Healthcare professionals' experience of teenage pregnancy and motherhood in Haiti.

OBJECTIVES: The aim of this study was to explore healthcare professionals' experience of pregnant and motherhood in adolescence in Haiti. METHODS: The methodology for collecting and analyzing qualitative data was based on John Dewey's social survey. The study was conducted in nine health institutions in the North and North-East departments of Haiti from October 2020 to January 2021. Data were collected through individual semi-structured interviews with 15 healthcare professionals. All interviews were audio-recorded. The recordings were listened to carefully and transcribed in verbatim form. After checking and validation, the verbatims in Word format were exported to QDA Miner software version 6.0.5 for coding. The data were analyzed using Paillé and Mucchielli thematic analyses. RESULTS: Health professionals such as gynecologists, nurses, midwives, nursing assistants, matrons and health workers took part in the study. These study participants indicate that teenage pregnancy and motherhood are social and public health problems whose negative consequences affect teenage girls, children, healthcare professionals, the healthcare system, and Haitian society in general. The services offered to adolescent girls are medical, educational, psychological, economic, and social in nature. When caring for pregnant adolescents during the transition to motherhood, healthcare professionals face many challenges that are linked to the socio-economic status and physiological reality of adolescents, as well as the healthcare system. CONCLUSIONS: Programs involving home care visits should also be set up to offer ongoing support to pregnant or parenting teenagers. The distribution of food aid or materials such as clothing, hygiene products and baby kits should also be considered.

Spectrum of prevalent cardiovascular diseases in urban Port-au-Prince, Haiti: a population-based cross-sectional study.

Background: Eighty percent of global cardiovascular disease (CVD) is projected to occur in low- and middle -income countries (LMICs), yet local epidemiological data are scarce. We provide the first population-based, adjudicated CVD prevalence estimates in Port-au-Prince, Haiti to describe the spectrum of heart disease and investigate associated risk factors. Methods: Demographic, medical history, clinical, imaging and laboratory data were collected among adults recruited using multistage random sampling from 2019 to 2021. Prevalent CVD (heart failure, stroke, ischemic disease) were adjudicated using epidemiological criteria similar to international cohorts. Multivariable Poisson regressions assessed relationships between risk factors and prevalent CVD. Findings: Among 3003 participants, median age was 40 years, 58.1% were female, 70.2% reported income <1 USD/day, and all identified as Black Haitian. CVD age-adjusted prevalence was 14.7% (95% CI 13.3%, 16.5%), including heart failure (11.9% [95% CI 10.5%, 13.5%]), stroke (2.4% [95% CI 1.9%, 3.3%]), angina (2.1% [95% CI 1.6%, 2.9%]), myocardial infarction (1.0% [95% CI 0.6%, 1.8%]), and transient ischemic attack (0.4% [95% CI 0.2%, 1.0%]). Among participants with heart failure, median age was 57 years and 68.5% of cases were among women. The most common subtype was heart failure with preserved ejection fraction (80.4%). Heart failure was associated with hypertension, obesity, chronic kidney disease, depression, and stress. Interpretation: Early-onset heart failure prevalence is alarmingly high in urban Haiti and challenge modelling assumptions that ischemic heart disease and stroke dominate CVDs in LMICs. These data underscore the importance of local population-based epidemiologic data within LMICs to expedite the selection and implementation of evidence-based cardiovascular health policies targeting each country's spectrum of heart disease. Funding: This study was funded by NIH grants R01HL143788, D43TW011972, and K24HL163393, clinicaltrials.govNCT03892265.

AEDES AEGYPTI KNOCKDOWN RESISTANCE MUTATIONS AND DENGUE VIRUS INFECTION IN HAITI.

