularly its social justice-based mission to provide a preferential option for the poor in health care," he said.

How did you become involved in the cholera vaccination project in Haiti, and what were the goals of the project?

In the summer of 2011, I returned to Haiti after earning a master’s degree in public health at the Institute of Tropical Medicine of Antwerp, Belgium, on a Joint Japan/World Bank scholarship, when one of my mentors, Dr. Louise Ivers, PIH’s senior health and policy adviser, asked me to be the cholera vaccine project coordinator. The pilot project launched in one of the rural sections of Saint-Marc, which was where the first cases were reported during the outbreak in October 2010.

In addition to immunologically protecting this high-risk population, a secondary goal was to demonstrate the feasibility of the vaccine campaign because some experts believed it could not be executed successfully because of logistical constraints, costs, and social unrest. Oral cholera vaccines also were in short supply.

If successful, we wanted to use the results of this pilot program to advocate for more investment in cholera vaccine and a possible nationwide scale-up as one of the integral responses to the current epidemic, and upcoming endemicity.

Describe the cholera vaccination efforts overall.

The project was executed concomitantly by two organizations: By PIH/ZL in the rural setting of Saint-Marc and by the nongovernmental organization GHESKIO (Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections) in an urban setting in the capital, Port-au-Prince.

The cholera vaccine consists of two oral doses administered 2-6 weeks apart. Children younger than 1 year and pregnant women were excluded. Before the immunization, we conducted a census in the target area to preregister those who were eligible and to give them a vaccine card with a barcode that would give them access to their doses. We sent a team of 50 enumerators to the field and each recorded demographic data and eligibility status of the people living in the households via electronic data collection using Samsung Galaxy tablets. This census gave us the chance to explain the vaccine’s benefits, while educating the population about hygiene and sanitation, regardless of whether they were eligible to receive the vaccine.

We were not able to implement the campaign exactly as planned, because of a concurrent national vaccination campaign, which targeted newborns through children aged 9 years and also included the polio vaccine (polio and cholera vaccines must be administered 2 weeks apart because of possible interactions).

To avoid interfering with the national campaign, we split our campaign into two phases: the phase I vaccination was for individuals aged 10 years and older, and phase II included children aged 9 years and younger. The campaign lasted more than 1 month, with some breaks between the phases and the doses.

We had 40 teams (each team had two vaccinators and one registrar with the tablet) who were sent to various posts within the targeted area to vaccinate the eligible people. The community health workers and a sound truck service raised awareness before, during, and after each dose and each phase. First, the teams started at fixed vaccinations posts to capture as many people as possible. When fewer people showed up at the fixed posts, the teams started mobile posts to connect with the people who are farther away. Finally, when the number of the vaccinees was low at the mobile posts, we gave a list of the people left to be vaccinated to the teams and they started going door-to-door to do active case finding.

What were some of the challenges of administering the vaccines in a setting with limited medical resources?

The delay from the national polio vaccination campaign made our campaign last longer than we expected. Logistically, this resulted in greater challenges to keep the vaccines in cold chain and to reach some remote areas before the rainy season. Despite these challenges, we had a motivated, committed, and vigilant staff that worked hard to monitor the cold chain, and continually conducted regular thermometer readings and inspections of the cold container, cold boxes, and vaccine carriers (thermoses). Many of our teams did not hesitate to take canoes or donkeys or even to cross flooded rivers to reach vaccine recipients when our trucks could not reach those areas.

We experienced some issues with the technology used for data collection, though we did anticipate some problems. We had a team in United States and another in Haiti who were able to work together to respond quickly and effectively and resolve hardware, software, and Internet connection problems. The teams worked late nights to address those issues and to produce data reports, which allowed us to strategize our activities more effectively and efficiently. We also had a team on standby in our Saint-Marc office that could help locate the unique ID of a vaccine recipient in case the registrar in the field was unable to find the record on their tablet.

Another hurdle involved a group of farmers who we could not find during the daily vaccination periods because they were working late on their land. We sent some teams on later shifts, starting in the field in the afternoon and staying late into the evening in order to catch those recipients.

What are the plans for the vaccination program going forward?

