Multiple Hurdles in Treating Lymphatic Filariasis –A “Disease of the Poor” in Haiti.
Z. Nackerdien
Lymphatic Filariasis – The Need for Treatment and the University of Notre Dame Program
Beset by the plagues of poverty, political instability and infectious diseases, Haiti remains on the world’s radar as a place of ongoing suffering. Headlines skim the surface of its promising origins as the world’s first black-led republic,1 and linger on the more familiar tales of political violence under the leadership of past presidents, notably the Duvaliers (“Papa” and “Baby Doc”) and Jean-Bertrand Aristide. As if political disasters were not enough, Haiti has had to deal with an alphabet soup of hurricanes, storms, earthquakes and tsunamis recorded as early as 1770.1 Compounding the country’s problems, is the lack of sanitation and an inadequate health infrastructure which have created a perfect breeding ground for infectious diseases. Among these scourges, lymphatic filariasis (LF), a mosquito-transmitted parasitic disease, is known to be endemic to the region and is a leading cause of permanent disability worldwide.2, 3 Viewed as a remnant of the slave trade, this disease occurs mainly in Haiti in the Western hemisphere, where at least 10% of individuals are symptomatic and more than half the population in high transmission areas could be asymptomatic carriers.4
Although the disease is seldom fatal, the passage and procreation of the roundworm, Wuchereria bancrofti, wreaks havoc to the lymphatic system of affected individuals. 4 Threadlike worms lurk in their favorite nesting areas (breasts, genitals and legs),5 releasing millions of baby worms into the blood and causing lymphedema in many affected individuals. The one-two combination of untreated parasitic and accompanying microbial infection cause the debilitating and disfiguring condition of elephantiasis. Fortunately, individuals and health organization have waged an ongoing war against this emblematic “disease of the poor.” One such effort is the LF-elimination initiative directed by Father Tom Streit, affectionately known as Pere Tom,4 who directs the program under the auspices of the University of Notre Dame (UND). Sarah Craig, the program manager, estimated that there are about 45 people currently engaged in efforts in Leogane , a coastal town, as well as offices and the Hopital Sainte Croix in the capital, Port Au  Prince. Together with other researchers in Haiti, it had been determined that the only option for effective LF elimination was mass drug administration to the local population for the duration of the worm life cycle i.e. 5 years. 4 The UND initiative in partnership with IMA World Health and in support of the Haitian government had in fact achieved its goal of 5.2 million treatments per annum in the 2009/2010 treatment cycle. In 2008, 50 of the most at-risk 140 communities were treated for this disease using the WHO-recommended approach of mass drug administration (MDA) with drugs that target both LF and intestinal worms (S. Craig, personal communication). 
Earthquake aftermath
Located on the western side of the island of Hispaniola, Haiti is perched on a fault zone predicted in 1979 to have the highest probability of rupturing into a big quake.7The date, January 12 2011, marks the one-year anniversary of the devastating earthquake which hit this impoverished nation and its painful consequences unfolded in television images and stories of untold suffering and death. In addition to killing as many as 300 000 people, toppling buildings and leaving 1.5 million homeless,6 this earthquake slowed the LF program and many other health initiatives in the country. Moments before the event, UND workers and their collaborators were enjoying drinks on the fourth floor of a Port Au Prince hotel on that fateful day. Ms. Craig recalled feeling the building collapse until “we ended up somewhere between the first and second floor with rubble beneath us.” The survival of the workers and heroic relief efforts by others are outlined in a Science article4 and further described on the UND web site.8
By January 20 at least 52 4.5-rated aftershocks had been reported. Like other health initiatives in the country, the program switched immediately from research to disaster management mode. Leogane, eighteen miles away from Port Au Prince and near the epicenter of the quake which registered 7.0 on the Richter scale, counted 30 000-40 000 among its dead and 80-90% of its buildings were completely decimated.9 Medical supplies rapidly dwindled as the staff treated thousands of hungry, dehydrated and wounded Leogane residents. It was the UND staff on the ground that facilitated the transformation of a local highway into a makeshift landing strip so that much-needed additional supplies could be flown in to save lives. Against a distant backdrop of debris and growing refugee camps, different medical teams worked feverishly to treat the traumatized residents. Similar stories of suffering and medical relief echoed across Port Au Prince.
