Team 5


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Team 5

  1. 1. From Crisis to Opportunity The U.N.-Haiti Cholera Settlement Fund Team 5: Brian Wayda Amogh Sivarapatna Ffyona Patel Fjodor Melnikov Travis Whitfill Kevin Nay Yaung
  2. 2. Overview Problem Plan of Action Implementation • Projected burden of cholera • Root cause analysis • Phased response • Supports and enhances National Plan • Fund oversight and disbursement • Addressing settlement claims • Guidelines for UN 2
  3. 3. Without intervention, cholera will become endemic to 2000 Haiti New cases per week 1500 $22.3 million in total costs Annual burden 1000 $3.7 million in healthcare costs 90,000 cases per year 9000 deaths 500 0 Jan-13 2013 Problem Jan-14 2014 Jan-15 2015 Action Plan Implementation Jan-16 2016 Jan-17 2017 3
  4. 4. Root cause analysis shows four factors contributing to cholera V. Cholerae, El Tor introduced U.N. MINUSTAH ENDEMIC HEALTH CHOLERA Problem Action Plan Implementation 4
  5. 5. Root cause analysis shows four factors contributing to cholera V. Cholerae, El Tor introduced U.N. MINUSTAH HEALTH Problem Action Plan Implementation 5
  6. 6. Environmental factors contributing to cholera V. Cholerae, El Tor introduced U.N. MINUSTAH Inadequate waste disposal Poor water supply Climate/ Geography Endemic Cholera Problem Action Plan Implementation 6
  7. 7. Existing National Plan - Environment Section 2014-2016 2017-2019 2020-2023 TOTAL $M Water supply 825 Wastewater DINEPA strengthening 468 224 Total $ Problem $1516M Action Plan Implementation 7
  8. 8. Enhancements to National Plan incorporate WASH improvements Section 2014-2016 2017-2019 2020-2023 TOTAL $M Water supply 825 Wastewater DINEPA strengthening WASH improvements 468 224 470 TOTAL $ $1986M $1 USD invested results in $5–6 USD in economic 1 benefits results, depending on WASH intervention Problem Action Plan Implementation 8
  9. 9. Innovative, sustainable WASH solutions INNOVATIVE TOILET DESIGN:  Increases efficiency  Decreases costs Problem Action Plan Implementation 9
  10. 10. Social factors contributing to cholera V. Cholerae, El Tor introduced U.N. MINUSTAH ENDEMIC CHOLERA Attitudes toward healthcare Poor hygiene habits Displaced population Problem Action Plan Implementation 10
  11. 11. Existing National Plan - Social Section 2014-2016 2017-2019 2020-2023 TOTAL $M Health promotion 54 Hygiene practices Institutional strengthening 19 36 Total $ Problem $109M Action Plan Implementation 11
  12. 12. Enhancements to National Plan utilize integrated media Section 2014-2016 2017-2019 2020-2023 TOTAL $M Health promotion 54 Hygiene practices Institutional strengthening 19 Integrated media 21 36 $130M Problem Action Plan Implementation 12
  13. 13. Targeted media campaigns to reach Haitians Senegal targeted marketing: Community communications • NGO involvement with local entities Mass media • TV, radio, print • Citizen journalists Direct to consumer Wall marketing in Benin: • SMS/mobile alert (42% of pop. in 2011) • Technology Problem Action Plan Implementation 13
  14. 14. Health system factors contributing to cholera V. Cholerae, El Tor introduced U.N. MINUSTAH ENDEMIC CHOLERA Lack of antibiotics, ORS Poor lab/ surveillance Shortage of providers, health posts Problem Action Plan Implementation 14
  15. 15. Existing National Plan: health system Section 2014-2016 2017-2019 2020-2023 TOTAL $M Healthcare services 83 Essential medicines Micronutrient deficiencies 95 20 $198M Problem Action Plan Implementation 15
  16. 16. Enhancements to National Plan apply manpower and technology Section 2014-2016 2017-2019 2020-2023 TOTAL $M Healthcare services 83 Essential medicines Micronutrient deficiencies Health care delivery innovations 95 20 200 $398M Problem Action Plan Implementation 16
  17. 17. Multifaceted, essential roles of Community Health Workers Employment • Recruit from schools and community • Target = ~10,500 nationwide, 50% in rural areas Problem Action Plan • Screening & referrals • Home visits • Case management Logistics Implementation Administration • Electronic/ mobile records (OpenMRS jr.) • Monitoring and evaluation • Health education and communityspecific demonstrations Education 17