We finished the vaccination campaign on June 19, 2012. We vaccinated more than 40,000 people. The next step is to evaluate the feasibility and the effectiveness of the project by assessing the operational activities, community acceptance, and cost effectiveness. We also are planning a case-control study. The vaccine already has been proven to be safe and effective.

What have you found most rewarding about your work on this program?

For me, the most rewarding part of this program was that we were able to deliver vaccine to this vulnerable population and protect them from this deadly disease. Ideally, this will help them maintain good health, so that they can continue to work and be productive to help their families survive. Seeing not only this population’s poor life conditions but also their acceptance of the vaccine inspired me and gave me more strength to continue the advocacy and the fight for a national scale-up vaccine campaign.

Think globally. Practice locally.

U.S.-trained internists who have practiced abroad will receive a $100 stipend for contributing to this column. For details, visit the World Wide Med column at www.internalmedicinenews.com or send an e-mail to [email protected].

In the wake of a cholera outbreak in Haiti in 2010, Partners in Health, the Boston-based nonprofit advocacy and global health organization, developed an ambitious pilot program to vaccinate against cholera, with Dr. Max Raymond in charge of the implementation. Dr. Raymond was born in Haiti and earned his medical degree there in 2004, at the Université Notre Dame d’Haiti, Port-au-Prince.

He first became involved with PIH (and its sister organization in Haiti, Zanmi Lasante) shortly after completing his medical studies, when he was invited to manage a program to combat sexually transmitted infections, tuberculosis, and HIV/AIDS in a commune of the Artibonite Valley.

Courtesy Dr. Max Raymond

"I accepted this position because I knew about the high quality work that PIH/ZL was doing in another region of the country, particularly its social justice-based mission to provide a preferential option for the poor in health care," he said.

How did you become involved in the cholera vaccination project in Haiti, and what were the goals of the project?

In the summer of 2011, I returned to Haiti after earning a master’s degree in public health at the Institute of Tropical Medicine of Antwerp, Belgium, on a Joint Japan/World Bank scholarship, when one of my mentors, Dr. Louise Ivers, PIH’s senior health and policy adviser, asked me to be the cholera vaccine project coordinator. The pilot project launched in one of the rural sections of Saint-Marc, which was where the first cases were reported during the outbreak in October 2010.

In addition to immunologically protecting this high-risk population, a secondary goal was to demonstrate the feasibility of the vaccine campaign because some experts believed it could not be executed successfully because of logistical constraints, costs, and social unrest. Oral cholera vaccines also were in short supply.

If successful, we wanted to use the results of this pilot program to advocate for more investment in cholera vaccine and a possible nationwide scale-up as one of the integral responses to the current epidemic, and upcoming endemicity.

Describe the cholera vaccination efforts overall.

The project was executed concomitantly by two organizations: By PIH/ZL in the rural setting of Saint-Marc and by the nongovernmental organization GHESKIO (Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections) in an urban setting in the capital, Port-au-Prince.

The cholera vaccine consists of two oral doses administered 2-6 weeks apart. Children younger than 1 year and pregnant women were excluded. Before the immunization, we conducted a census in the target area to preregister those who were eligible and to give them a vaccine card with a barcode that would give them access to their doses. We sent a team of 50 enumerators to the field and each recorded demographic data and eligibility status of the people living in the households via electronic data collection using Samsung Galaxy tablets. This census gave us the chance to explain the vaccine’s benefits, while educating the population about hygiene and sanitation, regardless of whether they were eligible to receive the vaccine.

We were not able to implement the campaign exactly as planned, because of a concurrent national vaccination campaign, which targeted newborns through children aged 9 years and also included the polio vaccine (polio and cholera vaccines must be administered 2 weeks apart because of possible interactions).

To avoid interfering with the national campaign, we split our campaign into two phases: the phase I vaccination was for individuals aged 10 years and older, and phase II included children aged 9 years and younger. The campaign lasted more than 1 month, with some breaks between the phases and the doses.

