C OALITION FOR CHOLERA PREVENTION AND CONTROL THIRD ANNUAL MEETING SUMMARY REPORT 22-23 October 2014 Decatur, Georgia

Coalition for Cholera Prevention and Control Third Meeting Task Force for Global Health Decatur, Georgia October 22-23, 2014 Report Table of Contents Executive Summary

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I.

Welcome and Introductions

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II.

Global Situation of Cholera – Status of Oral Cholera Vaccine Stockpile

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III.

Updates from the Field 1. Centers for Disease Control and Prevention 2. DOVE Project 3. GAVI 4. IDEA 5. International Centre for Diarrhoeal Disease Research, Bangladesh 6. International Medical Corps 7. Médecins sans Frontières 8. UNICEF (Including International Rescue Committee)

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IV.

Panel on Vaccine Development, Manufacture and Supply 1. International Vaccine Institute 2. PaxVax 3. Sanofi-Pasteur 4. Eubiologics Company

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V.

Coalition Charter – Discussion and Ratification

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VI.

The Global Task Force on Cholera Control and the Coalition Identification of Appropriate Areas for Collaboration

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VII.

Country Presentations and Reports from work groups

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1. 2. 3. 4.

People’s Republic of Bangladesh Republic of Haiti Republic of Mozambique Republic of Uganda

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VIII.

Report on UN Response to Independent Expert Review Panel on Haiti Outbreak Response

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IX.

Advocacy and Resource Mobilization 1. Rotary Club Collaboration with the Coalition 2. Resource Mobilization for Cholera Prevention and Control

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X.

Planning the way forward

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Annexes 1. Meeting Agenda 2. Participant List 3. Coalition Charter 4. Global Task Force on Cholera Control Terms of Reference 5. UN Follow-up to Recommendations of the Independent Expert Review Panel 6. Institute for Justice and Democracy in Haiti Letter 7. Rotary Funding – Project Resources

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Acronyms ACIP AWD CCPC CDC CFR CPHL CTC DAC DINEPA DOVE DRC EPI FDA GAVI GHESKIO GOARN GTFCC HIV Icddr,b IDB IDEA IEDCR IER IFRC IMC IRC ISDR IVF IVI MDG MINUSTAH MOHFW MSF MSPP OCV ODA OIM/IOM ORS PAHO

Advisory Committee on Immunization Practices Acute Watery Diarrhea Coalition for Cholera Prevention and Control Centers for Disease Control and Prevention Case Fatality Rate Central Public Health Laboratory (Uganda) Cholera Treatment Center Development Assistance Committee Direction Nationale de l’Eau Potable et de l’Assainissement (Department of Water and Sanitation – Haiti) Delivering Oral Vaccine Effectively Democratic Republic of Congo Expanded Program on Immunization Food and Drug Administration Global Alliance for Vaccines and Immunizations Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections Global Outbreak Alert and Response Network Global Task Force on Cholera Control Human Immunodeficiency Virus International Centre for Diarrhoeal Disease Research, Bangladesh InterAmerican Development Bank Initiative against Diarrheal and Enteric Disease in Africa and Asia Institute of Epidemiology and Disease Control and Research Independent Expert Review International Federation of the Red Cross and Red Crescent International Medical Corps International Rescue Committee Integrated Disease Surveillance and Response Intravenous Fluid International Vaccine Institute Millennium Development Goal United National Stabilization Mission in Haiti Ministry of Health Family and Welfare Médecins Sans Frontières Ministry of Public Health and Population Oral Cholera Vaccine Overseas Development Assistance International Organization for Migration Oral Rehydration Solution Pan American Health Organization

PCR PSI RDT TB UN VIS WASH WHO

Polymerase chain reaction Population Services International Rapid Diagnostic Testing Tuberculosis United Nations Vaccine Investment Strategy Water Sanitation and Hygiene World Health Organization

Executive Summary The third annual meeting of the Coalition for Cholera Prevention and Control was held on October 22-23, 2014. The meeting opened with a report of the global cholera situation and updates on progress from Coalition members. A draft charter for the Coalition was discussed and ratified by members. This was followed by a discussion of appropriate areas for collaboration between the Coalition and the Global Task Force on Cholera Control (WHO). The two-day meeting primarily focused on assessing the status of cholera in four individual countries with recommendations on priority action items from working groups composed of a wide range of experts. Representatives from Bangladesh, Haiti, Mozambique and Uganda each gave a brief overview of the cholera burden of disease, past and present disease character, scope and trend, governmental and non-governmental capacity to respond, and successes, challenges and barriers to effective prevention. Coalition members were divided into four work groups organized by country and charged with identifying key issues and barriers, and potential opportunities, resources and approaches for accelerated improvement in cholera prevention and control efforts for each country. The work groups reported back in plenary session with specific recommendations and concrete actions that the Coalition could take. Dr. Alejandro Cravioto reported on the findings of the Independent Expert Review Panel on the United Nations’ response to the Haiti cholera outbreak in 2010. In order to address advocacy and resource mobilization, three Rotary International members talked about how their organization could support cholera control and prevention efforts and how Coalition members could leverage the considerable resources they have to offer. This was complemented by an overview of other potential resources for cholera control operations and Coalition activities. Finally, Dr. Hinman wrapped up the meeting with a discussion of next steps. In the coming year the Coalition will liaise with country partners in Bangladesh, Haiti, Mozambique and Uganda and look for opportunities to advance the countries’ cholera prevention and control objectives where possible using Coalition technical resources. The Coalition will continue to support and complement the Global Task Force on Cholera Control, carry out advocacy and resource mobilization, and seek support for the Coalition beyond February 2016.

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I.

Welcome and Introductions

Alan Hinman, Co-Investigator for the Coalition (The Task Force for Global Health), welcomed all participants and outlined the meeting objectives: • Update Coalition members on the current situation with cholera globally • Provide a platform for Coalition members to share their current activities • Discuss the relationship between the Coalition and WHO’s Global Task Force on Cholera Control • Develop an approach for doing a status assessment of cholera prevention at the level of individual countries, which would include four countries sharing the current status of their cholera situation followed by intensive work group sessions to identify priority action items • Discuss possible Coalition activities in the area of advocacy and resource mobilization • Develop a Coalition plan of action for 2015 Louise Ivers, Co-Investigator (Partners in Health), noted that the Haiti cholera epidemic that has claimed more than 8000 Haitian lives came to the world’s attention exactly four years ago. Despite much progress, there is still considerable work to do, however the Ebola epidemic has now taken the spotlight off cholera. II. Global Situation of Cholera – Status of Oral Cholera Vaccine Stockpile Stephen Martin, Medical Officer, Department of Pandemic and Epidemic Alert and Response, World Health Organization The oral cholera vaccine (OCV) stockpile created in June 2013 has contributed to a new feeling of optimism about cholera, yet there remains tremendous disparity between the number of cholera cases reported by ministries of health and global estimates of cholera cases. In 2013 only 15 countries reported cases. There is some evidence that the stockpile is encouraging more accurate diagnosis and reporting. Bangladesh, India and Pakistan have increased the number of cases reported. In 2014, 63,000 cases and 1300 deaths have been reported to date. The OCV stockpile provides access to two million doses of Shanchol annually for use in outbreaks and humanitarian crises. There is also limited use of vaccine with short shelf life for pre-emptive campaigns in endemic settings. As of September 30, 633,335 doses were available for deployment, with an additional 514,100 doses expected in the fourth quarter. From June 2013 to July 2014, 1.3 million doses have been released to ministries of health, principally in the Democratic Republic of Congo, South Sudan, Guinea, Ethiopia, Haiti, and Nepal. Approximately half of the distributed doses were used in humanitarian crisis settings with the balance used to control cholera hot spots in endemic settings. As awareness of the stockpile increases, so does the need to manage expectations around vaccine availability and use. In November 2013 the GAVI Vaccine Alliance allocated USD 115 million to fund the OCV stockpile over the next five years. Supply constraints necessitate targeted use of the vaccine. Inability to reach the entire target population during the September 2013 OCV campaign in the DRC illustrates the challenges of vaccine supply constraints.

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GAVI and the Global Task Force on Cholera Control (GTFCC) are developing a standardized framework to determine when and where to use the vaccine and how to prioritize requests. Current decisions are supported by consideration of the following criteria: • Epidemic or humanitarian emergency vs. endemic setting • Water and sanitation status • Implementation plan - national distribution vs. targeted hotpots • Evaluation plan GAVI approval was for use of the stockpile in emergencies, not in hot spots with recurrent seasonal outbreaks. This decision has to be reevaluated for endemic control. Evaluations have been conducted in the DRC and South Sudan but further studies are needed to support wider use of the vaccine. In 2018 GAVI will consider whether to open a window to support use of the vaccine in endemic settings. Further evidence is needed to inform GAVI’s deliberations. Comments and Discussion The stockpile creates a false market by stimulating demand and production. A recent Gates-funded audit found the cost of vaccine production in India was higher than what was charged. There are some concerns that once cholera vaccines are available on the open market, the stockpile could shut down. There are also some encouraging developments. The International Vaccine Institute (IVI) is looking at whether Bangladesh can produce vaccines for local use, and whether Korea can increase its production. The government of Bangladesh is discussing whether oral cholera vaccine should be included in routine immunization. To assure sufficient demand, there will be a need to increase public awareness of the vaccine and to make the vaccine widely available on the local level. III.

Updates from the Field

1. Centers for Disease Control and Prevention Eric Mintz, MD, MPH and Division of Foodborne, Waterborne and Environmental Diseases and Kashmira Date, MD MPH, Global Immunization Division In the last 50 years, the number of cholera cases in the U.S. has ranged from 1 to 100 per year, mostly acquired abroad. There were 48 cases from Haiti between 2010 and 2013, but none to date in 2014. The Haiti epidemic is flattening out, but there are still deaths and hospitalizations, primarily in four departments. The CDC is assisting the Ministry of Public Health and Population (MSPP) with cholera surveillance, laboratory testing and environmental microbiology, and has developed a cholera curriculum for medical schools in Haiti. CDC’s WASH activities in Haiti include studies of water quality and use; wastewater disposal; rehabilitation and disinfection of rural water supplies; promotion of household water treatment and storage; a total sanitation campaign; and support of the Regional Coalition to Eliminate Cholera. The Ministry of Health in Liberia recently asked for help with suspected cholera cases. CDC supplied rapid diagnostic tests and demonstrated that chlorine treatment of water did not yield false negatives. Now there is concern about addressing a dual epidemic of cholera and Ebola. Domestically, there are discussions regarding formation of a cholera work group for the Advisory Committee on Immunization Practices (ACIP).

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CDC’s OCV activities: • In Haiti, providing technical assistance for OCV campaign monitoring and evaluation, with the MSPP, PAHO and UNICEF. • In Thailand, working with the Ministry of Public Health and others to evaluate OCV interventions in refugee camps. • Development of global stockpile monitoring and evaluation framework and guidelines. • Member of several technical advisory boards looking at OCV as part of an integrated strategy. 2. DOVE Project (Delivering Oral Vaccine Effectively) David Sack, Principal Investigator, Professor of International Health, Johns Hopkins University, Bloomberg School of Public Health The DOVE Project is based at Johns Hopkins University, funded by the Bill & Melinda Gates Foundation, and works in collaboration with many organizations, including WHO and UNICEF. Its goal is to ensure populations at risk of cholera benefit from receiving OCV in an appropriate and effective manner. OCV can make a huge impact, if it is produced inexpensively in sufficient quantities, can be provided to the right populations at the right time, and is integrated with WASH and case management. Policy makers will need to learn how and when to use the vaccine and the health system will need to develop a coordinated mechanism to deliver the vaccine properly. DOVE has four objectives: 1) provide research and evaluation support for current and future OCV projects; 2) develop a practical OCV toolkit to guide discussions on use and evaluation of OCV; 3) characterize the epidemiology of cholera in an African setting, and 4) disseminate the results of OCV programs and opportunities. DOVE supports global efforts by providing technical assistance and consultancies to agencies and countries considering use of OCV, providing resources and training materials, and supporting WHO and other agencies with cholera control efforts. DOVE has current projects in Cameroon and Uganda. While there are predictable outbreaks in Bangladesh, in Africa there is more variability in hot spots from year to year. OCV is sometimes cost effective but it depends on a number of variables. Computer models for decision making and vaccine targeting have been developed at Johns Hopkins University. They enable mapping to understand where the cholera burden is and to estimate benefits from different vaccination strategies, such as use of single-dose vaccines in emergencies. DOVE is also involved in laboratory innovations that include a modified dipstick assay to detect cholera in feces using filter paper. 3. GAVI – The Vaccine Alliance Lisa Lee, VMD, MPH, MSc, Consultant In 2013 a GAVI Vaccine Investment Strategy (VIS) analysis looked at periodic campaigns in endemic settings, targeting children ages 1-15. Settings had high incidence and moderate case fatality rates (CFR). The analysis found the cost per death averted was quite high, due in part to high delivery costs. However, there was a lack of surveillance data and questions about herd effects. It’s a targeted strategy, so it is difficult to define the scope and shape of the investment and there is very little data on an optimal strategy for targeting 1-4 year old children. The GAVI board is also concerned about the sustainability of supporting long-term periodic campaigns.

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The objectives of the board’s decision to make a 5-year investment in the global stockpile were to increase demand and incentivize production and supply, improve capacity to control epidemic cholera, and strengthen the base of evidence for reconsideration of investment in OCV for endemic control in the next VIS. To adequately inform the 2018 VIS process, there is a need for robust monitoring and evaluation of any OCV use during the next two years. GAVI secretariat activities included completion of a landscape analysis to identify key issues and questions regarding the VIS. Four areas of research were identified: 1. Identify settings and strategies for delivering vaccine cost effectively and achieving some control in endemic settings. 2. Reduce uncertainty around disease burden and demand forecasts, including detailed mapping of incidence and mortality rates. 3. Reduce uncertainty around vaccination impact, looking for proposals from countries with highly endemic cholera to field test innovative ways to deliver vaccine. 4. Improve product characteristics of the vaccine itself, including development of lower-cost vaccines. 4. IDEA (Initiative against Diarrheal and Enteric Disease in Africa and Asia) Luc Hessel, MD, General Secretary, Enteric Diseases Expert Bureau Asia and Africa IDEA is a network of national stakeholders involved in enteric diseases management who are committed to help define and implement effective measures against cholera in Africa and Asia. IDEA incorporates interaction to share information, experience and best practices, and to increase partnerships and networking; data to provide guidance on strategies and resource allocation; empowerment of local actors to support interventions and facilitate communication; and advocacy to increase awareness and commitment of decision makers. In 2014, IDEA is advocating for national and local policy makers to support three critical interventions as part of a comprehensive strategy: 1. Bringing together all concerned authorities at the highest executive level for additional improvement of current food and WASH interventions to significantly contribute to achievement of the MDGs 2. Establishing and strengthening robust surveillance systems as an investment in public health, the economy, and social welfare 3. Introduction of cholera vaccination as part of a comprehensive and integrated strategy to ultimately eliminate cholera. IDEA proposes the following concrete actions/policies: 1. Develop national action plans in cholera vulnerable countries 2. Support and foster decision makers’ recognition of cholera as a public health issue that can be prevented, controlled and eliminated 3. Ensure provision of safe water, sanitation and hygiene in support of MDG7 4. Establish efficient cholera surveillance systems 5. Support availability, recommendation and use of oral cholera vaccine coordinated with other interventions 6. Improve knowledge and attitudes about cholera among the public. IDEA’s added value is to give a voice to the field through a bottom-up and transversal process; to develop interdisciplinary, multi-sectoral and cross-border approaches to cholera prevention and control;

