ENDING CHOLERA: IMPLICATIONS FOR THE WATER, SANITATION AND HYGIENE SECTOR

WELCOME AND INTRODUCTION

Thomas Handzel PhD, MSPH

Centers for Disease Control and Prevention

UNC Water and Health Conference

November 1, 2018Center for Global Health

Emergency Response and Recovery Branch

BACKGROUND

Estimated 2.9 million cases and 95,000 deaths due to cholera occur annually

47 countries affected

Haiti outbreak (2010 – present)• >819,000 cases

• >9,700 deaths

Yemen (2016-present)• > 1,000,000 suspect cases?

Contributing factors to increased cholera transmission• Population increase

• Increased urbanization and expansion of urban settlements

• Conflict, natural disasters and mass population displacements

• Role of climate change

Launched in October 2017

Reduce deaths due to cholera

Eliminate cholera in selected countries

Integrated strategy involving surveillance, laboratory, case management, OCV and emphasis on water, sanitation and hygiene

Long term prevention depends on sustainable WASH services

Consistent with WASH development goals under the SDGs

ROADMAP TO 2030WHAT IS NEW?

OBJECTIVE OF THIS SESSION

Increase awareness of the Roadmap and disseminate information on progress to date

Engage partners to become involved in the Roadmap• GTFCC is membership based

Continue to engender coordination among stakeholders

INTRODUCTION OF PANEL

Kate Alberti, Technical Officer Cholera Program, WHO and Global Task Force for Cholera Control (GTFCC)

Monica Ramos, WASH Working Group Coordinator, GTFCC

Guy Hutton, Senior WASH Advisor, UNICEF

Paul Christian Namphy, National Cholera Response Coordinator, DINEPA, Haiti

Questions and answers

Panel Discussion – Facilitated by Rick Gelting, CDC

THANK YOU!

For more information please contact Centers for Disease Control and Prevention

1600 Clifton Road NE, Atlanta, GA 30333

Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348

Visit: www.cdc.gov | Contact CDC at: 1-800-CDC-INFO or www.cdc.gov/info

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Center for Global Health

Emergency Response and Recovery Branch

CHOLERA INVESTMENT CASEGuy Hutton, UNICEF

Stefano Malvolti, Angela

Hwang, Melissa Ko, MMGH

1 November 2018

INVESTMENT CASE STRUCTURE AND CONTENT

The issue

The opportunity

Benefits

Resource requirements

Sustainability plan

Alignment with other strategies

Challenges, Risks, and Mitigation

Measurement and Evaluation8

COST-BENEFIT MODELLING

Roadmap package includes response preparedness, surveillance, WASH interventions (‘basic’ plus safety), OCV and improved case management

2 OCV campaigns assumed, 3 years apart (1-3 years to complete)

All countries except conflict-affected projected to achieve 80% WASH coverage by 2030, from half the % of SDG baseline

Start year: based on country’s readiness to operationalize the roadmap

End year: based on whether higher or moderate capacity, or crisis context

Costs and benefits modelled until 2040

WASH benefits are many, but the model included only reductions in diarrheal disease and time savings

9

PROJECTED NUMBER OF GLOBAL CHOLERA CASES AVERTED FROM IMPLEMENTING ROADMAP

10

CHOLERA

CASES

Averted

Cases

DRAFT – NOT FOR QUOTATIONPlus up to 130,000 fewer cholera deaths per

year by 2030 from roadmap

PROJECTED NUMBER OF GLOBAL (OTHER) DIARRHEA CASES AVERTED FROM IMPLEMENTING ROADMAP

12

DIARRHEA

CASES

(MILLIONS)Averted

Cases

DRAFT – NOT FOR QUOTATIONPlus up to 150,000 fewer diarrheal deaths per

year by 2030 from roadmap

COST BREAKDOWN OF ROADMAP IMPLEMENTATION

Total cost,

globally

~ US$ 3.3

billion

annually in

2018 prices

(2018-30)

DRAFT – NOT FOR QUOTATION

BENEFIT BREAKDOWN OF ROADMAP IMPLEMENTATION

Total benefits,

globally

~ US$ 33

billion

annually in

2018 prices

(2018-30)

DRAFT – NOT FOR QUOTATION

GLOBAL COSTS & BENEFITS OF IMPLEMENTING ROADMAP

BILLION

US$

DRAFT – NOT FOR QUOTATION

33

3.3

BENEFIT-COST RATIOS FROM 2018-2040, DISCOUNTED

DRAFT – NOT FOR QUOTATION

NEXT STEP: MAKE MODEL AVAILABLE TO COUNTRIES TO SUPPORT NATIONAL PLANNING & ADVOCACY

Based on the global model:

1. Adjustable country cost-benefit model with list of variables

2. Output screen (tables, graphs)

3. Reporting template automatically filled

4. Written guideline on how to adjust values in model for country customization

5. In-country technical assistance18

THANK YOU FOR YOUR ATTENTIONAcknowledging the inputs of the GTFCC Secretariat and Investment Case Advisory Group

