Development of a Cholera Vaccination Policy on the Island of Hispaniola, 2010-2013

Deployment of oral cholera vaccine (OCV) on the Island of Hispaniola has been considered since the emergence of the disease in October of 2010. At that time, emergency response focused on the time-tested measures of treatment to prevent deaths and sanitation to diminish transmission. Use of the limited amount of vaccine available in the global market was recommended for demonstration activities, which were carried out in 2012. As transmission continues, vaccination was recommended in Haiti as one component of a comprehensive initiative supported by an international coalition to eliminate cholera on the Island of Hispaniola. Leveraging its delivery to strengthen other cholera prevention measures and immunization services, a phased OCV introduction is pursued in accordance with global vaccine supply. Not mutually exclusive or sequential deployment options include routine immunization for children over the age of 1 year and campaigns in vulnerable metropolitan areas or rural areas with limited access to health services. BACKGROUND Cholera emerged on the Island of Hispaniola in October of 2010. During the first peak of the outbreak, which lasted from October of 2010 to March of 2011, 526,351 and 22,344 suspect and confirmed cases were reported in Haiti and the Domini- can Republic, respectively. 1 Cholera transmission has con- tinued thereafter, although at much decreased rates. Cholera surveillance data for the first 2 years of the Haitian outbreak have been reviewed. 2 Since October of 2010, the Ministries of Health of Haiti and the Dominican Republic, the Pan American Health Organi- zation (PAHO; the regional office for the Americas of the World Health Organization (WHO)), and partners have repeatedly considered the deployment of oral cholera vaccine (OCV) along with other prevention and control measures. At PAHO, the deliberations of the Technical Advisory Group on Vaccine-Preventable Diseases (TAG)—a group of public health experts that has advised the organization on national and regional immunization policies since 1983—provided the formal platform for the development of a regional policy on cholera vaccination. Before the emergence of cholera in Haiti, there had been no need for TAG to review the use of cholera vaccines. At the global level, the WHO Strategic Advisory Group of Experts on Vaccines and Immunization discussed the evidence on cholera vaccination and made recommendations in October of 2009. 3 In the process of developing a regional policy, four elements have played a central role: the characteristics and availability of OCV offered globally, the progression of the cholera outbreak, the progressive recovery of the institutional capacities of the Haitian Government after the 2010 earthquake, and the crea- tion of a regional partnership for the elimination of cholera transmission on the Island of Hispaniola. We review here how these elements evolved over time and their relation to the policymaking for the Island of Hispaniola. OCV characteristics and availability. Two OCVs, trade names Dukoral (Crucell, Stockholm, Sweden) and Shanchol (Shanta Biotechnics, Hyderabad, India), are marketed glob- ally. Both are whole-cell, inactivated vaccines that require at least two doses in a primary immunization series. However, they differ in indication, formulation, and presentation (Table 1). 4 Compared with Dukoral, Shanchol offers opera- tional advantages: it does not require administration with a buffer solution, it requires significantly less cold chain vol- ume, it can be administered from 1 year of age (versus 2 years of age), and its price is one-third per dose the price of Dukoral. The field implications of these characteristics were documented in several mass vaccination campaigns carried out after emergencies and/or cholera outbreaks. 4