[Show abstract][Hide abstract] ABSTRACT: In mass vaccination campaigns, large volumes of data must be managed efficiently and accurately. In a reactive oral cholera vaccination (OCV) campaign in rural Haiti during an ongoing epidemic, we used a mobile health (mHealth) system to manage data on 50,000 participants in two isolated communities.
[Show abstract][Hide abstract] ABSTRACT: Studies of the immunogenicity of the killed bivalent whole cell oral cholera vaccine, Shanchol, have been performed in historically cholera-endemic areas of Asia. There is a need to assess the immunogenicity of the vaccine in Haiti and other populations without historical exposure to Vibrio cholerae.
We measured immune responses after administration of Shanchol, in 25 adults, 51 older children (6-17 years), and 47 younger children (1-5 years) in Haiti, where cholera was introduced in 2010. A≥4-fold increase in vibriocidal antibody titer against V. cholerae O1 Ogawa was observed in 91% of adults, 74% of older children, and 73% of younger children after two doses of Shanchol; similar responses were observed against the Inaba serotype. A≥2-fold increase in serum O-antigen specific polysaccharide IgA antibody levels against V. cholerae O1 Ogawa was observed in 59% of adults, 45% of older children, and 61% of younger children; similar responses were observed against the Inaba serotype. We compared immune responses in Haitian individuals with age- and blood group-matched individuals from Bangladesh, a historically cholera-endemic area. The geometric mean vibriocidal titers after the first dose of vaccine were lower in Haitian than in Bangladeshi vaccinees. However, the mean vibriocidal titers did not differ between the two groups after the second dose of the vaccine.
A killed bivalent whole cell oral cholera vaccine, Shanchol, is highly immunogenic in Haitian adults and children. A two-dose regimen may be important in Haiti, and other populations lacking previous repeated exposures to V. cholerae.
[Show abstract][Hide abstract] ABSTRACT: Background. The epidemics of food insecurity, malnutrition, and human immunodeficiency virus (HIV) frequently overlap. HIV treatment programs increasingly provide nutrient-dense ready-to-use supplementary foods (RUSFs) to patients living with HIV and food insecurity, but in the absence of wasting, it is not known if RUSF confers benefit above less costly food commodities. Methods. We performed a randomized trial in rural Haiti comparing an RUSF with less costly corn-soy blend plus (CSB+) as a monthly supplement to patients with HIV infection who were on antiretroviral therapy (ART) <24 months prior to study start. We compared 6- and 12-month outcomes by ration type in terms of immunologic response, body mass index (BMI), adherence to ART, general health quality of life, household food insecurity, and household wealth. Results. A cohort of 524 patients with HIV receiving ART was randomized and followed over time. Median CD4 cell count at baseline was 339 cells/µL (interquartile range [IQR], 197-475 cells/µL) for the CSB+ group, and 341 cells/µL (IQR, 213-464/µL) for the RUSF group. Measured outcomes improved from baseline over time, but there were no statistically significant differences in change for BMI, household wealth index, hunger, general health perception score, or adherence to ART by ration type at 6 or 12 months. The RUSF group had higher CD4 count at 12 months, but this was also not statistically significant. Conclusions. In 12 months of follow-up, there was no statistically significant difference in outcomes between those receiving RUSF-based compared with CSB+-based rations in a cohort of HIV-infected adults on ART in rural Haiti.
[Show abstract][Hide abstract] ABSTRACT: The impact of phage predation on bacterial pathogens in the context of human disease is not currently appreciated. Here, we show that predatory interactions of a phage with an important environmentally transmitted pathogen, Vibrio cholerae, can modulate the evolutionary trajectory of this pathogen during the natural course of infection within individual patients. We analyzed geographically and temporally disparate cholera patient stool samples from Haiti and Bangladesh and found that phage predation can drive the genomic diversity of intra-patient V. cholerae populations. Intra-patient phage-sensitive and phage-resistant isolates were isogenic except for mutations conferring phage resistance, and moreover, phage-resistant V. cholerae populations were composed of a heterogeneous mix of many unique mutants. We also observed that phage predation can significantly alter the virulence potential of V. cholerae shed from cholera patients. We provide the first molecular evidence for predatory phage shaping microbial community structure during the natural course of infection in humans.DOI: http://dx.doi.org/10.7554/eLife.03497.001.