Haiti is home to approximately 11 million people and has a high incidence of vector-borne disease, including more than 70,000 cases of dengue per year. Vector control is difficult in Haiti and adulticide spray of malathion is the main method of control employed during the outbreak of disease although pyrethroids are used in both bed net campaigns and in widely available aerosol cans for personal use. However, limited pathogen or insecticide resistance surveillance data are available for making operational decisions. In this study, we assessed Aedes aegypti from serial surveillance collections from 3 locations for the presence of dengue virus serotypes 1-3 (DENV1-3) by polymerase chain reaction and assessed, by melt curve analysis, samples from 10 locations in 2 departments for the presence of two mutations (V1016I and F1534C), that in combination, are linked to strong pyrethroid insecticide resistance. Only one of the 32 tested pools was positive for the presence of dengue virus. The two knockdown resistance (kdr) mutations were present in all locations. The 1016I mutation frequency varied from 0.29 to 0.91 and was in all sites lower than the 0.58-1.00 frequency of the 1534C mutation. We also observed that the genotype homozygous for both mutations (IICC), which has been linked to strong pyrethroid resistance, varied from 13 to 86% in each population. Notably, 3 locations - Ti Cousin and Christianville in Ouest department and Camp Coq in Nord department had more than 30% of the tested population without the presence of kdr mutations. These results indicate that the kdr markers of pyrethroid resistance are present in Haiti, at high frequency in several locations and, based on previous studies linking kdr genotypes and phenotypic resistance, that operational interventions with pyrethroids are not likely to be as effective as expected.

Electronic Medical Record Data Missingness and Interruption in Antiretroviral Therapy Among Adults and Children Living With HIV in Haiti: Retrospective Longitudinal Study.

Background: Children (aged 0-14 years) living with HIV often experience lower rates of HIV diagnosis, treatment, and viral load suppression. In Haiti, only 63% of children living with HIV know their HIV status (compared to 85% overall), 63% are on treatment (compared to 85% overall), and 48% are virally suppressed (compared to 73% overall). Electronic medical records (EMRs) can improve HIV care and patient outcomes, but these benefits are largely dependent on providers having access to quality and nonmissing data. Objective: We sought to understand the associations between EMR data missingness and interruption in antiretroviral therapy treatment by age group (pediatric vs adult). Methods: We assessed associations between patient intake record data missingness and interruption in treatment (IIT) status at 6 and 12 months post antiretroviral therapy initiation using patient-level data drawn from iSanté, the most widely used EMR in Haiti. Missingness was assessed for tuberculosis diagnosis, World Health Organization HIV stage, and weight using a composite score indicator (ie, the number of indicators of interest missing). Risk ratios were estimated using marginal parameters from multilevel modified Poisson models with robust error variances and random intercepts for the facility to account for clustering. Results: Data were drawn from 50 facilities and comprised 31,457 patient records from people living with HIV, of which 1306 (4.2%) were pediatric cases. Pediatric patients were more likely than adult patients to experience IIT (n=431, 33% vs n=7477, 23.4% at 6 months; P<.001). Additionally, pediatric patient records had higher data missingness, with 581 (44.5%) pediatric records missing at least 1 indicator of interest, compared to 7812 (25.9%) adult records (P<.001). Among pediatric patients, each additional indicator missing was associated with a 1.34 times greater likelihood of experiencing IIT at 6 months (95% CI 1.08-1.66; P=.008) and 1.24 times greater likelihood of experiencing IIT at 12 months (95% CI 1.05-1.46; P=.01). These relationships were not statistically significant for adult patients. Compared to pediatric patients with 0 missing indicators, pediatric patients with 1, 2, or 3 missing indicators were 1.59 (95% CI 1.26-2.01; P<.001), 1.74 (95% CI 1.02-2.97; P=.04), and 2.25 (95% CI 1.43-3.56; P=.001) times more likely to experience IIT at 6 months, respectively. Among adult patients, compared to patients with 0 indicators missing, having all 3 indicators missing was associated with being 1.32 times more likely to experience IIT at 6 months (95% CI 1.03-1.70; P=.03), while there was no association with IIT status for other levels of missingness. Conclusions: These findings suggest that both EMR data quality and quality of care are lower for children living with HIV in Haiti. This underscores the need for further research into the mechanisms by which EMR data quality impacts the quality of care and patient outcomes among this population. Efforts to improve both EMR data quality and quality of care should consider prioritizing pediatric patients.

Estimation of Adult Sex Ratio and Size-Related Sexual Dimorphism Based on Molecular Sex Determination in the Vulnerable La Selle Thrush, Turdus swalesi.

