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Remarks by Dr. Jon Andrus, Deputy Director, Pan American Health Organization, on the Occasion of the World Bank Meeting on Cholera

Washington, D.C.
April 11th, 2014

Madam Chair, Mary Barton and Honored Guests

I am delighted and honored to be here on behalf of the Pan American Health Organization. Several of my colleagues and staff from PAHO are here participating with event. Also, our Director, Dr. Carissa Etienne, is also here participating in the meetings on Universal Health Coverage with your President, Dr. Jim Kim. I would like to personally thank President Jim Kim and all our colleagues at the World Bank for organizing this technical conference on global lessons for the elimination of cholera from Haiti. It is wonderful and exciting for us to be here.

Acknowledgement of the Global Lessons on Cholera

Let me just say from the onset, with respect to the first of the global lessons learned on coordination and governance, (mentioned this morning) it is important that we acknowledge the leadership role played by the respective Governments of Haiti and the Dominican Republic since January 2012, when the Presidents launched the Call to Action for the international community to support major new investments in safe water, sanitation, and hygiene to eliminate cholera from Hispaniola.

We also acknowledge the Ministry of Health and DINEPA ‘s leadership in 2012-2013 to develop the national plans for the long haul 10 years, and in the more immediate 2 years, to eliminate cholera transmission, using key interventions that will lead to the eventual interruption of cholera transmission. The same must be said for the leadership played by the Ministry of Health and INAPA in the Dominican Republic.

Several of the global lessons on cholera control and elimination mentioned in the World Bank’s presentation this morning have been carefully incorporated and costed into the two plans. Indeed, several of these lessons were published in a special publication of the American Journal of Tropical Medicine in October last year.

The plans incorporate a vision to adopt a phased approach over a ten-year period. They focus on inter-sectoral coordination, capacity building, and monitoring and evaluation, combined with cost-effective interventions in epidemiological and water quality surveillance, the distribution of ORT, and nationwide education and hygiene promotion campaigns. Health promotion efforts include the importance of tackling food-borne illnesses as part of a behavioral change approach. Improved access to quality water and sanitation services in remote areas are also essential for elimination.

Lessons from the Implementation of Oral Cholera Vaccine

Of relevance to today’s discussion, while the longer-term safe water and proper sanitation components are being addressed, time-tested public health measures for cholera outbreak response - namely preventive measures and treatment to avert deaths and halt transmission remain essential. Any death caused by cholera in Haiti should be considered completely unacceptable. To that end, amongst these measures, I would like to focus on the benefits of implementing targeted vaccination and communication campaigns. The National Cholera Elimination Plan foresees the vaccination of 600,000 people with the oral cholera vaccination in areas of persistence. This is because of limited supply, ideally if we had enough vaccine the government would like vaccinate everyone.

But first a little background information.

During the World Health Assembly in 2011, Member States called for an integrated, comprehensive strategy of cholera prevention and control worldwide.

A WHO/ICG OCV stockpile has since been established to respond to outbreaks.

Between April and June 2012, as part of the national plan, the Ministry of Health spearheaded a pilot of cholera vaccination with the technical and financial support of UNICEF, PAHO/WHO, CDC, GHESKIO and Partners In Health. The campaign targeted two at-risk communes - one urban and one rural. An additional campaign conducted in July 2013 vaccinated >100,000 individuals.

Two key lessons from these cholera vaccination demonstration projects in Haiti noted: i) community acceptance of cholera vaccination; and ii) the feasibility of administering the vaccine on a large-scale in both rural and urban settings.

At the same time, the pilot demonstrations underscored the importance of substantial planning prior to vaccination, the need for a reliable cold chain and other logistic resources, ongoing monitoring of vaccination activities, and communication activities involving the community, opinion leaders and the media. CDC has since undertaken an impact evaluation of the interventions.

Technical Advisory Group (TAG) Recommendations

Taking these lessons into account, an internationally constituted Technical Advisory Group (TAG) that met at PAHO in October 2012 recommended that OCV be used in Haiti as a complementary tool to social mobilization, active case-finding and the national immunization services.

Additional Evidence – CDC Statistical Model

Additional evidence on the impact of OCV combined with water and sanitation interventions has been provided through a statistical model developed by CDC. The results were published in the same special issue of the American Journal for Tropical Medicine and Hygiene in October 2013 that I mentioned previously.

The model shows that over the next two decades 89,000 cases of cholera could be averted – this means an additional 11,000 cases could be prevented when implementing both types of interventions together .

However, cholera experts agree that cholera vaccination alone will not prevent long-term risk of disease outbreaks and resurgence without ongoing efforts to improve water, sanitation, and hygiene. This is the key message. It must be done hand-in-hand. In fact we propose to include OCV as a component of the umbrella of protection against diarrhea. This means with rotavirus vaccination as well.

Based on the epidemiological data management and analysis made regularly by health authorities on the cholera situation in the country, MSPP/DINEPA have planned to implement OCV interventions in a phased approach over 2014 – 2015 with the support of PAHO/WHO and UNICEF and through NGO partners.

The campaign will be implemented in areas considered as high risk in the most vulnerable Departments of North, Center, Artibonite and West. Vulnerable communities have been defined as having: high attack rate, high case fatality rate, limited access to health care, poor access to water and sanitation, early increase of cases in the cholera season, and areas with dynamic commercial activities (exchanges, population movements).

At this point I would like to sincerely acknowledge the commitment and support of Paul Farmer and Pedro Medrano of the UN in these efforts to ensure the opportunity of vaccination and saving lives in the short run is not missed.

With regards to PAHO, our role in support of the Ministry of Health will entail:

• Continuing to coordinating the technical advisory group

• Provision of technical support to vaccination activities in the field, including training of health personnel

• Provision of logistical support for vaccine distribution

• Provision of support for vaccine storage

UNICEF will be responsible for supporting the communication and social mobilization and community training activities, and CDC will continue to support the evaluation of immunization activities.

The monitoring of the project will be carried out through PAHO/WHO’s country office and partners like CDC, UNICEF, and others. PAHO intends to convene a group of scientific experts that will help evaluate efforts and ensure we are using every opportunity to document lessons learned.

Based on the lessons learned plus the confirmed availability of 400,000 doses of OCV, the campaign aims to cover 200,000 persons in a 2-dose strategy targeting vulnerable communities. An additional 600,000 doses will become available in the second half of the year and will be procured to vaccinate 300,000 individuals in a third campaign for late 2014.

The cost of the campaign in July/August 2014 is US$2.7 million. Complementary funds for the third campaign are presently being sought. And, I must ask would the World Bank consider supporting the MOH in this endeavor?

Success in the National Expanded Program of Immunization (EPI)

PAHO and partners view the implementation of this portion of the National Plan as a reflection of other good news stories in Haiti. For example, over the past three years, despite the challenges arising from the earthquake, there has been notable progress in Government capacity to lead other national initiatives such as achieving universal coverage for immunization with support from the Global Alliance for Vaccine Initiative (GAVI).

We have witnessed the successful introduction of the new pentavalent vaccine throughout Haiti in 2012. Pneumococcal and rotavirus vaccines are also being introduced - preventing 20,000 deaths in infants, and demonstrating the strength of community-based interventions through 9000 volunteers and strong logistics.

Thank you. We looking forward to working with all partners committed to eliminating cholera and ensuring safe water and sanitation as basic human rights on the island of Hispaniola.