Running head: CHOLERA PREVENTION IN HAITI 1

Coming Together to Prevent Cholera in Haiti

Brenda Barrow, Brian Doster, Kristen Goncalves, and Kathy Le

California State University, Stanislaus

CHOLERA PREVENTION IN HAITI 2

Coming Together to Prevent Cholera in Haiti

Executive Summary

Cholera is a severe illness that causes hundreds of thousands of deaths every year

(Centers for Disease Control and Prevention [CDC], 2014). This rising bacterial epidemic

affects populations that live in places with inadequate water treatment, poor sanitation, and

subpar hygiene. These factors increase the risk of obtaining cholera, and are highly prevalent in

the population of the Haitian people. A person may contracts this illness through drinking

contaminated water or food, but it may not be spread through direct contact of an ill person. If

an individual is not treated, dehydration due to diarrhea takes affect and death can occur in a

matter of hours (CDC, 2014).

Many attempts have been made to decrease the incidence of cholera in Haiti. Previously,

programs have implemented preventative measures, such as proper stool disposal, water

purification tablets, and the potential for the incorporation of a cholera vaccine into the

population (CDC, 2014). In order for these methods to be successful, programs have

implemented education and materials to prevent the spread of cholera in Haiti. Within these

programs, education also focused on how to distinguish the signs and symptoms of cholera,

along with how to treat the illness if one becomes ill. These previous preventative techniques

have shown educational and implementation means have been beneficial, and have exposed

those that have not shown great success (CDC, 2014).

The program proposed in this paper aims to decrease the incidence of cholera in post-

earthquake Haiti. Increasing the number of households with knowledge of cholera prevention

techniques, increasing the number of households engaging, and demonstrating in safe sanitation
CHOLERA PREVENTION IN HAITI 3

practices are all the objectives that will be achieved. These objectives will be implemented with

identifications of community leaders, developing a curriculum, holding trainings for the leaders,

conducting rally posts, and evaluation through self-reported surveys, on-site spot checks, and

home visits by the trainers. With direct implementation of cholera prevention into the

community with village leaders, the support of citizens will be increased, therefore making a

behavior change more effective. The expected outcome of the program is a 50% decrease in

cholera incidences in Haiti during the first year of implementation. The program will need 80

board members consisting of nurses, doctors, trainers, educators, volunteers, and community

leaders. It will also require a grant for $1,070,750 because Haiti has a wide population of people

suffering from cholera. There are approximately 10,000,000 people that require ample supplies,

equipment, and educators.

Background

On January 12, 2010 a devastating earthquake struck the country of Haiti, which killed

over 200,000 people and displaced more than 1.5 million (Centers for Disease Control and

Prevention [CDC], 2011). Ten months following this shattering event, the Haitian Ministry of

Public Health and Population (MSPP), which is equivalent to Americas CDC, started

recognizing that an abundance of Haitians were presenting with sign and symptoms of cholera.

Cholera is a waterborne bacterium that causes acute watery diarrhea which leads to rapid

dehydration, electrolyte imbalances, and potentially death (National Center for Biotechnology

Information [NCBI], 2011). On October 22, 2010, the government confirmed the existing

pathogen to be Vibrio cholerae and declared the situation as the worlds largest cholera outbreak

in over a century (CDC, 2011). According the United Nations, the cholera epidemic in Haiti is

still plaguing the country with 736,376 suspected cases and 8,768 deaths recorded in March 28,
CHOLERA PREVENTION IN HAITI 4

2015 since the start of the outbreak (United Nations [UN], 2015). Furthermore, in 2015 there

were 11,721 cases and 113 mortalities. This reveals that the epidemic is still causing devastation

for the people of Haiti (UN, 2015).