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and to work collaboratively and synergistically with other international and national groups (e.g., Global Task Force on Cholera Control, Global Alliance Against Cholera). 5. International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) John D. Clemens, MD, PHD, Executive Director The Bangladesh Cholera Epidemiology Center (Dhaka Hospital Surveillance) reported 15,000 cholera patients were treated last year. Most cases arise in urban settings, reflecting increasing urbanization, with many people living in slums with poor water and sanitation conditions. There are several major studies of Shanchol in progress: • A Phase IV cluster randomized effectiveness trial of Shanchol vs. Shanchol plus WASH is focused on determining the impact of a two-dose regimen of Shanchol on severely dehydrating, cultureproven cholera when given either with or without a Behavior Change Communication (BCC) intervention. Vaccine protective effectiveness, after two years follow up, was 53% for the vaccine only group and 58% for vaccine plus BCC, which were comparable. • The Phase III randomized, placebo-controlled trial of a single dose of Shanchol in urban Dhaka slums has enrolled roughly 200,000 non-pregnant individuals, >1 year old. The objective is to determine the protective efficacy of a single-dose regimen of Shanchol against treated episodes of culture-proven Vibrio cholerae 01 diarrhoea during 6 months following dosing. Analysis is about to begin. • A demonstration project of a 2-dose regimen of Shanchol, delivered through the Government of Bangladesh EPI in a rural population of about 30,000, achieved 92% coverage. • Finally, there were temperature stability studies of Shanchol in 580 healthy adult volunteers. At the request of WHO’s Global Outbreak Alert and Response Network (GOARN), icddr,b teams carried out trainings in Jordan, northern Iraq and south Sudan to address cholera outbreaks. 6. International Medical Corps Topher Finley, Manager Foundation and Corporate Relations In 2012 UNICEF, the International Medical Corps (IMC) and the International Rescue Committee (IRC) were funded by the Bill & Melinda Gates Foundation to look at providing OCV in emergency settings. The pilot is focused on the DRC, Cameroon, Chad and Sierra Leone to 1) build capacity of local ministries of health to incorporate OCV as part of an integrated response into their national cholera strategy, 2) plan for a response to a declared outbreak, where government requests support through the OCV stockpile, and 3) document the process to share information about accessing the stockpile and integrating OCV with other activities. In February 2014 activities were initiated in Cameroon with a national workshop conducted by IMC. The organization is providing ongoing technical assistance to the government of Cameroon and other partners related to recent cholera outbreaks in the far north of Cameroon. In the DRC the inquiry process has begun, with a workshop planned for January 2015.

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7. Médecins Sans Frontières Myriam Henkens, MD, International Medical Coordinator Many MSF activities are integrated with other organizations reporting. MSF is conducting field activities including vaccination in Kalemie (DRC) as part of an integrated approach to addressing hot spots and high-risk zones. Overall coverage is quite good, but lower among those >15 years. MSF is currently conducting a vaccination campaign in a Gambela, Ethiopia refugee camp housing South Sudanese. A risk analysis targeted 195,000 people, including refugees and the surrounding host population. The campaign achieved 99% coverage for first dose, and 70% for second dose among refugees, with somewhat lower coverage for the host population. However there were some discrepancies in reporting. Wastage rates were very low (<1%). A third round may be needed to provide a second dose to those who received their first dose during the second round of the campaign. MSF had planned to finalize its cholera guidelines this year, but Ebola may cause delays. 8. UNICEF (Includes International Rescue Committee) Kate Alberti, Senior Programme Specialist, Cholera, UNICEF, New York UNICEF provides resources and tools to support country-specific projects, and supports country progress through a long-term country presence. UNICEF is very active in addressing cholera in West Africa, particularly in lake and river basin areas. Cross-border exchange of information, data and investigation is critical. UNICEF promotes the ‘Sword and Shield” approach, which combines hitting the epidemic hard while implementing prevention components. Prevention components include social mobilization, safe water supply, sanitation, community-led total sanitation, and WASH. Preparedness elements include: training, promotion of cross-border exchanges and investigations, risk assessment, and prepositioning of both WASH and medical supplies. UNICEF emphasizes ending open defecation at the village level and promoting WASH in schools, with a long-term view that goes beyond cholera. Control components include: training and prepositioning supplies; promoting WASH to cholera treatment centers (CTC); household water treatment; social mobilization and hygiene promotion; and coordination. UNICEF supports OCV use as part of prevention and control. Working in partnership with IMC and IRC in West Africa, UNICEF is working with governments to raise awareness on the potential role of OCV in addressing cholera control and prevention, and how governments can access the vaccine. In Chad, UNICEF helped the MOH understand what the vaccine is and why the country would want to use it. UNICEF is currently looking at risk assessment and integration of OCV as part of a national cholera control plan. UNICEF also supported OCV campaigns in South Sudan and Haiti, and has developed a cholera toolkit in French and English. Recent workshops were conducted in Dakar to review the Sword and Shield approach and in the Niger River Basin to develop a roadmap for cross-border collaboration among Niger, Nigeria, Cameroon and Chad. IV.

Panel on Vaccine Development, Manufacture and Supply

1. Sachin N. Desai, MD, Medical Epidemiologist, Development and Delivery, International Vaccine Institute Dr. Desai described the status and results of several Shanchol studies.

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The 5-year efficacy trial (Kolkata 2006-2011)- A randomized placebo-controlled trial (population 66,360 received two doses 2-4 weeks apart) demonstrated 65% cumulative efficacy. Two smaller studies in Kolkata piggy-backed and supported the 5-year trial, a dose interval study and a boosting trial. Immunogenicity data from these three studies provided an evidence base to help support easing the delivery system, For example, the dose interval study found a four-week schedule with Shanchol was not inferior to a two-week trial, with public health implications for flexible dosing. The boosting trial found that a two-dose boosting in an endemic area of Kolkata increased titers similar to a primary series. A one-dose regimen also showed similar titers. The efficacy data help show how to move forward with implementation. A demonstration project in northeastern India showed that it was feasible to deliver the cholera vaccine to 32,000 people using existing public health infrastructure, with 74% effectiveness after two doses. A bridging study in Ethiopia (Addis Ababa 2013) demonstrated robust immunogenicity. The study was designed to gather data from less endemic areas outside of Asia. Analysis of single-dose trial is underway in Dhaka with 205,661 volunteers aged >1 year.

Current vaccines in production through technology transfer: • Shanchol, produced by Shantha Biotech in India, has been prequalified by WHO since September 2011. Two doses are administered 2 weeks apart to subjects >1 year old. IVI current studies are focused on the efficacy of a booster dose given at 5 years, the possible range in duration between the first and second doses, efficacy of a single dose in endemic populations, immunogenicity and safety of the vaccine in infants, and feasibility of co-administration of OCV with other EPI vaccines. • Euvichol is produced by EuBiologics in South Korea. Current studies are focused on improving the bulk formulation. EuBiologics hopes to increase annual production to 25 million doses. • Incepta, manufactured in Bangladesh, provides a high quality vaccine for local use, at ~1 USD /dose. • mORCVAX, manufactured by VABIOTECH (Vietnam), is developing new Good Manufacturing Process (GMP) standards and planning to conduct bridging studies with the goal of licensure in Vietnam by end of 2016 and WHO prequalification by 2018. 2. Laura Efros, PhD, Head of Government Affairs and Public Policy, PaxVax, Inc. PaxVax is a small recently established vaccine company, which is developing single-dose live attenuated cholera vaccine that targets military and travel markets. PaxVax is also focused on creating a developing country market. Immunogenicity studies conducted in 2013 showed the vaccine was well-tolerated and very efficacious. PaxVax plans to file for US licensure in 2015. A Mali study is underway to improve a formulation appropriate for pediatric populations and improve stability to reduce cold chain requirements. 3. Lynn Morgan, Senior Director, Global Immunization Policy, Sanofi-Pasteur Shanchol is an oral ready-to-use liquid vaccine commercially available since 2009, which provides protection with two doses taken two weeks apart. The vaccine, manufactured by Shantha in India, is licensed in 12 African countries, India, Uruguay and Haiti for use in children > 1 year. It is also WHO prequalified. Post-campaign studies on pregnant women who inadvertently received the vaccine have been conducted, but the current recommendation remains not to vaccinate pregnant women. Shantha is studying ways to broaden the populations that can use and benefit from the vaccine. Studies exploring product stability and storage at higher temperatures are currently underway with plans to release a

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modified label early next year. Next steps include supporting Shanchol’s integration in comprehensive approaches to cholera control; simplifying support chain conditions for field use; improving production yield; data generation on other populations, e.g.,<1 year; improving presentation; and building demand for Shanchol to justify more routine usage of the vaccine. 4. Dr. Sue-Nie Park, Vice President, Eubiologics, (by phone from Korea) EuBiologics, a private Korean pharmaceutical company, is developing and manufacturing Euvichol, an oral cholera vaccine for use in developing countries. The company is using production technology transferred by the International Vaccine Institute. Phase III clinical trials carried out in the Philippines, with demonstrated results comparable to Shanchol, are concluding. The company has applied to the Korean FDA for licensure of Euvichol. Licensure is anticipated within the next several months and the company hopes to submit a dossier to WHO seeking pre-qualification. V. Coalition Charter – Discussion and Ratification (Annex 4) David Sack, MD, and Alan R. Hinman, MD, MPH In February 2013 a governance working group was formed (Mark Rosenberg, Roger Glass, Myriam Henkens, Louise Ivers/Paul Farmer, David Sack and Jordan Tappero) to develop the terms of reference and a draft charter to govern the Coalition. The group developed a survey to gather opinions and perspectives from Coalition members on a range of issues impacting cholera prevention and control to determine how the Coalition could make a significant contribution to addressing cholera globally and how to effectively organize the group’s collective efforts. A draft charter was presented for discussion and ratification. Discussion Consensus to ratify the charter was achieved (WHO subsequently indicated its consent). In addition to ratification, the group discussed emerging issues, such as geographic barriers and vulnerable populations (pregnant women, HIV positives, refugees, malnourished and children < 5) that the Coalition should take into consideration, particularly when making recommendations on the research agenda. The Global Task Force on Cholera Control (GTFCC) and the Coalition (CCPC) – Identification of Appropriate Areas for Collaboration Alan Hinman, MD, MPH, and Stephen Martin, MD

VI.

World Health Assembly resolution 64.15 (2011) called on the Director General of the World Health Organization to revitalize the Global Task Force on Cholera Control (GTFCC) and to strengthen its work in this area. The Bill & Melinda Gates Foundation provided funding to the Task Force for Global Health to work with WHO to revitalize the GTFCC. During 2013 and early 2014, WHO, the Task Force for Global Health, and an expert group reflecting a variety of perspectives identified the relevant global stakeholders, conducted in-depth interviews and surveys, and synthesized the recommendations of key stakeholders in a set of draft recommendations submitted to the Director General. The final recommendations accepted by the Director General focused the Global Task Force’s efforts around four objectives (Annex 3). 1. Support the design and implementation of global strategies to contribute to capacity development for cholera prevention and control globally. 2. Provide a forum for technical exchange, coordination, and cooperation on cholera-related activities to strengthen countries’ capacity to prevent and control cholera, especially those related to

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implementation of proven effective strategies and monitoring of progress, dissemination and implementation of technical guidelines, operational manuals, etc. 3. Support development of a research agenda with special emphasis on evaluating innovative approaches to cholera prevention and control in affected countries. 4. Increase the visibility of cholera as an important global health problem through integration and dissemination of information about cholera prevention and control, and conducting advocacy and resource mobilization activities to support cholera prevention and control at national, regional and global levels. In June 2014, WHO convened the first meeting of the GTFCC. Membership will include core member institutions (UNICEF, IFRC, MSF, ICDDR,B, CDC, and WHO) and 12-13 other institutions serving timelimited terms. Working groups in surveillance and epidemiology, OCV, case management, WASH, and communication/social mobilization, led by a member of the GTFCC, are projected to begin meeting before the end of 2014. The Coalition is a member of the GTFCC and will help with recruiting individuals with specific expertise and a range of perspectives to participate in working groups. The GTFCC is also asking for Coalition support in terms of coordination of partners, recommendations and guidance, and ensuring coordination and standardization of approaches at the country level. The GTFCC must start planning for a world with sufficient OCV, incorporating it into an integrated approach to cholera. Discussion focused on the relationship between the GTFCC and the Coalition, comparative strengths of each organization, and where greater clarity is needed. GTFCC membership is for two to three years and no one who has applied has been rejected up to now. The Coalition is an inclusive group and builds on members’ contributions. The structure of the CCPC allows it to be flexible and act quickly when speed is essential. WHO is overburdened, facing great expectations with inadequate resources. With the emergence of Ebola, there is concern cholera will no longer be a priority. The Coalition could take on advocacy and resource mobilization, while the GTFCC could focus on setting guidelines and producing manuals, with support from individual Coalition members. The GTFCC will be working through working groups that will propose guidelines to be submitted through the WHO process, which can be lengthy. Working groups are time limited and focus on specific issues. Parallel organizations create confusion in global cholera efforts. One suggestion was for the GTFCC and the Coalition to merge. Another suggestion was a new name to distinguish between the old and new Task Force. VII. Country Presentations and Reports from Work Groups Representatives from each of four countries – Bangladesh, Haiti, Mozambique and Uganda - gave a brief overview of the cholera burden of disease, past and present disease character, scope and trend, governmental and non-governmental capacity to respond, and successes, challenges and barriers to effective prevention. This information is summarized in the sections that follow as: Background, Current Capacity, and Major Gaps and Barriers. Coalition members were divided into four work groups and assigned to participate in breakout sessions organized by country. Group members collaborated to identify key issues and barriers, and potential opportunities, resources and approaches for accelerated improvement in cholera prevention and control efforts for each country. The work groups reported back in plenary session with specific recommendations and concrete actions that the Coalition could take. The work group reports are summarized in the Recommendations and Concrete Actions sections.