Sex-determination is of particular importance in avian ecology and conservation. However, many bird species show no conspicuous sexual dimorphism, such as the La Selle Thrush, Turdus swalesi, a vulnerable species endemic to Hispaniola. We captured individuals in southeastern Haiti, in 2019-2022. For each one, we collected contour feathers or blood samples for molecular sex identification based on the CHD-1 gene. In addition, we took body measurements of several captured individuals and recorded their weight. Out of a total of 65 birds, 45 were identified as males and 20 as females, indicative of a significantly male-biased sex ratio. However, analyses of first captures showed that the sex ratio at our study site was male-biased only outside of the breeding season, suggesting that females may disperse at that time while males remain on their territories. Sexual dimorphism was limited to wing chord length and tail length, with males being larger than females. Tail length was the best predictor of sex in a logistic regression model and correctly classified about 80% of individuals as male or female. We discuss our results in relation to previous studies of sex ratio and sexual dimorphism in turdid species and address their relevance for the conservation of avian species in one of the major protected forest areas in Haiti.

Invisible cancers: Seeing, knowing, enacting and proving cancers in Haiti.

In Haiti, pathological confirmation of a cancer diagnosis is often delayed or impossible, imaging is expensive and imperfect, and many tests are unavailable. Physicians frequently struggle to establish cancers at a level of certainty required by "evidence based" standards, delaying definitive diagnosis and rendering some cancers permanently "suspected." I use 22 months of participant observation at the two largest cancer treatment programs in Haiti, as well as throughout Haiti's fragmented healthcare system, to look closely at processes of diagnosis and management of suspected 'cancers' which may never fully come to be. I argue that as global oncology becomes increasingly standardized, local practices are forced into alignment with a global knowledge basis that governs the knowability/unknowability of cancer. Using three case studies drawn from this work, I examine relationships among visibility, power, expertise and the replication of inequity through the governance of knowledge production. Finally, I examine the implications of these processes for cancer care in the global south.

Determining the cost and cost-effectiveness of childhood cancer treatment in Haiti.

Haiti is a low-income country with one of the lowest human development index rankings in the world. Its childhood cancer services are provided by a single hospital with the only dedicated paediatric oncology department in the country. Our objective was to assess the cost and cost-effectiveness of all types of childhood cancer in Haiti to help prioritise investments and to support national cancer control planning. All costing data were collected from the year 2017 or 2018 hospital records. Costs were classified into 11 cost categories, and the proportion of the overall budget represented by each was calculated and converted from Haitian Gourde to United States dollars. The 5-year survival rate was retrieved from hospital records and used to calculate the cost-effectiveness of disability-adjusted life year (DALY) averted, using a healthcare costing perspective. Additional sensitivity analyses were conducted accounting for late-effect morbidity and early mortality and discounting rates of 0%, 3% and 6%. The annual cost of operating a paediatric oncology unit in Haiti treating 74 patients with newly diagnosed cancer was $803,184 overall or $10,854 per patient. The largest cost category was pharmacy, constituting 25% of the overall budget, followed by medical personnel (20%) and administration (12%). The cost per DALY averted in the base-case scenario was $1,128, which is 76% of the gross domestic product per capita, demonstrating that treating children with cancer in Haiti is very cost-effective according to the World Health Organisation Choosing Interventions that are Cost-Effective (WHO-CHOICE) threshold. In the most conservative scenario, the cost per DALY averted was cost-effective by WHO-CHOICE criteria. Our data will add to the growing body of literature illustrating a positive return on investment associated with diagnosing and treating children with cancer in even the most resource-limited environments. We anticipate that these data will aid local stakeholders and policymakers when identifying cancer control priorities and making budgetary decisions.

Determinants of continued breastfeeding in children aged 12-23 months in three regions of Haiti.

Objectives: To identify the prevalence and determinants of continued breastfeeding in Haitian children aged 12-23 months. Methods: Three cross-sectional surveys were conducted yearly during the summers of 2017 to 2019 as part of a 4-year (2016-2020) multisectoral maternal and infant health initiative in the regions of Les Cayes, Jérémie, and Anse d'Hainault in Haiti. A total of 455 children 12-23 months of age and their mothers participated in the study. A child was considered to be continuing breastfeeding if the mother reported giving breast milk in the 24-hour dietary recall. Unadjusted and adjusted prevalence ratios were estimated, and associations were assessed between continued breastfeeding and explanatory factors related to sociodemographic characteristics, household food security, maternal nutrition, and breastfeeding knowledge and practices. Results: The prevalence of continued breastfeeding was 45.8%. Continued breastfeeding was significantly more prevalent among younger children, children who did not have a younger sibling, children whose mother was not pregnant, those living in the Jérémie region, children who had been exclusively breastfed for less than 1 month, and children whose mother knew the World Health Organization's recommendation for continued breastfeeding up to 2 years or beyond. Conclusions: The study results highlight the need for geographically equitable access to tailored and adequate health services and education that support breastfeeding in a way that is compatible with the local context.

