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