The Haiti Epidemic Advisory System (HEAS)

The Death of a Child With Tetanus

As a pediatrician and a father of two young, healthy girls, sometimes it is difficult for me to separate my experience in the world of operational biosurveillance and the tremendous human suffering we are seeing in Haiti.  It is hard not to lean back and cry every now and then...

The following account comes from Dr. Mark Pearlmutter (posted on Jan 26th), and I would encourage everyone to read his blog.  I offer the below as a testimony to this poor little girl and the suffering she went through.  It is so hard for us in a developed nation with our standard of care to imagine the agony this poor child went through prior to her death.  She and her family are in our prayers:

Today, I awoke to the news that our 4 year old who was diagnosed with tetanus decompensated during the night.  She was without family which perhaps explained her sad penetrating eyes.  On the day of her arrival, she presented to us with a crush injury to both of her legs.  She required extensive surgical debridement, a procedure that extensively cleans a wound.  The following day she developed a fever and generalized spasm of her muscles, especially her jaw.  Her body would arch back in that typical way I’ve seen only in text books.  She was immediately given antibiotics antispasmodics and returned to the OR to further clean her wounds, hoping to reduce the bacterial tetanus load.   The timing of this event couldn't have been better as our new ventilator had just arrived that day.  However, the following night, her IV accidentally fell out, and unfortunately wasn't noticed until the effect of the medications wore off.  By this time she was ins severe respiratory distress.  The best decision was to transfer the patient to a higher level of care, the US Navy hospital US Comfort, Project Hope's ship located in Port Au Prince harbor.

At the bedside of such a sick child, it's always hard to rationally think through the difficulty of focusing on one child at the risk of not being available for multiple other patient victims.  As I ran the non breathing child across our soccer field converted Helipad my singular thought was that this young girl could survive and possibly lead an entirely normal life.  Her limp warm body on my lap contrasted with the cool hard steel floor that I sat on.  I was reminded of the frailty of life, and how dependent this adorable girl’s life was on the proper cadence of my delivery of ventilations with an antique ambu bag.  As we swept across the country side on the chopper I had the time to reflect on the past few days.  Up to this point there really hadn't been any time to think about the intense and indescribable situation that both the Haitian people and our medical team had experienced. 

 

We arrived on the US Comfort approximately 25 minutes later.  There we were directed down the elevator into the pediatric ICU where a team of 10 were awaiting us.  We provided a brief report to the medical officer in charge and were ushered back to a holding area waiting for the next Navy chopper to take us back home.  The return trip was much more relaxing and provided a respite from the stark reality on the ground.

 

It amazed me that although we had 250 patients in our hospital compound, the entire team was emotionally connected to the fate of this child.  Part of this was because not one of us had diagnosed seen or treated a case of tetanus.  But I'm convinced it was more to do with the dependent fragility of a sick child who was alone without her parents.  We all assumed a surrogate role that went beyond simply being medical caregivers.  Now all we could was hope and pray that the exceptional care being provided on the US Comfort would make a difference.

 

The next day we got word that the parents arrived by bus (a 36 hour ordeal) from Port au Prince.  Our hearts went out to the parents as we told them about their child.  We showed them pictures of their child, initially intended for didactic purposes.  Who would have known that these pictures would be the last they would see of their child.  Their daughter, our surrogate child, had succumbed to the effects of overwhelming tetanus infection.  Although we all mourned the loss of this child, we took solace and were even somewhat uplifted when the parents thanked us for all that we had done.   

 

As I watched them leave our compound, I couldn't help but feel that the entire country of Haiti had become our surrogate child.

Diarrheal Outbreak Among Aid Workers At Quisqueya School, PAP

"Because of the poor quality drinking water and unsanitary conditions there is an outbreak of diarrhea amongst most of the aid workers living at the Quisqueya School [coordinates +18° 33' 41.93", -72° 19' 16.61"]. This can quickly turn into a major problem and further exacerbate the already tenuous hydration concerns. Everyone on the team is taking daily medication to try and fend off these problems. The team is being very careful with food and is purifying water from the showers for drinking."

More Malaria and Tetanus Reported

-Some hospitals report half their pediatric patients have malaria

-Two tetanus-related deaths at a temporary field hospital at Haiti’s international airport. More cases reported.

