Investigation of Canine-Mediated Human Rabies Death, Haiti, 2015.

In Haiti, an investigation occurred after the death of a 4-year-old girl with suspected rabies. With tips provided by community members, the investigation led to the identification of 2 probable rabies-related deaths and 16 persons bitten by rabid dogs, 75% of which chose postexposure prophylaxis. Community engagement can bolster rabies control.

Dog-Mediated Human Rabies Death, Haiti, 2016.

Haiti has experienced numerous barriers to rabies control over the past decades and is one of the remaining Western Hemisphere countries to report dog-mediated human rabies deaths. We describe the circumstances surrounding a reported human rabies death in 2016 as well as barriers to treatment and surveillance reporting.

Effectiveness of monovalent rotavirus vaccine against hospitalizations due to all rotavirus and equine-like G3P[8] genotypes in Haiti 2014-2019.

BACKGROUND: Rotavirus vaccines are effective in preventing severe rotavirus. Haiti introduced 2-dose monovalent (G1P[8]) rotavirus vaccine recommended for infants at 6 and 10 weeks of age in 2014. We calculated the effectiveness of rotavirus vaccine against hospitalization for acute gastroenteritis in Haiti. METHODS: We enrolled children 6-59 months old admitted May 2014-September 2019 for acute watery diarrhea at any sentinel surveillance hospital. Stool was tested for rotavirus using enzyme immunoassay (EIA) and genotyped with multiplex one-step RT-PCR assay and Sanger sequencing for stratification by genotype. We used a case-negative design where cases were children positive for rotavirus and controls were negative for rotavirus. Only children eligible for vaccination were included and a child was considered vaccinated if vaccine was given ≥ 14 days before enrollment. We used unconditional logistic regression to calculate odds ratios and calculated 2-dose and 1-dose vaccine effectiveness (VE) as (1 - odds ratio) * 100. RESULTS: We included 129 (19%) positive cases and 543 (81%) negative controls. Among cases, 77 (60%) were positive for equine-like G3P[8]. Two doses of rotavirus vaccine were 66% (95% CI: 44, 80) effective against hospitalizations due to any strain of rotavirus and 64% (95% CI: 33, 81) effective against hospitalizations due to the equine-like G3P[8] genotype. CONCLUSIONS: These findings are comparable to other countries in the Americas region. To the best of our knowledge, this is the first VE estimate both against the equine-like G3P[8] genotype and from a Caribbean country. Overall, these results support rotavirus vaccine use and demonstrate the importance of complete vaccination.

Costs and effectiveness of alternative dog vaccination strategies to improve dog population coverage in rural and urban settings during a rabies outbreak.

Dog-rabies elimination programs have typically relied upon parenteral vaccination at central-point locations; however, dog-ownership practices, accessibility to hard-to-reach sub-populations, resource limitations, and logistics may impact a country's ability to reach the 70% coverage goal recommended by the World Organization for Animal Health (OIE) and World Health Organization (WHO). Here we report the cost-effectiveness of different dog-vaccination strategies during a dog-rabies outbreak in urban and peri-urban sections of Croix-des-Bouquets commune of the West Department, Haiti, in 2016. Three strategies, mobile static point (MSP), mobile static point with capture-vaccinate-release (MSP + CVR), and door-to-door vaccination with oral vaccination (DDV + ORV), were applied at five randomly assigned sites and assessed for free-roaming dog vaccination coverage and total population coverage. A total of 7065 dogs were vaccinated against rabies during the vaccination campaign. Overall, free-roaming dog vaccination coverage was estimated at 52% (47%-56%) for MSP, 53% (47%-60%) for DDV + ORV, and 65% (61%-69%) for MSP + CVR (differences with MSP and DDV + ORV significant at p < 0.01). Total dog vaccination coverage was 33% (95% CI: 26%-43%) for MSP, 49% (95% CI: 40%-61%) for MSP + CVR and 78% (77%-80%) for DDV + ORV (differences significant at p < 0.001). Overall, the least expensive campaign was MSP, with an estimated cost of about $2039 per day ($4078 total), and the most expensive was DDV + ORV with a cost of $3246 per day ($6492 total). Despite the relative high cost of an ORV bait, combining DDV and ORV was the most cost-effective strategy in our study ($1.97 per vaccinated dog), largely due to increased efficiency of the vaccinators to target less accessible dogs. Costs per vaccinated dog were $2.20 for MSP and $2.28 for MSP + CVR. We hope the results from this study will support the design and implementation of effective dog vaccination campaigns to achieve the goal of eliminating dog-mediated human rabies deaths by 2030.

Quantifying the risk of rabies in biting dogs in Haiti.