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1. Cholera in the People’s Republic of Bangladesh Presenters: Tajul Islam Abdul Bari, MD, Programme Manager EPI and Surveillance, Directorate General of Health services, and Abdul Kalam Azad, PhD, Assistant Director General, Planning and Development, Directorate General of Health Services, Ministry of Health & Family Welfare Background Bangladesh has the world’s highest population density and is the country most affected by climate change. However it has a good health system with local access to services. Bangladesh’s health improvement is considered a global miracle: 92% of households have access to safe drinking water, there is wide availability and knowledge of oral rehydration treatment, 63.5% have means of safe disposal of human waste, and only 3% practice open defecation. Cholera has existed on the Indian subcontinent for centuries and spread beyond the subcontinent in 1817. It is endemic in south Asia, especially in the Ganges Delta region. Contaminated water and food are the main vehicles of transmission. For a long time, the government hid the existence of cholera to protect the seafood export industry. Outbreaks are seen during floods, cyclones and other natural disasters, when hygiene maintenance and locating safe water and food become significant challenges in affected areas. The most recent outbreaks have occurred in 6 districts of Bangladesh. The cholera response involves the Institute of Epidemiology and Disease Control and Research (IEDCR), the Ministry of Health, Family and Welfare (MOHFW), and the icddr,b. A provisional national plan has been developed. Cholera vaccine production in Bangladesh has begun and can be expanded. There is a need to increase awareness of the vaccine and discuss its inclusion in routine immunization. A positive policy environment in favor of vaccines and other protection measures exists, but the country needs an effective mechanism for identification of cholera cases and subsequent treatment. Current capacity • Diagnostic: The IECDR and icddr,b have culture and rapid diagnostic test capacity that can be expanded to medical college hospitals. Isolation of cholera vibrios from diarrhea cases is done by icddr,b and IEDCR through foodborne illness surveillance and enteric disease surveillance systems. There is potential capacity for cholera reporting at district levels, but currently only diarrheal disease is reported. Extension of diagnostic confirmation to the district and sub-district levels is needed. • Surveillance: The Institute of Tropical and Infectious Diseases and nine cholera surveillance sites (7 district hospitals and 2 medical college hospitals) report annually on estimated cholera cases and percentage of cholera cases among patients with diarrheal disease. Outside this network, there is no cholera case confirmation or culture & sensitivity testing conducted. • Prevention: Strengthening conventional approaches to water and food safety and addressing foodborne diseases remains a priority for cholera control and prevention. • Treatment: All health facilities can treat cholera once diagnosis is made. Major gaps and barriers • Surveillance – gaps in funding, capacity and training • Insufficient case confirmation capacity • Insufficient routine surveillance of city water • Access to improved water • EPI system targets a limited population, i.e., young children and women of childbearing age • Storage capacity and cold chain infrastructure constraints, especially outside of Dhaka

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All vaccines procured via UNICEF must be WHO pre-qualified Insufficient coordination among strong vertical programs

WORK GROUP FEEDBACK Recommendations • Incorporate programmatic perspective and needs in developing and labeling vaccine. • Incorporate clinician and patient feedback on ideal oral vaccine presentation and taste • Use improved surveillance and water testing to identify potential “hot spots” and target specific areas for micro interventions in WASH or vaccine • Help define parameters for rapid response electronic surveillance data • Determine most appropriate and effective vaccination strategies and delivery systems, e.g., geographic and age group targeting; EPI distribution, school-based vaccination, or over-the-counter dispensary. • Conduct a pilot study on alternative delivery systems to enable OTC sales at pharmacies in rural areas • Develop a standardized approach to assessing cholera situation (scorecard) with an alert system/RAG rating • Define high-risk areas at local level, e.g., color coded for immediate local reaction Concrete actions • Improve surveillance and cholera case confirmation to better understand epidemiology for optimal vaccine use • Match Incepta vaccine to user needs • Generate data for GAVI investment decisions Discussion Government involvement in water and sanitation is essential to control cholera and other diarrheal diseases. Despite the high access to improved water sources and knowledge of WASH, flooding and monsoons contaminate water sources. Improved ability to predict to the timing of these events would help. Environmental pollution is also a factor. Forty percent of the population lives in slums, often using open water sources. Even tap water is not completely safe for drinking. Households that cannot afford to boil their water or buy bottled water are at risk. Bangladesh is working to increase the utility of public health surveillance, mapping disease incidence and mortality data to inform targeted vaccination efforts. Such efforts are more cost-effective and efficient than vaccinating the entire population. GAVI is collecting vaccine impact and mortality data on a variety of cholera strains circulating in different parts of Bangladesh. The national health information system is constantly monitoring cholera variants for early warning detection of changing strains and serotypes. There is concern that climate change may increase the potential for new strains of cholera to emerge. Studies will also assess the impact and cost effectiveness of lower-cost delivery strategies, such as school-based distribution and integration with other routine services. School-based distribution is favored because EPI is focused on young children and oral cholera vaccine is targeted to school-aged children. Bangladesh is also looking at adult vaccination supported by industry as a work benefit.

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The government of Bangladesh is considering ways to increase access and ease of delivery once Shanchol is licensed in the country. Making OCV available through pharmacies is one option. Additional studies in progress in Bangladesh include assessing thermo-stability of the Incepta vaccine and possible inclusion of infants in clinical trials. 2. Cholera in the Republic of Haiti Presenters: Dr. Natael Fenelon, and Dr. Anne Marie Desormeaux, Ministry of Public Health and Population Background About 48.6% of Haiti’s 10,745,665 inhabitants live in urban areas; 64% have access to safe water but only 26% dispose of human waste safely. There was no cholera in Haiti before October 2010. It first appeared after the earthquake. After an initial rapid rise in cases and deaths, there has been a gradual significant decrease, but cases still occur every year. The current level of human transmission is low; the attack rate has decreased from 3.44% to 0.11% since the epidemic began, with a correspondingly significant decrease in the case fatality rate from 2.21 to 0.92 between 2010 and 2014. Those responsible for the cholera response in Haiti include government agencies (Ministry of Health, Direction Nationale de l'Eau Potable et de l'Assainisse -DINEPA, Ministry of Environment, Ministry of Interior Affairs), as well as non-government and international organizations (e.g., WHO, UNICEF, MSF, OIM, Partners in Health, CDC, GHESKIO, UN, World Bank, IDB, Médecins du Monde, and the Red Cross). A national response plan has been developed and is in progress. Current Capacity • Diagnostics: A comprehensive lab network – national reference labs, regional and district level labs – and ten rapid intervention teams are in place. Diagnostic capacity includes rapid diagnostic tests and cultures. Rapid testing is available at the district level (Cholera Treatment Centers). Most cases are clinically diagnosed, but samples of about 3% of cases are sent to the national lab for culture since every outbreak must have lab confirmation. • Surveillance: Cholera is a reportable disease, differentiated from acute watery diarrhea. The cholera surveillance subsystem is established and is being integrated into the national surveillance system. • Prevention: Social mobilization is underway (communications and training). WASH technicians at the DINEPA, rapid intervention teams, and community health workers can be mobilized and there is capacity to establish satellite Cholera Treatment Centers (CTC) quickly when needed. OCV is used in combination with water and sanitation, only administered in the most affected areas, based on surveillance data. • Treatment: Undertaken by the rapid intervention teams and the CTC network Major gaps and barriers • The cholera elimination plan needs to be adapted to specific local situations • Limited financial and human resources to implement the plan particularly at the community level • Lack of sustainable coordination of donors and external assistance. • Knowledge is not fully disseminated to the community level • Gaps in case identification at the community level • Regional diagnostic labs are not fully operational • Insufficient political will and commitment

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• • •

Limited accessibility to healthcare facilities, i.e., cholera treatment centers Limited awareness of prevention, diagnosis and treatment measures at the community level Inadequate WASH infrastructure.

WORK GROUP FEEDBACK Recommendations • Strengthen the early warning system • Foster collaboration and coordination among all actors and sectors for better local response and greater sustainability • Implement measures to protect water sources and increase availability of sanitation facilities, particularly in vulnerable areas • Implement planned use of OCV • Foster strict implementation of hygiene rules. Concrete Actions • Support for the national cholera elimination plan: Assess, review and revise with key stakeholders, including the community level; identify financial and human resources to support specific needs: and create a mechanism to package temporary outside aid so it leaves sustainable infrastructure and capacity behind. • Training/human resources: train regional lab personnel and support sharing of best practices for prevention and surveillance among community health workers • Operational research focused on understanding persistence of cases in some areas • Advocacy: Support multi-sectoral coordination and coordination among external donors at the national level; raise awareness and promote participation in the Regional Coalition to Eliminate Cholera in Hispaniola; engage and empower community level workers and increase involvement of community leaders (key influencers) • Increase diagnostic capacity of regional labs and make rapid diagnostic tests available in all facilities Discussion It is not unrealistic to eliminate cholera in Haiti since it only appeared 4 years ago. The National Plan sets target incidence rates for each year. The objective for 2014 was less than 0.5% and it is currently 0.11%. A serologic study in one commune found a high rate of acquired immunity. However sanitation is still a challenge in rural areas. The policy is to ask communities to take responsibility for latrines rather than have organizations build them. Total sanitation projects take time to implement and it’s hard to keep donors, partners and government focused on long-term projects. The time frame and scale of a sustainable water and sanitation intervention is unclear. Large numbers of rapid diagnostic tests are sent to Haiti, but there are questions about how they are done and the epidemiological framework for testing. There needs to be a more precise picture of confirmed cases treated in the cholera treatment centers. CTC labs are confirming 73% of cholera cases, but more coordination and support are needed among teams within departments that run the RDT program. There is less capacity to respond to outbreaks and treat cholera now that earthquake damage donations have stopped. One approach to improving sustainable capacity might be from a health systems perspective, building a health system that can also respond to emergencies. Haiti could learn from

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Bangladesh. A suggestion was made that there be a stockpile of treatment capacity, like the vaccine stockpile. It could include cots that can be flown in by WHO. It would be better to coordinate with ongoing activities in Haiti, e.g., the World Bank, the InterAmerican Development Bank, the UN, the Regional Coalition to Eliminate Cholera in Hispanola, and Spanish Cooperation, rather than create parallel processes. 3. Cholera in the Republic of Mozambique Presenters: Jose Langa, and Liliana Baloi, Ministry of Health, Mozambique Background Mozambique’s history includes colonization and two wars, with only 22 years of peace. Current systems continue to experience difficulties. Only 43% of the estimated 24 million inhabitants have access to safe water and 19% have sanitation conditions that allow for safe disposal of human waste. Cholera is endemic and widespread. Every year suspected cases are reported in one or more of the eleven provinces, but there is no discernable pattern, geographically or seasonally. When the first case was reported in 1973, the fatality rate was very high, but it has since been reduced to less than 1%. The Ministry of Health is responsible for prevention and control, together with the Ministry of Public Works and Housing, the Ministry of Environment, and city councils. International NGOs (e.g., Red Cross, MSF, PSI, UNICEF, World Vision, Save the Children, CARE) are given roles and specific tasks by the Center for Cholera Treatment. A cholera prevention and control operations manual to guide stakeholders during outbreaks has been published. Now in its third edition, it is revised from time to time but important components, such as vaccines, are still missing. Current capacity Diagnostic: All 9 provincial labs can culture V. cholerae and the Institution Nouvell Source can perform PCR (polymerase chain reaction) testing for V. cholerae in hours. Once cholera is confirmed, central and local multi-disciplinary teams are mobilized and health units start reporting cases to the central level daily using SMS (text messaging). Mozambique does not use rapid diagnostic tests because a high rate of false negatives was found when use was piloted in 2011. Surveillance: All acute watery diarrhea (AWD) cases are reported weekly. When a sudden increase in cases is seen, laboratory confirmation of cholera is required. Only 9 labs can culture for cholera, mostly in provincial capitals. Cholera is based on AWD surveillance with three ‘triggers’ for lab confirmation, using the WHO ‘clinical cholera’ case definition. There is annual training for lab, epi and clinical staff from affected districts, based on the operations manual. Prevention: Mozambique experimented with OCV (Dukoral) in 2003, but that did not lead to further use. WASH coverage is low (49% for water, 21% for sanitation) and there is poor communication between Ministry of Health and Ministry of Public Works regarding water and sanitation issues. There are radio messages on cholera during the outbreak season. Treatment: The reported case fatality rate is low – 0.87% (2009-2011). Annual training in use of the operations manual is provided.

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Major gaps and barriers • General lack of communication among government agencies. • Despite the operations manual, there is no National Cholera Plan and cholera is not on the radar. HIV, TB and malaria get consistent funding, but cholera is political and only gets attention when outbreaks occur. • Diagnostic: Only nine labs can culture V. cholerae. Transportation of samples is slow and expensive and laboratory bottlenecks impact surveillance and response. • Surveillance: It is difficult to predict time and location of outbreaks, case data are incomplete (e.g., re age, sub-district, etc.), and case definition is insensitive. Cholera is included in acute diarrheal surveillance, but it is often too late to intervene when cholera is identified. • Treatment: There is mistrust and hostility against health workers. The Guidelines were last updated 5 years ago and new modalities like zinc are not included. • Prevention: Cholera is not prioritized in WASH activities. The Department of Health just treats outbreaks without long-term environmental control. OCV has not been used since the 2003 Beira trial. Radio messages are broadcast when nobody is listening and are not well designed to reach those most at risk for cholera. WORK GROUP FEEDBACK Recommendations • Create a separate surveillance system for cholera. • Enhance laboratory-based surveillance by empowering local labs. • Engage stakeholders in controlling environmental risk factors. • Improve notification and information systems. • Combine other preventive measures with those in use, e.g., vaccines. Concrete actions General • Mobilize resources specifically for cholera • Advocate to bring attention to cholera and the need for capacity building • Provide technical assistance with development of a national plan for cholera prevention and control Diagnostic • Training and support for labs in V. cholerae culture • Explore alternative transportation systems, such as HIV/AIDS, polio, private companies • Strengthen lab capacity locally, to include use of RDT/filter paper and culture confirmation, structured as a formal pilot project with well-defined outcomes Surveillance • Update 2009-2014 analysis to help predict future outbreaks • Analyze Africhol surveillance data to help complete missing case data Treatment • Help de-politicize cholera by improving education, health promotion, and cholera/WASH integration in affected areas during off-season • Address antibiotics and zinc use in the Operations Manual or National Plan • Translate WHO, CDC and other training documents into Portuguese Prevention • Engage the Ministry of Public Works to prioritize cholera in WASH

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• • • •

Address OCV in proposals and the National Plan Provide training in applying for the WHO stockpile Support development of radio messages and telenovelas addressing cholera Provide examples and partners for school health promotion and WASH programs.

Summary: Even working with limited resources, Mozambique has been able to identify and control outbreaks. NGO’s play a crucial role. Some of their practices should be institutionalized by government agencies. Mozambique has a long way to go in terms of research, policies, and practices. Discussion Cholera reference resources, such as WHO manuals and guidelines and the UNICEF toolkit, are not available in Portuguese, resulting in significant barriers to dissemination of relevant information throughout the health care and cholera stakeholder community. Some materials in Portuguese have been made available through targeted trainings. Brazil has conducted public health trainings in Africa and has provided some cholera training materials. Cuba has provided support in Angola. PAHO and UNICEF provide some materials in Portuguese but they have to be verified for accuracy before reproduction and use. Rotary could help eliminate stigma and de-politicize cholera through local Rotary chapter members who are often influential members of the business community. Local members are often well-connected with national political leaders and could increase the visibility of cholera as a public health issue. Sharing information about meetings such as the annual Coalition meeting could help to raise national awareness in Mozambique. Mozambique has a unique cholera pattern among African nations. Cholera pops up randomly but never really leaves. That pattern could provide useful information to GAVI for the 2018 Vaccine Investment Strategy Review, and to others interested in cholera research. It may be productive for the Ministry of Health to learn about how to access the OCV stockpile. Coordination between WASH and public health is a generic issue. Milwaukee has durable coordination between the two sectors, and could provide lessons learned. Integration of WASH and HIV is another model, where awareness has been raised that using safe water can prolong the lives of HIV patients. Address ineffectiveness of chlorine spraying in updating the Operations Manual. When patients leave the CTC, a preventive medicine agent follows up with an epidemiological investigation, which includes spraying with chlorine. Studies in Bangladesh show many household members are also infected. DOVE is trying to map the burden of cholera across Africa. When local gaps are seen, strengths can be shared across countries, e.g., how water and sanitation and climate affect the burden of disease. Mozambique is integrating its surveillance system, with technical working groups for cholera, HIV, and malaria. Annual training specific to cholera has improved cholera data. Training also includes treatment and prevention. 4. Cholera in the Republic of Uganda Presenters: Prof. Christopher Garimoi Orach, MD, Head of Department of Community Health and Behavioural Health, Makarere School of Public Health, and Dr. Godfrey Bwire, MD, Control of Diarrhreal Diseases Unit, Ministry of Health

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Background Uganda is a small, poor country with very high population growth (3.3%) and total fertility (6.2) rates. About 72% of the population has access to safe water, and 59% has access to safe disposal of human waste. The first cholera outbreak was in 1971 during Idi Amin’s time. The disease progressed from being epidemic to endemic in the 2000s, along borders with the DRC and S. Sudan. During 1997/98, major flooding caused large outbreaks affecting 43 of 45 districts. Currently cholera is localized in hot spots in districts bordering Kenya, South Sudan, and the DRC, and along major water bodies. In 2014, 316 cases were reported with 9 deaths, spread among 10 districts. Risk factors for outbreaks include poor access to safe water, inadequate sanitation, and adverse weather conditions. Uganda also has many mobile communities, such as fishermen and pastoralists, and refugees from insecurity in neighboring countries and within the region. There are 200,000 refugees from the DRC, Rwanda and South Sudan, plus internally displaced people. The war in the north has subsided, but refugees from other countries remain in refugee settlements. The Ministry of Health is responsible for coordinating the cholera response, with the Ministry of Water and Environment, Education, Office of the Prime Minister and local government, supported by WHO, UNICEF, Uganda Red Cross, MSF and other NGOs, and external projects, such as Africhol and DOVE. The Tull Oil Company is also supporting the response to cholera. The six countries in the East African community work together during outbreaks and Uganda has protocols of understanding with the DRC. Current capacity National capacity to respond to cholera has improved. A process to develop a national cholera plan was initiated but was inadequately funded so no plan currently exists. Cholera cases and deaths are differentiated from acute watery diarrhea. Diagnosis of cholera is based on WHO guidelines, using standard case definitions. Diagnosis is clinical at the local level. There is capacity to do cultures at the regional level, however many regional labs are poorly equipped and confirmation is required at the central level. Rapid diagnosis tests are being introduced through the DOVE project at Johns Hopkins University and the CDC. Current treatment is ORS + zinc. Antibiotics are used for severe cases (Tetracycline or Ciprofloxacin). There is no stockpile for IVF or ORS, as these can be accessed easily in hospitals. Local hospitals make their own ORS. There is a pilot oral cholera vaccine program in two hotspots/high-risk sites, border areas with mobile populations (fishermen), which needs to be supported by research on effectiveness so policymakers can make decisions. Uganda has experience in piloting mass campaigns with other vaccines. Community health workers and village health teams already in place could deliver the vaccines. Major gaps and barriers Diagnostics: There is only one reference laboratory and two regional labs that can do microbiological culture. In the six districts with Africhol surveillance, Cary-Blair media is available, which is transported to the regional labs. In other districts, if there is an outbreak someone goes to the outbreak area and collects specimens to be brought to CHPL for testing, which takes 4-5 days. Surveillance: Clinical surveillance uses a clinical definition based on WHO criteria, which does not identify children <2 years. Integrated Disease Surveillance and Response (ISDR) is in place, but there is limited capability to identify cases.

