Global Health Security in Action: Helping Haiti to Prevent, Detect and Respond to Vaccine-Preventable Diseases
Immunization has long been recognized as the first line of defense in an effective approach to public health. It is also one of the most efficient and cost-effective public health interventions in the world and has the potential to have an important and positive impact on global health security.
Appropriate use of vaccines can stop the spread of vaccine-preventable diseases (VPDs) by reducing the number of people who are at risk of infection and decreasing the likelihood that diseases will cross borders and spread to neighboring countries.
Given the importance of vaccination, CDC is spending time, money and staff power in Haiti to improve the country’s ability to systematically and comprehensively protect people of all ages against VPDs, and prevent the spread of infections to the rest of the Americas, and the world.
CDC’s work to improve immunization in Haiti has included ensuring the elimination of measles, rubella and congenital rubella syndrome; responding to a nationwide cholera epidemic; assisting with new vaccine introductions; and building country capacity for disease detection and response.
- Ensuring that measles, rubella and congenital rubella syndrome are eliminated
Measles is one of the most contagious of all infectious diseases. In developing countries, as many as one child out of every ten who become sick with measles can die from the disease. Rubella infection during pregnancy can have devastating effects on the unborn baby, including miscarriage or a combination of birth defects known as congenital rubella syndrome (CRS), which includes heart disease, blindness, deafness, and mental retardation.
A vaccine to prevent rubella was introduced in Haiti during a nationwide measles-rubella, and polio vaccination campaign that lasted from November 2007 to December 2008. A total of 4.5 million children and adolescents aged 1–19 years (roughly 40% of the country’s population) were vaccinated to rapidly boost Haiti’s population immunity against measles, rubella and polio.
In 2010, there was a devastating earthquake. The natural disaster greatly affected health services, including the routine immunization program. Although in Haiti MR vaccine is routinely recommended for children aged 9-11 months only 59% of Haitian children younger than 1 year of age received measles-rubella (MR) vaccine in 2011.
A vaccination coverage rate above 90% with two doses of MR vaccine is necessary to ensure that a country’s population is protected from the spread of measles or rubella viruses. To improve immunization coverage with MR vaccine in Haiti, CDC provided scientific expertise and funding to the Haitian Ministry of Health and Population (MSPP), Pan American Health Organization (PAHO), and the United Nations’ Children’s Fund (UNICEF) to implement a national MR mass vaccination campaign from April to June 2012. The campaign targeted children younger than 10 years of age to provide an additional opportunity for MR vaccination and raise population immunity.
At the request of MSPP and PAHO, CDC designed and funded a national vaccination coverage survey to evaluate the success of the measles-rubella campaign by determining the percentage of children in the target age group who were vaccinated during the campaign. A team of 25 CDC-trained Haitian interviewers went door-to-door to administer the questionnaire to 7,000 households representing 10,000 children.
The results were encouraging. We found that 91% of children 1-9 years of age had received at least one dose of MR vaccine. Nearly 30% of the children who were interviewed got their first MR dose during the campaign, and more than half of children 1-9 years of age got their second dose, a significant milestone toward providing those children with complete protection against measles and rubella. The measles-rubella vaccination campaign was instrumental for raising measles and rubella immunity levels in children in Haiti.
- Responding to a deadly cholera epidemic
After more than half a century without a cholera outbreak, Haiti is experiencing one of the largest cholera epidemics ever recorded in a single country. The outbreak began after the 2010 earthquake and accounted for 57% of all cholera cases and 53% of all cholera deaths reported to the World Health Organization (WHO) in 2010, and 58% of all cholera cases and 37% of all cholera deaths in 2011. In February 2013, the Haiti MSPP launched the 2013-2022 national plan of action for the elimination of cholera in Haiti. Although access to safe water, adequate sanitation, and hand washing with soap are the cornerstones of cholera prevention, WHO has recommended the use of oral cholera vaccines (OCV) as an additional public health tool in complex emergencies. The Haitian government plans to vaccinate 600,000 persons who are at high risk of cholera as a short-term solution to control the spread of cholera.