  18. 18. Biological factors contributing to cholera V. Cholerae, El Tor introduced U.N. MINUTSAH Low pre-existing immunity Malnutrition ENDEMIC CHOLERA Problem Action Plan Implementation 18
  19. 19. Existing National Plan: biological Section 2014-2016 2017-2019 Epidemiological surveillance Microbiology research Research capacity building 2020-2023 TOTAL $M 16 5 11 $73 Problem Action Plan Implementation 19
  20. 20. Enhancements to National Plan: Vaccination for health Section 2014-2016 2017-2019 Epidemiological surveillance Microbiology research Research capacity building 2020-2023 TOTAL $M 16 5 11 Vaccines 40 $73 Problem Action Plan Implementation 20
  21. 21. Lack of vaccine supply is the primary barrier Supply Advance commitments Purchasing consortium Allocate Adapt Problem Action Plan Implementation 21
  22. 22. Lack of supply is the primary barrier Supply Allocate Vary coverage targets according to risk Adapt Problem Action Plan Implementation 22
  23. 23. Lack of supply is the primary barrier Supply Allocate Adapt Problem Action Plan Implementation Update based on real-time surveillance 23
  24. 24. Foreseen barriers to implementation Lack of coordinated approach Problem Action Plan Implementation 24
  25. 25. Foreseen barriers to implementation Lack of coordinated approach Inefficient funding streams Problem Action Plan Implementation 25
  26. 26. SWAp maximizes efficiency, accountability, & community involvement Sector-wide Approaches Program (SWAp) Sector Coordination Committee SCC Forum and Working Groups • Discuss NGO activities • Address local issues • Accept New Organizations • Informal setting • Approve funding • Planning and Oversight • Regular meeting • Regular Reports Working Groups Direct Interventions Population • Community funds • Quality assurance • Local interventions • Local labor 26
  27. 27. SWAp integrates national plans with foreign investments SWAp Working Groups SWAp NGOs Local Government Global Funds Problem Action Plan Implementation 27
  28. 28. Foreseen barriers to implementation Lack of coordinated approach Inefficient funding streams Lack of political credibility Problem Action Plan Implementation 28
  29. 29. Justification for Settlements Right to water Right to Health Arbitrary deprivation of life Right to Effective Remedy Universal Declaration of Human Rights Universal Declaration of Human Rights American Declaration on the Rights and Duties of Man American Declaration on the Rights and Duties of Man American Declaration on the Rights and Duties of Man Inter-American Court of Human Rights Violations: Universal Declaration of Human Rights U.N. Human Rights Council Human rights laws: General Assembly U.N. Committee on Economic, Social, and Cultural Rights Negligent oversight of its own forces‟ waters and sanitation Problem Failing to prevent introduction of cholera into Haiti. Lack of infrastructure Action Plan Implementation 8,100 lives claimed by epidemic in Haiti Foreclosed any potential remedy for Haitians who contracted cholera 29
  30. 30. Cholera Recovery Payment Program (CRPP) 1 2 Apologize to Haitian people Form claims commission to appropriate funds 3 Cease involvement by Dec. 2017 CRPP 5 Community funds 4 Payments to families of deceased victims For adult victims: $5,000 For children victims: $1,000 Problem Action Plan Implementation 30
  31. 31. Community Sustainability Fund: key component of CRPP 1 Cease involvement by Dec. 2017 Apologize 5 CRPP 2 Claims commission Community funds 4 3 Problem Payments Action Plan Implementation CSF 31
  32. 32. Guidelines for UN 1 Actuate settlements Problem 2 Restructure SOFA agreements Action Plan Implementation 3 Restructure U.N.‟s legal immunity 4 Create a culture of accountability task force 32