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Prevention: There are inadequate funds to improve access to safe water and sanitation, especially along major water bodies. WASH interventions need to be tailored to specific areas, for example sanitation infrastructure is impacted by collapsing soil. There is no national plan for cholera control. WORK GROUP FEEDBACK Recommendations • Improve diagnosis by building capacity to do culture in at least two additional labs in two hospitals, in the north and southwest. The expansion of rapid diagnostic testing to all 10 districts may require fewer laboratories. RDTs could be scaled up through DOVE, which would lighten demand on labs. • Strengthen surveillance: Supplement IDSR with case-based surveillance to identify cholera cases and outbreaks (similar to Africhol sites). Train health workers in clinical diagnosis of cholera in all 10 districts, especially in areas bordering lakes and international borders. Resources to support training will be required. Extend the Africhol surveillance project to cover all at-risk districts. • Increase awareness of health workers on cholera. • Conduct health education/WASH campaigns using innovative, regional-specific interventions (e.g., latrines that can withstand soil collapses). • Pilot OVC demonstration projects and collect data to support use in affected communities (fishermen) or hot spots (border districts). • Conduct environmental studies to determine hiding places of the vibrio during non-epidemic periods, as well as rapid diagnostics studies, behavioral studies of fishermen, and vaccine acceptance and efficacy studies. • Develop a National Plan for Cholera Control • Provide safe water to communities and health education for sanitation improvement. • Increase cross-border surveillance and response. Concrete actions • Train health workers in diagnostics, case identification and treatment • Support rapid diagnostic test use, especially on false negatives • Expand surveillance beyond district where Africhol is working, and sustain Africhol’s current work • Develop a National Cholera Plan • Generate evidence for OCV use (80,000 people) • Mobilize WASH strategies. Discussion Diarrhea is common near water bodies in Uganda; only when people start dying is cholera suspected and treatment centers are established. There is lab confirmation at the beginning of an outbreak; throughout the outbreak there is sampling to monitor whether the outbreak is decreasing. When an outbreak is first reported, all cases that fit the clinical definition are reported as cholera, so case fatality rates may seem low. Higher CFRs may actually be due to better diagnosis. When people stop coming to the treatment centers, the outbreak is considered over. There are no studies of sensitivity and specificity of case definitions. Uganda currently uses WHO guidelines, which only specify confirmation of the initial 10 samples. There would also be problems transporting all the samples to a laboratory. Partnering with Rotary offers an opportunity to get needed resources to target the hot spots.

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VIII. Report on the Independent Expert Review Panel on Haiti Outbreak Response Alejandro Cravioto, Scientific and Academic Consultant, Academia Nacional de Medicina de México. After the earthquake in Haiti, a large cholera outbreak took the country by surprise and was confirmed on October 22, 2010. These were the first cases in 100 years. The outbreak took over 8,000 lives. It was widely believed that it was introduced by United Nations troops (MINUSTAH). An independent panel was commissioned by the UN Secretary General to investigate and to determine the source of the outbreak. No UN facilities or personnel were used in conducting the investigation. The findings were sent directly to the Secretary General. The panel included Dr. Cravioto and three other cholera experts. A three-pronged approach was used with concurrent analyses of epidemiological, water and sanitation, and microbiological and molecular data. The investigators analyzed UN and hospital records, and interviewed Cuban doctors, Partners in Health, Albert Schweitzer Hospital personnel and others. They also inspected Nepalese facilities at the Mirebalais MINUSTAH and investigated the facilities’ waste disposal practices. A new group of peacekeeping soldiers from Nepal had arrived just before the outbreak occurred. A water and sanitation investigation confirmed that the Artibonite River was the source of the outbreak, a site with a great amount of human activity. Molecular investigations: Two Haitian strains were compared with strains from outbreaks in other parts of the world (Bangladesh, Mozambique, India and Kenya). Peruvian strains had previously jumped to Mexico as a result of human activity. The strains in Haiti were similar to those from south Asia, but the investigators did not have access to Nepalese strains. Indian and Bangladeshi strains are similar. Research has shown that some strains migrated from the Bay of Bengal or Indonesia to Latin America in the 80s and 90s, but these new strains appeared to have migrated directly from south Asia to Haiti. If the strains were from Nepalese soldiers, they would have had to stay in the intestinal tract of the Nepalese forces for 14 days because none of the Nepalese were sick when they arrived in Haiti. After the report was finished the Nepalese strains were shared, and they were exactly the same as the strains identified in Haiti. Conclusion: Research findings indicate that the 2010 Haiti cholera outbreak was caused by bacteria introduced into Haiti as a result of human activity, specifically by contamination of the Artibonite River with a pathogenic strain of the current South Asian type Vibrio cholera. Recommendations from the Independent Expert Review team were as follows: • Populations coming from endemic areas should receive a prophylactic dose of an appropriate antibiotic. • UN personnel coming from an endemic area to an area without cholera should receive a prophylactic antibiotic or an oral cholera vaccine. • Fecal waste should be treated using on-site systems that inactivate pathogens before disposal. • Case management should be improved to decrease case fatality rates. • International community should recommend reactive vaccination in similar situations. • Molecular techniques should be used to track epidemics. The UN rejected the recommendation for prophylactic use of antibiotics based on concerns related to fostering antibiotic resistance. The recommendation to give oral vaccine to troops coming from endemic countries was also rejected, since the UN views this as a responsibility of the soldiers’ country of origin. The IER team insisted that sanitation of camps had to be improved, especially waste disposal practices.

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None of the waste removal recommendations have been implemented. In September 2013, on the west coast of Mexico, 180 cholera cases appeared. The strain identified was similar to the one in Haiti, which indicates that endemicity in Haiti is now affecting the rest of Latin America. Long-term carriage of cholera in the body is a concern. (UN Response to the Recommendations – Annex 5) Discussion/Comments • The recommendation for a single dose for peacekeepers going to endemic countries is not prophylactic - it’s treatment of potentially infected individuals. Even a small reduction in probability of carrying a strain to another country can yield big benefits in cases averted and lives saved. • “Cholera in the time of Ebola”: When other diseases come into the spotlight, cholera gets displaced. We don’t pay attention until outbreaks become a threat to us. Cholera can kill, but our water system protects us in the U.S. Ebola is more threatening, but it comes from ‘over there’. Prevention is a hard sell when the threat is not imminent. Do we do surveillance to protect ourselves or because we care about people in Haiti? When institutions have to balance “doing no harm” against failing to act, they lose sight of the perspective of patients and their families. Holding institutions accountable is something this Coalition can do. • Cholera crosses borders all the time. Most UN peacekeepers are coming from cholera endemic areas and going to risky areas. Giving everyone prophylaxis is costly. • UN peacekeepers could become a resource for cholera control and prevention, with training. IX. Advocacy and Resource Mobilization Mark Rosenberg, MD, MPP, CEO & President, The Task Force for Global Health 1. Rotary Club Collaboration with the Coalition Presenters: Bob Hope, Director, Rotary Club Atlanta/President, Hope Beckham, Inc., Robert Hall, President of Dunwoody Rotary and member of Rotary International Board, and Jonathan Yaeger, President, Rotary Club of North Atlanta/Owner, Data Savers, Inc. Bob Hope provided an overview of Rotary International, which as an organization has the capacity to mobilize support for an initiative on a global scale. It has 34,000 clubs around the world, with 1.2 million members. Rotarians are generally leaders in the business community who can provide spearheading influence and mobilize resources. There are 335 active Rotary clubs just in the four countries that participated in this year’s Coalition meeting. Clubs work individually and collaboratively on specific projects. Polio eradication is the largest coordinated effort. Since the first polio vaccine was sent to the Philippines from Italy in 1979, Rotary has delivered 3 billion doses of polio vaccine around the world and helps to build infrastructure necessary to fight diseases. At a district Rotary conference earlier this year, Mark Rosenberg CEO of the Task Force for Global Health, suggested Rotarians consider cholera as the next thing that Rotary could take on to change the world after polio eradication. Rotary International has defined six priority areas: Promoting peace, fighting disease, providing clean water, saving mothers and children, supporting education, and growing local economies. Cholera fits in all six areas. Globally Rotary mobilizes 20 Action Groups focused on specific issues, such as child slavery. Action Group boards can help with networking and connecting resources. For example, in Pakistan, where there were about 1200 Rotarians, the polio effort was fragmented with no one spearheading the effort., so Rotary International brought the head of Rotary in Pakistan together with the CDC’s Country Director.

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Bob Hope is enthusiastic that Rotary could do the same for cholera by learning the needs, stimulating partnerships and sharing resources, initiatives and brainpower to resolve the cholera problem. Robert Hall talked about raising awareness of cholera and making it more visible. Rotary clubs go to developing countries, raise money to build schools, and take along doctors and engineers. Rotarians are already comfortable working with diseases because of polio. They like a reason to travel to an exotic place and they like to give money. Rotary’s marketing department actively acknowledges the work of its members and raises awareness through media using celebrities. The Coalition could use Rotary tools to produce a cholera message or press release that Rotary can run nationally or locally, for example, celebrities drinking clean water and talking about waterborne diseases and cholera. Water is clean and comfortable for a company like CocaCola to tap into. We can help you. John Yaeger talked about different funding available within Rotary at club, district and global levels, how to contact Rotary at each level and how to leverage Rotary’s resources. A summary handout was shared with participants (Annex 7). Rotary is about volunteerism and one has to start by finding someone willing to step up and drive home the initiative. Each club has people who are willing to take on projects, with no overhead or costs to you. 1. Individual clubs can fund anything and anywhere they want. The best way to let an individual club know about your needs is to speak at a weekly meeting, which is by invitation only. At the club level, there are people who are willing do specific things, like passing out educational materials or translating materials into Portuguese, which won’t cost you anything. 2. District grants range from $2500 to $3000 and fund things like putting up a website. However, they must start and end within a one-year period of time, which can be hard to do remotely. Some useful information can be made available, including lists of all Rotary clubs by country, lists of district governors for each district of those countries (names and contact information). You can contact district governors and ask them about committed individuals in active clubs who make be receptive to ideas for initiatives. 3. Global grants are available to applicants in the target or host country, but an individual has to start the initiative. That person has to submit a grant application, defining exactly what the money will be used for, along with a community needs assessment, which has to come from the host country. Lists of projects can be made available. Currently there are 25 projects in Uganda, for example, mostly water and sanitation projects, which are listed on www.globalgrants.org. Last year Rotary funded 653 grants ranging from $30,000 to $400,000 per grant. Small gains in cholera can be made by improving water quality. John proposed using an interactive web platform, called www.collaborate.org, to coordinate global projects and share resources and information around the world. Comments Liliana Dengo-Baloi, a meeting participant representing the Mozambique Ministry of Health, is a Rotarian. Rotary has been active in Mozambique for 15 years and currently has seven Rotary clubs. There are Rotary clubs in virtually every country in Africa. Joint projects are often undertaken by two or more clubs. US-based Rotarians rely on African Rotarians to identify the problems on the ground. A simple Google search will locate information on contacting Rotary Clubs in most countries. Seed grants from Rotary often attract participation by individuals and foundations. Rotary’s sustained efforts and results have made Rotary a respected partner among development organizations

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2. Resource Mobilization for Cholera Control Operations and for the Coalition Bernhard Liese, MD, MPH, Department Chair International Health, Georgetown University Overseas Development Assistance (ODA) provided to the health sector has doubled in the last decade. Many diseases have been marketed successfully. Multi-sectoral assistance has increased as well. ODA disbursements for cholera have increased and decreased over the last decade, but the percentage committed to cholera has remained very small, averaging 0.66% from 2008 to 2012. Malaria and HIV/AIDS get a large proportion of health funding. The Global Fund and GAVI are two big new actors in the health funding arena. Potential resources for cholera include Development Assistance Committee (DAC) donors, and multilaterals for infrastructure, water and sanitation, and urban development. There are likely to be adjustments in portfolios over the next few years, offering more opportunity for cholera funding. The significant resources currently being committed to Ebola may provide an opportunity to raise awareness and resources for cholera where there are overlapping or complementary objectives. Development banks are responsive to health issues, because of the importance of workforce health to agricultural objectives. (The World Banks funds schistosomiasis control out of agriculture budgets.) The question is who has the technical resources to help with cholera. One should also look at what non-DAC governments, such as Brazil and Russia, have to offer in terms of resources. Traditional donors will not be a good source for initial funding. Most health programs [for specific diseases] are supported by an alliance or a coalition, which can help with advocacy and marketing. Foundations and organizations like Rotary are active in the health area. Suggestions: • Set a medium-term timeline (3 to 4 years) • Pursue multiple avenues in parallel (advocacy and marketing, for example). • Strive for clarity and simplicity of goal and message. • Do not give up, wear the traditional donors down. Persistence, persistence, persistence! • Promote ongoing dialogue and constantly provide feedback to donors. Discussion How do we make the law of unintended consequences work for us? Ebola should be seen as an opportunity. The current epidemic is centered in urban slums, which will consequently become a major target of development efforts. Our strength as a coalition is the diversity and complementary objectives of our membership, and the shared opportunity of the annual meeting to meet and exchange ideas. All health facilities and clinics where people go for preventive services should have safe water for drinking and hand washing, and adequate sanitation facilities, not just to prevent cholera or Ebola. Rotary does clinics very well. X.