In August and September 2013, with the financial support of UNICEF, MSPP conducted an OCV campaign targeting almost 108,000 persons aged 1 year and older in Petite Anse and Cerca Carvajal, two affected areas. In collaboration with MSPP, CDC implemented various monitoring and evaluation surveys to identify lessons that could be applied to future OCV campaigns in Haiti. These surveys consisted of:
- Pre- and post-vaccination campaign assessments to evaluate the impact of the campaign on community knowledge, attitudes and practices regarding cholera, safe water, sanitation, hygiene, and immunization practices,
- A vaccination coverage survey to identify vaccine acceptability, barriers to vaccination, and any adverse events reported after receiving the oral cholera vaccine, and,
- A vaccine effectiveness study to assess the success of the vaccine in preventing severe cholera in vaccinated areas.
Analysis of the coverage survey and implementation of the vaccine effectiveness study and post-KAP survey are currently underway.
- Preparing for the introduction of new vaccines
Having a well-functioning cold chain is an absolute necessity before any new vaccine introduction. CDC is providing financial support to MSPP, PAHO and UNICEF to increase the cold chain capacity at all levels. In 2012-2013, CDC funded the installation of 2 new cold rooms in the central vaccine warehouse, 78 solar refrigerators at department (“state”) level, and in 2014, is funding the installation of solar refrigerators in health facilities.
These infrastructure improvements facilitated the introduction of pentavalent vaccine in 2012. This vaccine protects children against 5 serious diseases with 1 shot: diphtheria, tetanus, pertussis (whooping cough), hepatitis B, and Haemophilus influenzae type b (Hib) disease (which can cause pneumonia and meningitis).
Rotavirus vaccine, which protects against the leading cause of severe and fatal diarrhea worldwide, is scheduled for introduction in 2014 and has already been transported from the central vaccine warehouse to the solar fridges in the departments. Pneumococcal conjugate vaccine will be introduced in Haiti in 2015 to protect against pneumonia, the #1 killer of children younger than 5 years of age worldwide. These efforts will protect more children from sickness and death from VPDs, and will reduce the risk of VPD outbreaks in Haiti and the Americas.
- Building country capacity for disease detection and response and program improvement
A good surveillance system is needed to detect and immediately respond to outbreaks. Haiti is at high risk of importations of polio, measles and rubella with subsequent spread to the population, because of the continual influx of aid workers and sub-optimal vaccination coverage in the Haitian population. In addition, polio, like cholera, can easily spread through the sewage system if it is brought into the country, given the poor sanitation and infrastructure in Haiti. Therefore strong surveillance systems are needed to prevent disease importation.
To identify the strengths and weaknesses of VPD surveillance and provide recommendations to Haiti, CDC conducted an evaluation of the VPD surveillance system in 2013. Due to the work of CDC staff embedded at PAHO and field workers from the Stop Transmission of Polio (STOP) program, there have been significant improvements in the detection and tracking of measles and rubella since 2012. However, identification and reporting of cases of acute flaccid paralysis, which is necessary in order to identify any case of polio, and of neonatal tetanus were very weak. In addition, some healthcare providers were unfamiliar with case definitions and reporting requirements.
To respond to this need, CDC developed and conducted a 4-day training workshop on VPD surveillance and outbreak response. More than 50 people participated, including epidemiologists and data managers at the national level, and epidemiologists, immunization managers, and laboratory technicians in the departments. All the participants were satisfied with the training, and felt that their knowledge had improved. CDC also provided financial and technical support to MSPP to establish 6 sentinel sites for rotavirus and meningitis surveillance. Data from those sites will help document the impact of rotavirus and pneumococcal vaccines after they are introduced.
In addition, in March 2014, CDC, PAHO and MSPP provided additional training to 30 more immunization staff on the use of immunization recoding forms, analysis and interpretation of immunization data and calculation of vaccine needs. These trained professionals will, in turn, be training vaccinators in health facilities on the same concepts, enabling them to identify and address any weaknesses in their immunization program and thereby contribute to improved vaccine coverage. Participants found the interactive case studies and exercises prepared by CDC to be highly instructive and enjoyable, and requested similar methodologies for future trainings.
What’s next for immunization in Haiti?
CDC will continue to provide technical and financial support to ensure that all children in Haiti receive life-saving vaccines and thereby protect the Americas from VPDs. Future projects in Haiti include improving the quality of immunization data to ensure valid documentation of vaccination, and hepatitis B surveys to document the burden of hepatitis B in mothers and children in Haiti. Results would help justify the introduction of a birth dose of hepatitis B vaccine in Haiti.
CDC is helping to rebuild Haiti’s immunization system as part of overall health system reconstruction. By building Haiti’s capacity to prevent, detect and respond to public health threats, we are contributing to overall global health security – because diseases do not respect geographical boundaries.