Achieving coordinated national immunity and cholera elimination in Haiti through vaccination
Authors: Lee Elizabeth C. , Chao Dennis L. , Lemaitre Joseph , Matrajt Laura , Pasetto Damiano , Perez-Saez Javier , Finger Flavio , Rinaldo Andrea , Sugimoto Jonathan D. , Halloran M. Elizabeth , Longini Ira M. , Ternier Ralph , Vissieres Kenia , Azman Andrew S. , Lessler Justin , Ivers Louise C. 
Published: November 2019

SummaryBackgroundCholera was introduced into Haiti in 2010. Since, there have been over 820,000 reported cases and nearly 10,000 deaths. The year 2019 has seen the lowest reported number of cases since the epidemic began. Oral cholera vaccine (OCV) is safe and effective, but has generally not been seen as a primary tool for cholera elimination due to a limited period of protection and constrained supplies. Regionally, epidemic cholera is contained to the island of Hispaniola. Hence, Haiti may represent a unique opportunity to eliminate cholera by use of OCV.MethodsWe assess the probability of elimination and the potential health impact of OCV use in Haiti by leveraging simulations from four independent modeling teams. For a 10-year projection period, we compared the impact of five vaccination campaign scenarios, differing in geographic scope, vaccination coverage, and rollout duration to a status quo scenario without vaccination. Teams used common calibration data and assumptions for vaccine efficacy and vaccination scenarios, but all other model features and assumptions were determined independently.FindingsA two-department OCV campaign proposed in Haiti’s national plan for elimination had less than 50% probability of elimination across models, and only ambitious, nationwide campaigns had a high probability of reaching this goal. Despite their low probability of elimination, two-department campaigns averted a median of 13-58% of infections across models over the five years after the start of vaccination campaigns; a nationwide campaign implemented at the same coverage and rollout duration averted a median of 58-95% of infections across models.InterpretationDespite recent declines in cholera cases in Haiti, bold action is needed to promote elimination of cholera from the region. Large-scale cholera vaccination campaigns in Haiti offer the opportunity to synchronize nationwide immunity, providing near-term protection to the population while improvements to water and sanitation infrastructure create an environment favorable to long-term cholera elimination.Research in ContextEvidence before this studyWe searched PubMed without language or date restrictions on October 4, 2019 for all records matching (“cholera*” AND “Haiti” AND (“vaccin*” OR “elim*”)) in any field and added one known article on the probability of elimination of cholera that was not indexed by PubMed to our review. Of 94 results, four articles were not about the cholera outbreak in Haiti or the use of cholera vaccination, and 34 were not original research articles. Fourteen articles presented research on cholera biology or cholera vaccine biology, either through discussion of Vibrio cholerae genetics, immunogenicity of oral cholera vaccine (OCV), or prospective vaccine candidate antigens. Twenty articles assessed OCV vaccine effectiveness, evaluated OCV campaign implementation or attitudes and knowledge about cholera control, or presented lessons learned on outbreak response and policy as a result of the Haiti cholera outbreak. Seven articles were about general cholera outbreak epidemiology in Haiti, and six articles were related to cholera transmission models outside our research scope.Of the nine remaining articles, five examined the impact of potential OCV campaigns at an early time point when Haiti’s cholera outbreak still exhibited epidemic dynamics, and one other projected the impact of the OCV campaigns planned after Hurricane Matthew in 2016. Two of the articles considered prospects for cholera elimination in Haiti in 2013 and 2014 and found that further targeted interventions were needed. One final study from 2017 modeled the possibility for OCV campaigns to eliminate cholera transmission in the Ouest department within a few years.Added value of this studyPrevious assessments of the impact of OCV use in Haiti occurred during early points of the outbreak when OCV campaigns were unlikely to lead to cholera elimination. Our study projects cholera transmission in Haiti with multiple years of more recent data, and directly examines prospect of cholera elimination in the status quo and under various mass OCV campaign scenarios. In bringing together results from multiple modeling teams, our study provides robust evidence about the current state of cholera transmission across Haiti and the potential impact of multiple mass OCV campaign scenarios.Implications of all of the available evidenceWhile 2019 has seen the lowest number of cholera cases in Haiti since the outbreak began, model simulations suggest that it may be possible for cholera transmission to persist without additional cholera control interventions.While a single two-department vaccination campaign may avert roughly 13-58% of infections with V. cholerae over a five year period, only a nationwide campaign led to a high probability of cholera elimination. Ambitious nationwide vaccination campaigns may break the cycle of endemic cholera transmission in Haiti as long-term improvements to water and sanitation infrastructure, which will limit the effects of potential re-introductions of Vibrio cholerae, are being made.