Planning the way forward

Dr. Hinman summarized the meeting accomplishments, which included: • An update on the global situation with cholera and the OCV stockpile • Brief updates from Coalition members • Updates from vaccine manufacturers • Ratification of the Coalition charter • Discussion of the relationship between CCPC and GTFCC

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•

Presentations on the status of cholera in Bangladesh, Haiti, Mozambique, and Uganda.

Next steps In 2014-2015 the Coalition will liaise with Bangladesh, Haiti, Mozambique and Uganda. The country reports identified shared capacity gaps and areas for improvement across these countries: national plans, improved surveillance, and health worker training. The Coalition is not funded to provide technical assistance to the four countries, but many Coalition members can provide assistance through other funding. The Coalition can harness knowledge and skills, coordinate teleconferencing, maintain working groups on each of the four countries, and help to inform working groups on specific topics, such as training and technical assistance in diagnosis and surveillance, development of national plans, and advocacy. The Coalition will continue to support and complement the Global Task Force on Cholera Control, carry out advocacy and resource mobilization, and seek support for the Coalition beyond February 2016. Comments and recommendations • Design a standardized template for a country profile/cholera status assessment, working with IDEA, Africhol, UNICEF, WHO/GTFCC and DOVE. • Adapt general prevention and control recommendations to specific settings. • Look for synergies among existing initiatives and exercises. Don’t duplicate activities like mapping. • Establish working groups around diagnosis and surveillance. • Promote south/south collaboration and peer exchange around common issues, such as what a national plan should include, e.g., operational plan in an outbreak vs. strategies to prevent outbreaks. • Continue inter-country sharing of cholera burden of disease, best practices, etc. • Establish an Internet chat room. • Secure funding to hold Coalition meetings closer to each of the four countries, bringing neighboring countries to the meeting. • Develop a template and other tools that can be used to start local discussions with stakeholders, for assessing the cholera situation and developing an action plan. • Reach out to Rotary clubs in the four countries, and provide contact information for district governors and information on Rotary International grants. • Encourage stakeholders to raise resources in country to organize workshops. • Tap into Africhol and DOVE for intra-country meetings, e.g., DOVE mapping/country profiles. • Invite the same four countries to the Fourth Meeting see if this meeting has made a difference. • Be clear about the differences between the GFTCC and the Coalition to avoid confusion among members of both. • Complement, support and nudge WHO, given the Coalition’s greater flexibility and fewer restraints. Get funding from the private sector and industry, which WHO cannot do. • Publish the basic information and conclusions of this meeting in the media. Meeting adjourned.

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Meeting of the Coalition for Cholera Prevention and Control Task Force for Global Health, Inc. Atlanta October 22-23, 2014 Conference Agenda

Objectives for the meeting    

 

Update Coalition members on current situation with cholera globally Provide a platform for Coalition members to share their current activities Discuss relationship of the Coalition and WHO’s Global Task Force on Cholera Control (GTFCC) Develop an approach for doing a status assessment of cholera prevention and control at the level of individual countries o Participating countries will share current status of cholera and cholera prevention/control o Intensive work group session with Coalition members to develop plans of action for implementing the comprehensive strategy for cholera prevention and control Discuss possible Coalition activities in the area of advocacy and resource mobilization Develop a Coalition plan of action for 2015

Wednesday, October 22, 2014 8:30 – 9:15 AM

Welcome & introductions

Alan Hinman, Co-investigator for the Coalition will welcome participants to the third meeting of the Coalition and outline the objectives for the meeting. Louise Ivers, Co-investigator, will welcome the group on behalf of Paul Farmer, followed by participant introductions.

 

Alan R. Hinman, MD, MPH, Director for Programs, Center for Vaccine Equity, The Task Force for Global Health Louise Ivers MD, Senior Health and Policy Advisor, Partners In Health; Associate Professor of Global Health and Social Medicine, Harvard Medical School

9:15 – 9:45 AM Global situation of cholera – status of oral cholera vaccine stockpile Stephen Martin, Medical Officer, Department of Pandemic and Epidemic Alert and Response. World Health Organization, will provide an update on the global status of cholera and a report on the financial and operational aspects of the oral cholera vaccine stockpile. Presentation (10m) will be followed by group discussion (20m). 9:45 - 10:45 AM

Updates from the Field

Updates (3-5m) by organizational partners on their current cholera activities. 

Centers for Disease Control and Prevention Kashmira Date, Medical Epidemiologist, Global Immunization Division Richard Gelting, PhD, PE, Health Systems Reconstruction Team National Center for Global Health

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Annex 1

  

    

  10:45 – 11:00 AM 11:00 – 11:30 AM

Eric Mintz, MD, Lead, Global Water, Sanitation and Hygiene Epidemiology Team, Division of Foodborne, Waterborne, and Environmental Diseases DOVE Project David Sack, MD, Principal Investigator, Professor of International Health, Johns Hopkins University, Bloomberg School of Public Health GAVI Lisa Lee, VMD, MPH, MSc, Consultant Initiative against Diarrheal and Enteric Diseases in Africa and Asia (IDEA) Luc Hessel, MD, General Secretary, Enteric Diseases Expert Bureau Asia & Africa International Centre for Diarrhoeal Disease Research, Bangladesh John Clemens, MD, PhD, Executive Director International Medical Corps Topher Finley, Manager Foundation and Corporate Relations International Rescue Committee Justine Landegger, MPH, Technical Health Advisor Médecins Sans Frontières Myriam Henkens, MD, International Medical Coordinator Rotary Bob Hope, Director, Rotary Club Atlanta/President, Hope-Beckham, Inc. Jonathan Yaeger, President Rotary Club of North Atlanta/DataSavers,Inc. UNICEF Kate Alberti, Sr. Programme Specialist Cholera Africhol Martin Mengel, MD, MSc, MSE, Project Director (via phone)

Morning Break Vaccine development, manufacture, and supply – current & future

A panel of representatives from vaccine manufacturers will provide updates on available vaccines, vaccines in development, future supply and potential barriers and constraints.  Sachin Desai, MD, Medical Epidemiologist, Development and Delivery, International Vaccine Institute  Laura Efros, PhD, Head of Government Affairs and Public Policy, PaxVax, Inc.  Lynn Morgan, Sr. Director, Global Immunization Policy, SanofiPasteur  Sue-Nie Park, PhD, MD, Vice President, Eubiologics Company (via phone) 11:30 – 12:00 PM

Coalition Charter

David Sack and Alan Hinman will present the Coalition Charter for discussion and ratification. 

David Sack, MD, Principal Investigator, DOVE Project/Professor of International Health, Johns Hopkins University, Bloomberg School of Public Health  Alan R. Hinman, MD, MPH, Director for Programs, Center for Vaccine Equity, The Task Force for Global Health

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Annex 1

12:00– 12:30 PM

The Global Task Force on Cholera Control and the Coalition

Stephen Martin and Alan Hinman will provide an update on the Global Task Force and the role of the Coalition as a member. Discussion on key issues will follow providing Coalition members an opportunity to identify the most appropriate areas for collaboration. 12:30 – 1:00 PM

Lunch

1:00 – 3:00 PM

Country presentations and discussions

In preparation for work group sessions, country representatives will provide a brief overview of the cholera burden of disease, past and present disease character, scope and trend; governmental and non-governmental capacity to respond; and successes, challenges and barriers to effective prevention and control. Presentations (20m) will be followed by discussion (10m). 

People’s Republic of Bangladesh Tajul Islam Abdul Bari, MD, Programme Manager EPI and Surveillance, Directorate General of Health Services Abul Kalam Azad, PhD, Assistant Director General, Planning and Development, Directorate General of Health Services



Republic of Haiti Natael Fenelon, MD, Ministry of Public Health and Population Anne-Marie Desormeaux, MD, Ministry of Public Health and Population



Republic of Mozambique Jose Paulo Langa, PhD, Head of Microbiology, National Reference Lab, National Institutes of Health (INS) Liliana Dengo-Baloi, Biologist/Public Health Surveillance Coordinator



Republic of Uganda Bwire Godfrey, MD, Control of Diarrheal Diseases Unit, Ministry of Health, Kampala, Uganda Christopher Orach, MD, Head of Department of Community Health and Behavioural Health, Makerere University

3:00 – 3:15 PM

Robert Hall, Director, RotaryClub of Dunwoordy/Owner, HRHRecruiting

3:15 – 3:30 PM

Afternoon Break

3:30 – 5:00 PM

Breakout sessions

Country representatives will provide a summary of national capacities in cholera surveillance, diagnosis, prevention and treatment. In collaboration with Coalition members, country partners will identify key issues and barriers, potential opportunities, resources and approaches for accelerated improvement in cholera prevention and control efforts within their country. 5:00 – 5:15 PM

Adjourn

6:00 – 6:30 PM

Reception – Mary Gay House, 716 West Trinity Place, Decatur, GA

6:30 – 8:00 PM

Dinner – Mary Gay House, 716 West Trinity Place, Decatur, GA

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Thursday, October 23, 2014 8:30 – 10:00 AM

Working group reports from the country sessions

Country representatives and working group members will summarize the work group findings and proposed plans. Each presentation (25m) will be followed by discussion (20m).   10:00 – 10:30 AM

Bangladesh – Myriam Henkens Haiti – Luc Hessel

Morning Break

10:30 AM – 12:00 PM Working group reports (cont)  Mozambique – Eric Mintz  Uganda - Firdausi Qadri 12:00 – 1:00 PM

Lunch

1:00 – 2:00 PM

UN response to Independent Expert Review Panel on Haiti outbreak response

In light of the recent UN response to the Independent Panel of Experts on the Cholera Outbreak in Haiti, we have planned a session to discuss the recommendations of the expert review panel and the UN response, with particular emphasis on the recommendations for use of OCV and antibiotic treatment for UN Peacekeepers from cholera-endemic countries.   2:00 – 3:00 PM

Alejandro Cravioto, MD, Scientific and academic consultant, Academia Nacional de Medicina de México Mark Rosenberg, MD, MPP, CEO & President, The Task Force for Global Health, Inc.

Advocacy and resource mobilization

Discussion of approaches to advocacy and resource mobilization at global, national, and local levels, including possible partnerships with Rotary International and individual Rotary Clubs. 

 Mark Rosenberg, MD, MPP, CEO & President, The Task Force for Global Health, Inc.  Bob Hope, Director, Rotary Club of Atlanta/President, Hope-Beckham, Inc.  Bernhard Liese, MD, MPH, Department Chair International Health, Georgetown University  Jonathan Yaeger, President, Rotary Club of North Atlanta/Owner, Data Savers, Inc. 3:00 – 3:15 PM

Afternoon break

3:15 – 4:00 PM

Planning the way forward

Group discussion of priority activities for the Coalition over the coming year. 4:00 PM

Adjourn

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Annex 2

Participant List Kate Alberti Senior Programme Specialist Cholera UNICEF [email protected]

Tajul Islam Abdul Bari, MD Programme Manager EPI and Surveillance Directorate-General of Health Services Bangladesh [email protected]

Mohammad Ali, PhD Senior Scientist, Dept. of International Health Johns Hopkins University Bloomberg School of Public Health [email protected]

Dennis Chao, PhD Senior Staff Scientist Vaccine and Infectious Disease Division Fred Hutchinson Cancer Research Center University [email protected]

Charles Patrick Almazor, MPH Director of Clinical Services Zanmi Lasante [email protected]

Wilbur Chen, MD Associate Professor, Department of Medicine Center for Vaccine Development University of Maryland School of Medicine [email protected]

Jerome Ateudjieu, MD, MPH Research Officer Ministry of Public Health Republic of Cameroon [email protected]

John D. Clemens, MD, PhD Executive Director International Centre for Diarrhoeal Disease Research (iccdr,B) [email protected]

Abul Kalam Azad, PhD Assistant Director General (Planning & Development) Director, Management Information System (MIS) Directorate General of Health Services Bangladesh [email protected]

Alejandro Cravioto, MD, PhD Scientific and Academic Consultant Academia Nacional de Medicina de México [email protected]

Andrew Azman DOVE Project Johns Hopkins University Bloomberg School of Public Health [email protected]

Kashmira Date, MPH Medical Epidemiologist Global Immunization Division Centers for Disease Control and Prevention [email protected]

Pradip Bardhan, MD Chief Physician International Centre for Diarrhoeal Disease Research (iccdr,B) [email protected]

Amanda Debes, MS DOVE Project Johns Hopkins University Bloomberg School of Public Health [email protected]

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Annex 2

Jaqueline Deen, MD DOVE Project Johns Hopkins University Bloomberg School of Public Health [email protected]

Natael Fenelon, MD Medical Epidemiologist National Situation Room Ministry of Public Health and Population (MSPP) Haiti [email protected]

Liliana Dengo-Baloi Biologist and Public Health Surveillance Coordinator Republic of Mozambique [email protected]

Topher Finley Manager, Foundation and Corporate Relations OCV Communications International Medical Corps (IMC) [email protected]

Denise DeRoeck, MPH DOVE Project Johns Hopkins University Bloomberg School of Public Health [email protected]

Bwire Godfrey, MD Control of Diarrheal Diseases Unit Ministry of Health Republic of Uganda [email protected]; [email protected]

Sachin Desai, MD Associate Research Scientist International Vaccine Institute [email protected]

CAPT Richard J. Gelting, PhD, PE Health Systems Reconstruction Team Center for Global Health Centers for Disease Control and Prevention [email protected]

Isabelle Deschamps, MD Senior Director, Head of Immunization Policy for Africa & Global Health Organizations Sanofi-Pasteur [email protected]

Robert Hall Director, Rotary Club of Dunwoody Owner, HRHRecruiting [email protected]

Anne-Marie Desormeaux, MD ENT Specialist, Epidemiologist Ministry of Public Health and Population (MSPP) Haiti [email protected]

Myriam Henkens, MD International Medical Coordinator Médecins sans Frontières [email protected]

Laura Efros, PhD Head of Government Affairs & Public Policy PaxVax, Inc. [email protected]

Luc Hessel, MD General Secretary, Enteric Diseases Expert Bureau Asia & Africa Initiative against Diarrheal and Enteric Diseases in Africa and Asia (IDEA) [email protected] Lisa Lee, VMD, MPH, MSc Consultant GAVI [email protected]

Alan Hinman, MD, MPH Director for Programs, Center for Vaccine Equity The Task Force for Global Health, Inc. [email protected]

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Annex 2

Bob Hope Director, Rotary Club of Atlanta President, Hope-Beckham. Inc. [email protected]

Justin Lessler, MD Assistant Professor, Epidemiology Johns Hopkins University Bloomberg School of Public Health [email protected]

Terri Hyde, MD, MPH Chief, Strengthening Immunization Systems Branch Global Immunization Division Centers for Disease Prevention and Control [email protected]

Bernhard Liese, MD, MPH Chair, Department of International Health Georgetown University [email protected]

Louise Ivers, MD, MPH, DTM&H Senior Health and Policy Advisor Partners In Health Associate Professor of Global Health and Social Medicine Harvard Medical School [email protected]

Anna Lena Lopez, MD Associate Professor, Child Health and Human Development National Institutes of Health University of Philippines [email protected]

Samantha Kluglein Sr. Associate Director for Programs Center for Vaccine Equity The Task Force for Global Health [email protected]

Francesco Luquero, MD, MPH, PhD Medical Epidemiologist Epicentre Médecins sans Frontières [email protected]

Jose Paulo Langa, PhD Head of Microbiology , National Reference Lab National Institutes of Health (INS) Republic of Mozambique [email protected]

Stephen Martin, MD Medical Officer Department of Epidemic and Pandemic Alert and Response Emergency Vaccines and Stockpiles World Health Organization [email protected]

Justine Landegger, MPH Technical Advisor Health International Rescue Committee (IRC) [email protected]

Helen Matzger, MPH Program Officer Vaccine Delivery Team Bill & Melinda Gates Foundation [email protected]