Ending cholera : a global roadmap to 2030

Kate Alberti WHO/GTFCC, UNC November 2018

MAJOR CHOLERA OUTBREAKS 2017

Haiti:

13 747 cases

159 deaths

Nigeria (Borno):

5 365 cases

61 deaths

DRC:

54 166 cases

1 172 deaths

Sudan (AWD)

36 460 cases

818 deathsSince August ‘16

South Sudan

20 438 cases

436 deathsSince August ‘16

Somalia

79 172 cases

1 159 deaths

Ethiopia (AWD)

48 617 cases 880

deaths

Yemen

(1 019 044) cases

2 237 deaths

Zambia (Lusaka)

3 714 cases

75 deathsTo Feb. 07 2018

Early detection and immediate response to outbreaks

CHOLERA HOTSPOTS IN AFRICA 2010-2016

Source: A Azman and J Lessler, Johns Hopkins University

HIGHLY ENDEMIC SETTINGS:MANY OUTBREAKS ARE PREDICTABLE

THE GLOBAL TASK FORCE ON CHOLERA CONTROL

Common vision that collective action can stop cholera transmission and end cholera deaths

Provide a forum for technical exchange, coordination,

and cooperation on cholera-related activities to

strengthen countries’ capacity to prevent and control

cholera

Support global strategies for cholera

prevention and control

Support the development of a research agenda with

special emphasis on monitoring and evaluating

innovative approaches to cholera prevention and

control

Increase the visibility of cholera as an important

global public health problem

GTFCC CURRENT STRUCTUREGTFCC

Coordination of Technical Working Groups, oversight of technical guidance development

GTFCC SECRETARIAT- Hosted at WHO

WORKING GROUPS

Provide technical expertise on cholera specific topics to

develop evidence based guidance on cholera control.

• WASH WG – UNICEF

• OCV WG – CDC

• Case Management WG – icddr’b

• Surveillance Lab – Insitut Pasteur

• Surveillance Epi - Epicentre

SUPPORT TO

COUNTRIES

GTFCC: NETWORK OF INSTITUTIONS WITH THE AIM TO CONTROL AND PREV ENT CHOLERA GLOBALLY

Implementing the Roadmap in countries

ORAL CHOLERA VACCINE USE, DEMAND, AND PRODUCTION, 1997-2018*(27 OCT)

DINEPA’S LINKING ROLE:

NATIONAL CHOLERA ELIMINATION PLAN – LONG TERM

(PNEC-LT)

MINISTERE DE SANTE PUBLIQUE ET DE LA POPULATION, MSPP

CHOLERA ELIMINATION IN HAITI

CHOLERA’S TOLL IN HAITI 2010-2018 MORBIDITY

1

TOTAL CASES 2010-2018: 819,402 (MSPP)

TOTAL DEATHS: 9,787 (MSPP)

2010 ’ 2011 ‘ 2012 ‘ 2013 ‘ 2014 ‘ 2015 ‘ 2016 ‘ 2017 ‘ 2018’

DATA: MSPP DELR WEEKLY EPIDEMIOLOGICAL REPORT, 2018 SE42 -

1

CHOLERA STATUS IN HAITI DURING MID-TERM

Cholera Suspected Cases, Haiti, Years 2016-2018

Graph showing the past 3-

year cholera burden at

country level (morbidity and

mortality). Graphs are also

available at the level of

geographic department.

Baselines are measured for

national incidence, as well

as the geographic

departments with greatest

departmental incidence

(Artibonite, Ouest, Centre).

Red Alert Incidence critiera:

"at least one suspected

cholera death, at least 10

suspected cases, or at least

5 suspected cases coming

from a limited geographical

area." DATA: MSPP DELR WEEKLY EPIDEMIOLOGICAL REPORT, 2018 SE42 -

25 PRIORITY COMMUNES - CRITERIA

1

.

• High priority Communes (Type A)50% of the time incidence >10 cases/week

• Communes Type B and C 19-50% of time incidence >10 cases/week

• Prioritize communal sections within the 25 priority communes + additional based on 2018 cases

MAP OF PRIORITY COMMUNES

.

All southern departments (South East, Nippes, South, Grande Anse) and north east calm for the last 18 months

………….

Other priority

communes:

Verrettes (Art.)

Dessalines(Art.)

Limbe (N)

Borgne (N)

Port-de-Paix (NW)

Cerca la Source (C)

(+ Commune Sections of

Cornillon, Belladere, Ennery,

St. Saut, Boucan Carre, et

St. Louis du Nord RURAL +

PV URBAN)

WHAT IS IN THE LONG TERM: 2019-2022

1

.