Endorsement of HIV misconceptions over time among females and males in Haiti.

To address high HIV prevalence rates in Haiti, disseminating information about HIV transmission has been emphasized. Yet, after several decades, we do not know how effective HIV information dissemination has been in reducing HIV misconceptions. Using the 2005-06, 2012, and 2016-17 Haiti Demographic and Health Surveys and applying logistic regression, we found nuanced gender dynamics in endorsing HIV misconceptions over time. Among females at the bivariate level, the odds of endorsement of HIV misconceptions in 2012 (OR = 0.87, p < 0.05) and 2016-17 (OR = 0.68, p < 0.001) had declined compared to 2005-06. At the multivariate level, however, we observed that demographic factors suppressed the difference between 2005-06 and 2012, although those in 2016-17 (OR = 0.71, p < 0.001) were still less likely to endorse HIV misconceptions. However, this relationship disappeared once we added behavioral factors (OR = 0.93, p > 0.05). Among males, after controlling for demographic, socioeconomic, and behavioral factors at the multivariate level, those in 2012 (OR = 1.55, p < 0.001) and 2016-17 (OR = 1.24, p < 0.01) were more likely to endorse HIV misconceptions compared to men in 2005-06. We recommend that while improving women's access to HIV services, it is important to incorporate the HIV needs of males into the National HIV policy priority areas.

COVID-19 knowledge and mental health impact assessment in Haiti.

Mental health is a significant public health challenge globally, and one anticipated to increase following the COVID-19 pandemic. In many rural regions of developing nations, little is known about the prevalence of mental health conditions and factors that may help mitigate poor outcomes. This study assessed the impact of the COVID-19 pandemic on mental health and social support for residents of rural Haiti. Data were collected from March to May 2020. The Patient Health Questionnaire subscales for anxiety and depression, and the Perceived Stress Scale were utilized in addition to tailored questions specific to COVID-19 knowledge. Half (51.8%) of the 500 survey respondents reported COVID-19-related anxiety and worrying either daily or across a few days. Half (50.2%) also reported experiencing depression daily or across several days. Most (70.4%) did not have any social support, and 28.0% experienced some stress, with 13.4% indicating high perceived stress. Furthermore, 4.6% had suitable plumbing systems in their homes. The results were immediately actionable, informing the implementation of a mental health counseling program for youth following a loss of social support through school closures. Long-term investments must be made as part of public health responses in rural communities in developing nations, which remain under-studied.

A case of placental site trophoblastic tumor managed in a low resource setting.

Placental trophoblastic site tumor (PSTT) is a rare type of gestational trophoblastic neoplasia (GTN). PSTT has a higher mortality than other types of gestational trophoblastic disease (GTD), with a rate of 16.1%, due to its relatively unpredictable behavior and reduced response to chemotherapy. Its diagnostic and management are very challenging in Low resources settings particularity in Haiti where MRI, PET Scan and IHC are not available. Further, the follow-up is very difficult because of social, political, and economic issues limiting the capacity of our patients to be present at all scheduled visits. No case of PSTT has been publicly described yet the Haitian experience in the literature in the management of such case compared to the developed world. We present a case of PSTT successfully diagnosed and managed at Mirebalais University Hospital (MUH) in Haiti with the support of telepathology and intentional partners while highlighting the difference that we observed compare to the developed world.

"I Am Half of a Person": Lived Experiences of Individuals Living With Ostomy After Surgery in Rural Haiti.