Martin Mengel, MD, MSc, MSE, Project Director Africhol [email protected]

Sue-Nie Park, MD Vice President Eubiologics Co [email protected]

Mark McKinlay, PhD Director, Center for Vaccine Equity The Task Force for Global Health, Inc. [email protected]

Mark Pietroni, MD Director of Public Health South Gloucestershire, UK [email protected]

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Annex 2

Eric Mintz, MD Leader, Global Water, Sanitation, and Hygiene Epidemiology Team Division of Foodborne, Waterborne, and Environmental Diseases Centers for Disease Control and Prevention [email protected]

Firdausi Qadri, PhD Senior Scientist, Immunology Laboratory International Centre for Diarrhoeal Disease Research (iccdr,B) [email protected]

Lyn Morgan Senior Director Global Immunization Policy Vaccine Advocacy and Policy Sanofi-Pasteur [email protected]

Mark Rosenberg, MD, MPP President & CEO The Task Force for Global Health, Inc. [email protected]

Jared Omolo, MD Resident Advisor Rwanda Field Epidemiology and Laboratory Training Program Rwanda [email protected]

Edward T. Ryan, MD Director, Tropical Medicine Massachusetts General Hospital Division of Infectious Diseases Tropical & Geographic Medicine Center [email protected]; [email protected]

Christopher Orach, MD Associate Professor and Deputy Dean Head of the Department of Community Health and Behavioural Sciences Makerere University Republic of Uganda [email protected]

David Sack, MD Principal Investigator, DOVE Project Professor, International Health Johns Hopkins University Bloomberg School of Public Health [email protected]

Jean William Pape, MD Director, GHESKIO Cornell University Haiti [email protected]

Dipika Sur, MBBS Deputy Director National Institute of Cholera and Enteric Diseases India [email protected]

Jordan W. Tappero, MD, MPH Director, Division of Global Health Protection Centers for Disease Control and Prevention [email protected] Lorenz Von Seidlein, MD, PhD Coordinator Asia Pacific Malaria Elimination Network (APMEN) Menzies School of Health Research [email protected] 32

Annex 2

Ebile Walter DOVE Project Johns Hopkins University Bloomberg School of Public Health [email protected] Jonathan Yaeger President, Rotary Club of North Atlanta Data Savers, LLC [email protected]

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Annex 3

Charter for the Coalition for Cholera Prevention and Control October 30, 2014 The Coalition is a voluntary global collaboration of individuals and organizations committed to develop, support, and improve the widespread application of a comprehensive, integrated strategy for prevention and control of cholera incorporating the appropriate use of oral cholera vaccines (OCV) and other new approaches. 1.

Goal of the Coalition for Cholera Prevention and Control (CCPC): • Stop cholera transmission and end cholera deaths

2.

Coalition strategies to reach this goal include: • • • • • • • • • • • •

3.

Coalition structure: • • •

4.

The Coalition is an informal group of individuals and organizations motivated by the same goal – to stop cholera The Coalition has working groups on advocacy/communication and resource mobilization with the potential for supporting working groups for other priority areas The Task Force for Global Health serves as Secretariat/Convener

Membership: •

5.

Supporting and complementing the Global Task Force on Cholera Control (GTFCC) coordinated by WHO Facilitating widespread implementation of a comprehensive and integrated strategy for prevention and control of cholera Providing a forum for stakeholders’ discussion and collaboration Striving to achieve consensus among Coalition members Raising awareness of cholera and the ways to prevent and control it Identifying financial, human, and technical resources required to reach the goal and working to mobilize them Identifying and addressing obstacles to better prevention and control of cholera Serving as a strategic and scientific resource on emerging issues Helping identify a research agenda and set research priorities, particularly in the area of intervention research Ensuring effective knowledge management—generating, integrating, disseminating, and applying knowledge about cholera and its prevention and control Involving individuals and organizations from affected countries in the Coalition Working with other entities involved in the prevention of diarrheal diseases, including water, sanitation, hygiene, and other sectors such as tourism, commerce, and trade

Any individual or organization sharing in, and willing to work towards, the goal of the Coalition can be a member

Management: • • • • •

The Coalition will observe principles of transparency, efficiency, effectiveness The Coalition will normally meet at least once a year Coalition meetings will be carefully planned and thoughtfully managed to maximize the value of participants’ time Coalition statements and recommendations reflect collective views of participants and do not necessarily represent the policies of their agencies The Coalition will generate funding to ensure its efficient and effective working 34

Annex 4

Global Task Force on Cholera Control April 23, 2014

Terms of Reference Global Task Force on Cholera Control (GTFCC) Background The 2011 WHA 64.15 resolution (“Cholera mechanisms for control and prevention”) requested the WHO Director-General to revitalize the Global Task Force for Cholera Control (“GTFCC”) and to strengthen WHO’s work in this area, including improved collaboration and coordination among relevant WHO departments and other relevant stakeholders.

Status The GTFCC is administered by the World Health Organization ("WHO") through its Department of Pandemic and Epidemic Diseases. The GTFCC is a collaborative mechanism between interested parties including WHO and GTFCC members, and is not an independent legal entity. For this reason, the GTFCC cannot conduct any actions in its own name. The operations of the GTFCC shall in all respects be administered in accordance with the WHO Constitution, WHO’s Financial and Staff Regulations and Rules, Manual provisions, and applicable policies, procedures and practices.

1. Functions Vision GTFCC members share a vision that collective action can stop cholera transmission and end cholera deaths. The purpose of the GTFCC is to support increased implementation of evidence-based strategies to control cholera. The GTFCC aims to achieve this through strengthened international collaboration and improved coordination amongst stakeholders active in cholera-related activities. GTFCC activities will aim to raise the visibility of cholera as a public health issue, facilitate sharing of evidence-based practices, and contribute to capacity development in all areas of cholera control. The GTFCC shall not be responsible for developing any technical norms or standards. Objectives The GTFCC members agree with the specific objectives of the GTFCC as stated below: 1. To support the design and implementation of global strategies to contribute to capacity development for cholera prevention and control globally. 2. To provide a forum for technical exchange, coordination, and cooperation on cholerarelated activities to strengthen countries’ capacity to prevent and control cholera, especially those related to implementation of proven effective strategies and monitoring of progress, dissemination and implementation of technical guidelines, operational manuals, etc. 3. To support the development of a research agenda with special emphasis on evaluating innovative approaches to cholera prevention and control in affected countries. 4. To increase the visibility of cholera as an important global public health problem through integration and dissemination of information about cholera prevention and

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Global Task Force on Cholera Control April 23, 2014

control, and conducting advocacy and resource mobilization activities to support cholera prevention and control at national, regional, and global levels.

2. Membership Members At least for the initial phase, the GTFCC shall have 15 to 18 members, or less. Members of the GTFCC will be identified and invited by WHO. The GTFCC will be open to institutions, including non-governmental and community-based organizations, international and intergovernmental organizations, universities, hospitals, and ministries. Members must demonstrate a clear interest and expertise on disciplines and perspective relating to cholera control. Relevant fields include, but are not limited to, epidemiology, public health, paediatrics, internal medicine, infectious diseases, water, sanitation, drug regulation, programme management, immunization delivery, health-care administration, logistics, communication, program evaluation and health economics. Members may have a three-year membership in the GTFCC , which may be extended after the initial term. Any member may terminate its involvement in the GTFCC by providing written notice to WHO in its capacity as provider of Secretariat services to the GTFCC. In addition, WHO, in its discretion, may terminate the participation in the GTFCC of any member. The GTFCC will select from amongst its members a Chairperson. The Chairperson of GTFCC is expected to serve as Chairperson for three years. After the initial selection of a Chairperson, future Chairs will need to have served as a member of GTFCC for a minimum of one year before taking up Chairmanship. GTFCC participation is open and on a voluntary basis. No dues will be charged. All member organizations agree to promote the provisions of WHA 64.15 and abide by these Terms of Reference.

3. Management Secretariat support Secretariat and planning support of the GTFCC will be provided by WHO acting through the Department of Pandemic and Epidemic Diseases (hereinafter referred to as the “Secretariat”). Information exchange The GTFCC will normally meet biannually and may utilize face-to-face,teleconferences or other electronic communication meeting methods . Special meetings may be called to address emerging issues. Meetings and Teleconferences will be convened by the Secretariat and can be hosted by members as agreed. Decision-making Decisions concerning GTFCC activities will be taken by consensus. Working groups and experts GTFCC Working Groups may be established as resources intended to increase the effectiveness of GTFCC. The Working groups are established to prioritize issues within a particular area and to mobilize external expertise for answering specific questions identified by GTFCC when the issue is particularly complicated and additional time, expertise, and discussion are required. Iindividual experts may be consulted and/or invited by the

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Global Task Force on Cholera Control April 23, 2014

Secretariat to provide advice to WHO on specific technical issues in accordance with WHO rules and procedures. Financing of and fundraising for the GTFCC GTFCC members will not be remunerated for their participation in GTFCC. Each member is, in principle, responsible for meeting its own expenses in relation to the GTFCC (including, but not limited to, travel and subsistence for the attendance of GTFCC meetings). However, in the interest of ensuring appropriate geographical representation in GTFCC, WHO may on a case by case basis, and subject to the availability of funds, pay for the travel and per diem of a limited number of GTFCC members to attend GTFCC meetings. All activities undertaken by the GTFCC, as opposed to those undertaken by GTFCC members in their individual capacities, including its day-to-day operations and the Secretariat support, are subject to the GTFCC Secretariat receiving adequate funds for that purpose. Finally, WHO may also raise funds from other sources to support the work of the GTFCC, in accordance with WHO's established policies and principles. All GTFCC Secretariat funds shall be administered in accordance with WHO's financial regulations, rules, and practices and is subject to WHO's normal programme support costs.

4. Information and documentation Publication As a general rule and subject to its discretion, WHO shall be responsible for issuing publications about GTFCC activities. All decisions about the preparation and dissemination of publications made by GTFCC Members (other than WHO) concerning GTFCC activities shall be made by consensus. Copyright in any publication made by WHO shall be vested in WHO. This also applies if the work is issued by WHO and is a compilation of works by GTFCC Members or is otherwise work prepared with input from one or more GTFCC Members. Copyright in a specific separable work prepared by a GTFCC Member shall remain vested in that Member (or remain in the public domain, if applicable), even if it forms part of another work that is published by WHO and of which WHO owns the copyright as a whole. Copyright in a publication prepared and issued by a GTFCC member shall remain vested in that member or shall be put in the public domain if such GTFCC member so chooses. "Publications" include any form, whether paper or electronic, and in any manner. Parties are always allowed to cite or refer to GTFCC publications, except for purpose of promoting any commercial products, services or entities. Any publication about GTFCC activities issued by a GTFCC Member other than WHO shall contain appropriate disclaimers as decided by WHO, including that the content does not necessarily reflect the views or stated policy of the participating organizations, agencies and institutions (including WHO, acting as the Secretariat for the GTFCC). Communication The conclusions of GTFCC meetings shall be made public, including through the Weekly Epidemiological Record and WHO web site.

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Global Task Force on Cholera Control April 23, 2014

GTFCC Members shall not make public statements about GTFCC activities or public statements on behalf of WHO unless specifically requested to do so by W HO. The contributions to the GTFCC made by GTFCC Members will be acknowledged by WHO in accordance with it applicable rules, policies and practices. Confidentiality: GTFCC Members agree:  To maintain confidentiality of information shared among GTFCC Members, except when explicitly indicated otherwise by WHO ; 

To maintain confidentiality about views of the various Members and the deliberations of the GTFCC, except with regard to agreed statements and reports issued by WHO or with the consent of WHO; and



Not to make public statements about GTFCC activities or public statements on behalf of WHO unless specifically requested to do so by WHO or with the prior consent of WHO.

Liability Under no circumstances shall WHO assume any liability for acts carried out by GTFCC Members regardless of whether such acts were carried out in the name of the GTFCC. Furthermore, WHO in its sole discretion, may refrain from implementing any decision of the GTFCC if in the view of WHO, such decision gives rise to undue financial, legal or reputational liability or is contrary to WHO Rules, Regulations Administrative practices and programmatic and technical policies. Amendments These Terms of Reference may be amended by WHO and all GTFCC Members shall be informed of such changes and shall be required to endorse them as a condition for their continuous participation in the GTFCC.

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Annex 5

Fact Sheet United Nations follow-up to the recommendations of the Independent Panel of Experts on the Cholera Outbreak in Haiti Background Following the first instances of cholera in Haiti that were reported in mid-October 2010, the UN Secretary-General appointed a panel of independent scientific experts on the cholera outbreak. The Independent Panel presented its report at the United Nations Headquarters on 3 May 2011 and to the Government of Haiti through the Special Representative of the Secretary-General for Haiti on 4 May 2011. The Independent Panel made seven recommendations on cholera prevention and response. Upon receipt of the report, the Secretary-General convened a Task Force with representatives of UNDP, UNICEF, WHO and several offices and departments of the United Nations, which also included relevant United Nations actors and observers, to review the recommendations of the Independent Panel and provide ongoing advice to the Secretary-General on their implementation.

Follow-Up in Response to the Seven Recommendations Recommendation I The Independent Panel of Experts noted that the Haiti cholera outbreak highlights the risk of transmitting cholera during mobilization of population for emergency response. To prevent the introduction of cholera into non-endemic countries, it recommended that United Nations personnel and emergency responders traveling from cholera endemic areas should either receive a prophylactic dose of appropriate antibiotics before departure or be screened with a sensitive method to confirm absence of asymptomatic carriage of Vibrio cholerae, or both. Follow-up 1. The United Nations is committed to protecting the health of the people it serves, UN personnel and emergency responders and to preventing the transmission of disease through its medical policies and practices. United Nations guidelines are based on guidance provided by the World Health Organization (WHO). 2. The United Nations has worked to support the objective of lowering the overall risk of spreading the disease through the promotion of proper personal hygiene and cholera prevention training for UN personnel. In the context of UN peacekeeping, the Department of Peacekeeping Operations (DPKO) and Department of Field Support (DFS), in partnership with Medical Services (Department of Management) and the Integrated Training Service (DPKO-DFS), have developed a training plan for Troop and Police Contributing Countries (TCCs/PCCs) designed to reinforce proper hygiene and cholera prevention. This plan complements other hygiene initiatives already taking place as part of in-mission training for all categories of UN uniformed personnel. The plan is included in the Medical Support Manual for missions and makes the availability of cholera training materials more explicit, stressing the requirement for, and importance of, cholera prevention 39

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training within the established pre-deployment training programmes. The training is carried out by each TCC/PCC before deployment to the field. Further in-mission training on cholera prevention is provided systematically by civilian and military medical personnel in each peacekeeping operation as part of a larger focus on prevention of water-borne diseases. 3. The specific proposal for the wide-scale use of prophylactic antibiotics is based on the assumption that antibiotics provided to UN personnel and emergency responders from cholera endemic areas would eradicate the carrier state and thereby the risk of cholera introduction into non-endemic countries through asymptomatic carriers. There are currently divergent views within the medical community on expected benefits from such a practice, including experts who recommend against this practice. 4. Those experts and institutions that recommend against the practice of mass prophylaxis are concerned that the prophylactic use of antibiotics could encourage selection and spread of antibiotic resistant pathogenic bacteria, leading to (i) the risk that antibiotic resistant strains of Vibrio cholerae may further develop; and (ii) the risk that other organisms may develop resistance, compromising the use of that antibiotic in the management of other infectious diseases. The indiscriminate use of antibiotics for a wide variety of diarrheal diseases has contributed to the spread of resistance. 5. Given the limited evidence related to the benefits of mass prophylaxis, and the divergence in expert views on this issue, WHO convened a PAHO/WHO Expert Group on 9 December 2011 to specifically review the above recommendation. This group of experts produced a report: “PAHO/WHO Expert Consultation on Pharmacological Measures for Prevention of Cholera Introduction in Non endemic Areas”. The report concluded that “it is not possible to endorse any recommendation about antimicrobial mass treatment of or screening for asymptomatic carriers (due to) lack of evidence on the efficacy, safety, and risks of the administered treatment and on the sensitivity and cost-effectiveness of the current technology for detecting asymptomatic carriers in a timely fashion”. The PAHO/WHO report further concludes that “the prevalence of asymptomatic cholera carriers and disseminators in any group of potential peacekeepers is unknown, and there is no evidence that similar azithromycin treatment could eradicate that state” and “implementing a policy without an evidence base is not ethical and should not be done”. 6. The recommendation related to screening of personnel was carefully considered by the United Nations Task Force. Screening to confirm the absence of asymptomatic carriage of cholera poses immense challenges due to the lack of sufficiently sensitive screening methods and technology. Currently, the screening of asymptomatic individuals to detect transient asymptomatic or mild infection is not possible because the relatively low levels of cholera bacteria present would not be detectable. Even if a screening test with adequate sensitivity and specificity is indeed available, such interventions would require the necessary substantial infrastructure for sampling, including equipment and supplies for invasive rectal swabbing, safe transportation of samples, and appropriate quality standards for medical personnel performing the testing. Should a decision be taken in the future to perform mass screening of personnel (if and when a viable screening test becomes available), it should be noted that additional questions relating to ethics and confidentiality would need to be carefully considered and negotiated.