  33. 33. Summary & Highlights Biological: $73M Health system: $398M Environment Social: $130M CRPP:$ 407M • Outcome 1: WASH innovations • Outcome 2: Increase sanitation coverage to 85% of Haiti Social • Outcome 1: Integrated media campaign • Outcome 2: 75% of population understand hygiene Health system • Outcome: Increase primary care access to 60% Environment: $1,986M Biological • Outcome: Immediate vaccination CRPP • Outcome 1: Settlements • Outcome 2: Community fund 33
  34. 34. Thank You! Mesi! Questions? Kesyon? 34
  35. 35. Appendices 35
  36. 36. Appendix: Risk Analysis Corruption and Inefficiency risk financial losses Natural Disasters and Disaster risk Epidemics Inadequate funding Financial risk Problem Action Plan Implementation • International Control • Personal Exchange • Local Oversight • Community Fund • Improved Infrastructure • Conduct Guideline • • Long term oversight Supporting SWAp funds 36
  37. 37. All published studies predict sustained cholera transmission • Five independent studies estimate Ro > 1; this is consistent with sustained (endemic) cholera transmission over the long-term (>10 years) Estimates of Reproductive Number (Ro) for cholera in Haiti 2.0 (Bertuzzo et al) 2.6 (Chao et al) 1.06 – 1.73 (Chunara et al) 1.04 – 1.51 (Chunara et al) 2.1 – 2.9 (Tuite et al) (Ro < 1) Elimination Ro = 1 (Ro > 1) Endemic • Several experts agree with this conclusion, e.g., “A decline in cholera prevalence in early 2011 is part of the natural course of the epidemic, and should not be interpreted as indicative of successful intervention.” (Andrews and Basu 2011); “Endemic cholera to continue for many years…unless a coordinated effort is mounted “ (Sack 2011) 37
  38. 38. Derivation of projected cholera incidence • Based on an assumption of a constant, steady-state level of cholera incidence • There is a close relationship between access to improved sanitation and cholera incidence, as shown in the graph below. We extrapolate the predicted cholera incidence for Haiti based on its position on this graph. Cholera incidence vs. % of population lacking sanitation access for 66 countries with endemic cholera Annual cholera incidence (per 1000 persons) 6 R² = 0.1703 5 4 Haiti 3 2 1 0 0 10 20 30 40 50 60 70 80 90 100 % of population without access to improved sanitation • Haiti currently has 74% of the population lacking access to improved sanitation; extrapolating from the curve above, we estimate a base case annual cholera incidence of 1.5 cases per 1000 people • We use lower bound and upper bound estimates of 1 and 2cases per 1000, respectively; noting that countries of similar sanitation levels fall in this incidence range • Cholera incidence data from: David Sack. “Cholera Burden of Disease Estimates” • Sanitation estimates from: WHO + UNICEF Joint Monitoring Programme for Water and Sanitation 38
  39. 39. Mathematical model for quantifying deaths and costs due to cholera 10% 75% 90% 75% 25% 25% 10% 90% 39
  40. 40. Mathematical model for quantifying deaths and costs due to cholera: Assumptions • • • • • • • • Mortality rate : 1% 75% of all infections receive treatment 75% of all requiring treatment are hospitalized Non-treated and treated cases result in lost workdays, hospitalized days, and ambulatory clinic visits (see specific assumptions on previous slide) Number of years of lost life due to cholera calculated as: (0.8 x [country life expectancy – 15]) + (0.2 x [country life expectancy – 30]) Costs of each hospitalized day to healthcare system: $50.68 Costs of each clinic visit to healthcare system: $9.66 Value of lost life and missed workdays calculated based on per capita annual ($460) and daily GDP, ($1.26) respectively Assumptions based on And WHO-CHOICE 40
  41. 41. Cost-effectiveness and real world efficacy of vaccines in Haiti Field trials have shown efficacy of 66% (Trach et al; Vietnam), 50% (Thiem et al; Vietnam), and 67% (unpublished interim analysis; Kolkata, India) 41
  42. 42. Elimination will require more intensive intervention in some areas Estimates of Reproductive Number by department Mukandavire et al (2013) 42