NGOs Pushing For Latrines, Ground Disease Surveillance Systems Standing Up

We are seeing requests for latrine construction in the IDP camps now culminate in action by responders- an excellent development.  PAHO has indicated disease surveillance networks are coming on-line.  All good developments.  More specific disease surveillance is needed at this point as we begin to move out of the emergency / trauma injury treatment phase of response.

Suspected Measles Cases - Verified As Chickenpox

Suspected measles cases were investigated by PAHO/WHO and determined to be chickenpox.  One report of healthcare worker from the States getting dysentery.

More Reports of Diarrheal Illness Increase

(MSF) New Carrefour Hospital reporting increasing incidence of diarrhea.

Clinic near the PAP airport reporting "30 women deep, most holding babies sick with fever, diarrhea and rashes from living on the street."

PAP- "Overwhelmed medical clinics are seeing their first cases of children's dysentery, parasites and diarrhea."

Malaria Incidence Escalating

The hospital administrator for Bernard Mevs Hospital located near the Port-au-Prince airport has reported an escalating number of pediatric malaria cases requiring treatment.  The hospital official noted a limited supply of anti-malarial pharmaceuticals available.  The following prophylaxis treatments remain effective against Plasmodium falciparum in Haiti: Atovaquone/ proguanil, chloroquine, doxycycline and mefloquine. 

Suspected Measles Cases and Increasing Caseload of Diarrheal Disease Identified in Leogane

The Pan American Health Organization (PAHO) reports suspected cases of measles in Leogane.  Measles vaccination coverage has risen steadily in Haiti since initial data was recorded by the World Health Organization (WHO) in 1982; however, in the past decade measles vaccination coverage has plateaued at approximately 57-58% annually.  To achieve herd immunity, vaccination coverage of 90% or above is required, although vaccination coverage levels below 80% may be sufficient to prevent sustained measles transmission among susceptible populations.  In addition, cases of tetanus have been reported in Leogane, and medical teams at unspecified locations have reported a growing caseload of diarrhea in the last two to three days. 

UNICEF, in collaboration with the Ministry of Health and WHO/PAHO, will begin a vaccination campaign against diphtheria and tetanus, DTT and measles on 2 February. Children aged 6 months to at least 5 years will be among the targeted groups (approximately 600,000 children) and will also be provided vitamin A.

Rain Reported in Haiti: Conditions Optimizing For Epidemic Diarrhea

"It rained the night before. Just a drizzle, and not for long, but it was enough to remind everyone of what's at stake."  This validates the forecast provided in a prior post.

John Ibbitson wrote an entire piece this morning discussing the anxiety building around the complications rainfall will bring to responders in Haiti.  As we have reported several times here and later validated by PAHO, diarrheal illness is spreading in the IDP camps, and the situation is primed for an acutely disruptive epidemic of diarrheal illness.  

Indicators are aligning now for an epidemic of diarrheal illness.  Steady rains begin in March.

Personal Protective Kits For Zimbabwe... Pandemic Vaccine For Haiti?

The best countermeasure for pandemic H1N1 is the vaccine.  USAID has announced they will be donating 50,000 personal protective kits to Zimbabwe in collaboration with the World Health Organization (WHO). 

"This equipment will be critical to the people of Zimbabwe in the event of an outbreak of H1N1 virus," commented USAID Director Karen Freeman.  "We are committed to helping Zimbabweans combat the H1N1 flu and other diseases at the community level."

Zimbabwe is a country in but a slightly better socio-economic position than Haiti.  Zimbabwe has been in serious decline since  its inception and leadership under Mugabe following the Rhodesian Front War of the late 1970s.  It is debatable whether Zimbabwe is in state failure.

In the coming months Haitians may face ongoing hardship from infectious disease, as we have highlighted in this blog.  One of those concerns is pandemic influenza.  Our team provided early warning of poor clinical and social outcomes observed in indigenous peoples in multiple countries who had poor access to adequate medical care.  The current situation in Haiti, despite ongoing (and heroic) medical support being provided by the international community, is analogous.  Should pH1N1 begin to transmit in Haiti among an already stressed, malnourished and displaced population, what is the capacity for pediatric intensive care and children on ventilators?  It is our belief pH1N1 will not spread in the same vigorous manner as in a temperate zone country's winter due to tropical humidity, temperature and open air conditions.  However, with the coming rainy season and overcrowded IDP camps, there is uncertainty how much risk the situation actually represents.

As with protective personal equipment provided for Zimbabwe and southern Africa, pandemic vaccine for Haiti's refugee camps should be a point of consideration.