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Recommendation II United Nations missions commonly operate in emergencies with concurrent cholera epidemics. The Independent Panel of Experts recommended that all United Nations personnel and emergency responders traveling to emergencies should receive prophylactic antibiotics, be immunized against cholera with currently available oral vaccines, or both, in order to protect their own health and to protect the health of others. Follow-up 1. As of October 2010, the UN recommended that all UN personnel, including troops of TCCs/PCCs, are offered the oral cholera vaccine. Recognising that the vaccine does not eradicate a carrier state, it is nonetheless useful to protect the individual who is vaccinated from developing new, active disease, or a new carrier state, and thereby reducing disease transmission. The vaccines used, either as primary immunization or booster, are part of a comprehensive risk assessment undertaken before deployment. 2. Before every TCC/PCC troop deployment, recommendations on the appropriate vaccinations and prophylaxis are provided, based on considerations of a health risk assessment of the country they are deploying to and of current existing WHO guidelines. With regard to Haiti, the UN Medical Services Division has recommended that all personnel, including TCC/PCC, be vaccinated against cholera before deployment. It should be noted that the vaccination of TCC/PCC troops remains a responsibility of the TCCs or PCCs. Additional issues related to prophylactic antibiotics for cholera are covered in question 1, above.

Recommendation III The Independent Panel of Experts recommended that to prevent introduction of contamination into the local environment, United Nations installations worldwide should treat faecal waste using on-site systems that inactivate pathogens before disposal. These systems should be operated and maintained by trained, qualified United Nations staff or by local providers with adequate United Nations oversight. Follow-up 1. The proper management and oversight of waste water treatment at UN installations, including the proper management and oversight of UN waste water treatment service providers (where utilized) is a priority for all UN Missions. The UN fully endorses the use of independent on-site waste water treatment plants in UN Missions, where this is the most effective method to ensure that untreated effluent is not discharged from UN installations into the environment. In some instances, properly designed and well-maintained traditional waste water treatment systems may provide an effective alternative, particularly for smaller UN installations such as team sites or field offices. The Task Force recommended that the most effective and appropriate waste water solutions be used in all UN installations, following a comprehensive assessment of each location. 2. Following the recommendations of the Independent Panel, the UN has undertaken substantial actions to improve wastewater management in field missions. All missions have provided action plans to ensure that all their wastewater facilities meet the minimum required standards set by the

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Organization’s Environmental Policy. Missions are implementing these plans and report on the range of actions being taken, and highlight any areas that require further headquarters attention and guidance. 3. The actions undertaken in some field mission and being undertaken in others include improvements to and better monitoring of existing facilities, installation of independent wastewater treatment plants, and inspection and closer supervision of contractors involved in wastewater disposal. The UN also continues to strengthen operational and oversight capacity. 4. In Haiti, MINUSTAH had successfully established a fully functional Environmental Unit and has performed a detailed analysis of all the mission’s wastewater facilities. The mission actively inspects and reviews its sanitation and waste management mechanisms to ensure that acceptable standards are maintained. MINUSTAH has installed 32 wastewater treatment plants throughout the country and closely monitors the proper disposal of untreated wastewater into governmentapproved disposal sites.

Recommendation IV The Independent Panel of Experts recommended that to improve case management and decrease the cholera case fatality rate, United Nations agencies should take stewardship in: a) Training health workers, especially at the treatment centre level; b) Scaling up the availability and use of oral rehydration salts at the household and community levels in order to prevent deaths before patients arrive at treatment centres; and c) Implementing appropriate measures (including the use of cholera cots) to reduce the risk of intra-facility transmission of cholera to health staff, relatives and other patients. Follow-up 1. Despite severe infrastructure and financial constraints, important strides have been made in combating cholera in Haiti. There has been a drastic reduction in the number of suspected cholera cases and deaths from cholera, particularly in 2013. The 5483 suspected cases and 36 fatalities reported by the Ministry of Health for May 2014 (provisional numbers) are the lowest number of cases and fatalities registered since the outbreak was declared, and represent a 75 per cent decrease from the same period in 2013. The overall incidence of the disease has been reduced by half and fatality rates are below one per cent, the target rate set by WHO globally. These results confirm that efforts to tackle the epidemic are working. 2. The Government of Haiti launched its National Plan for the Elimination of Cholera (2013-2022) on 27 February 2013, along with a two-year operational component of the Plan. The United Nations system in Haiti (including IOM, MINUSTAH, PAHO/WHO, OCHA, UNDP, UNICEF and UNOPS) has been supporting the Government of Haiti’s response to the cholera epidemic, including in the critical areas outlined in the above recommendation. A comprehensive report of the ongoing efforts related to the response, as well as update on activities and progress is available on the UN's website and is updated on a regular basis. 3. The UN’s strategy to support the implementation of the Government’s plan aims at curtailing the epidemic and reducing the number of cases and deaths resulting from cholera. As such, the UN

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strategy includes activities in all aspects of cholera prevention and response including epidemiological surveillance, health and hygiene promotion, medical treatment and water, hygiene and sanitation. 4. Within this context, the UN has been supporting national authorities to ensure free access for cholera patients to adequate treatment and safe water as a first life-saving intervention for cholera patients. The UN is further assisting national health authorities to integrate cholera treatment services into the national health system in order to guarantee the sustainability of treatment of patients. The UN is also supporting efforts to ensure that fast and reliable data on the evolution of the epidemic is available and ensure there is a rapid response to all alerts detected. 5. To do so, the UN helped establish a national data collection and reporting system to monitor cholera cases, in partnership with the Centres for Disease Control and Prevention (CDC). Thanks to this system, 1,150 alerts on suspected cases of cholera were received through the system and responded to with health and water interventions. The UN has further invested significantly to sensitize and equip the population with the knowledge of how to protect themselves, their families and their communities from cholera. Investing on knowledge and practice of safe hygiene behaviour is the most cost-effective way of reducing the risk of cholera in the country. The UN has also helped increase access to clean water and to health centres for the population. Furthermore the UN is supporting the Government to increase the use of rapid tests to differentiate cholera from acute diarrhoea and strengthen their laboratory test capacity to better isolate and tackle the disease. 6. Since 2012, the UN has helped rehabilitate water and sanitation infrastructure in department hospitals and improved water quality in 80 health centres. Because human excreta is a major risk of contamination within treatment centres, the UN continues to support desludging and disinfection of sanitation facilities and has funded the repair of the government’s sanitation truck fleet, dedicated to ensuring the desludging of treatment centres. 7. The UN is also supporting the Ministry of Health to carry out a vaccination campaign targeting 600,000 people in areas of cholera persistence. The first phase of the campaign took place in August 2013, targeting 107,906 people in two affected communes. A second phase is planned in the coming months targeting an additional 200,000 people. 8. The combination of these efforts has had a direct impact in the reduction in the number of cases and fatalities related to cholera. An increase in targeted water and sanitation activities in areas of cholera persistence is being foreseen by the UN to consolidate these gains.

Recommendation V The Independent Panel of Experts recommended that to prevent the spread of cholera, the United Nations and the Government of Haiti should prioritize investment in piped, treated drinking water supplies and improved sanitation throughout Haiti. Until such time as water supply and sanitation infrastructure is established: a) Programmes to treat water at the household or community level with chlorine or other effective systems, hand-washing with soap and safe disposal of faecal waste should be developed and/or expanded; b) Safe drinking water supplies should continue to be delivered and

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faecal waste should be collected and safely disposed of in areas of high population density, such as the spontaneous settlement camps. Follow-up 1. The United Nations has called on the international community to support the Government of Haiti’s National Plan and to scale up water and sanitation in Haiti. Although Haiti's sanitation coverage has marginally risen from 19 per cent in 1990 to 24 per cent in 2012 due in large part to the earthquake response, Haiti has fallen further behind the rest of the region in that time period (67 per cent to 82 per cent). And while more Haitians in urban areas now have access to improved sanitation facilities, rapid urbanization means these percentages have actually gone down. The most excluded population is in rural areas, where sanitation coverage is only 16 per cent and sometimes health infrastructures are absent and cholera response can be a bigger challenge. Nearly 3.9 million people (38 per cent of the population) lack access to safe drinking water1. 2. The UN’s strategy of engagement with regards to water and sanitation includes an emergency response mechanism for water and sanitation to respond to cholera alerts and a sustainable community-based water, sanitation and hygiene (WASH) programme to increase access to safe water, sanitation and hygiene for the population, particularly women and children. 3. As part of this strategy, the UN has expanded its rapid response activities to protect households and communities in areas affected by cholera outbreaks. In cooperation with NGO partners present in all 10 departments of Haiti, UNICEF works with technical field staff from the national water and sanitation directorate (DINEPA) and local authorities to deliver an emergency WASH response to cholera spikes within 48 hours. Activities include sensitization on the treatment of water consumed by households in affected neighbourhoods, the delivery of hygiene materials (soap, aquatabs, etc.) to support household sanitation and hygiene and the immediate repair of water points and systems in communities affected by cholera. 4. The UN is also carrying out sustainable community-based WASH projects in areas of cholera persistence. This includes the drilling of 100 boreholes and WASH facilities in 300 schools, supporting a nation-wide marketing strategy to promote larger household water treatment and storage and hand-washing with soap and supporting community sanitation in areas of cholera persistence. The UN, in cooperation with government partners, is also supporting increased access to safe water, including through the strengthening of a water systems chlorination control, along with the chlorination of water tankers in the two metropolitan areas of Port-au-Prince and Cap Haitian. 5. As recommended by the Independent Panel of Experts, the UN also supports the collection and safe disposal of faecal waste. The UN has been supporting the desludging of latrines in IDP camps since 2010. In 2012, UNICEF supported desludging for over 300,000 IDPs. In 2013 UNICEF continued to support desludging in IDP camps in the metropolitan area of Port-au-Prince, which accounts for 98 per cent of the remaining displaced population. With the support of the UN, DINEPA established and is maintaining a waste site, and has recently started to desludge health facilities in the areas worst affected by cholera.

1

WHO/UNICEF Joint Monitoring Programme (JMP) for Water Supply and Sanitation, http://www.wssinfo.org/

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6. Funding to continue and sustain the progress made from the above critical activities described above is urgently required. This is in addition to the essential long term investments in water and sanitation. The Government’s 10-year plan requires US$2.2 billion for the long-term elimination of the disease through large-scale development of public health and sanitation infrastructure. Of this amount, $448 million is required for the first two years (2013-2015). About half or $222 million of the $448 million have so far been mobilized by international partners. 7. Since the outbreak, the UN has expended $140 million on the cholera response. The total amount required for the UN’s Support Plan covering humanitarian and development activities during 20142015 is $69 million. As of May 2014, some $32 million has been received, from the UN Central Emergency Response Fund and the Governments of Canada, Japan and the UK. This is vastly insufficient to meet urgent needs. The lack of available funds today risks the departure of cholera actors, which could compromise gains attained so far and lead to resurgence in suspected cases.

Recommendation VI The Independent Panel of Experts recommended that the international community should investigate the potential for using vaccines reactively after the onset of an outbreak to reduce cholera caseload and spread of the disease. Follow-up 1. The United Nations Task Force established by the Secretary-General fully endorsed the use of vaccines reactively after the onset of a cholera outbreak as part of an integrated overall response and particularly when other interventions cannot be delivered effectively, which is in line with WHO guidelines. WHO recommends that immunization with currently available cholera vaccines be used in conjunction with the usually recommended control measures in areas where cholera is endemic as well as in areas at risk of outbreaks. Vaccines provide a short term impact while longer term activities like improving water and sanitation are put in place. 2. On 14 August 2012, the PAHO Technical Advisory Group on Vaccine-Preventable Diseases recommended the introduction of the cholera vaccine in Haiti with the goal of moving toward universal vaccination for the people of Haiti. 3. In 2013, PAHO/WHO and UNICEF began working with partners to support the Ministry of Health to vaccinate 600,000 people in areas of cholera persistence. The first phase of the campaign took place in August 2013, targeting 107,906 people in two affected communes. A second phase of the campaign targeting 200,000 people will be implemented in 2014. 4. The United Nations is appealing to the international community to urgently mobilize the necessary funds to expand the vaccination campaign. Combined with vital longer term investments in water and sanitation, the CDC estimates that the vaccination program could prevent nearly 90,000 new cases of cholera over the next two decades and significantly contribute to defeat the disease’s spread. 5. The United Nations has urged the international community, including governments and partners who use cholera vaccines reactively, to actively engage with WHO with regard to the monitoring and assessment of such interventions and in the gathering of evidence on their impact.

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6. The United Nations has worked with the global health community to create a global stockpile of oral cholera vaccine (OCV), as an additional tool to help control cholera epidemics. As global vaccine production is limited, during the period from July 2013 through June 2014, the stockpile will gradually have two million doses of vaccine, primarily intended for outbreak interventions. 7. The OCV stockpile is managed by the International Coordinating Group (ICG). The ICG has managed similar stockpiles of meningococcal meningitis and Yellow Fever vaccines for outbreak response over the past 12 years. The ICG is comprised of four decision making partners: the International Federation of Red Cross and Red Crescent Societies (IFRC), Médecins Sans Frontières (MSF), United Nations Children's Fund (UNICEF) and WHO, which also serves as the Secretariat. 8. In November 2013, the GAVI Alliance Board approved a contribution towards a global cholera vaccine stockpile for the period 2014-2018 to increase access to oral cholera vaccine in outbreak situations and endemic settings. 9. Embedded within the OCV stockpile mechanism is a system of monitoring and evaluation. As experience and data accrue, the results of evaluations should enable continuous improvement in the structure and functioning of the stockpile and inform the use of OCV as a public health tool. The ICG members are communicating with partners and stakeholders to increase awareness of the OCV stockpile and placing the vaccine in the context of an integrated cholera response which is based around early detection and case management, provision of safe water, sanitation and raising awareness among the affected communities.