Intestinal ostomy can have significant effects on lives and lived experiences. However, limited research exists on the experiences of persons with ostomy in low-resource settings, such as rural Haiti. This study aimed to explore the lived experiences of Haitians with an ostomy, focusing on the physical, psychological, and social aspects of their post-operative lives. We conducted 9 semi-structured, in-depth interviews with participants who had undergone ostomy surgery at the Hôpital Universitaire de Mirebalais in Haiti. Employing interpretative phenomenological analysis (IPA), we iteratively examined transcripts to identify convergent and divergent codes, which were then grouped into themes to better understand the participants' experiences. Three themes emerged: (a) ostomy as a social disease, which has severe impacts on relationships and place in society; (b) ostomy as altering self-image, leading participants to reflect on their identity and the underlying causes of their condition and to reevaluate their necessities and abilities; and (c) ostomy as an arduous medical journey, characterized by pain, distress, uncertainty, and disillusionment, but also resiliency, improvisation, and hope. This study highlights the multifaceted experiences of persons with ostomy in the low-resource rural environment of Haiti and underscores the need for improved access to medical care, financial support, and psychosocial and caregiving resources for these individuals. Findings also emphasize the importance of medical providers' improved understanding in making medical decisions, and cultural and socioeconomic factors in developing effective support strategies.

The HIV epidemic in Haiti: is disability a factor?

People with disabilities (PWD) are thought to be low risk for HIV because of social norms regarding disability and sex. However, qualitative studies indicate they are at risk and are not being reached by HIV programs. The Demographic and Health Survey (DHS) conducted in Haiti in 2016 included HIV biomarker data and disability status. Crude and adjusted odds ratios were calculated using a disability severity indicator as the independent variable and HIV infection as the dependent variable. Covariates were selected based on theory and previous studies. Individuals reporting milder disabilities had a higher odds of HIV infection in the crude model (OR:1.65; CI: 1.16-2.34) and those adjusted for demographics (OR:1.73; CI:1.19-2.51) and sexual activity (OR:1.60; CI:1.06-2.42). Those with moderate and more severe disabilities have the same odds of HIV infection as the general population. PWD are HIV-positive and at risk of HIV infection. Based on this, it is essential that HIV education, testing, and treatment programs are inclusive of PWD. Accessible HIV education materials need to be created. HIV testing programs should involve PWD in planning and implementation. Providers of HIV care must be trained regarding the needs of PWD for reproductive healthcare.

Trends and factors associated with recent HIV testing among women in Haiti: a cross-sectional study using data from nationally representative surveys.

INTRODUCTION: In the Latin America and Caribbean region, Haiti is one of the countries with the highest rates of HIV. Therefore, this study examined the factors associated with HIV testing among women in Haiti and trends in HIV testing in 2006, 2012, and 2016/17. METHODS: Data from the last three Haitian Demographic and Health Surveys (2006, 2012, and 2016/17) were used. The analysis was restricted to women aged of 15-49 years who made their sexual debut. STATA/SE 16.0 was employed to analyze the data by computing descriptive statistics, Chi­square, and multilevel regression model to describe the trends and identify factors associated with HIV testing in Haiti. P-value less than 0.05 was taken as a significant association. RESULTS: HIV testing prevalence increased more than twofold from 2006 (8.8%) to 2017 (21.3%); however, it decreased by 11.6% between 2012 and 2016/17. Additionally, the results indicated that age, place of residence, region, education level, wealth index, mass media exposure, marital status, health insurance, age at first sex and number of sexual partners were significantly associated with HIV testing. CONCLUSIONS: To significantly increase HIV testing prevalence among women, the Haitian government must invest much more in their health education while targeting vulnerable groups (youth, women in union, and women with low economic status).

A retrospective study on cholera understanding and WASH (water, sanitation, and hygiene) behavior among adolescents in three regions of La Gonâve, Haiti.

BACKGROUNDS: This study assesses the impact of Water, Sanitation, and Hygiene (WASH) interventions on cholera understanding and hygiene practices in La Gonâve Island, Haiti. It examines the changes after implementing interventions in seven villages across the Downtown, Mountain, and Seaside regions. METHODS: A retrospective investigation surveyed 210 school students from each region using a validated questionnaire. It assessed knowledge, attitudes, practices (KAP), and environmental aspects related to cholera and hygiene. Data analysis involved descriptive statistics and chi-square tests. RESULTS: The study highlights significant disparities in education levels, toilet ownership, and healthcare access. Challenges in finding public toilets (86.67%) and accessing water sources (67.78%) are consistent across regions, with Seaside facing financial constraints (85.00%) and water cost concerns (91.67%). Attitudes toward hygiene vary, with the Mountain region having the highest 'Never' responses for handwashing (38.89%), and Downtown leading in water treatment practices (11.67%). There is a strong willingness to share health knowledge, particularly in Downtown (100.00%). Seaside (83.33%) and Downtown (73.33%) revealed a higher cholera awareness, while nearly half of Mountain students lacked knowledge (54.44%). CONCLUSIONS: This study highlights significant disparities in WASH practices among La Gonâve's adolescents in Downtown, Mountain, and Seaside regions. Urgent interventions are crucial for improving sanitation, ensuring clean water access, and implementing targeted hygiene education, especially in the resource-constrained Mountain and Seaside areas. The findings underscore the vital roles of adolescents and schools in disseminating knowledge, with further research needed to explore intervention differences.