[Show abstract][Hide abstract] ABSTRACT: Background: Zanmi Lasante (ZL)/Partners In Health (PIH), has delivered community-based primary healthcare in central Haiti since 1986. Building on that model, ZL responded swiftly to the 2010 cholera epidemic, establishing Cholera Treatment Centers (CTCs) and community-based education and prevention efforts in support of the Haitian Ministry of Health (MOH). We report trends of the epidemic in the Centre and Artibonite Departments of Haiti through May 2013. Methods: Cases of cholera were diagnosed using clinical case definition in patients presenting with acute watery diarrhea. Data were collected using CTC case and death registers across 10 supported CTCs in central Haiti. ZL staff used data dashboards to monitor site case volume, case-fatality rate (CFR) and attack rates. Results: Between October 2010 and May 2013, 102,255 cholera cases were treated at ZL/MOH sites, representing almost 1/6 of all cases reported nationally. 1,129 cholera-related deaths were registered (cumulative CFR of 1.1%). Data from surveillance activities were fed back to implementation teams to facilitate targeted community-level interventions. In the past 12 months, a drop in CFR (0.6%) and new cases (11,196 from 6/2012-5/2013) was seen. Significant geographic variation in remaining burden exists, with half of the recent cholera cases seen at 2 of the 10 CTCs. Discussion: Cholera cases continue to cause morbidity and mortality in Haiti. However, at PIH/ZL sites, CFR has decreased over the duration of the cholera epidemic. Our data demonstrate that very low CFRs are achievable in rural Haiti.
141st APHA Annual Meeting and Exposition 2013; 11/2013
[Show abstract][Hide abstract] ABSTRACT: A cholera epidemic has claimed the lives of over 8,000 Haitians and sickened 650,000 since the outbreak began in October 2010. Early intervention in the epidemic focused on case-finding, treatment, and water and sanitation interventions for prevention of transmission. In December 2011, the Minister of Health of Haiti called for a demonstration of the acceptability and feasibility of the use of OCV in urban and rural Haiti. This presentation describes the department of rural Haiti and a second region in urban Port-au-Prince in addition to other ongoing treatment and control measures. Despite logistics and cold chain challenges, 100,00 individuals were successfully vaccinated with OCV in the region, with 90.8% of those completing their second dose.
141st APHA Annual Meeting and Exposition 2013; 11/2013
[Show abstract][Hide abstract] ABSTRACT: Background: Zanmi Lasante (ZL), sister organization of Partners In Health (PIH) in Haiti, has provided care in Haiti to over 24,000 HIV patients in 12 clinical sites. In 2002, an electronic medical record (EMR) system was implemented to improve HIV care and program surveillance. Infrastructure and other challenges compromised data quality, preventing full realization of these goals. We describe outcomes of a data quality audit (DQA) designed to increase EMR utility for surveillance and improvement in our HIV program.
Methods: Concordance between paper and electronic records was evaluated on selected key data elements, including patient status, date of last visit and last medication pickup and last CD4 result. Paper records were considered the gold standard. Discordance rates were measured and EMR data were corrected based on the paper chart.
Results: As of April 2013, the DQA was completed on 22,434 patient records (87% of ever-registered patients). 8,704 (38.8%) patients had a discordant status, compared to only 7.5% of patients for last visit date and 4.3% for last CD4 count. Based on improved data quality, targeted outreach driven by EMR data was initiated for patients at risk for default and those in need of CD4 count monitoring.
Discussion: An up-to-date EMR with quality data is crucial for a large scale HIV program to have real-time access to accurate patient data for care and program surveillance to rapidly identify individuals in need of additional services. Only by measuring and improving data quality can EMR's realize their full potential in these dual roles.
141st APHA Annual Meeting and Exposition 2013; 11/2013
[Show abstract][Hide abstract] ABSTRACT: A cholera epidemic has claimed the lives of more than 8,000 Haitians and sickened 650,000 since the outbreak began in October 2010. Early intervention in the epidemic focused on case-finding, treatment, and water and sanitation interventions for prevention of transmission. Use of oral cholera vaccine (OCV) as part of a complementary set of control activities was considered but initially rejected by policymakers. In December 2011, the Minister of Health of Haiti called for a demonstration of the acceptability and feasibility of the use of OCV in urban and rural Haiti. This paper describes the collaborative activity that offered OCV to one region of the Artibonite Department of rural Haiti in addition to other ongoing treatment and control measures. Despite logistics and cold chain challenges, 45,417 persons were successfully vaccinated with OCV in the region, and 90.8% of these persons completed their second dose.
The American journal of tropical medicine and hygiene 10/2013; 89(4):617-624. · 2.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Haiti's cholera epidemic has been devastating partly due to underlying weak infrastructure and limited clean water and sanitation. A comprehensive approach to cholera control is crucial, yet some have argued that oral cholera vaccination (OCV) might result in reduced hygiene practice among recipients. We evaluated the impact of an OCV campaign on knowledge and health practice in rural Haiti.