Recommendation VII The Independent Panel of Experts noted that recent advances in molecular microbial techniques contributed significantly to the investigative capabilities of their report. It recommended that through its agencies, the United Nations should promote the use of molecular microbial techniques to improve surveillance, detection, and tracking of Vibrio cholerae, as well as other disease-causing organisms that have the potential to spread internationally. Follow-up 1. The United Nations strongly supports calls for the international scientific community to enhance its research focus on the use of molecular microbial techniques and in the development of appropriate technologies to assist with the timely detection of Vibrio cholera. This research should also be extended to other disease-causing organisms that have the potential to spread internationally. 2. WHO, with the support of the wider UN system, has taken proactive steps to help coordinate the efforts of the scientific community. This has included a review of laboratory tools best adapted to the surveillance and tracking of cholera strains and the identification of WHO collaborating centres and associated partners. 3. In response to the recommendation of the Independent Panel of Experts, WHO has initiated a mapping of the existing rapid diagnostic tests for the detection of cholera. There are ongoing plans

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to evaluate the technical specifications of available tests, together with assessments of their field performance in order to elaborate recommendations for their use, alone or in combination with other existing techniques. In 2013, WHO initiated a project to study the feasibility of an innovative diagnostic technology that will support simultaneous detection of a wide range of pathogens, including agents responsible for acute diarrhoea. *****

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October 8, 2014 Coalition for Cholera Prevention and Control c/o Task Force for Global Health 325 Swanton Way Decatur, GA 30030 Dear Coalition Members: I am the Executive Director of the Institute for Justice & Democracy in Haiti (IJDH), a nonprofit organization based in Boston, Massachusetts. IJDH and its Haitian partner, the Bureau des Avocats Internationaux (BAI), have worked to advance human rights in Haiti for the past twenty years and have advocated for victims of the devastating cholera epidemic since 2011. I am writing to express our respect for the work of the Coalition for Cholera Prevention and Control, and to request your support and ideas for our ongoing efforts to secure an adequate and just response to the epidemic in Haiti. As you know, cholera broke out in Haiti in October 2010. To date, it has killed over 8,500 and has infected more than 700,000 Haitians, or approximately 7% of the population. Strong evidence indicates that cholera was introduced to Haiti, a country where cholera had never before been reported, by soldiers of the UN Stabilization Mission in Haiti (MINUSTAH). The soldiers were deployed from Nepal, which was experiencing a cholera epidemic at the time, without being tested or treated for the disease. They were stationed on a MINUSTAH base that regularly discharged untreated human waste into a tributary of the Artibonite River, Haiti’s largest river, that is relied on by tens of thousands of Haitians for drinking water, washing, and farming. International journalists documented sewage pipes emptying into the tributary. 1 Residents of a nearby town had reported noxious odors emanating from the base’s discharges well before the cholera outbreak.2 Several genetic and epidemiological studies have linked the introduction of the disease to the MINUSTAH base, including the UN’s own Independent Panel of Experts, which concluded that “[t]he evidence overwhelmingly supports the conclusion that the source of the Haiti cholera outbreak was due to contamination of the Meye Tributary of the Artibonite River with a pathogenic strain of current South Asian type Vibrio cholerae as a result of human activity.”3

1

Katz, Jonathan. “UN probes base as source of Haiti cholera.” Associated Press. 28 October 2010. . 2 Id. 3 Daniele Lantagne et al., “Final Report of the Independent Panel of Experts on the Cholera Outbreak in Haiti.” May 2011. < http://www.un.org/News/dh/infocus/haiti/UN-cholera-report-final.pdf>.

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Genetic testing of the strain in Haiti determined it to be a “perfect match” to the Nepal strain.4 In short, the “strain was not indigenous to Haiti”5 and likely emanated from Nepalese peacekeeping troops. Once introduced, cholera flourished due to Haiti’s ineffective and fragmented water and sanitation sectors. 6 Only 17 percent of the population has access to improved sanitation that “hygienically separates human excreta from human contact.” 7 Less than 30 percent of the population has access to basic sewage infrastructure.8 These sanitation problems provided a ripe environment for the rapid contamination of water supplies and the consequent spread of the cholera in Haiti. The disease has now plagued the country for approximately four years, resulting in the worst single-country cholera epidemic in modern times. Despite the well-documented need for water and sanitation infrastructure to curb transmission, the majority of Haitians still lack access to clean water and there has been little improvement to the sanitation infrastructure. These persistent structural problems have created an environment where cholera cannot be controlled or eradicated without reform of the country’s water and sanitation sectors. Unfortunately, the response from the UN and the international community has not met the challenge posed by cholera. While international interventions, especially medical care and water treatment have saved lives, they have not addressed the underlying infrastructure problems. The UN theoretically recognized its obligation to eliminate cholera in Haiti by announcing its support for the Initiative for the Elimination of Cholera in the Island of Hispaniola in 2012, but two years later the organization has provided only 1% of the funding needed, and repurposed another 9% from undelivered earthquake donations. Moreover, the UN has refused to implement clear recommendations by the UN’s own panel of experts as well as other respected medical professionals such as Dr. David Sack for effectively addressing and preventing cholera outbreaks elsewhere, even as peacekeepers regularly deploy from endemic to non-endemic countries. Meanwhile, Haitians continue to live in fear of contracting cholera. Together with the BAI, IJDH has been advocating for a just response to the cholera epidemic since 2011. In light of the evidence connecting the introduction of cholera to MINUSTAH operations, we made several attempts to engage the UN directly to secure a just response to the crisis. In November 2011, we submitted claims on behalf of 5,000 families seeking relief. In February 2013, the UN rejected the claims as “not receivable.” Soon thereafter, in August 2013, Yale Law School and the Yale School of Public Health released a definitive report on the UN’s role in the cholera outbreak and explained how the UN has legal obligations to hear claims from 4

Daniele Lantagne, G. Balakrish Nair, Claudio F. Lanata & Alejandro Cravioto, The Cholera Epidemic in Haiti: Where and How Did It Begin? Current Topics in Microbiology and Immunology (2013), at § 2.2 [hereinafter Where and How Did It Begin?]. 5 Louise Ivers, “A Chance to Right a Wrong in Haiti.” THE NEW YORK TIMES. 22 February 2013. . 6 Daniele Lantagne, et al., Where and How Did It Begin? at 13. 7 World Health Organization, Progress on Sanitation and Drinking Water: Fast Facts (2013), . 8 Universal Periodic Review: Report on Right to Food, Water and Sanitation, Republic of Haiti, 12th Session of the Working Group on the UPR, Human Rights Council, Oct. 3-11, 2011, at 6.

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Haitian cholera victims. 9 In addition, media outlets around the world criticized the UN’s dismissal in front-page stories and editorials. The Washington Post stressed that “by refusing to acknowledge responsibility, the United Nations jeopardizes its standing and moral authority in Haiti and in other countries where its personnel are deployed,” 10 and The New York Times urged the organization to “acknowledge responsibility, apologize to Haitians and give the victims the means to file claims against it for the harm they say has been done them.”11 Despite these attempts to urge the UN to take responsibility, the organization continued to refuse to consider victims’ claims or acknowledge its role in the epidemic. Having exhausted other avenues, in October 2013, we filed a class action lawsuit against the UN in the U.S. District Court for the Southern District of New York. The first hearing in the case will take place on October 23, 2014. We initiated our advocacy to advance the rights of the Haiti cholera victims, but it soon became clear that advancing accountability for cholera was important for decreasing the risks of similar epidemics and other public health crises, including sexual assault, among the vulnerable populations that host peacekeeping missions. Cholera was introduced to Haiti, not by a sudden accident, but by a sustained refusal by the UN to respond to well-known risk factors, especially the long-term discharge of human wastes into a highly-used river system. UN peacekeeping missions have similarly disregarded public health risks in other contexts, especially sexual assault by peacekeepers. Holding the UN accountable for the costs of its recklessness in Haiti would encourage the UN to reduce the risks of future accountability worldwide by reducing its recklessness. While the pending case against the UN in federal court is an effort to obtain redress for Haiti cholera victims, it also represents a broader effort to protect vulnerable populations like Haitians from devastating cholera epidemics. Public health organizations such as Partners in Health and Physicians for Haiti have joined this effort by using their health expertise to respond to the ongoing epidemic and to advocate for a stronger response from the UN, including efforts to ensure that measures are put in place to prevent a similar crisis from occurring elsewhere. Human rights experts and officials affiliated with the UN have also spoken out about the need for UN accountability and a sustained commitment to building water and sanitation infrastructure in Haiti. Catarina de Albuquerque, Special Rapporteur on the Human Right to Safe Drinking Water and Sanitation, recently called on the UN to eradicate the disease and to “meet that commitment by providing adequate resources.” 12 She stressed that the organization should “establish

9

“Peacekeeping without Accountability,” Transnational Development Clinic, Yale Law School. 6 August 2013. . 10 Editorial Board. “United Nations must admit its role in Haiti’s cholera outbreak.” THE WASHINGTON POST. 16 August 2013. . 11 Editorial Board. “Haiti’s Imported Disaster.” THE NEW YORK TIMES. 12 October 2013. . 12 Report of the Special Rapporteur on the human rights to safe drinking water and sanitation, Common Violations of the Human Rights to Water and Sanitation, Human Rights Council, ¶ 34, U.N. Doc. A/HRC/27/55 (June 30, 2014) (by Catarina de Albuquerque).

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appropriate accountability mechanisms for ongoing and future missions as well as to review and reinforce measures for adequate sanitation and preventive measures.”13 We are reaching out to you as leaders of the public health community who have dedicated time and resources to combatting cholera globally and have insights into the most efficacious and responsible responses to crises such as this. We would greatly appreciate your support and input on how we can partner with the public health community to expand that community’s advocacy on behalf of a sustainable, just response to the cholera epidemic in Haiti, and reduction of public health risks to peacekeeping mission host countries worldwide. Thank you for your kind consideration of this request. We look forward to collaborating with you to advance health and justice in Haiti and elsewhere.

Very truly yours,

Brian Concannon, Jr., Esq. Director

13

Id.

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Overview of Rotary Project Funding Resources in re: Coalition Partners Rotary is a service organization consists of approximately 1.2 million members in 34,000 clubs throughout the world. Rotary members donate their time and money to local, national and international projects within six Areas of Focus, including the humanitarian goals of Disease Prevention and providing Clean Water and Sanitation, among others. Although significant changes to the way that The Rotary Foundation of Rotary International awards grants were made in 2010, project funding is usually obtained through one of three venues: • Individual club funding Individual Rotary clubs may fund projects or make donations on their own. The size of the donations often depends upon the size of the club and the resources of its individual members. For example, an Atlanta club may decide to make a onetime expenditure of $5,000 to dig wells in Peru. The advantage of individual club funding is largely discretionary: there is a wide range of autonomy for what a club can do with its money, and the decision and allocation processes can happen quickly. The donations may be ongoing, and they can be used for international projects. Obtaining funds for Coalition initiatives Rotary International, the administrative body of Rotary, does not provide contact information for individual clubs, to prevent mass solicitation by third parties. Donations are usually initiated by club members. Third parties may establish relationships with individual clubs or club members, often by making clubs aware of a need during a presentation at regular meeting. However, presentations are by invitation only, making any direct solicitation a challenge. • District Grants Rotary clubs are organized into districts, which are subsets of zones. District Grants are small grants typically totaling from $2,250 – $3,000 are available for special projects, which must be pre-approved through an application

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process. The size of and application process for District Grants vary from District to District. Most District Grants are used for local projects. Because District Grants must originate and their corresponding projects completed within one fiscal year, they are generally impractical for international initiatives. • Global Grants Rotary Foundation’s Global Grants “support large international activities with sustainable, measurable outcomes in at least one of Rotary’s Areas of Focus. Grant partners form international partnerships that respond to real community needs.” During FY 2013-14, there were 653 Humanitarian Projects – predominantly Clean Water and Sanitation initiatives. The monies used in large-scale projects are made available through the Rotary Foundation, which sets rules and guidelines for application, use and disbursement. A main link to various references detailing Global Grants may be found at: https://www.rotary.org/en/take-action/apply-grants/global-grants Rotary International has taken on projects supported by all of its members and clubs. Such is the case for Rotary’s signature project called PolioPlus™. Since its initiation in 1985, Rotary and its partners have helped reduce the number of annual cases from 350,000 to fewer than 250 and remain committed until every child is safe from the disease. Rotarians have contributed over $1.2 Billion and countless volunteer hours towards the eradication of polio. I have reprinted an excerpt below: ________________ HOW TO USE THEM A key feature of global grants is partnership, between the district or club where the activity is carried out and a district or club in another country. Both sponsors must be qualified before they can submit an application. To be successful, your application must: • Be sustainable and include plans for long-term success after the global grant funds have been spent • Include measurable goals • Align with one of our areas of focus • Respond to real community needs

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• Actively involve Rotarians and community members • Meet the eligibility requirements in the grants terms and conditions Applications are accepted throughout the year and reviewed as they are received. HOW THEY’RE FUNDED The minimum budget for a global grant activity is $30,000. The Foundation’s World Fund provides a minimum of $15,000 and maximum of $200,000. Clubs and districts contribute District Designated Funds (DDF) and/or cash contributions that the World Fund matches. DDF is matched at 100% and cash is matched at 50%. [Thus, the total available funding ranges from $30K to $400K]. RESOURCES & REFERENCE • Terms and Conditions for Rotary Foundation District Grants and Global Grants • Areas of Focus Policy Statements • Grant Management Manual • Six Steps to Sustainability • Grants travel request • Global Grant Lifecycle • Cadre of Technical Advisers • Global Grant Monitoring and Evaluation Plan Supplement • Global Grant Online Application Process • 10 Ways to Improve Your Global Grant Application TOOLS • Take a course on Rotary grants in the Learning Center • Get started with the grants application tool • Check our discussion groups ROTARY SUPPORT • District Rotary Foundation committee • Regional Rotary Foundation coordinator • Rotary grant officer • Club Rotary Foundation committee

________________ A simplified overview of the Global Grant Process It is important to understand that Rotary is a “bottom-up” organization. In other words, project initiatives and actions begin at the club level, often arising from the passion and commitment of a club member – even Rotary’s huge PolioPlus™ program began this way.

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Annex 7

Global Grants are matching grants – 50% of the grant funds must be raised by the sponsoring club and/or district. Note that individual Rotarians and clubs are involved from start to finish. Although The Rotary Foundation approves and partially funds Global Grants, the initial genesis of a project occurs locally. Thus, third parties (such as Coalition Partners) must be able to identify committed Rotarians within a local club operating in the proposed project area, who agree on the objectives, and are willing to initiative the Global Grant application process and work with sponsoring Rotary partners in foreign countries. It takes quite a bit of work to get a Global Grant started; the application requirement requires a community needs assessment and other requisites, which are detailed in the “RESOURCES & REFERENCE” section noted above. There is a timeline involved, and the entire process from start to raising funds to completion often takes a few years. Patience and persistence are essential. Nonetheless, in spite of these apparent obstacles, every year hundreds of large dollar Rotary Foundation Global Grant projects are started, and others are completed. To get a better idea of the scope and types of Global (matching grant) Rotary projects, visit: http://www.matchinggrants.org/global/ The data on the site can be searched by country, location, district, type (title), and other metrics, including ongoing vs. completed projects. How would a Coalition member or other third-party spark Rotary involvement in a Disease Prevention or Clean Water project, for a benefit of a poor country far away? The key is to enlist the help of the District Governor within the designated Rotary District of the target area. District Governors have contact information for all of the clubs in their region (which is not made available by Rotary International). They also know which clubs are most active; which ones may have passionate and capable members for the project in question, and can judge if a prospective project is likely to be beneficial (and practical). Some countries have more than one zone and multiple District Governors. The Task Force for Global Health, Inc. will have contact information for the District Governors of the four target countries. If you have Rotary related questions, please feel free to contact me by e-mail at: [email protected]. Jon Yaeger, President The Rotary Club of North Atlanta (USA) October 20, 2014

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