  43. 43. Elimination will require more intensive intervention in some areas Estimates of Necessary Vaccine coverage to achieve Ro < 1 Department Vaccination Coverage Resulting in <1 Haiti[Country] 45.4 Artibonite 79.5 Centre 34.3 Grande Anse 27.2 Nippes 6.9 Nord 44.4 Nord Ouest 36.4 Nord Est 38.9 Ouest**[Ouest] 19.9 Port-au-Prince[Ouest] 60.5 Sud 39.5 Sud Est 18.3 Ouest 54.2 Mukandavire et al (2013) 43
  44. 44. Projected shortfall of oral cholera vaccine (internationally) International Vaccine Initiative. “An Investment Case for Accelerated Introduction of oral cholera vaccine” 44
  45. 45. Appendix: Existing Strategies • National Plan for Elimination of Cholera in Haiti (2013-2022) • U.S. Embassy partnership framework to support Haiti‟s health strategy (2012-2017) • Haitian Ministry of Health Director‟s Plan (2012-2022) 45
  46. 46. Appendix: Haitian Healthcare System Overview • 7.9% of GDP on health expenditures vs international Abuja target of 15% • Major impediments to health care • Over 40% lack access to health care • Few health care personnel relative to residents • Nature of funding – 21% public; 79% private • NGO/ INGO/ Bilaterals/ Multilaterals provide services in tandem and sometimes primary to MSPP • Mixed format of delivery in rural versus urban areas • Geographic, environmental differences in burden of disease and proximity to health care facilities • Health insurance, where existent, is mainly private • Economics need to shift to allow for sustainable health care system 46
  47. 47. Appendix: Overarching health system problems: not just cholera Cholera is the latest manifestation of the overarching problems, not the problem itself 47
  48. 48. Appendix: Reducing NGO Duplication • Currently, few barriers to NGO/ IGO/ etc. entry into Haiti • Equal information: Use interactive, real-time mapping to showcase where health care service deficits exist and what kinds of services are needed • Pop. Count • Disease prevalence • Other key statistics • Encourage NGO/ IGO entities to specialize and collaborate • • Rather than 900+ NGO/ IGO entities doing a little bit of everything, simplify stream of major NGOs to those with long-term, demonstrable successes and stakes in Haiti and incentivize their subcontracting with smaller NGOs to do specialty work System of major NGOs will simplify accountability 48
  49. 49. Appendix: Targeted geographic intervention Estimates of Reproductive Number by department 49
  50. 50. Appendix: Priority zones for WASH Intervention 50
  51. 51. Appendix: Vaccination is cost-effective Problem Action Plan Implementation 51
  52. 52. Appendix: Highlights of current national plan for elimination of cholera Environmental: Increase water/sanitation coverage to 85% of population Health systems: Increase primary care access to 80% from 46% Biological: Better epidemiological surveillance Social: 75% of population understanding hand washing importance • Construction • Chlorination • Economic self-sufficiency • Healthcare facility strengthening • Oral rehydration points • Collaborations between public/private/NGOs •Cholera vaccination campaign •Compulsory notification system •Routine microbiological study • Hygiene practices and national standards • Multipurpose community agents • Local community health clubs 52
  53. 53. Appendix: Timeline of results for 2022 plan End of 2014 Annual cholera incidence rate from 3% to less than 0.5 -Intensify health promotion -High-level committee carries out monitoring and evaluation functions, advocate strengthening regulatory/legal frameworks, admin/management procedures -Prioritize mountainous rural villages and communities where there is shortage of health facilities and to protect welfare (Artibonite, central and western with hotspots such as Western Grande Anse and Aquin, border areas) End of 2017 Reduced to less than 0.1% -Regularly chlorinated/monitored all public water supplies, -All national research labs functional and generate surveillance data End 2022 Reduced to less than 0.01% -Access to potable water and sanitation at least average level of Latin America and Carribean -Strong lab surveillance component -75% of general population have knowledge of prevention measures 53