We administered baseline surveys on knowledge and practice relevant to cholera and waterborne disease to every 10th household during a census in rural Haiti in February 2012 (N = 811). An OCV campaign occurred from May-June 2012 after which we administered identical surveys to 518 households randomly chosen from the same region in September 2012. We compared responses pre- and post-OCV campaign. Post-vaccination, there was improved knowledge with significant increase in percentage of respondents with ≥3 correct responses on cholera transmission mechanisms (odds ratio[OR] 1.91; 95% confidence interval[CI] 1.52-2.40), preventive methods (OR 1.83; 95% CI 1.46-2.30), and water treatment modalities (OR 2.75; 95% CI 2.16-3.50). Relative to pre-vaccination, participants were more likely post-OCV to report always treating water (OR 1.62; 95% CI 1.28-2.05). Respondents were also more likely to report hand washing with soap and water >4 times daily post-vaccine (OR 1.30; 95% CI 1.03-1.64). Knowledge of treating water as a cholera prevention measure was associated with practice of always treating water (OR 1.47; 95% CI 1.14-1.89). Post-vaccination, knowledge was associated with frequent hand washing (OR 2.47; 95% CI 1.35-4.51).
An OCV campaign in rural Haiti was associated with significant improvement in cholera knowledge and practices related to waterborne disease. OCV can be part of comprehensive cholera control and reinforce, not detract from, other control efforts in Haiti.
[Show abstract][Hide abstract] ABSTRACT: Cholera is an acute watery diarrheal disease caused by infection with Vibrio cholerae. The disease has a high fatality rate when untreated and outbreaks of cholera have been increasing globally in the past decade, most recently in Haiti. We present the case of a 28-year-old Haitian male with a history of severe untreated mental health disorder that developed acute fatal watery diarrhea in mid-October 2010 in central Haiti after drinking from the local river. We believe he is the first or among the first cases of cholera in Haiti during the current epidemic. By reviewing his case, we extracted lessons for global health on the importance of mental health for overall health, the globalization of diseases in small communities, and the importance of a comprehensive approach to the health of communities when planning services in resource-poor settings.
The American journal of tropical medicine and hygiene 01/2012; 86(1):36-8. · 2.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Cholera is an acute, severe diarrheal disease caused by Vibrio cholerae that affects millions of people each year. Without prompt rehydration, death can occur within hours of the onset of symptoms. In October 2010, cholera emerged in Haiti, and the resulting large epidemic continues today. As of August 29, 2011, more than 439,000 cases have been reported in Haiti, with over 6,200 deaths. This review covers important features of epidemiology, pathogenesis, treatment and prevention of cholera, with a focus on the ongoing epidemic in Haiti.
Current Infectious Disease Reports 12/2011; 14(1):1-8.
[Show abstract][Hide abstract] ABSTRACT: Food security exists when all people, at all times, have physical, social, and economic access to sufficient, safe, and nutritious food that meets their dietary needs and food preferences for an active and healthy life. Food insecurity is the converse state, is often associated with poverty and low income, and has important implications for the health and nutrition of individuals. Given their contribution to food production and preparation, their role in society as child bearers and caregivers, the increasing number of female-headed households worldwide, and their disproportionately poor economic status, women need special consideration in discussions of food insecurity and its effect on health, nutrition, and behavior. This article reviews the scientific literature on issues related to women and food insecurity. Food insecurity is associated with obesity, anxiety, and depressive symptoms; risky sexual behavior; poor coping strategies; and negative pregnancy outcomes in women, although evidence about the direction and causality of associations is unclear. There is a lack of evidence and understanding of the effects of food insecurity in resource-poor settings, including its effect on weight, nutritional outcomes, and pregnancy outcomes, as well as its effect on progression of diseases such as HIV infection. More research is needed to guide efficient interventions that address food insecurity among women. However, practical experience suggests that both short-term assistance and longer-term strategies that improve livelihoods, address behavioral and coping strategies, acknowledge the mental health components of food insecurity, and attempt to ensure that women have the same economic opportunities, access to land, and economic power as men are important.
American Journal of Clinical Nutrition 11/2011; 94(6):1740S-1744S. · 6.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: At least 36 countries are suffering from severe shortages of healthcare workers and this crisis of human resources in developing countries is a major obstacle to scale-up of HIV care. We performed a case study to evaluate a health service delivery model where a task-shifting approach to HIV care had been undertaken with tasks shifted from doctors to nurses and community health workers in rural Haiti.
Data were collected using mixed quantitative and qualitative methods at three clinics in rural Haiti. Distribution of tasks for HIV services delivery; types of tasks performed by different cadres of healthcare workers; HIV program outcomes; access to HIV care and acceptability of the model to staff were measured.
A shift of tasks occurred from doctors to nurses and to community health workers compared to a traditional doctor-based model of care. Nurses performed most HIV-related tasks except initiation of TB therapy for smear-negative suspects with HIV. Community health workers were involved in over half of HIV-related tasks. HIV services were rapidly scaled-up in the areas served; loss to follow-up of patients living with HIV was less than 5% at 24 months and staff were satisfied with the model of care.
Task-shifting using a community-based, nurse-centered model of HIV care in rural Haiti is an effective model for scale-up of HIV services with good clinical and program outcomes. Community health workers can provide essential health services that are otherwise unavailable particularly in rural, poor areas.
PLoS ONE 01/2011; 6(5):e19276. · 3.53 Impact Factor