RESULT TITLE MAIN INDICATORS RESULT BUDGET

4.0 Governance and Coordination 13 activities, 22 indicators US $9M

4.1 Production of drinking water(access to 2.8 M more people)

Urban: >80 L/day pers.,

Rural >40 L/day/pers.,

priority communes / SC

US $269M (83%)

4.2 Regulation of water quality Public: 90% >0.5 mg/L,

Private 90% no Ecl,

80%>0.5 mg/L,

WtPnt: 80% HH use

HHWT

US $12.5 M

4.3 General Sanitation (access +1M) 1M people end OpAirDef

Measure sanit. Baselines

125 markets / 200 pb.sch.

US $32 M

TOTAL US $322.5

MT (7/2016-12/2018): Total Plan Cost: US$178

LT (1/2019-12/2022): Total Plan Cost: US$390, of which US$322.5 is the WASH Component

LT: WASH Component separate Axis from rest of the Battle Against Transmission (Axis III)

1

DINEPA’s Interventions – Success Examples

2013-2017

• Water supply: Rehabilitation / Chlorination / Construction

• Sanitation: National Total Sanitation Campaign, / 4 human fecal sludge treatment stations

• RRT: Implementation : Rapid response mechanism (>92% cases responses < 48h 2017);

(joint alert-response mechanism MoH/DINEPA/UNICEF/NGOs)

• PNEC-MT (DINEPA CNRC / MSPP / Partners) – Drafting / validation (2016), followed by:

Commune action / intervention plans (PAC/PPI)

• National mapping of water points (DINEPA / OREPA w/ WB, IADB, UNICEF, Haiti

Outreach)

1

WASH RESULTS

• Contributed to cholera incidence rate DECREASE

( 18.38 / 1000 inhab. in 2010 1.03 – 1.20 / 1000 inhab. in 2017, and

0.27/ 1000 for 1st 42 weeks of 2018. So 2018 goal 1.00 / 1000 largely met.)

• 2012-2017 : Improved WASH coverage rates: > 300,000 new individuals have access

to drinking water (result of infrastructure built and rehabilitated), estimated national

sanitation coverage 26% 28% .

• SISKLOR Implementation (chlorine residual monitoring system):

APPROXIMATELY 30% Piped Systems are integrated into monitoring system of

water quality.

• 18/01/31 New DINEPA / Donor approach (MT/LT): evaluation (MT), drafting (LT),

and re-prioritization of investments according to cholera-incidence criteria.

1

ENTER THE YEAR 2018

• WASH mobile teams (EMO-EPAH, DINEPA / UNICEF / partner MIX.)

Water treatment monitoring + interventions, parallel activities to RRT

• Operations “Coup de Poing” (“Sword” / Surge”) summer 2017 + summer 2018 +

Ongoing coordination and targeted sensitization activities in West, Artib.,…)

• CORNILLON OUTBREAK: Late May – Present:

Plurality of cholera cases in Haiti. (Over 150, 20-30%). PRIORITY of 2018!

Response: RRT, Opening of 2nd CTDA, Massive Sensitization, and advocacy

for Water improvement Package: in High-Cholera Incidence Communal Sections

–8 upcoming projects planned

1

2831

12 11 103

6 47 8

22

7

0%

10%

20%

30%

0

10

20

30

40

SE23 SE24 SE25 SE26 SE27 SE28 SE29 SE30 SE31 SE32 SE33 SE34 SE35

CORNILLON weekly (SE23-35) case distribution (# cases and hospital lethality)

Nbre de cas letalite

WASH HEALTH

EMO-EPAH EMIRA

CHALLENGES

3 Absolute requirements to irreversibly eliminate cholera in Haiti (NO

RETURNS!) 1-Solid fundraising / funding predictability (pre-2018 challenge!);

2-sound, efficient management of cholera financial, human, and technical resources,

(perpetual challenge!) (support DINEPA: CNRC/DRU, DA, DQE,

ONEPA, and OREPA / URD / TEPAC / ACEPA)

3-domestic and international political will

(UN Pledges, US Senate, Haitian Gvt. Recent Speech at UN)

CONCLUSIONS

.

•Current case-loads are approaching zero (30-60 / wk), thanks improved coordination

+ response, but cholera can/could be eliminated more quickly, and irreversibly, with

major improvements in water and sanitation access, and behavior change /

improved sanitation and hygiene practices.

• 3 key behavior changes:

• Everyone is drinking treated water,

• Everyone is defecating in toilets, and

• Everyone is washing their hands at key moments.

Not rocket science! We can do this!

(4th critical element: Protocol MUST be followed in handling cholera deaths).

•CRITICAL TO ACCOMPANY MOST VUNLERABLE SEGMENTS OF HAITIAN SOCIETY, via EMIRA,

EMO-EPAH, PARTNER EXTENSION AGENTS. MIXED TEAMS. BEST INVESTMENT POSSIBLE!

MINISTERE DE SANTE PUBLIQUE ET DE LA

POPULATION, MSPP

THANK YOU

DECISION-MAKERS AND CONCERNED CITIZENS CAN MAKE A DIFFERENCE, WHETHER IN HAITI, THE US, OR WORLD-WIDE.

DINEPA’S CRITICAL CNLCC (NAT. CELL BATTLE AGAINST CHOLERA) PARTNERS: