Operational Biosurveillance

Disaster Conditions Declared in Pestel, Grand Anse, Haiti

The Haiti Epidemic Advisory System (HEAS) is scrambling now to issue an Emergency Appeal, as cholera has most certainly reared its head yet again, this time in Grand Anse with 445 cases and 59 fatalities.

Observations Regarding the Implementation of the Haiti Epidemic Advisory System

We have successfully triggered a social network to support reporting of disease events in Haiti called the Haiti Epidemic Advisory System (HEAS). We now have 150 members with representatives from nearly every major NGO, smaller NGOs, unaffiliated clinicians, and key Haitian authorities. What we have executed is a system that mirrors a basic sociological process we have seen in many other operating environments to support warning functions such as:

• The World Health Organization IHR reporting system (official, publicly visible) versus ProMED, the Global Outbreak Alert and Response Network (GOARN), and the now-defunct World Health Organization Outbreak Verification List (OVL) systems (unofficial, offline).
• The National Biosurveillance Integration Center (official) versus the BIWAC/Wildfire system (unofficial, offline) In other words, we continue to observe a very important sociological phenomenon that relates to the process of getting people to routinely report information- specifically, important public health information – that would not be reported under formal networks.

We are still in crisis mode in Haiti.  As such, the challenges for effective formal medical surveillance remain.  Others have published outlining the need for alternative reporting systems for disease events, again highlighting a basic sociological phenomenon.

Especially as it pertains to emerging crises, we have found over our 12-year career that “tip” information regarding infectious disease events is often received through trusted one-to-one communications. When this one-to-one communications are coupled with well-architected, intelligent social networks, a new, more robust type of situational awareness and collective intelligence emerges that can drive agile, proactive, rapid response in emergent situations.

This is absolutely a complimentary process to formal public health reporting, as currently facilitated by the Haitian Ministry of Health, PAHO, and CDC in Haiti.  Metrics for success when constructing a warning system are always so difficult to define. But we do have two important ones:

• People are reporting disease events in a way that supplements reporting in the formal medical surveillance system.
• Several of the major NGOs have proactively moved medical countermeasures and logistics into position in anticipation of a possible infectious disease crisis – as a result of advisories sent to them from the HEAS community effort.

We are currently in emergency mode monitoring for a potential crisis of pediatric diarrheal disease.  Unfortunately, the same cultural resistance to change in the public health community is present in our attempts to properly fund and maintain the capability: 

"[thanks for your] detailed follow-up message, which has been reviewed by the... health teams in Haiti. They appreciate the interest but, for now, find the current procedures satisfactory to their objectives."

As mentioned before, this same sociological process delayed public benefit of weather forecasting by decades.  In the case of Haiti, it is actively impeding our attempts to mitigate large scale child mortality with the advent of the rains.  Unfortunately in this case, the risk relates not only to the tragedy of children dying in Haiti after there was a major loss of life due to the earthquake, but also represents an important contributing factor to destabilizing the region.  We have seen in other cultures that unexpected fatalities involving children- particularly if perceived to be preventable- is a key trigger for social outcry.  In the context of the current situation in Haiti, where the public is already aware of a mismatch between donations and ground implementation of those monies, there is a very real possibility of civil unrest.

Warning systems are contentious constructs.  The reaction two nights ago at the UN Health Cluster to a recent posting of an HEAS advisory related to malaria is revealing.  Comments by public health professionals were indignant, saying "we already knew that".  The disconnect is the translation of awareness to proactive action.  In the case of malaria, there have been robust discussions with the MENTOR Initiative about malaria surveillance, control, and emergency preparedness.  MENTOR is an excellent effort that has been proactively engaged in dialog with the HEAS community, very much to their credit and to the benefit of the community.  However, pediatric diarrheal disease is more likely to abruptly overwhelm the already fragile medical infrastructure and therefore more likely to fall in the range of being labeled a crisis or disaster.  It is therefore more likely to contribute to social destabilization.  

Translation to action is a difficult process.  The issuance of a warning is an important step in sensitizing a community who internalize that information, cross-check the validity of the warning, and then decide whether the information is relevant to their operations or not (i.e. confirmatory behavior).  Another way to view confirmatory behavior is to consider it a part of active surveillance.  We often see the "all is clear" type reporting through this process, which enables detection of negative as well as positive signature patterns.  Proof of successful translation to action was demonstrated by the above-mentioned metrics for success:

• People are reporting disease events in a way that supplements reporting in the formal medical surveillance system.
• Several of the major NGOs have proactively moved medical countermeasures and logistics into position in anticipation of a possible infectious disease crisis – as a result of advisories sent to them from the HEAS community effort.

The more troublesome aspect of situational awareness-driven warning systems is they promote transparency.  In other words, it is a vehicle for accountability.  Receipt of a warning automatically places the recipient in a position of accountability.  If they act to mitigate a crisis before it happens, then the recipient and those they server are pleased if the crisis indeed manifests (or no social outcry is observed that challenges the credibility of the recipient organization).  If the recipient does not act, and a crisis occurs when their receipt of the information was known broadly, then the question of "why did you do nothing" appears.  For a bureaucrat, this places them directly in the line of sight, a most difficult position to be in when risk-averse.

Information Sharing In Disaster Response: Towards An International Standard

Wired.com mentioned our efforts in a recent article that quoted USSOUTHCOM: "they are poised to integrate some crowdsourcing to see what the situation is on the ground with respect to medical information. Eventually, that kind of tool could be used for biosurveillance –- monitoring and mapping the outbreak of infectious diseases."

The 2010 Haiti disaster response effort was my first time interacting with a US federal agency in such an open framework as that offered by APAN.  I was introduced via our participation in Crisis Mappers and collaborative discussions with InSTEDD and Ushahidi.  Although I appreciate USSOUTCOM's desire to remain conservative in their assessment of APAN's utility, from the perspective of operational biosurveillance it is frankly a breath of fresh air.

Two key observations that are relevant to the Wired article (and why it is so important to recognize Crisis Mappers community and APAN as setting the new world standard in crisis communications):

1. The bigger the organization, as embodied by funding lines, personnel, and complexity of task it has claimed, the less likely it is able to participate effectively in near-real time operational biosurveillance communications.  This is especially true when considering the ultimate objective of issuing warnings.
2. As the emergency response community has always emphasized, the need to understand which individuals are gatekeepers versus bridges is critical. 

Currently the best and most timely information we receive from Haiti is from individuals, the majority of whom work in smaller, more agile organizations.  We avoid gatekeepers.  One multi-billion dollar US NGO flatly declined to participate in information sharing, claiming "we already know there are outbreaks in Haiti".  Technically speaking, at the time of the comment there were no outbreaks reported in Haiti, just sporadic, expected reporting of baseline disease.  This particular NGO has a history of little to no cooperation with other NGOs, a common problem in the NGO world.  But this is not to pick on a particular organization or community of organizations- this is a human problem related to trust and other factors that dictate whether one individual(s) will chose to share information with another.

The challenge of managing crisis information flows was highlighted brilliantly by Uriel Rosenthal, Paul 't Hart, and Michael T. Charles (1989): 

• In crisis situations, formal rules and procedures give way to informal processes and improvisations.  Necessity is the mother of invention.  Under the pressure of the circumstances, official authorities may be overruled by situational leaders.  Formal authority loses out to legitimate power.  For making critical decisions, official qualifications and jurisdictions happen to be less important that the capacity for a resolute and rapid response to the crisis.  This is precisely what Crisis Mappers and APAN represent, as well as the entire warning process of the 2009 pandemic H1N1 influenza from our perspective.

• Public agencies can be viewed as information processing systems... They tend to be disposed to consume information that is easy to categorize, leaning towards so-called programmed decisions.  Here I would propose "public agencies" in this era includes both governmental and non-profit organizations

• Crisis information does not fit in with this pattern.  Crisis information is threatening, it is frightening, it is unfamiliar, it is new, it is surprising and it has 'never been heard before'.  Crisis information is unprecedented, and it is critical, yet ambiguous.  It may come in massive quantities, yet 'just that damned thing we must know, we do not' (at other stages during the same crisis, lack of new data, subsequent rumor circuits and other forms of non-information may produce another and often unthought of challenge to decision makers).  It cannot be categorized in usual ways.  Nonetheless, crises demand rapid information processing, but also very careful information processing.  Under these circumstances the usual patterns of organizational and interorganizational communication do not suffice.
  

• In crisis situations there is a considerable increase in the volume and speed of upward and downward communications... High level officials directly communicate with low-ranking bureaucrats.  Key decision makers run the risk of being overwhelmed by an overload of information from sources of which they are unfamiliar.  

• In crisis situations, on the other hand, decision makers tend to give priority to the source of information instead of its content.  They are inclined to rely on trusted, and liked sources.  In conflict crises they may become completely consumed in closed communication circuits made up solely of allies, adherents, and friends.  This point is dead-on.

• Paradoxically enough, potentially rewarding channels of communication are often closed off by strategies or tactics that are destined to isolate the opponents.  In such cases it may become impossible to acquire accurate information about the most crucial aspects of the crisis.

With the tremendous variety of international assistance being provided by so many different professional disciplines, organization types, and governments, action certainly speaks loud in terms of coming together to help others.  But the issue of open information sharing is such an important one, and one we must continue to push on.  The unfortunate fact remains there are several major organizations responding in Haiti now, flush with funding, who are not participating in situational awareness.

Participation in situational awareness is absolutely essential for the following reasons:

• rapid identification of events that may result in additional loss of life or further disruption in the response theater
• rapid identification of victims' needs not otherwise identified 
• improved response logistics, efficiency, and cost

I would propose it be considered a mandatory international standard for any responding organization or individual to share situational awareness if they intend to participate in a disaster response theater.  Donors and taxpayers should insist on this standard as well. 

References:

Rosenthal U, 't Hart P, Charles MT.  The World of Crises and Crisis Management.  In: Rosenthal U, 't Hart P, Charles MT, eds Coping With Crises: The Management of Disasters, Riots and Terrorism.  Springfield: Charles C. Thomas; 1989:3-33.

Official Versus Unofficial Reporting in Operational Biosurveillance

Current experience with the Haiti disaster response has provoked memories of the early days of the 2009 H1N1 pandemic, where unofficial reporting mechanisms preceded official reporting.  It is clear the work of the unofficial human "mash-ups" like Crisis Mappers Net, with partners like Ushahidi, InSTEDD, HealthMap, and many others are showing a new, agile mechanism for gathering and reporting crisis information.  Right now we are observing tremendous chaos and delays in reporting information from the larger NGOs and official organizations who are on the ground in Haiti- where the bigger and more beaurocratic the organization, the more difficult it is to coordinate information flow in an environment where agility is becomes most important.  This is the classic hallmark of a disaster, where the demand for information is tremendous... a demand at odds with the very nature of a cumbersome beaurocratic entity.

Below is a chart of unofficial versus official reporting in the early days of the 2009 H1N1 pandemic.  Even inside the United States there were tremendous time differences between unofficial reporting of suspected cases and official reporting by CDC, which was reflective of lack of available test kits for pH1N1, the hierarchical nature of reporting at the local, state, and national levels, and the methodical process of forensic epidemiological investigation.  When considering the interface of national level reporting to WHO, the same kinds of time delays were also observed.

The numbers in the left and right-hand columns represent the difference in days between first report of suspect cases of H1N1 and first report of laboratory confirmation.

It has been said here we are witnessing the birth of a new professional discipline in the realm of operational biosurveillance... a discipline that places a higher premium on unofficial reporting because the output of this community is timely, relevant warning of biological threats to society.

As we are observing right now in Haiti, the phenomenon of time delays between unofficial and official reporting is certainly not unique to operational biosurveillance.

Panic and Flight Behavior Reporting During Infectious Disease Events, Crises, and Disasters

The idea of people “panicking” due to disaster is a misnomer.  The literature repeatedly shows the normal response is to bond and protect loved ones- to the point of even placing individuals in greater harm. 

 

Assertions of the sociological and anthropological community are this phenomenon is universal for disasters of any etiology- including epidemics.  However, a literature review of studies supporting the assertion that social behavior in the context of epidemic-caused disasters is similar to that seen in natural disasters is limited.

 

We undertook a review of ProMED reports for the ten-year period January 1, 1998 to December 31, 2007.  Known biases in ProMED during this period included a bias towards English language reporting on human health events.  The results were interesting.  Only 1.7% of the reports in this period covering infectious disease events affecting humans or animals contained the word “panic”.  Of these “panic” reports, we noted the following:

 

1.     Concern about the potential for “panic” (61%)

2.     “Panic” reported with no behavioral evidence (27%)

3.     “Panic” reported with behavioral evidence (12%)

 

Bottom line, when “panic” was reported in association with an infectious disease event, it was a rare phenomenon.  Evidence of actual anxiety behavior associated with the word “panic” was even more rare: 0.2% of all reports during a ten-year period.

 

The concept of “panic” as people behaving like asocial animals is a myth.  All of the instances of anxiety behavior reported in association with “panic” were protective behaviors. 

 

To dive even deeper into this, we explored the number of times flight behavior was reported in ProMED during the same ten-year period.  By “flight” we were specifically looking for public-initiated evacuation or abandonment of their community or family members.

 

In total, only 0.1% of all reports contained mention of flight behavior where public-initiated abandonment of a community or family members due to an epidemic was reported. 

 

Family member abandonment was documented in one instance: Marburg hemorrhagic fever in Uige, Angola.  On the date of this particular report, May 4, 2005, there were 313 cases and 280 deaths (89% fatalities) reported the prior day. This was more than six weeks after the discovery of the first outbreak of Marburg hemorrhagic fever ever reported in Angola.  A family reportedly abandoned a one-month-old baby whose mother had died of Marburg infection and fled the village.  There was no indication the family abandoned any other family member.  Neighbors feared contact with the baby and allowed the child to starve to death.  The context of this report was one of epidemic resurgence involving substantial struggle with effective containment.  Fatalities were reported on a daily basis.

 

In summary, The majority of “panic” and flight behavior reporting involved zoonotic diseases associated with causing active serious illness in humans at the time of reporting.  Specifically, provocation of community and family abandonment involved diseases that, at the time of reporting, caused serious and lethal human disease.  All reporting of community or familial abandonment occurred in undeveloped or developing countries.  Of note, no reporting of “panic” or flight behavior was documented for Haiti in this ten-year period.

 

Despite the known biases in ProMED during the period of study and the fact all global infectious disease events during the time period studied were not reported in ProMED, we have found it to be highly analogous to our operational experience. 

 

When considering the current critical information requirements for the Haiti disaster, it is our hope this information places “panic” and flight behavior reporting in perspective- it is a very rare phenomenon, but when documented usually represents a situation worthy of time-sensitive awareness and scrutiny.

 

 

NOTE: New Website Link For Haiti Operational Biosurveillance

In order to facilitate a dedicated website and output for disaster response in Haiti, we will move all further postings on Haiti to "Haiti: Operational Biosurveillance".  Please update your bookmarks and RSS links accordingly.

Arrival of 53 Haitian orphans in Pittsburgh: All In Good Health

The arrival of 53 orphans from BRESMA orphanage in Port-au-Prince were examined by physicians in Pittsburgh today.  All were in good health.  Some children had mild respiratory illness considered common and routine for their age.  Pittsburgh is the first city in the United States to receive orphans from Haiti. 

Haiti: Prioritized Critical Reporting Requirements and Indicators For Operational Biosurveillance

Geographic Scope: Hispaniola Island, inclusive of the countries of Haiti and Dominican Republic

Emphasis: infectious disease capable of generating acute disruption within the response theater

Specific Diseases of Interest: anthrax, dengue, diarrheal disease, pandemic influenza

Event Indicators:

1.     Report of public-initiated evacuation, migration, or flight from habitation site due to perception or rumor of disease

2.     Report of public “panic” due to perception or rumor of disease

3.     Report of medical infrastructure, either indigenous or response agency-deployed assets, becoming acutely overwhelmed due to disease

4.     Report of abrupt increase in disease prevalence, especially involving an efficiently transmitting agent such as influenza

5.     Report of acute disease affecting animals potentially serving as protein sources to the indigenous population such as cattle or poultry

See prior post, Haiti: Operational Biosurveillance Priorities For Potentially Disruptive Infectious Disease Events, for background information.

Haiti: Operational Biosurveillance Priorities For Potentially Disruptive Infectious Disease Events

UPDATED 0410 GMT 17 JAN 2010- UPDATED INFORMATION HIGHLIGHTED IN RED

Summary

 

We consider anthrax, dengue, diarrheal disease, and pandemic influenza to be key diseases of potential for generating acute disruption in the context of the current disaster response operation in Haiti.

 

Introduction

 

On 1/12/2010 at 10:19:57 PM UTC (26 minutes after the event), the team received a Red Alert from GDACS regarding a 7.3M earthquake in Haiti.  The team immediately activated operational biosurveillance support activities.

 

Figure 1.  Earthquake impact zone in Haiti.

 

Figure 1 displays the impact zone.  The focus of this assessment pertains to this figure and is concerned with operational biosurveillance issues which may or may not overlap what are considered public health priorities.  In this assessment we recognize the following key points about earthquake disasters:

 

1.    Large-scale epidemics are not typically triggered by earthquakes.  However, seasonal disease baselines are still observed such as malaria and dengue in the case of Haiti that may complicate response operations.

