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Op Ed on elimination of cholera transmission in Haiti and the Dominican Republic

Op Ed Published in The Lancet on 11 January 2012

Mirta Roses Periago, Thomas R Frieden, Jordan W Tappero, Kevin M De Cock, Bernt Aasen, Jon K Andrus

One of the largest recent cholera epidemics to affect a single country began in Haiti in October, 2010, just 10 months after a devastating earthquake had struck the nation's capital. Within a month, cholera had spread throughout Haiti and cases were being reported by its shared island neighbour, the Dominican Republic. In Dec, 2011, 522 335 cholera cases and 7001 deaths had been reported in Haiti,1 with an additional 21 432 cases and 363 deaths reported in the Dominican Republic.2 The 2-year anniversary of the earthquake is an opportune time to refocus national and international efforts on the elimination of cholera transmission in Hispaniola.

In the past year, the international community has supported cholera prevention and control strategies for Haiti and the Dominican Republic.3, 4 These strategies include: improving access to safe drinking water by increasing chlorination of public and household water supplies, increasing water quality monitoring, tracking disease spread and response through surveillance, promoting safe hygiene, encouraging safe food handling practices and policies, and ensuring quality clinical care and treatment at health facility and community levels. If the evidence supports the introduction of oral cholera vaccine in this setting, another tool may be available in the fight against this disease.4, 5 These life-saving interventions must be strengthened and sustained. Despite these efforts, however, there are more than 200 new cholera cases daily in Haiti during the dry season, with more than 1000 cases arising each day in the rainy season.1 Cholera elimination will require renewed efforts to ensure that safe water and sanitation are provided to every resident.

Haiti is the most underserved country in the western hemisphere in terms of water and sanitation infrastructure.6 In 2008, 63% of Haitians had access to improved drinking water and 17% had access to improved sanitation, such as flush toilets, septic tanks, ventilated improved pit latrines, and composting toilets. This low figure for access to sanitation had decreased from 26% in 1990, making Haiti one of the few countries where overall sanitation coverage has declined for reasons other than population growth. By contrast, in 2008, 86% of Dominicans and 93% of people living in the Latin American and Caribbean region had access to improved drinking water, and 83% and 80% had access to improved sanitation, respectively.6 Millennium Development Goal (MDG) 7 encompasses a commitment to halving the proportion of the world's population without access to improved water and sanitation by 2015. Failure to attain MDG targets in Haiti for access to improved water (74%) and sanitation (63%)7 will facilitate continued cholera transmission on the island, placing the entire region at risk.

During the Latin America epidemic of the 1990s, cholera spread to more than 20 countries in 2 years. With support from the international community, investments in water and sanitation infrastructure contributed to the virtual elimination of epidemic cholera from Central and South America within 8 years.8, 9 These interventions also led to well documented decreases in other waterborne diseases, such as typhoid fever and hepatitis A, and to reductions in infant and child mortality.9, 10 The control of epidemic cholera in Latin America in the 1990s underlines the current need for investment in safe water and sanitation infrastructure in Haiti.

In March, 2010, the international community pledged billions to assist Haiti.11 There has already been major investment by some partners. The USA has committed more than $3 billion in humanitarian relief, recovery, and reconstruction assistance. However, other partners are needed to address the funding gap for water and sanitation infrastructure. To that end, on Jan 11, 2012, the Governments of Haiti and the Dominican Republic launched a call to action for major investment in safe water, sanitation, and hygiene, particularly in Haiti. Future progress will specifically require: prioritising the development of sustainable safe water, sanitation, and hygiene infrastructure; the creation of a technical advisory group of experts to oversee the development of a costed plan of action with a timeline for completion; and honouring pledged post-earthquake funding commitments and recruiting new donors. This effort will not be cheap.12 Estimated costs from the Inter-American Development Bank, the Office of the Haitian Prime Minister, and the World Bank have ranged from $746 million to $1·1 billion.7, 13 However, the benefits would be enormous. Answering this call to ensure access to clean water and improved sanitation in Haiti will decrease the burden of cholera and other diarrhoeal diseases and prevent the further spread of cholera beyond the island of Hispaniola.

MRP is Director of the Pan American Health Organization. TRF is Director of the Centers for Disease Control and Prevention. JWT is Director of the CDC's Health Systems Reconstruction Office. KMDC is Director of the CDC's Center for Global Health. BA is Regional Director for Latin America and the Caribbean for the United Nations Children's Fund. JKA is Deputy Director of the Pan American Health Organization. We declare that we have no conflicts of interest.

References
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2 Ministry of Public Health of the Dominican Republic. Weekly epidemiological bulletin number 51. Dec 24, 2011 (in Spanish). http://www.sespasdigepi.gob.do/documentos/Boletin%20Semanal%202011/BoletinEpidemiologicoSemanal-SE51-2011.pdf. (accessed Jan 8, 2012).
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