Haitian women in New York City use global food plants for women's health.

BACKGROUND: Despite the availability of mainstream biomedical healthcare in New York City (NYC), community-based ethnomedicine practices remain a low-cost, culturally relevant treatment for many immigrants. Previous urban ethnobotany research in NYC has established that several Caribbean communities continue using medicinal plants for women's health after immigration. This study sought to address to what extent: (1) NYC Haitian women continue using medicinal plants for women's health after migration; (2) their plants and the conditions treated were similar to those identified in an earlier survey with NYC immigrants from the Dominican Republic. METHODS: Through an ethnobotanical survey, 100 Haitian women living in NYC and born in Haiti were interviewed about their knowledge of medicinal plants for women's health conditions. Reported species were purchased based on local names in NYC Haitian stores and markets, vouchered, and identified. RESULTS: Nearly all Haitian women (97%) reported using medicinal plants while living in Haiti. Most Haitian women continued using medicinal plants after coming to the USA (83%). The 14% decrease, although significant (z = 3.3; p = 0.001), was mainly due to logistical difficulties with sourcing plants after recent immigration. Popular medicinal plant species reported were primarily global food plants, re-emphasizing the intertwined food-medicine relationship in Caribbean diasporas. Comparison with data from NYC Dominicans identified childbirth and puerperium, gynecological infections, and vaginal cleansing as priority Haitian women's health concerns treated with plants. CONCLUSION: Our findings support the global nature of Caribbean migrant plant pharmacopeia, predominantly centered around food plants and adapted to transnational urban settings. They underscore cultural diversity, dispelling the notion of one uniform traditional knowledge system labeled "Caribbean." The importance of preventative medicine for women's health, particularly the regular consumption of "healthy" foods or teas highlights the role food plants play in maintaining health without seeking treatment for a particular condition. Cross-cultural comparisons with other NYC Caribbean immigrants emphasize the importance of conducting ethnobotanical surveys to ground-truth plant use in the community. Such surveys can also identify culture-specific health priorities treated with these plants. Healthcare providers can leverage these insights to formulate culturally relevant and community-tailored healthcare strategies aligned with Haitian women's health beliefs and needs.

Maladi Nanm, Maladi Zonbi, & Maladi Lalin: A qualitative study of cultural concepts of distress in northern Haiti.

Cultural Concepts of Distress (CCDs) are culturally constructed diagnostic categories that exist within a specific society or culture. While several studies have assessed CCDs around the world, few studies have examined them in Haiti. This qualitative study examines manifestations of anxiety and depression via "sent spirits" in the form of maladi nanm ("Soul disorder") and maladi zonbi ("Zombie disorder"), and bipolar disorder in the form of maladi lalin ("Moon disorder"). Examples of CCDs were recorded as part of a study which interviewed 96 outpatients at the first mental health center in northern Haiti. Using qualitative methods, the authors identified three specific CCDs as reported by mental health patients. Maladi nanm and maladi zonbi represent alternative explanatory models of anxiety and depression in which the sufferer views mental illness as stemming from a sent spirit, or spirit which is intentionally sent supernaturally with the intent to cause harm. Maladi lalin is experienced by patients with bipolar disorder who associate cycles of mania and depression as in-sync with the phases of the moon. Understanding culture-bound forms of mental distress in settings such as Haiti is essential to developing accurate psychometrics for measuring mental health, as well as ensuring culturally appropriate and effective diagnosis and treatment.

Effectiveness of the Euvichol® oral cholera vaccine at 2 years: A case-control and bias-indicator study in Haiti.