However, the number of suspected cases has substantially decreased each year since the

onset in 2010. In 2010, there were 185,351 reported cases and 3,951 reported deaths attributed

to cholera (United Nations [UN], 2014). In 2011, there were 351,839 reported cases and 2,918

deaths. In 2012, there were 101,503 cases and 908 deaths. In 2013, there were 58,574 cases and

581 deaths. In 2014, there were 27,388 cases and 297 deaths. Finally, in the first few months of

2015, there were 11,721 cases and 113 deaths (UN, 2014). These statistics show that the

incidence of cholera in Haiti has decreased since its outbreak. However, there are still many

obstacles to overcome in order to help the Haitian people break this distressing barrier towards

wellness. The obstacles include lack of hygiene, water sanitation education, patient

transportation, and treatment (NCBI, 2011). A team of organizations including members of the

MSPP, Interior, Direction Nationale de lEau Potable et de LAssainissement (DINEPA, Haiti's

National Directorate for Water Supply and Sanitation), United Nations Childrens Emergency

Fund (UNICEF), World Health Organization (WHO), and CDC have formulated a direct plan to

help lessen the epidemic (UN, 2015). In the last two decades, comprehensive and community-

based case have decreased Haitis infant mortality rate by two-thirds and cut the acquired

immunodeficiency syndrome (AIDS) epidemic in half (NCBI, 2011). This model has clearly

been effective across developing countries and will continue to be applied for the cholera

outbreak. Their plan to eliminate cholera in Haiti may be summed up in four key operations

(UN, 2015). The first operation is to create an epidemiological surveillance in order to track the

disease's progression. Next is to provide a health promotion component, which will help prevent
CHOLERA PREVENTION IN HAITI 5

future outbreak by educating the people of Haiti. Thirdly, they will provide medical treatment to

all Haitians, which may be seen in the form of vaccination. Finally, they plan to implement a

water, hygiene, and sanitation campaign that will educate and deliver clean water to all people in

affected areas. With these efforts their hope is that in the near future the epidemic of cholera will

be eradicated; however, this may only be accomplished through a combined efforts of national

awareness (UN, 2015).

Literature Review

In the composition of the following articles, data and evidence were collected to see what

has been done in response to the prevention of cholera in Haiti. Through these various articles,

information was obtained regarding preventive measures and educational methods used to

combat the epidemic of cholera. Multiple preventive measures have been implemented in Haiti,

such as water purification tablets, proper stool disposal, and a potential for a cholera vaccine.

Many educational programs and materials have been implemented in Haiti to prevent the spread

and learn how to treat cholera if signs and symptoms do occur. With this background

knowledge, the further implementation of preventive techniques through educational means can

be better formulated to reach the greatest number in Haiti.

Upon further research, a study encompassed the efforts of the CDC and the Haitian

Ministry of Public Health and Population to develop educational materials to prevent and treat

the cholera outbreak in Haiti (Rajasingham et al., 2011). The purpose of this study was to

provide a comprehensive training program that could easily and effectively teach community

health workers in Haiti on how to prevent and treat the cholera epidemic from progressing any

further than it had already. The method used was teaching 24 community health workers through
CHOLERA PREVENTION IN HAITI 6

the means of interactive training modules, educational training manuals, and low literacy posters.

After the conclusion of the training, they instructed the 24 original participants to go educate

others in Haiti on how to prevent and treat cholera. The results were obtained by a completion of

a self-reported survey questionnaire by 14 of the original 24 participants, which concluded that

the 14 participants educated an additional 2,314 individuals throughout Haiti on how to fight the

cholera epidemic. The recommendations further needed in this study were more complete

evaluation methods on educational materials used and that only 14 of the original 24 participants

completed the follow-up questionnaire. Additionally, there could have been some bias or

deceiving data in the questionnaires because they were self-reported (Rajasingham et al., 2011).

Additional research conducted by Tuite et al. (2011) expanded on the efforts of scientists

and researchers to formulate a strategy to understand and prevent the spread of cholera in Haiti in

2010. Their purpose was to predict the spread of the epidemic by using a regional mathematical

model in order to create a disease-control plan that could prevent further spread of the disease.