Rabies is a fatal viral disease typically transmitted through the bite of rabid animal. Domestic dogs cause over 99% of human rabies deaths. Over half of the world's population lives in a country where the canine rabies virus variant is endemic and dog bites are common. An estimated 29 million people worldwide receive post-bite vaccination after being exposed to animals suspected of rabies. Accurate and timely risk assessment of rabies in biting dogs is critical to ensure that rabies PEP is administered to all persons with a suspected rabies exposure, while avoiding PEP administration in situations where rabies can be definitively ruled out. In this study, a logistic regression model was developed to quantify the risk of rabies in biting dogs, using data from Haiti's animal rabies surveillance program. Significant risk factors identified in the model were used to quantify the probability of rabies in biting dogs. The risk of rabies in a biting dog as assessed through Haiti's rabies surveillance program was highly elevated when the dog displayed hypersalivation (OR = 34.6, 95% CI 11.3-106.5) or paralysis (OR = 19.0, 95% CI 4.8-74.8) and when the dog was dead at the time of the assessment (OR = 20.7, 95% CI 6.7-63.7). Lack of prior rabies vaccination, biting 2 or more people, and if the dog was a puppy also increased the probability that a biting dog would have rabies. The model showed high sensitivity (100%) and specificity (97%) when examined using validation data. This model enables us to project the risk of rabies in biting dogs in Haiti shortly after the bite event and make provisional PEP recommendations prior to laboratory testing or dog quarantine results. Application of this model may improve adherence to PEP for bite victims who can be educated on the quantitative risk of the exposure event. This model can also be used to reduce unnecessary PEP costs when the risk of rabies is determined as sufficiently low and the animal is available for observation.

Oral cholera vaccination coverage after the first global stockpile deployment in Haiti, 2014.

INTRODUCTION: In 2014, an oral cholera vaccine (OCV) campaign targeting 185,314 persons aged ≥1 years was conducted in 3 departments via fixed post and door-to-door strategies. This was the first use of the global OCV stockpile in Haiti. METHODS: We conducted a multi-stage cluster survey to assess departmental OCV coverage. Target population estimates were projected from the 2003 Haiti population census with adjustments for population growth and estimated proportion of pregnant women. In the three departments, we sampled 30/106 enumeration areas (EAs) in Artibonite, 30/244 EAs in Centre, and 20/29 EAs in Ouest; 20 households were systematically sampled in each EA. Household and individual interviews using a standard questionnaire were conducted in each selected household; data on OCV receipt were obtained from vaccination card or verbal report. We calculated OCV campaign coverage estimates and 95% confidence intervals (CIs) accounting for survey design. RESULTS: Overall two-dose OCV coverage was 70% (95% CI: 60, 79), 63% (95% CI: 55, 71), and 44% (95% CI: 35, 53) in Artibonite, Centre, and Ouest, respectively. Two-dose coverage was higher in the 1-4 years age group than among those ≥ 15 years in Artibonite (difference: 11%; 95% CI: 5%, 17%) and Ouest (difference: 12%; 95% CI: 3, 20). A higher percentage of children aged 5-14 years received both recommended doses than did those ≥ 15 years (Artibonite: 14% (95% CI: 8%, 19%) difference; Centre: 11% difference (95% CI: 5%, 17%); Ouest: 10% difference (95% CI: 2%, 17%). The most common reason for not receiving any OCV dose was being absent during the campaign or not having heard about vaccination activities. CONCLUSIONS: While coverage estimates in Artibonite and Centre were comparable with other OCV campaigns in Haiti and elsewhere, inadequate social mobilization and outdated population estimates might have contributed to lower coverage in Ouest.

Rabies vaccine initiation and adherence among animal-bite patients in Haiti, 2015.

BACKGROUND: Approximately 59,000 people die from rabies worldwide annually. Haiti is one of the last remaining countries in the Western Hemisphere with endemic canine rabies. Canine-mediated rabies deaths are preventable with post-exposure prophylaxis (PEP): wound treatment, immunoglobulin, and vaccination. In countries where PEP is available, variability in healthcare seeking behaviors and lack of adherence to recommended treatment guidelines could also contribute to these deaths. Yet, few studies have addressed these issues. METHODS: We examined animal-bite reporting and assessed adherence to treatment guidelines at nine healthcare facilities in Haiti. We analyzed individual-level, de-identified patient data (demographic characteristics, geographic location, healthcare facility type, vaccine administration, and bite injury information) using descriptive analyses and logistic regression to examine factors associated with receiving PEP. FINDINGS: During the 6 month study period, we found 2.5 times more animal-bite case-patients than reported by the national surveillance system (690 versus 274). Of the 690 animal-bite patients identified, 498 (72%) sought care at six PEP providing facilities. Of the case-patients that sought care, 110 (22%) received at least one rabies vaccine. Of the 110 patients, 60 (55%) received all five doses. Delays were observed for three events: when patients presented to a facility after an animal-bite (3.0 days, range: 0-34 days), when patients received their fourth dose (16.1 days, range: 13-52 days), and when patients received their fifth dose (29 days, range: 26-52). When comparing vaccination status and patient characteristics, we found a significant association for bite location (p < .001), severity rank score (p < .001), geographic location (p < .001), and healthcare facility type (p = .002) with vaccination. CONCLUSION: High levels of underreporting identified here are of concern since vaccine distribution may, in part, be based on the number of animal-bite cases reported. Given that the Haitian government provides PEP to the population for free and we found animal-bite victims are seeking care in a timely manner─ reducing rabies deaths is an achievable goal.