OBJECTIVES: The World Health Organization recommends the use of oral cholera vaccine (OCV) in cholera control efforts. Euvichol®, pre-qualified in 2015, is the leading component of the Global OCV stockpile, but data on its field effectiveness are limited. To evaluate Euvichol® vaccine effectiveness (VE), we conducted a case-control study between September 2018 to March 2020 following an OCV campaign in November 2017 in Haiti. METHODS: Cases were individuals with acute watery diarrhea. Stool samples were tested by culture and real-time polymerase chain reaction of the Vibrio cholerae ctxA gene. Cases were matched to four community controls without diarrhea by residence, enrollment time, age, and gender, and interviewed for sociodemographics, risk factors, and self-reported vaccination. Cholera cases were analyzed by conditional logistic regression in the VE study. Non-cholera diarrhea cases were analyzed in a bias-indicator study. RESULTS: We enrolled 15 cholera cases matched to 60 controls, and 63 non-cholera diarrhea cases matched to 249 controls. In the VE analysis, eight (53%) cases reported vaccination with any number of doses compared to 43 (72%) controls. Adjusted two-dose OCV VE was 69% (95% CI -71 to 94%). CONCLUSIONS: Between 10-27 months after vaccination, Euvichol® was effective and similar to Shanchol™, suggesting that it can serve as one component of multi-sectoral comprehensive cholera control.

AN ESSENTIAL TOOL TO BE OPTIMIZED: SYNDROMIC MANAGEMENT OF VAGINAL DISCHARGE IN HAITI.

Background: Haiti, like many low-income countries in crisis, has limited resources for etiologic diagnosis of vaginal discharge. As such, we sought to characterize variability in diagnoses of women presenting with vaginal discharge syndrome, with the goal to improve standardization of syndromic management. Materials and Methods: Participants aged 18 years and older endorsing vaginitis, or dysuria were recruited at Jerusalem Clinic over two, one-week periods in April 2018 and July 2019. We calculated Spearman rank correlations among history, exam findings, and diagnoses based on clinical presentation, to understand presentation groupings and their management. Results: Among 98 women, median age was 33.5 years, and most frequent symptoms were: vaginal discharge (97%), vaginal itch (73%), and/or suprapubic pain (68%). Most common physical exam findings were vaginal discharge (86%), suprapubic/lower quadrant tenderness (29%), cervical motion tenderness (24%), and cervical erythema (20%). Most symptoms and physical exam findings were weakly correlated with each other. Nearly one-third (31%) were diagnosed with normal physiologic vaginal discharge or no diagnosis, followed by Bacterial vaginosis (31%), vulvovaginal candidiasis (15%), cervicitis/PID (13%), and STI (7%). No reported symptoms strongly differentiated diagnostic categories. Diagnoses varied considerably by exam findings. Conclusions: The weak correlations between symptoms, exam findings, and diagnoses could represent variability in assessment. In the absence of reliable and accessible laboratory testing, the importance of standardizing syndromic management becomes increasingly relevant. Results from our study support the utility of speculum examination and more standardized documentation of physical exam findings. Next steps include the development of local algorithms to promote standardization of treatment of vaginal discharge syndrome.

Costs of Digital Adherence Technologies for Tuberculosis Treatment Support, 2018-2021.

Digital adherence technologies are increasingly used to support tuberculosis (TB) treatment adherence. Using microcosting, we estimated healthcare system costs (in 2022 US dollars) of 2 digital adherence technologies, 99DOTS medication sleeves and video-observed therapy (VOT), implemented in demonstration projects during 2018-2021. We also obtained cost estimates for standard directly observed therapy (DOT). Estimated per-person costs of 99DOTS for drug-sensitive TB were $98 in Bangladesh (n = 719), $119 in the Philippines (n = 396), and $174 in Tanzania (n = 976). Estimated per-person costs of VOT were $1,154 in Haiti (87 drug-sensitive), $304 in Moldova (173 drug-sensitive), $452 in Moldova (135 drug-resistant), and $661 in the Philippines (110 drug-resistant). 99DOTS costs may be similar to or less expensive than standard DOT. VOT is more expensive, although in some settings, labor cost offsets or economies of scale may yield savings. 99DOTS and VOT may yield savings to local programs if donors cover infrastructure costs.