The case-area targeted rapid response strategy to control cholera in Haiti: a four-year implementation study

PLoS Negl Trop Dis. 2019 Apr 16;13(4):e0007263. doi: 10.1371/journal.pntd.0007263. eCollection 2019 Apr.

Abstract

Background: In October 2010, Haiti was struck by a large-scale cholera epidemic. The Haitian government, UNICEF and other international partners launched an unprecedented nationwide alert-response strategy in July 2013. Coordinated NGOs recruited local rapid response mobile teams to conduct case-area targeted interventions (CATIs), including education sessions, household decontamination by chlorine spraying, and distribution of chlorine tablets. An innovative red-orange-green alert system was also established to monitor the epidemic at the communal scale on a weekly basis. Our study aimed to describe and evaluate the exhaustiveness, intensity and quality of the CATIs in response to cholera alerts in Haiti between July 2013 and June 2017.

Methodology/principal findings: We analyzed the response to 7,856 weekly cholera alerts using routine surveillance data and severity criteria, which was based on the details of 31,306 notified CATIs. The odds of CATI response during the same week (exhaustiveness) and the number of complete CATIs in responded alerts (intensity and quality) were estimated using multivariate generalized linear mixed models and several covariates. CATIs were carried out significantly more often in response to red alerts (adjusted odds ratio (aOR) [95%-confidence interval, 95%-CI], 2.52 [2.22-2.87]) compared with orange alerts. Significantly more complete CATIs were carried out in response to red alerts compared with orange alerts (adjusted incidence ratio (aIR), 1.85 [1.73-1.99]). Over the course of the eight-semester study, we observed a significant improvement in the exhaustiveness (aOR, 1.43 [1.38-1.48] per semester) as well as the intensity and quality (aIR, 1.23 [1.2-1.25] per semester) of CATI responses, independently of funds available for the strategy. The odds of launching a CATI response significantly decreased with increased rainfall (aOR, 0.99 [0.97-1] per each accumulated cm). Response interventions were significantly heterogeneous between NGOs, communes and departments.

Conclusions/significance: The implementation of a nationwide case-area targeted rapid response strategy to control cholera in Haiti was feasible albeit with certain obstacles. Such feedback from the field and ongoing impact studies will be very informative for actors and international donors involved in cholera control and elimination in Haiti and in other affected countries.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Cholera / epidemiology*
  • Cholera / prevention & control*
  • Disease Outbreaks*
  • Disease Transmission, Infectious / prevention & control*
  • Haiti / epidemiology
  • Health Services Research*
  • Humans
  • Infection Control / methods*
  • Infection Control / organization & administration*

Grants and funding

This study was supported by the United Nations Children's Fund (UNICEF)-Haiti, to a lesser extent the Assistance Publique – Hôpitaux de Marseille (AP-HM), the Ministry of Public Health and Population (MSPP) of Haiti, and the French Institut de Recherche pour le Développement (IRD). Authors from UNICEF-Haiti (GB, CE, SB, EB) played a role in data collection and interpretation, decision to publish, as well as preparation of the manuscript. Authors from MSPP (EM, RB, KP, JB, PA, DF, FDG) played a role in data collection and interpretation, decision to publish, as well as preparation of the manuscript. Authors from AP-HM (SR, JG, LO and RP) played a role in study design, data collection and analysis, decision to publish, and preparation of the manuscript. The author from IRD (PG) played a role in data collection and interpretation, decision to publish, as well as preparation of the manuscript. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.