  54. 54. Appendix: National Health Plan summary Areas Water and Sanitation Aims by 2022 -Increase coverage of access to 85% of population -Collect solid waste to 90% in port-au-prince and secondary cities to 80% Current situation/what has been done -Coverage of water supply (50% in urban and 30% in rural, high leakage in water supply networks of 90%) -Certain cities not included in previous reform framework -No specific legal framework for management of solid waste in Haiti -Only 8.5% connected to water distribution systems, 32% uses water from rivers, -10% of urban defecate openly, 50% of rural defecate in open areas -Fragmentation difficulties -Loss of trained and qualified staff to funding providers and NGOs Measures to solve -Construct and repair water supply networks, water supply for rural -Chlorination of water supplies -Promote economic self-sufficiency using microcredit funds Public health access -Increase % with access to primary healthcare for 46% to 80% -Increasing no of physicians and nurses per 100,000 population -47% of the population has no access to health services and that about 80% has access to traditional medicine -The public sector represents 35.7% of health infrastructure the mixed private sector 31.8%, and the private sector 32.5%. -Treat cholera like all other diseases -More health care facilities, strong community component -Oral rehydration points -Collaborate with pharmacy directorate -Cholera vaccine campaign by MOH Epidemiological surveillance Strengthen epi surveillance for timely detection -Strengthened surveillance through biological confirmation -Steering and coordination role of ministry of public health and population. -Rapid response and implementation teams created and stationed -Compulsory notification system for cholera -Research on outbreaks, routine collection and analysis for microbiological study -Structure implementation for emergency response to all events (capacity strengthening) Promotion of health and food hygiene 75% of general population understand importance of washing hands after defecating and before eating -Operational research -Build ,maintain and expand by religious orgs, NGOs and youth groups -Private sector collaboration -Media, comm. Radio networks -Hygiene practices, vigilance of population, national standards -Multipurpose community agent, one in every 500-1000 in at-risk areas -Local community health clubs 54
  55. 55. Appendix: Cost breakdown Section Environment Environment Environment Environment Health system Health system Health system Health system Biological Biological Biological Biological Social Social Social Social CDRP CDRP CDRP Action Plan Water supply Wastewater and excreta treatment DINEPA strengthening Waste collection and treatment Healthcare services Healthcare innovations Essential medicines Micronutrient deficiencies Epidemiological surveillance Microbiology research Research capacity building Vaccines Health promotion Hygiene practices Institutional strengthening Integrated social media campaigns Settlements Future settlements/emergencies Community fund TOTAL $M 825 468 224 470 83 200 95 20 16 5 11 40 54 19 36 21 7 100 300 $3B 55
  56. 56. Appendix: Towards a better framework for peacekeeping 4 1 STEP Actuate reparation 1 for victims 1. Appoint claims commissioner per the 2. 3. 4. 5. requirements of paragraph 55 in SOFA Create claims commission to pay victims Apologize to Haitian people Create guidelines for claims for future Community funds and overarching goal of health 3 STEP 2 STEP 2 Restructure SOFA agreements Ensure that SOFAs are followed in all following missions Allow for more accountability by third parties 3 Restructure U.N.‟s legal immunity Eliminate legal immunity of United Nations and establish a system of accountability 4 STEP 4 Establish long-term accountability Third-party accountability is necessary to hold U.N. accountable 56