Taking care of the injured and providing humanitarian relief proved only to be the beginning of the new challenges facing the UND initiative and other health programs operating in this country. Cholera, all too familiar in developing countries as a disease transmitted mainly through contaminated water and food, provided an unexpected new challenge. This disease, first reported on  21 October in the rural Artibonite region far away from Port Au Prince, spread like wildfire through the country with 121,518 cases, resulting in 63,711 hospitalizations and 2,591 deaths, reported as of December 2010.10 Crowded refugee camps, a population with no immunity against the microbe and a teetering healthcare provided the fuel for the cholera epidemic. Politics inevitably crept into containment efforts once the microbe was genetically matched with a South Asian strain. UN peacekeeping troops from Nepal were accused of being carriers of this virulent strain, precipitating riots against the UN and further impeding medical relief efforts.6 The rationale that the epidemic was imported flies in the face of expert opinion that Vibrio cholerae likely spread via the environmental route.11 This assessment is based on knowledge that the microbe, normally resident in low numbers in brackish water or found in association with small crustaceans in rivers and lakes, can proliferate in the presence of environmental stimuli such as increasing water temperatures and nutrient levels causing zooplankton blooms. Locals ingesting the water and poor sanitation facilitate the spread of the disease.11  
Cholera – A Dire Blow to the Program
Regardless of debates about the origins of the epidemic, the reality is that the LF program faces a formidable obstacle in cholera. Experts predict that cholera is likely to persist in Haiti, with the country facing 100 000 cases in the next few years, given its low ranking on the socioeconomic development scale.11 The current global cholera vaccine supply of ~ 100 000 is inadequate to protect all Haitian citizens. Since medications are consumed with local water to keep costs at a minimum, it is perhaps understandable that the Haitian government has asked the LF program to halt medication distribution due to the cholera outbreak. Thus, from a public health standpoint, cholera damaged the program far more than the earthquake. One estimate given was that 5-10 years would be needed to put an infrastructure in place to deal with the country’s health woes. Post-election riots may prolong the journey towards economic and health stability. 
Dateline NBC featured the heroic efforts of “Remote Area Medical” to provide some Haitians with cholera medicines (Remote Area Mountain Medical: http://insidedateline.msnbc.msn.com/_news/2011/01/05/5773247-jan-9-rescue-in-the-mountains). While these heroic efforts bear testament to the depths of human compassion, sustainable solutions are being sought for the plight of the Haitians. Chlorinated water and innovative biosand filter projects devised by the Clean Water for Haiti program (http://www.cleanwaterforhaiti.org/) may provide part of the answer, but each approach is subject to the need for additional funding. Given its commitment and successful public health track record in the country, the UND and its collaborators are seeking additional financial resources to expand the scope of the neglected tropical disease program in order to improve the overall quality of life of the Haitian people. 
REFERENCES
1.	Haiti country profile. (http://news.bbc.co.uk/2/hi/americas/country_profiles/1202772.stm)
2.	WHO. World Health Report. Geneva: World Health Organization.
3.	Beau de Rochars MV, Milord MD, St Jean Y, Desormeaux AM, Dorvil JJ, Lafontant JG, et al. Geographic distribution of lymphatic filariasis in Haiti. Am J Trop Med Hyg 2004;71(5):598-601.
4.	Roberts L. Relief among the rubble. Science 2010;327(5966):634-637.
5.	Reynolds M. Blessed are the healers
6.	Fraser B. Haiti still gripped by cholera as election looms. Lancet 2010;376(9755):1813-1814.
7.	Kerr RA. Seismology. Foreshadowing Haiti's catastrophe. Science 2010;327(5964):398.
8.	University of Notre Dame - Haiti Program
9.	Demas N. Wes, Jean Marc and the Fighting Irish of Leogane!
10.	Update on cholera --- Haiti, Dominican republic, and Florida, 2010. MMWR Morb Mortal Wkly Rep 2010;59(50):1637-1641.
11.	Enserink M. Infectious diseases. Haiti's outbreak is latest in cholera's new global assault. Science 2010;330(6005):738-739.