Their method involved a formulated mathematical model derived from regional data obtained

from the HealthMap system and The Centers for Disease Control and Preventions summary

report. The reports allowed them to predict possible person-to-person or waterborne spread of

cholera. Their results revealed 2.06 to 2.78 secondary cases per primary case that went without

intervention in the population based on region. However, investigation showed that the efforts of

public health interventions and the usage of vaccines greatly reduced the cholera epidemic in

Haiti. The gap of their study was that researchers used a limited amount of data to build the

model. However, they were fully aware that the projections of the spread of cholera in Haiti

could change at any time during the intervention process (Tuite et al., 2011).
CHOLERA PREVENTION IN HAITI 7

Another study conducted by Aibana et al. (2013) evaluated the impact of an oral cholera

vaccination campaign on knowledge and health practices in rural Haiti. The method applied was

the administration of baseline surveys on knowledge and practice relevant to cholera and

waterborne disease to every tenth household during a census in rural Haiti in February 2012.

The survey gathered information on sociodemographic characteristics, such as knowledge about

means of cholera transmission, preventive measures, and water treatment modalities like

practices related to frequency of water treatment and handwashing, type of toilet access, and

source of drinking water. The results demonstrated a significant increase in knowledge of

cholera transmission and prevention mechanisms as well as improvement in practices of water

treatment and frequent handwashing. This revealed that post-vaccination campaign, there was a

significant increase in baseline knowledge and improvement in practice essential to cholera

control. Recommendations for future research is that currently there is no available data on the

impact of a cholera vaccine program on knowledge and behaviors related to the epidemic of

cholera (Aibana et al., 2013).

The final study looked at the effectiveness of hygiene promotions in post-earthquake

Haiti (Contzen & Mosler, 2013). The method used was a cross-sectional data collection by

means of structured interviews in camps and various neighborhoods. The sample size consisted

of 811 individuals in Haiti. Analysis revealed six promotional channels with positive

associations with hand washing behavior, such as hygiene radio spots, radio programs with

experts answering listeners questions, material distributions with instructions for use,

information from friends or neighbors, hygiene theatres, and community clubs. However, five of

the promotional channels were negatively related with hand washing. Respondents who

experienced a focus group, stickers, posters and paintings, hygiene songs, special hygiene days
CHOLERA PREVENTION IN HAITI 8

and home visits tended to wash their hands less often. This study demonstrated that hygiene

promotions in emergency relief should not be designed and implemented according to standard

approaches based solely on the personal experience of relief workers. Instead, theories of

behavior change should be taken into account and promotions should be designed based on

evidence in order to specifically target those behavioral factors critical in eliciting the behavior in

question, like prevention for those in Haiti (Contzen & Mosler, 2013).

Through reading various research studies done on cholera in post-earthquake Haiti,

methods of prevention can be applicable to the epidemic. With effective education and

educational materials, the people in Haiti can benefit from a cholera free population. With

previous research on educational materials and the methods of teaching used in Haiti, new more

effective ways can be implemented to further educate more people in the prevention of cholera.

Formulating a new educational program that incorporates the leaders within each village and

allowing for teaching to occur within the homes of the population could decrease the amount of

cases of cholera yearly. Only through doing this, is it ensured that effective hygiene promotions

are implemented for the most vulnerable people, especially those affected by a humanitarian

disaster, like the people in Haiti suffering from cholera.

Logic Model

A logic model is a framework tool used to define how a program will work (National

Network of Libraries of Medicine, nd). These guidelines within the logic model allow for the

planning, implementation, and evaluation of a specific program. Therefore, the logic model of

this proposal is clearly represented in Appendix A. The main purpose of this initiative is to

decrease the incidence of cholera in Haiti post the 2010 earthquake by focusing on preventative
CHOLERA PREVENTION IN HAITI 9

measures and educating the Haitian people on sanitary procedures. The anticipated approach

involves the establishment of a diverse group that incorporates experts from various disciplines

to conduct a variety of tasks including a training of trainees. Trained trainees would then take

charge of identifying community and religious leaders to join in the efforts by helping educate

their villages and disseminate the message about cholera prevention. Additional ambassadors

and volunteers would also be trained in cholera prevention techniques. Trainers will then

conduct rally posts and at-home visits to educate and train families in cholera prevention.

Education will be provided on topics such as hand hygiene, safe food preparation and storage,

appropriate stool disposal, and water purification techniques. Appropriate tool kits containing

water purification tablets and informational pamphlets will be distributed to each household to

support the teaching objectives.

It is projected that 80% of home visits will be conducted by the fourth month. By the

fifth month, an estimated 50% of households will be surveyed for adherence to adequate water

purification techniques and stool proper stool disposal. Based on the interventions at stake, the

expectation is that by the fifth month, households will have increased knowledge on potential

sources of cholera, modes of transmission, and water treatment techniques for cholera

prevention. By the sixth month, surveillance will be conducted at random to monitor community

members adherence to cholera prevention measures by performing water testing and assessing

appropriate stool disposal. It is estimated that by the sixth month, 85% percent of households

will employ water purification techniques using purification tablets and 50% of households will

engage in proper stool disposal. Additionally, it is expected that community and religious

leaders will continue to disseminate and reinforce the training throughout villages to reach a goal

of 50% intervention of households being cholera free at the end of the 12th month. It has been
CHOLERA PREVENTION IN HAITI 10

projected that by the end of 12 months, there will be a decrease in morbidity and mortality, an

increase in the quality of life, and a decrease of infection rates to account for 50% decrease in the

incidence of cholera in Haiti. It is highly suspected that these interventions will deem effective

because community and religious leaders, which are highly regarded in their villages, will be

involved throughout the process, thus fostering a less tense and more trusting environment in the

interaction with Haitians. In addition, teaching will be reinforced as there will be visitations at

three month intervals to track progress and lifestyle changes that may have been implemented at

each household. Furthermore, tool kits with water purification tablets and pamphlets will serve

to further reinforce the teaching and procedures after the trainers have gone.

Program Goals and Objectives

The goal of the program is to decrease the incidence of cholera in Haiti post 2010

earthquake by 50% in the first 12 months. The programs first objective is to increase the number

of households with knowledge of cholera prevention techniques among the Haitian people by

25% in the first 6 months. This will be achieved by identifying community leaders, developing a

curriculum, training leaders, holding a training of the trainers, evaluating the training being done

in the community, monitoring the impact, and adjusting interventions or plans to help better

implement the education to increase proper cholera prevention techniques. The second objective

of the program is to increase the number of households engaging and demonstrating in safe

sanitation practices among the Haitian people by 25% in the second 6 months. This will be

accomplished by identifying community leaders, developing sanitation guidelines and policies,

training leaders, holding a training of the trainers, evaluating training being implemented in the

community, monitoring the impact, and adjusting possible interventions or plans to make the

behavior change of cholera prevention more effective.

CHOLERA PREVENTION IN HAITI 11

Technical Approach

A technical approach is a detailed accounting of how a group proposes going about a

specific project that is being presented. The work plan is outlined in Appendix B. The first

objective of this project is to increase the number of households with knowledge of cholera

prevention techniques among the Haitian people by 25% in the first six months. Staff, expert

consultants, partners, and stakeholders will be gathered first. The Cholera Prevention Team will

go into the community to find a group of respected elders and leaders from each of the ten

provinces. Educated health professionals, volunteers, and social workers will be recruited from

the United States from the CDC and the Red Cross. The stakeholders and partners will be WHO

and the UN. The knowledge and assets of the staff, experts, partners, and stakeholders will be

shared. Everyone will help develop a teaching plan on cholera prevention techniques. Next,

staff will be trained on how to implement the teach plan. The teach plan will include the signs

and symptoms of cholera. The teach plan will also include cholera prevention techniques. These

cholera prevention activities will include how to treat water using water purification tablets and

how to correctly demonstrate how to safely dispose of stools. The staff will also be trained on

how to communicate to and educate the community leaders. Then, the staff will also be trained

on have to hold the educational rallies and home visits. The staff will be evaluated and

monitored with post tests and physical checks at the teaching sites.

The second objective is to increase the number of households engaging and

demonstrating safe sanitation practices among the Haitian people by 25% in the second six

months. The primary task in helping the community identify the correct methods of purifying

water using water purification tablets would be to recruit trainers who can be trained and
CHOLERA PREVENTION IN HAITI 12

certified in this topic. The trainers will be the same as mentioned previously. The following step

that would have be undertaken is to gather up a group of ambassadors to be trained by certified

trainers in water decontamination procedures. These ambassadors can then go from house to

house reaching out to the members of the community and community leaders to provide them

with tool kits containing decontamination tablets and simple informational pamphlets that

include both illustrations and writing to deliver information and instructions. Additionally,

ambassadors can demonstrate the correct use of these tablets and educate people on the

mechanisms of action by which these tablets work. At the end of the teaching ambassadors can

test the residents on the education provided by having them demonstrate and by asking them

questions on key points from the education provided.

Monitoring and Evaluation Plan

Monitoring and evaluation methods will be conducted throughout the duration of the

program to assess the status of the community prior to the implementation of interventions and

post their implementation. Monitoring and evaluation methods will incorporate pre and post

testing, surveys, and on-site spot checks. Qualified personnel will analyze data collected from

such methods. Following analysis, findings will be disseminated to other members of the board

as well as community members to implement new measures that can fill any remaining gaps. In

order to ensure monitoring and evaluation deem effective, at timeline will be developed to track

and evaluate findings at the appropriate time intervals. At three months, community leaders will

be evaluated prior to their initial training via a pre-test. After completion of their training,

community leaders will be given a pot-test to evaluate their knowledge. The findings from both

pre and post testing will be utilized to assess the level of knowledge they have gained from the

training. During month three, a survey will also be conducted to analyze the status of the
CHOLERA PREVENTION IN HAITI 13

program and identify areas that need further development. A second community survey will be

conducted during month five to evaluate progress of the program, current status, and identify

areas that need additional work. By five months 50% of participants would have been surveyed

for prevention techniques. During this same time, participants will identify two cholera

prevention methods. At the sixth month, spot checks of the community will be conducted to

ensure that community members are adhering to sanitary practices disseminated by their

community leaders. A self-reported survey will also be distributed to assess understanding and

identify current practices and feelings about cholera prevention techniques including water

purification and proper stool disposal. By this same month period, 85% of households will

perform proper water purification techniques and 50% will demonstrate proper waste disposal.

After collection of the evaluations, data will be analyzed. Between six and nine months, the

findings will be disseminated. By the end of the 12 months, the program will be evaluated via a

compilation of data collected throughout the entirety of the 12-month program. During this time,

the goal of decreasing cholera incidences in Haiti will be determined either effective or

ineffective. If program seems ineffective, the program leaders will re-evaluate teaching

curriculum and assess the desire of the community leaders to change previous sanitation

techniques.

Budget

Due to this magnitude of the devastation and the large population of the island, an ample

source of resources will be needed to contribute in the efforts to reduce the number of casualties

and prevent the number of new cases. The budget will outline the operational costs, salaries and

personnel costs, travel costs, rental for location, technology, and monitoring and evaluation cost.

A visual representation of the budget may be seen in Appendix C. An estimated 80 employees

CHOLERA PREVENTION IN HAITI 14

will be needed to comprise the board. Public health departments, the WHO, and the CDC will

recruit board members. The board will be made up of expert trainers, health care professionals,

volunteers, and community leaders. Approximately 150 local volunteers will be recruited to help

in clerical and educational tasks and to assist with translation between English and French.

In order to conduct our program and deliver the interventions previously stated all

throughout Haiti, an estimated $1,070,750 will be required. A total of $215,000 will be allocated

for operational costs. This will include printed materials, water purification tablets, and water

treatment supplies. An additional $825,000 will cover salaries and personnel costs. This costs

will include the trainer fee, teacher fee, and health professional fee. It is necessary to distribute

an annual salary for all workers involved in the project. Travel costs are estimated to reach

$22,050 including the costs of airline fees and lodging. Rental for locations will be $2,000 and

will include classroom and rally spaces. Additionally, $1,650 will be allocated to technology

including all the computers, radios, and telephones. Monitoring and evaluation costs will total

$5,050. The magnitude and severity of the epidemic calls for immediate action in addressing the

situation, which requires an ample source of resources to combat the cholera epidemic in Haiti.

Conclusion

Nearly six years following the devastating earthquake in Haiti, that subsequently caused

one of the worlds largest cholera outbreaks, has in combination taken the lives of over 200,000

Haitians to date. This overwhelming half-decade has ultimately shaped the next generations of

Haitians in an exceptionally negative way; however, there is hope for the downtrodden people of

Haiti. This hope may be found in this organizations well thought out action plan, which may be

a chance for normalcy for the next generations of Haitian to live free from the shattering effects
CHOLERA PREVENTION IN HAITI 15

of cholera. In order for this plan to meet its high expectations, this organization needs financial

support, which may be certainly obtained through this prestigious grant. Helping this

organization means improving the outcome for the next generations of Haitian people.

References

Aibana, O., Franke, M., Teng, J., Hilaire, J., Raymond, M., & Ivers, L. C. (2013). Cholera

Vaccination Campaign Contributes to Improved Knowledge Regarding Cholera and

Improved Practice Relevant to Waterborne Disease in Rural Haiti. Plos Neglected

Tropical Diseases, 7(11), 1-8. doi:10.1371/journal.pntd.0002576

Centers for Disease Control and Prevention. (2011). Cholera in Haiti: one year later. Retrieved

from: http://www.cdc.gov/haiticholera/haiti_cholera.htm

Center for Disease Control and Prevention. (2014). Cholera- vibrio cholera infection. Retrieved

from http://www.cdc.gov/cholera/general/index.html

Contzen, N., & Mosler, H. (2013). Impact of different promotional channels on handwashing

behaviour in an emergency context: Haiti post-earthquake public health promotions and

cholera response. Journal Of Public Health (09431853), 21(6), 559-573 15p.

doi:10.1007/s10389-013-0577-4
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National Center for Biotechnology Information. (2011). Meeting cholera's challenge to Haiti

and the world: a joint statement on cholera prevention and care. Retrieved from:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3104956/

National Network of Libraries of Medicine. (nd). What is the logic model? Retrieved from:

https://nnlm.gov/outreach/community/logicmodel.html

Rajasingham, A., Bowen, A., O'reilly, C., Sholtes, K., Schilling, K., Hough, C., . . . Person, B.

(2011). Cholera Prevention Training Materials for Community Health Workers, Haiti,

20102011. Emerg. Infect. Dis. Emerging Infectious Diseases, 17(11), 2162-2165.

doi:10.3201/eid1711.110806

Tuite, A. R., Tien, J., Eisenberg, M., Earn, D. J., Ma, J., & Fisman, D. N. (2011). Cholera

Epidemic in Haiti, 2010: Using a Transmission Model to Explain Spatial Spread of

Disease and Identify Optimal Control Interventions. Annals of Internal Medicine Ann

Intern Med, 154(9), 593-601. doi:10.7326/0003-4819-154-9-201105030-00334

United Nations. (2014). UN fact sheet: combatting cholera in Haiti. Retrieved from:

http://www.un.org/News/dh/infocus/haiti/Cholera_UN_Factsheet_24 Feb_2014.pdf

United Nations. (2015). Haiti cholera response. Retrieved from

http://www.un.org/News/dh/infocus/haiti/Cholera_UN_Factsheet_Jan_Mar_2015.pdf