  57. 57. NGOs Appendix: Implementation stakeholders Provide supplies and technical support for cholera relief UNITED NATIONS Raise funds for MSPP and relief Appoint claims commissioner and disburse claims Support Haitian government Apologize to Haitian people Ensure peacekeepers are accountable for actions NATIONAL GOVERNMENTS Haiti – Fund and supply treatment centers; demand claims from U.N. WHO and Pan-American Health Organization United States – Fund treatment and MSPP plan, manage claims Aid funding of MSPP Others – fund treatment and MSPP Provide assistance to MSPP 57
  58. 58. Appendix: Community Building Education-to-Employment Pipeline 01. RECRUITMENT 02. ENGAGEMENT • Via community and education system, NGOs recruit qualified Haitians to work across generalized & specialized job types • Scholarships and fellowships for highdemand talent • Train-the-trainer model for long-term capacity building and sustainability • Three-year minimum commitment for underserved areas • Employ local experts whenever possible • 1:4 target NGO to Haitian hire ratio (1:10 for highly specialized jobs) • Community-oriented, “By Haitians, for Haitians” culture 03. RETAINMENT • Over time, transfer jobs in key areas to local agencies 58
  59. 59. Appendix: 182% ROI on Health Care Infrastructure Investments 3% 3% 4% For every $1 invested in health care infrastructure, the Haitian economy gains $1.82 across multiple sectors. 5% 6% 39% 7% Rental Housing Teaching Manufacturing Transportation Food Commerce Other Industry Health ROI 33% Source: PIH 59
  60. 60. Appendix: SWAp ensures compliance with international NGO governance best practices • Ownership requires national development strategies to be incorporated into operations. • Alignment entails that aid flows are correlated to national priorities, aimed at strengthening capacity and employing local procurement systems, while avoiding creating parallel structures. • Harmonization implies that implementing agencies use shared analysis and programming to avoid overlap. • Management encourages a results based, and transparent system for assessing progress against national development goals. • Accountability ensures that partner countries implement agreed commitments on aid effectiveness. Ownership Alignment Accountability SWAp Harmonization Management 60
  61. 61. Appendix: SWAp Program in Mozambique management costs Family and Reproductive Services Primary Care Health policy & admin. management 4 5 Personal Education and Training 3 24% 2 5 STD control (including HIV/AIDS) Population policy & admin. management 1 61
  62. 62. Appendix: The Overall Risks are Moderate 3 -Corruption and 1 financial losses - Natural Disasters 2 and Epidemics 2 3 -Inadequate funding 1 62
  63. 63. Appendix: Community Sustainability Fund: supports local projects, builds capacity, and responds to emergencies 1 • Finance public health and medical training for Haiti Nationals • Provide direct funding to local project on the ground 2 • Require public works in Haiti • Finance grants for local government projects • Work to minimize brain-drain • Support public and private entrepreneurship • Improve national labor force • Build economic resilience and diminish unemployment • Empower local communities CSF 4 • Ensure rapid response in case of emergencies • Support local relief efforts • Respond to extreme weather and seasonal events • Provide safeguards against international mishaps • Provide a large endowment fund • Ensure support for long-term projects • High growth potential with efficient saving and investment • Empower local economy in the global market • Reduce dependence on foreign donations 63 3