We had 40 teams (each team had two vaccinators and one registrar with the tablet) who were sent to various posts within the targeted area to vaccinate the eligible people. The community health workers and a sound truck service raised awareness before, during, and after each dose and each phase. First, the teams started at fixed vaccinations posts to capture as many people as possible. When fewer people showed up at the fixed posts, the teams started mobile posts to connect with the people who are farther away. Finally, when the number of the vaccinees was low at the mobile posts, we gave a list of the people left to be vaccinated to the teams and they started going door-to-door to do active case finding.

What were some of the challenges of administering the vaccines in a setting with limited medical resources?

The delay from the national polio vaccination campaign made our campaign last longer than we expected. Logistically, this resulted in greater challenges to keep the vaccines in cold chain and to reach some remote areas before the rainy season. Despite these challenges, we had a motivated, committed, and vigilant staff that worked hard to monitor the cold chain, and continually conducted regular thermometer readings and inspections of the cold container, cold boxes, and vaccine carriers (thermoses). Many of our teams did not hesitate to take canoes or donkeys or even to cross flooded rivers to reach vaccine recipients when our trucks could not reach those areas.

We experienced some issues with the technology used for data collection, though we did anticipate some problems. We had a team in United States and another in Haiti who were able to work together to respond quickly and effectively and resolve hardware, software, and Internet connection problems. The teams worked late nights to address those issues and to produce data reports, which allowed us to strategize our activities more effectively and efficiently. We also had a team on standby in our Saint-Marc office that could help locate the unique ID of a vaccine recipient in case the registrar in the field was unable to find the record on their tablet.

Another hurdle involved a group of farmers who we could not find during the daily vaccination periods because they were working late on their land. We sent some teams on later shifts, starting in the field in the afternoon and staying late into the evening in order to catch those recipients.

What are the plans for the vaccination program going forward?

We finished the vaccination campaign on June 19, 2012. We vaccinated more than 40,000 people. The next step is to evaluate the feasibility and the effectiveness of the project by assessing the operational activities, community acceptance, and cost effectiveness. We also are planning a case-control study. The vaccine already has been proven to be safe and effective.

What have you found most rewarding about your work on this program?

For me, the most rewarding part of this program was that we were able to deliver vaccine to this vulnerable population and protect them from this deadly disease. Ideally, this will help them maintain good health, so that they can continue to work and be productive to help their families survive. Seeing not only this population’s poor life conditions but also their acceptance of the vaccine inspired me and gave me more strength to continue the advocacy and the fight for a national scale-up vaccine campaign.

Think globally. Practice locally.

U.S.-trained internists who have practiced abroad will receive a $100 stipend for contributing to this column. For details, visit the World Wide Med column at www.internalmedicinenews.com or send an e-mail to [email protected].

In the wake of a cholera outbreak in Haiti in 2010, Partners in Health, the Boston-based nonprofit advocacy and global health organization, developed an ambitious pilot program to vaccinate against cholera, with Dr. Max Raymond in charge of the implementation. Dr. Raymond was born in Haiti and earned his medical degree there in 2004, at the Université Notre Dame d’Haiti, Port-au-Prince.

He first became involved with PIH (and its sister organization in Haiti, Zanmi Lasante) shortly after completing his medical studies, when he was invited to manage a program to combat sexually transmitted infections, tuberculosis, and HIV/AIDS in a commune of the Artibonite Valley.

Courtesy Dr. Max Raymond

"I accepted this position because I knew about the high quality work that PIH/ZL was doing in another region of the country, particularly its social justice-based mission to provide a preferential option for the poor in health care," he said.

How did you become involved in the cholera vaccination project in Haiti, and what were the goals of the project?

In the summer of 2011, I returned to Haiti after earning a master’s degree in public health at the Institute of Tropical Medicine of Antwerp, Belgium, on a Joint Japan/World Bank scholarship, when one of my mentors, Dr. Louise Ivers, PIH’s senior health and policy adviser, asked me to be the cholera vaccine project coordinator. The pilot project launched in one of the rural sections of Saint-Marc, which was where the first cases were reported during the outbreak in October 2010.

In addition to immunologically protecting this high-risk population, a secondary goal was to demonstrate the feasibility of the vaccine campaign because some experts believed it could not be executed successfully because of logistical constraints, costs, and social unrest. Oral cholera vaccines also were in short supply.