2.    Corpses do not typically trigger large-scale epidemics.

 

In operational biosurveillance, we adopt a conservatively aggressive posture when it comes to monitoring.  Here our purpose is to provide high-level analysis of the situation to identify potential disease-related occurrences that will further challenge the response efforts.  Several of the diseases mentioned in this report have the capacity to generate crises and disasters in their own right under the current conditions in Haiti.

 

Prioritized Diseases for Operational Biosurveillance During Disaster Response in Haiti

 

Here we focus on those diseases that pose the greatest challenge to response operations.  Diseases marked with an asterisk are the prioritized diseases we are monitoring closely due to probability for causing an acutely disruptive outbreak in the disaster response theater.

 

Table 1.  Operational biosurveillance priorities during disaster response operations in Haiti.  Important caveats: it is acknowledged that large-scale epidemics are rarely triggered by earthquakes.  Our operational posture is one of conservatism to anticipate unexpected events.  The bias is towards those infectious diseases capable of generating crises or disasters in their own right.

 

AIDS. The prevalence of HIV infection is estimated to be 4.5% (1.8%-7% in pregnant women).  The prevalence of chronic infection with Hepatitis B is moderate (2%-7%).  Prevalence of AIDS relates to TB prevalence (see below).

 

Anthrax*.  Considered “hyperendemic” in Haiti.  In the 1700s, it is believed Haiti was the site of the world’s largest epidemic of anthrax.  Of note, this  epidemic was thought to have been triggered by an earthquake on June 3, 1770 that led to massive destruction of civil infrastructure on the western end of Haiti and a resultant food crisis.  Slaves at the time were compelled to eat indigenous contaminated beef, as trade regulations prohibited importation of meat or fish.  Within 6 weeks, 15,000 fatalities were observed.  The last outbreak involving human cases of anthrax was documented on August 14, 2009, an unspecified number of human anthrax cases including one fatal case in Calumette, Bell-Anse commune. The source of the infection was suspected to be contaminated meat.  Calumette is an area east of Port-au-Prince that reported “moderate” perceived shaking.  It is believed the majority of anthrax cases are reported in southeast Haiti.  Currently, there is a efflux of refugees from Port-au-Prince to rural areas.  At this time, we do not know if refugees are migrating to this specific area of Haiti, however.   

 

Cholera.  “Some” activity may exist in the northwest portion of Haiti, but is not projected to be a concern.  We have not seen reports of cholera in the last 12 months in proximity to the disaster zone.  The next rainy season is not expected to begin until March, with typical seasonal peak in May.  Sewer and water lines are disrupted in the disaster zone.  Access to safe drinking water and proper sanitation facilities is crucial.

 

Dengue*.  The Dominican Republic and Haiti reported the tail end of a dengue fever epidemic with fatalities due to Dengue Hemorrhagic Fever (DHF) as recently as late December.  This epidemic had strained local medical infrastructure with the volume of cases numbering in the thousands.  The air temperature and humidity profile in Haiti is essentially optimized year-round; however, vector mosquito increases are typically seen following rainy periods. The next rainy season is not expected to begin until March, with typical seasonal peak in May.  Mosquito control under the present circumstances will be extremely difficult. 

 

Diarrheal and Waterborne Disease Not Otherwise Specified*.  Diarrheal disease is a serious and immediate concern.  The next rainy season is not expected to begin until March, with typical seasonal peak in May.  Sewer and water lines are disrupted in the disaster zone.  Access to safe drinking water and proper sanitation facilities is crucial to avoid outbreaks of diarrheal disease.

 

Diphtheria*.  On October 15, 2009, 11 cases were reported in the municipalities of Cap-Haitien to Pilate (4 deaths), Milot, Borgne, in the north of Gros Morne Gonaives in the Artibonite and Port-au-Prince.  Since the beginning of 2009, 19 cases with 9 deaths were reported throughout the country.  Diphtheria outbreaks have been reported since at least as far back as 1980 in Haiti.  In 2005 and 2006, more than 400 cases were reported.

Influenza*.  The primary concern here is pandemic H1N1.  Haiti has not experienced the same level of intense transmission as the temperate areas of the world, presumably due to its tropical climate and other factors.  That said, overcrowding of refugees in camps offers opportunity for outbreaks to evolve.  Intensive care capacity is minimal.  Therefore, high case fatality rates may be observed as have already been observed in multiple areas of the world among those with poor access to healthcare services.  Vaccination for pandemic influenza among the survivors is an important consideration.

 

Leptospirosis*.  Small scale outbreaks have been reported in past years during the same time period.  Dislocation of the rodent population may pose increased risk for an outbreak.  Leptospirosis has been associated with periods of heavy rain and flooding. The next rainy season is not expected to begin until March, with typical seasonal peak in May.