Impact of community-delivered SMS alerts on dog-owner participation during a mass rabies vaccination campaign, Haiti 2017.

Haiti has historically vaccinated between 100,000 and 300,000 dogs annually against rabies, however national authorities have not been able to reach and maintain the 70% coverage required to eliminate the canine rabies virus variant. Haiti conducts massive dog vaccination campaigns on an annual basis and utilizes both central point and door-to-door methods. These methods require that dog owners are aware of the dates and locations of the campaign. To improve this awareness among dog owners, 600,000 text messages were sent to phones in two Haitian communes (Gonaives and Saint-Marc) to remind dog owners to attend the campaign. Text messages were delivered on the second day and at the mid-point of the campaign. A post-campaign household survey was conducted to assess dog owner's perception of the text messages and the impact on their participation in the vaccination campaign. Overall, 147 of 160 (91.9%) text-receiving dog owners indicated the text was helpful, and 162 of 187 (86.6%) responding dog owners said they would like to receive text reminders during future rabies vaccination campaigns. In areas hosting one-day central point campaigns, dog owners who received the text were 2.0 (95% CI 1.1, 3.6) times more likely to have participated in the campaign (73.1% attendance among those who received the text vs 36.4% among those who did not). In areas incorporating door-to-door vaccination over multiple days there was no significant difference in participation between dog owners who did and did not receive a text. Text message reminders were well-received and significantly improved campaign attendance, indicating that short message service (SMS) alerts may be a successful strategy in low resource areas with large free roaming dog populations.

Cost-Effectiveness Evaluation of a Novel Integrated Bite Case Management Program for the Control of Human Rabies, Haiti 2014-2015.

AbstractHaiti has the highest burden of rabies in the Western hemisphere, with 130 estimated annual deaths. We present the cost-effectiveness evaluation of an integrated bite case management program combining community bite investigations and passive animal rabies surveillance, using a governmental perspective. The Haiti Animal Rabies Surveillance Program (HARSP) was first implemented in three communes of the West Department, Haiti. Our evaluation encompassed all individuals exposed to rabies in the study area (N = 2,289) in 2014-2015. Costs (2014 U.S. dollars) included diagnostic laboratory development, training of surveillance officers, operational costs, and postexposure prophylaxis (PEP). We used estimated deaths averted and years of life gained (YLG) from prevented rabies as health outcomes. HARSP had higher overall costs (range: $39,568-$80,290) than the no-bite-case-management (NBCM) scenario ($15,988-$26,976), partly from an increased number of bite victims receiving PEP. But HARSP had better health outcomes than NBCM, with estimated 11 additional annual averted deaths in 2014 and nine in 2015, and 654 additional YLG in 2014 and 535 in 2015. Overall, HARSP was more cost-effective (US$ per death averted) than NBCM (2014, HARSP: $2,891-$4,735, NBCM: $5,980-$8,453; 2015, HARSP: $3,534-$7,171, NBCM: $7,298-$12,284). HARSP offers an effective human rabies prevention solution for countries transitioning from reactive to preventive strategies, such as comprehensive dog vaccination.

Assessment of Drinking Water Sold from Private Sector Kiosks in Post-Earthquake Port-au-Prince, Haiti.

Consumption of drinking water from private vendors has increased considerably in Port-au-Prince, Haiti, in recent decades. A major type of vendor is private kiosks, advertising reverse osmosis-treated water for sale by volume. To describe the scale and geographical distribution of private kiosks in metropolitan Port-au-Prince, an inventory of private kiosks was conducted from July to August 2013. Coordinates of kiosks were recorded with global positioning system units and a brief questionnaire was administered with the operator to document key kiosk characteristics. To assess the quality of water originating from private kiosks, water quality analyses were also conducted on a sample of those inventoried as well as from the major provider company sites. The parameters tested were Escherichia coli, free chlorine residual, pH, turbidity, and total dissolved solids. More than 1,300 kiosks were inventoried, the majority of which were franchises of four large provider companies. Approximately half of kiosks reported opening within 12 months of the date of the inventory. The kiosk treatment chain and sales price was consistent among a majority of the kiosks. Of the 757 kiosks sampled for water quality, 90.9% of samples met World Health Organization (WHO) microbiological guideline at the point of sale for nondetectable E. coli in a 100-mL sample. Of the eight provider company sites tested, all samples met the WHO microbiological guideline. Because of the increasing role of the private sector in drinking water provision in Port-au-Prince and elsewhere in Haiti, this assessment was an important first step for government regulation of this sector.