  64. 64. References • • • • • • • • • • • • • • • • • • • • • • • • Haitian Director of Health Plan for 2012-2022,… National Haitian American Health Alliance report on State of Population Health in Haiti (October 2012), Haitian epidemiological map of weekly cholera incidence (1st week, January 2014), PAHO Haiti website,… UN Update Report on cholera in Haiti (November 2013), UN Fact Sheet on Cholera in Haiti (December 2013),… Haitian Epidemiological Map of Cholera incidence (January 2014), Haitian Epidemiological Map of Weekly Cholera incidence by Commune (January 2014), “Electronic Medical Record systems in developing countries,” World Health Organization (2007),,%20EHR%20Systems%20in%20Developing%20Countries.ppt Republic of Haiti, Ministry of Public Health and Population (2012). “National Plan for the Elimination of Cholera in Haiti 2013-2022.” Gelting et al. (2013) Am J Trop Med and Hyg, Lane MD et al. (2010), Sanitation and Health. PLoS Med 7(11): e1000363. OpenMRS jr. (2013) “Mobile Data Collection Project.” Hôpital Albert Schweitzer (2012). “Remote Data Collection Update.” Partners in Health (2013). “Open-source EMR: A New Model for Evidence-based Health Care in Haiti.” Washington Post Editorial Board (2013). “The United Nations‟ Duty in Haiti‟s Cholera Outbreak.” Transnational Development Clinic, Jerome N. Frank Legal Services Organization, Yale Law School, Global Health Justice Partnership of the Yale Law School and the Yale School of Public Health and Association Haitïenne de Droit de L‟Environnment (2013). “Peacekeeping without Accountability: The United Nations‟ Responsibility for the Haitian Cholera Epidemic.” Nienaber G. (2011) “Cholera Petition Suggests UN Caused „Involuntary Genocide‟ in Haiti.” LA Progressive. The Organization of American States (2013). “Reform of the Inter American Human Rights System must not weaken its capacity to protect victims.” United Nations website. “MINUSTAH: United Nations Stabilization Mission in Haiti” Bertuzzo, E. et al. Prediction of the spatial evolution and effects of control measures for the unfolding Haiti cholera outbreak. Geophysical Research Letters 38, L06403 (2011). International Vaccine Initiative. “An Investment Case for Accelerated Introduction of oral cholera vaccine” Tuite, A. L. et al. Cholera epidemic in Haiti, 2010: Using a transmission model to explain spatial spread of disease and identify optimal control interventions. Ann. Intern. Med. 154,293–302 (2011). Chunara, R., Andrews, J. R. & Brownstein, J. S. Social and news media enable estimation of epidemiological patterns early in the 2010 Haitian cholera outbreak. Am. J. Trop. Med. Hyg. 86, 39–45 (2012) 64
  65. 65. References (Continued) • • • • • • • • • • • Sack, D. “Cholera Burden of Disease Estimates” WHO + UNICEF Joint Monitoring Programme for Water and Sanitation Infectious Disease Cost Calculator WHO-CHOICE Ivers LC, Teng JE, Lascher J, Raymond M, Weigel J, Victor N, Jerome JG, Hilaire IJ, Almazor CP, Ternier R, Cadet J, Francois J, Guillaume FD, Farmer PE. Use of oral cholera vaccine in Haiti: a rural demonstration project. Am J Trop Med Hyg. 2013 Oct;89(4):617-24. Mukandavire Z, Smith DL, Morris JG Jr. Cholera in Haiti: reproductive numbers and vaccination coverage estimates. Sci Rep. 2013;3:997. doi: 10.1038/srep00997. Epub 2013 Jan 10. Chao DL, Halloran ME, Longini IM Jr. Vaccination strategies for epidemic cholera in Haiti with implications for the developing world.Proc Natl Acad Sci U S A. 2011 Apr 26;108(17):7081-5. doi: 10.1073/pnas.1102149108. Epub 2011 Apr 11. Sack DA. How many cholera deaths can be averted in Haiti? Lancet. 2011 Apr 9;377(9773):1214-6. doi: 10.1016/S0140-6736(11)60356-5. Epub 2011 Mar 15. Andrews JR, Basu S. Transmission dynamics and control of cholera in Haiti: an epidemic model. Lancet. 2011 Apr 9;377(9773):1248-55. doi: 10.1016/S0140-6736(11)60273-0. Epub 2011 Mar 15. Thiem VD, Deen JL, von Seidlein L, Canh do G, Anh DD, Park JK, Ali M, Danovaro-Holliday MC, Son ND, Hoa NT, Holmgren J, Clemens JD. Long-term effectiveness against cholera of oral killed whole-cell vaccine produced in Vietnam. Vaccine. 2006 May 15;24(20):4297-303. Epub 2006 Mar 20. Trach DD, Clemens JD, Ke NT, Thuy HT, Son ND, Canh DG, Hang PV, Rao MR. Field trial of a locally produced, killed, oral cholera vaccine in Vietnam. Lancet. 1997 Jan 25;349(9047):231-5. PubMed PMID: 9014909. 65