 

Malaria.  Highest rates of infection are observed from May to November.  Plasmodium falciparum accounts for nearly 100% of cases and is considered endemic to 75% of the land area in Haiti.

 

Measles.  Low herd immunity exists in Port-au-Prince.  The potential for a measles epidemic following introduction was demonstrated in 2000, where 992 cases were documented in Artibonite and Port-au-Prince following introduction from the Dominican Republic.  We believe a measles epidemic could be triggered if introduced.

Rabies.  There has been less than 5 canine cases of rabies reported in Haiti per year over approximately the last ten years.  Concern has been raised by veterinarians familiar with the situation in Haiti that dislocated companion animals will form roving packs, facilitating greater transmission of rabies among canine populations and perhaps place them in conflict with humans in their search for food.

Tuberculosis.  A high percentage (estimates as high as 50%) of Haitians with tuberculosis have AIDS.  Multi-Drug and eXtremely-Drug Resistance TuBerculosis (MDR- and XDR-TB) prevalences are unknown.  USAID considers Haiti to be associated with the highest per capita tuberculosis prevalence in the Latin American and Caribbean region.  With approximately 33,000 cases of active pulmonary tuberculosis believed to be in Haiti, tuberculosis is the country's greatest infectious cause of mortality after HIV.  The destruction of the prison and escape of 4,500 prisoners as well as the destruction of the Grace Children's Hospital, a 60-bed inpatient ward devoted to the treatment of pediatric tuberculosis, in Port-au-Prince may represent an influx of active tuberculosis into the community.

 

Typhoid.  Last outbreak in 2003 (200 cases, 40 fatalities) in Grand Bois.  More current data is unavailable, and risk is difficult to assess.

 

Endemic Disease Considerations in Haiti (Credit: GIDEON)

 

Aeromonas & marine Vibrio infx. (Latest Outbreak: 1976 - 386 cases)

AIDS

Amoeba - free living

Amoebic colitis

Angiostrongyliasis

Anthrax (Latest Outbreak: 2009 – multiple human cases)

Ascariasis

Blastocystis hominis infection

Brucellosis

Cholera

Cryptosporidiosis

Cyclosporiasis

Cysticercosis

Dengue

Diphtheria (Latest Outbreak: 2009 - 24 cases)

Escherichia coli diarrhea (Latest Outbreak: 1976 - 386 cases)

Filariasis - Bancroftian

Giardiasis

Gonococcal infection

Hepatitis B

Hepatitis C

Hepatitis E (Latest Outbreak: 1995 - 4 cases)

Histoplasmosis

Hookworm

Hymenolepis nana infection

Influenza (Latest Outbreak: 2010 – 92 pH1N1 cases reported, likely underreported)

Isosporiasis

Leptospirosis

Listeriosis

Malaria

Mansonelliasis - M. ozzardi

Measles (Latest Outbreak: 2000 - 992 cases)

Meningitis - bacterial (Latest Outbreak: 1994 - 100 cases)

Mumps

Pertussis

Poliomyelitis (Latest Outbreak: 2000 - 8 cases)

Rabies

Rubella

Salmonellosis (Latest Outbreak: 1976 - 386 cases)

Schistosomiasis - mansoni

Shigellosis (Latest Outbreak: 1976 - 386 cases)

Syphilis

Taeniasis

Tetanus

Trichinosis

Tuberculosis

Tungiasis (Latest Outbreak: 2004)

Typhoid and enteric fever (Latest Outbreak: 2003 - 200 cases)

West Nile fever

Yaws

 

Meteorological Baselines (Credit: Weather.com)

 

Port-au-Prince Seasonal Monthly Precipitation

 

Port-au-Prince Seasonal Monthly Temperatures

 

Further Reading and References           

 

1.  GIDEON.  http://www.cyinfo.com

2.  CDC. http://emergency.cdc.gov/disasters/earthquakes/healthconcerns_haiti.asp

3.  PAHO.  http://new.paho.org/disasters/

4.  Meteorological Information.  http://www.srh.noaa.gov/mfl/?n=haiti_support

5. WHO Preliminary Assessment.  Note this reflects general public health priorities which are slightly different than that presented by our team here.  http://www.reliefweb.int/rw/rwb.nsf/db900SID/DKAN-7ZRMLR?OpenDocument

 

 

Haiti: Vigilance

Monitoring the situation there closely.  More to follow.