The topic to be presented in our case study is titled: an outbreak halted in its tracks eliminating polio in Haiti. This was a great success in such a fragile country and had numerous great implications on the lives of Haitians and their neighbors.
So, what is polio?
Polio, also known as poliomyelitis, is a viral infectious disease. It usually spreads from person to person causing in most of the cases (almost 96%) no major symptoms. A minor portion of infected people however will develop dangerous symptoms. Of these symptoms, the most severe is paralysis. It affects 0.5% of people with polio and can lead to permanent disability and eventually death. The patient won’t be able to breath because of the paralysis of his respiratory muscles.
Poliovirus is very contagious and is spread from human-human interaction (as it only infects humans) through a contact with infected feces or through droplets from a sneeze. The poliovirus can also contaminate food and water in unsanitary places.
As there is no cure for polio, prevention is the most important weapon. There are 2 types of vaccines; the inactivated poliovirus vaccine (IPV) and oral poliovirus vaccine (OPV) .
2-Context in Haiti
After a violent coup d’état in 1991 where the president of Haiti was forced into exile after being overthrown, things got worse. Killings and political terrorism were the main headlines about Haiti worldwide. This lead to a suspension of support from a wide variety of donors to the people of Haiti, especially for the Ministry of Public Health and population and all its related programs . Moreover, Haiti’s health system started to degrade; polio vaccine coverage was at its lowest rates and poor sanitation was invading the country throughout the 90s .
Haiti’s government suspended its national immunization days after the region was considered polio-free in 1994. This was no good news. A country where vaccine is suspended, water is not clean, and sanitation is in its misery state, is just waiting for a polio outbreak .
Prior to the suspension of the polio immunization, the 2 types of vaccines were administered in Haiti (and worldwide). The IPV, as its name indicates, is injectable and is also made from a deactivated version of the poliovirus. The OPV, however, is cheaper and is administered orally. It is made from a weakened poliovirus and provides gut immunity. This type of vaccine is the main vaccination type for polio in developing countries , .
During all this chaos, Haiti’s epidemiological surveillance system (ESS) was still functioning normally. It had received a reported case of a sudden onset of paralysis in a 2-year-old girl living in the northwest department. The Haiti’s Ministry of Public Health and Population, PAHO’s Caribbean Epidemiology Center and the CDC investigated this incident and confirmed that this was a polio case . The most alarming fact in this situation is that the virus is a vaccine-derived poliovirus. It can be quickly transmitted and can cause paralysis . Following this incident, in 2001, 8 more cases in children not fully vaccinated emerged in Haiti along with 14 in the Dominican Republic .
The initial efforts to solve this problem (by vaccinating children) were not fruitful, largely due to the poor planning, and the heavy rain . Another subsequent round of immunization was then declared by the minister of health with the help of UNICEF, the Canadian government, USAID and others, mainly helping technically and financially; they launched a house-to-house vaccination and a school-based vaccination for children under 10. The government also worked on improving surveillance and inducing the population by offering money to every person reporting any similar case .
This particular case has arrived to this state because of many weaknesses in the major determinant of health. Below is stated the proximal, distal and contextual determinants that resulted in this outbreak in Haiti in 2001.
The outcome of this intervention, lead to the vaccination of more than 90% of the target population and eventually no new cases of paralytic polio were reported afterwards10. This campaign was a huge success because of many interconnected factors; the quick response by the government, its commitment to eliminate polio and its efficient coordination with international partners. It is also a success because, as believed by the Center for Global Development, it had great implications to population health, such as reduced mortality, given its low-cost intervention.
Given the sudden onset of the virus, the wiser choice was to start with the immunization campaign. However, this is certainly not enough to maintain a polio-free state. Improving water, sanitary system and hygiene education are a must to ensure the vanish of a new polio outbreak. Adding all these tasks to a constant surveillance and a continuous vaccination will strengthen the community in terms of protection against the virus. This way the intervention that had started in 2001 can be successfully sustained over time.
Moreover, this intervention was equitable as it reached all children with no preference of one sex or a socioeconomic class over the other. It was also equitable since it reached all children regardless of their place of residence in Haiti (rural and urban). However, this equity won’t be maintainable if another outbreak happens especially because the health facilities are limited and not available in the rural area and the poorer are more at risk and will eventually receive less care. Despite some difficulties in terms of equity, the intervention also had several effects on the health of the population, some of which meet the millennium goals such as the infant mortality reduction, the ability to fight other infectious diseases and the global Partnership for Development.
I believe that this type of intervention could be applicable to another context because mainly it did not require a special type of action different from any other polio case. However, I also think that the fact that Haiti is close to the USA and Canada and that there is flow of people from both ends, was a push for the immediate response. The international involvement might not have happened as quickly in a country in Africa with no direct contact with the “ruling” countries. Moreover, the government response was also a major factor in the intervention. It would be almost impossible to have a successful case in eliminating polio in a country with divided political groups (focusing only on how to defeat the other), or a country having a war. Moreover, contexts with religious extremism will also forbid any type of intervention coming from the west as they consider it to be a western conspiracy. For example, the Pakistani Taliban have been violently attacking polio vaccination workers because of religious edicts against the vaccination program. They claim them to be a plot to hinder Muslim sterility to ultimately delay the growth of their religion , . One way to conquer this fundamentalism is to address their religious leaders since they have a direct effect on rules and subsequently on the population.
Finally, to sum up this case study it is important to mention that the context surrounding the time when the outbreak happened had clearly a direct implication to the polio re-emergence (the sanitary state, the lack of vaccination…). On the other hand, many factors were the reason for the polio elimination success (international quick response, the dedicated activities of the government …). However, measures should be taken to avoid another outbreak and to maintain the polio-free state of the population (such as constant surveillance, improvement of the sanitary state…). One major lesson learned during the oral presentations and this case study, is that it is the populations and their government who dictate their destiny especially regarding health issues. The international community can boost and initiate a response but cannot maintain a specific (healthy) state in a country.