Haiti Epidemic Advisory System (HEAS) SitRep: UPDATED 1 MAR

Updated 1750 GMT, 1 MAR 2010

Biosurveillance Grid Status.  Formal medical surveillance is currently providing a partial picture of the ground situation.  There have been problems with data collection such as reporter fatigue and consistency in reporting.  We have noted several key diseases reported through informal surveillance not captured in the formal reporting surveillance process.  To-date, operational integration between the two processes has not occurred.

Meteorology.  See above for seasonal precipitation and temperature curves, respectively.  Periodic, localized rainfall continues to be documented, recently reported to be intense in Port-au-Prince.  Sustained rains and localized flooding anticipated beginning this month.  Flooding has already been reported in Les Cayes, an indicator of things to come.  There is a 1 in 3 chance substantial wide scale flooding will be observed in Haiti in April / May before the hurricane season.  There has historically been an association with flooding and deterioration of security in Haiti.   

Current Advisories and Situation Status.

Op Notes- Disruptors

Diarrheal illness.  A major international NGO informed us 120 out of 300 expatriates supporting their relief operation reported having diarrheal illness.  Ongoing reports of pediatric diarrheal disease in the IDP camps with associated mortality.  This has been a prominent focus of reporting by the Haitian public in Kreyol on SMS traffic, which we assess to be a true indicator of concern to the locals.  Salmonella and Shigella flexneri was discovered by laboratory confirmation in the US from a foodborne outbreak of diarrheal illness at a Belgian facility in Haiti on 13 FEB.  This finding was not unexpected.  

The UN Health Cluster continues to report "no outbreak or epidemic", however we propose use of those terms to be irrelevant from an operational perspective.  It is clearly a problem both from the perspective of the Haitians and responders, and is projected to become a serious issue worthy of generating crisis conditions in its own right in the coming weeks.

Precipitation will further compromise indigenous water sources and exacerbate what limited sanitation is available.  Access to appropriate sanitation remains a major gap in response, and challenges include a high water table, rocky ground, and difficulty finding adequate methods for disposal of human excrement that is present prior to installation of latrines in a given IDP camp.  Heavy rainfall may raise an already high water table, rendering pit latrines ineffective in many areas.  It is for this reason we assess rains in March and April will be a key period of risk ahead of the anticipated flooding brought on by the hurricane season in June.  As noted above, large scale flooding has been observed in Haiti as early as April, and Les Cayes has already reported flooding.

We expect to elevate the advisory level for diarrheal disease to a WARNING within the next 30 days.

Pandemic H1N1. Ongoing reports of acute respiratory disease in the IDP camps, however very limited and isolated reports of death due to pneumonia.  When reported, this has been observed in babies so far as we have seen.  Acute respiratory disease is the top cause of morbidity according to formal medical surveillance.  There remains no formal evaluation or laboratory confirmation of pH1N1 to our knowledge. Physicians with years of experience treating Haitian patients in Gonaive reported influenza-like illness and gastroenteritis they thought may have been due to pH1N1.  Again, without laboratory evaluation we cannot fully assess the risk of pH1N1 generating a crisis event in the IDP camps.

An Advisory was issued on 2 Feb based on the observation that patient transfers for ventilator beds has been extremely difficult, particularly in regards to pediatric beds.  Those at risk for severe clinical outcomes from pH1N1 infection include children and pregnant women.  Further, we have documented in multiple countries adverse clinical outcomes seen in indigenous peoples with poor access to adequate healthcare, as is the case in Haiti.  With the coming rains in March to encourage crowding in IDP camps, the potential for outbreaks is conservatively assessed to be moderate.  We have no evidence of pandemic vaccine deployment campaigns by responding agencies in Haiti.  There is potential to see serious pediatric illness requiring pediatric intensive care and ventilatory capabilities that are not currently present in Haiti should there be brisk transmission of pH1N1 in the context of low herd immunity.

We have observed an apparent difference between acute respiratory disease and diarrheal disease, where we have seen more reports of pediatric mortality due to diarrheal disease.  This would explain higher frequency of reporting this disease versus respiratory disease in Kreyol by the Haitian public via SMS. 

Dengue.  We have observed reports of dengue in patients, with <5 cases of suspected dengue hemorrhagic fever reported daily via formal medical surveillance.  Informal reporting has suggested a much higher incidence of dengue hemorrhagic fever, which we assess to be inaccurate.  Peer-reviewed literature does not support observation of high dengue hemorrhagic fever incidence in Haitians. 

Risk for outbreaks is moderate with the coming sustained rains in March, however the literature suggests presentation will be non-hemorrhagic dengue fever in Haitians.  Because all four dengue serotypes circulate and are hyperendemic in Haiti, there is some risk of dengue hemorrhagic fever in responders who have been exposed to other dengue serotypes in the past.  Vector breeding sites will increase, as will the potential for dengue transmission.  Heaviest transmission typically seen in the later half of the year, coinciding with increased optimization of air temperatures.  We have seen reports of Cuban teams engaged in vector control efforts.  It is unclear what the UN Health Cluster activity is in vector control.

Anthrax.  Extremely difficult to assess actual risk under present conditions.  Prudence suggests a conservative, vigilant, and proactive posture.  The concern is not related to the typical observation of cutaneous anthrax, which is easily treated with penicillin, but rather gastrointestinal anthrax observed after community consumption of anthrax-infected livestock.  Should the population experience food insecurity to the point of slaughtering livestock, the risk for a foodborne outbreak of anthrax may be present.  Given media sensitization around the disease, combined with high fatality rates observed in untreated gastrointestinal anthrax, it is highly likely any such outbreak would represent a crisis.  Prior post detailed risk factors for Artibonite Valley, which historically has seen a peak of human cases in the May-June time frame.  Human cases of anthrax has been documented before in many areas of Haiti.  The Animal Relief Coalition for Haiti (ARCH) is vaccinating livestock for anthrax, however they appear to be primarily based in PAP and it is a low level effort.  It is unknown what their plans are for a country-wide anthrax vaccination campaign.

Op Notes- Other Infectious Disease of Public Health Concern

Vaccine-Preventable Disease.  Vaccination campaigns are now ongoing to provide coverage for diphtheria, measles, mumps, rubella, pertussis, and tetanus.  Of these diseases, tetanus has been a prominent killer of children and adults, reported as occasional cases.  We have seen limited reports of clinically diagnosed measles and mumps, however no confirmed cases have been documented in Haiti through formal surveillance.  We have not seen any substantive cases reported for rubella, pertussis, or diphtheria.  Ground teams have indicated the vaccination campaign will last two weeks.  We have adjusted our risk projections based on this assertion to reflect a dramatic decrease in risk of seeing these diseases and therefore do not consider them to be likely disruptors.  Tetanus is discussed in further detail below.

Waterborne Disease.  Although stated in multiple media sources and quoted by several NGO representatives, risk of cholera is assessed to be extremely low because there has not been documented cases in Haiti in the last fifteen years (at least).  The appearance of cholera would have to be introduced by a foreign traveler to Haiti.  Diarrheal disease is covered above under "Disruptors" and is a major concern.  Typhoid has been documented, with fatalities that include children and adults.  Beyond ongoing campaigns to improve water and sanitation in Haiti, we have not seen a dedicated effort to combat typhoid.  Increased leptospirosis incidence has been observed in other countries during periods of heavy rainfall and flooding, and one military responder was reported to be infected.  This is a current concern in Haiti as flooding has already been documented in Les Cayes.  We do not assess typhoid or leptospirosis to be likely disruptors in the next 90 days, however we are monitoring closely and will re-assess as appropriate.

Vectorborne Disease.  Malaria is documented regularly and is considered a baseline, endemic disease in Haiti.  Transmission typically peaks in November, however we do expect outbreaks given crowding and increased vector counts in the May-June time period.  West Nile virus is present in Haiti and is expected to largely present as febrile illness with the occasional neurological sequelae.  It is typically seen in the latter half of the year as temperatures optimize for transmission.  It is possible to see increased activity in June.  We do not assess malaria or West Nile to be likely disruptors in the next 90 days, however are monitoring closely.

Other Respiratory-Transmitted Diseases.   Tuberculosis in its various forms of drug resistance has the potential to become a larger problem than it already was due to divestment and loss to follow up of tuberculosis patients from the sanitarium.  If they have joined IDP camps, the opportunity for transmission to others, including responders, is a risk.  Current crowding may favor increased transmission.

We have seen documentation and death of a responder due to meningococcal meningitis.  Both tuberculosis and meningococcal meningitis may be transmitted in close, crowded conditions as it observed in the IDP camps.  Heavy sustained rain encourages more person to person contact.  Meningococcal meningitis transmission is typically favored by low humidity, however the effect of crowding cannot be discounted as a concern for increased transmission.

Trauma and Surgical Related Infectious Disease.  Tetanus as a concern is also addressed above under Vaccine-Preventable Disease.  Gangrene and sepsis will continue to be serious challenges to surgical care when conducted outside the purview of a hospital facility able to observe proper infection control, however the current trend is declining.  Post-operative care remains a serious challenge in maintaining clean wounds, particularly in the field, however this issue is declining as well.

Other.  Rabies will likely pose a challenge in the weeks to come.  The International Fund for Animal Welfare (IFAW) reports they have been treating 50-100 canines daily, mainly traumatic injuries, with no report of infectious disease.  The Animal Relief Coalition for Haiti (ARCH) has reported treating 1,300 animals, 400 of which were dogs and cats.  They are vaccinating companion animals for rabies and livestock for anthrax.  They plan to raise funds to vaccinate poultry for Newcastle's disease.

Operational Definitions

Warning.  Indication of increasing incidence of an infectious disruptor agent, with alignment of optimized conditions to support transmission. 

Watch. Indication of increasing incidence of an infectious disruptor agent, without alignment of optimized conditions to support transmission. 

Advisory.  Presence of an infectious disruptor agent reported. 

Infectious disruptor agent.  An infectious disease capable of triggering crisis or disaster conditions

Infectious disease crisis: time-sensitive, non-routine organization-level decisions that may affect a local community’s activities of daily living. It is more common such decision-making falls within the roles and responsibility of a public health institution than a public or private hospital or individual healthcare provider. This becomes a community level decision-making activity in countries where there is no public health capacity.

Infectious disease disaster: when crisis mode decision making by public health officials or institution fails to control the situation, either from an informational or response perspective and substantial social disruption associated with features of community disintegration occurs as a result.  The term "community disintegration" refers to the dissolution of a community as a social unit. This is classically exemplified by the evacuation of a village due to an uncontrolled epidemic. Ebola is the archetype disruptor capable of generating this kind of social response in undeveloped areas of Africa.

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