If successful, we wanted to use the results of this pilot program to advocate for more investment in cholera vaccine and a possible nationwide scale-up as one of the integral responses to the current epidemic, and upcoming endemicity.

Describe the cholera vaccination efforts overall.

The project was executed concomitantly by two organizations: By PIH/ZL in the rural setting of Saint-Marc and by the nongovernmental organization GHESKIO (Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections) in an urban setting in the capital, Port-au-Prince.

The cholera vaccine consists of two oral doses administered 2-6 weeks apart. Children younger than 1 year and pregnant women were excluded. Before the immunization, we conducted a census in the target area to preregister those who were eligible and to give them a vaccine card with a barcode that would give them access to their doses. We sent a team of 50 enumerators to the field and each recorded demographic data and eligibility status of the people living in the households via electronic data collection using Samsung Galaxy tablets. This census gave us the chance to explain the vaccine’s benefits, while educating the population about hygiene and sanitation, regardless of whether they were eligible to receive the vaccine.

We were not able to implement the campaign exactly as planned, because of a concurrent national vaccination campaign, which targeted newborns through children aged 9 years and also included the polio vaccine (polio and cholera vaccines must be administered 2 weeks apart because of possible interactions).

To avoid interfering with the national campaign, we split our campaign into two phases: the phase I vaccination was for individuals aged 10 years and older, and phase II included children aged 9 years and younger. The campaign lasted more than 1 month, with some breaks between the phases and the doses.

We had 40 teams (each team had two vaccinators and one registrar with the tablet) who were sent to various posts within the targeted area to vaccinate the eligible people. The community health workers and a sound truck service raised awareness before, during, and after each dose and each phase. First, the teams started at fixed vaccinations posts to capture as many people as possible. When fewer people showed up at the fixed posts, the teams started mobile posts to connect with the people who are farther away. Finally, when the number of the vaccinees was low at the mobile posts, we gave a list of the people left to be vaccinated to the teams and they started going door-to-door to do active case finding.

What were some of the challenges of administering the vaccines in a setting with limited medical resources?

The delay from the national polio vaccination campaign made our campaign last longer than we expected. Logistically, this resulted in greater challenges to keep the vaccines in cold chain and to reach some remote areas before the rainy season. Despite these challenges, we had a motivated, committed, and vigilant staff that worked hard to monitor the cold chain, and continually conducted regular thermometer readings and inspections of the cold container, cold boxes, and vaccine carriers (thermoses). Many of our teams did not hesitate to take canoes or donkeys or even to cross flooded rivers to reach vaccine recipients when our trucks could not reach those areas.

We experienced some issues with the technology used for data collection, though we did anticipate some problems. We had a team in United States and another in Haiti who were able to work together to respond quickly and effectively and resolve hardware, software, and Internet connection problems. The teams worked late nights to address those issues and to produce data reports, which allowed us to strategize our activities more effectively and efficiently. We also had a team on standby in our Saint-Marc office that could help locate the unique ID of a vaccine recipient in case the registrar in the field was unable to find the record on their tablet.

Another hurdle involved a group of farmers who we could not find during the daily vaccination periods because they were working late on their land. We sent some teams on later shifts, starting in the field in the afternoon and staying late into the evening in order to catch those recipients.

What are the plans for the vaccination program going forward?

We finished the vaccination campaign on June 19, 2012. We vaccinated more than 40,000 people. The next step is to evaluate the feasibility and the effectiveness of the project by assessing the operational activities, community acceptance, and cost effectiveness. We also are planning a case-control study. The vaccine already has been proven to be safe and effective.

What have you found most rewarding about your work on this program?

For me, the most rewarding part of this program was that we were able to deliver vaccine to this vulnerable population and protect them from this deadly disease. Ideally, this will help them maintain good health, so that they can continue to work and be productive to help their families survive. Seeing not only this population’s poor life conditions but also their acceptance of the vaccine inspired me and gave me more strength to continue the advocacy and the fight for a national scale-up vaccine campaign.

Think globally. Practice locally.

U.S.-trained internists who have practiced abroad will receive a $100 stipend for contributing to this column. For details, visit the World Wide Med column at www.internalmedicinenews.com or send an e-mail to [email protected].