Haiti Epidemic Advisory System (HEAS) SitRep: UPDATED 13 MAR

Updated 1806 GMT, 13 MAR 2010

Tactical Ops.  Ground-deployed in Port-au-Prince since 3 March and actively conducting assessments.  Our objective has been to identify those infectious diseases that may abruptly overwhelm the ad hoc medical infrastructure or be perceived by the Haitian public to be unusual or unexpected.  In other words, identification and prioritization of those infectious diseases that may become a crisis or disaster.

Biosurveillance Grid Status.  Formal medical surveillance efforts remain operationally nascent.  Informal surveillance and ground ops expanding quickly in Port-au-Prince.  The ad hoc medical infrastructure largely supported by rotating medical responders (who are typically rotating every 1 to 2 weeks) and NGOs is contracting over time as international interest in Haiti declines.  Forty-six NGOs have departed since the earthquake according to the UN Health Cluster.  This likely represents the first responder community providing immediate trauma and recovery support.  We have further identified a critical problem with logistics, where responders are unsure of where supplies are located.  This is compounded by lack of efficient resource tracking at the hospitals and clinics.  The implication is the medical infrastructure in Port-au-Prince is becoming more sensitive to abrupt changes in patient flow, and it portends a high probability of losing control in the context of an outbreak response during the coming rainy season.

Meteorology.  See above for seasonal precipitation and temperature curves, respectively.  Over the last week it has been hot and dry in Port-au-Prince with a subsequent decline in air quality due to dust from building collapse and smoke from the burning of trash.  Disease patterns here appear to quickly change depending on whether there is a run of cloudy days and rain or a run of hot and dry conditions.  During the former we have seen upticks in waterborne disease, and during the latter more respiratory disease (including meningococcal disease).  Makes intuitive sense, but requires more time to develop a sense of confidence in this observation.

Medical Response Grid Status.  The operating status of the current ad hoc medical infrastructure, medical supply chain, patient transfer capability, laboratory capacity is impressive in regards to the range of medical options presented to the Haitian public- options they have not seen in this country before the earthquake such as the NICU and PICU.  That said, a substantial portion of the Haitian medical community were killed in the earthquake, and a large portion of the responders are on one to two week rotations.  Therefore, continuity and a baseline knowledge of operations is a challenge. Furthermore, these clinics and hospitals are operating without infectious disease early warning and tactical situational awareness.

Our experience today at the Petionville 82nd hospital is illustrative of response capacity.  We had a food distribution occur today during hot, dry conditions.  Members of the IDP camp cued up for nearly 3 hours waiting for food.  As the temperature climbed, fights were observed.  Then, seven people collapsed, one of whom stopped breathing and another had seizures.  Having to deal with this abrupt influx of patients overwhelmed the hospital staff.  We ran out to the crowd with gallons of water treated with oral rehydration salts in a desparate attempt to prevent further admissions.  Luckily, the food distribution concluded quickly, electrolyte solution was dispensed, and we had no further admissions.  We were lucky not to see more patients.  We nearly depleted our entire supply of oral rehydration salts. 

If projected to what would happen during an epidemic, it is likely our hospital would be overwhelmed quickly in terms of staffing, available beds, and supplies.  If extended to a grid level (i.e. multiple clinics and hospitals in Port-au-Prince) and complicated with poor travel conditions due to rain, we are likely to experience serious problems.

Current Advisories and Situation Status.

 

 

 
Op Notes- Disruptors

Diarrheal illness.  Diarrheal illness is currently on the decline or holding steady, depending on location.  We have observed a lower rate of diarrhea reporting and a drop in prevalence.  For instance, at the Petionville country club IDP hospital, we observed a drop from 50% prevalence in pediatric patients to a current level of ~20-30%.  Multiple sites we have surveyed around the city such as orphanages, other IDP camps, clinics, and hospitals have indicated less prevalence of ~15%.  It is our belief this is because we have had several days of hot weather that has dried out the environment.

The PICU at the Univ of Miami facility reported fatalities due to diarrhea / dehydration last week during the stretch of rainy days.  Currently they are seeing fatalities due to malaria and typhoid- a change in leading infectious disease resulting in fatalities.  Similar observations at General Hospital.  The amount of typhoid being reported warrants an adjustment to our assessment, where we now include typhoid as part of "diarrheal disease".  The majority of diarrheal disease in children is afebrile or with low fever, which may be assocciated with a variety of agents such as E. coli, rotavirus, norovirus, and giardia.  There is occasional report of febrile bloody diarrhea consistent with typhoid.  Given laboratory capacity is limited, we will not know the primary etiology, hence the syndromic categorization.

The risk of a crisis involving diarrheal disease with the advent of the rainy season remains moderate at present and will be high with sustained rains.  The sanitation status in the camps remains a serious concern, despite the provision in many locations of adequately chlorinated water.  The reason is due to the use of open buckets and subsequent contamination of the water.  Hand washing stations and personal hygiene education is not currently provided in Haiti and remains a significant cultural hurdle. Thus, even though the water is clean, hand washing and proper handling of the water once obtained from the source is contributing to the transmission of diarrheal disease. 

We have observed there is no preparedness planning exhibited by the involved NGOs, responders, and medical facilities.  There is no forward-deployment of resources that may be required to combat a crisis of diarrheal disease.  Coupled to lack of an early warning capability in Haiti, we expect the medical infrastructure to become overwhelmed.

With sustained rains we will elevate the advisory level to a WARNING, which is expected in within the month.

Pandemic H1N1.  Per ground truth, a transmission wave has not been observed in Haiti since the start of the pandemic.  While a mild disease for the vast majority of those affected, we are concerned about the current nutritional status of the population, overcrowding in the IDP camps, and the coming rains encouraging higher contact rates in the tents.  It is difficult to anticipate if and how many cases will be seen.  The concern relates to the presence of only one PICU in PAP that is easily overwhelmed if there is a demand for ventilatory care, and the overall difficulty in access to medical care throughout much of the city.  As we noted across many countries, lack of access to medical care was often associated with poor clinical and community outcomes.  The population of Haiti has not been vaccinated for pH1N1.

Influenza outbreaks and epidemics may be observed in tropical climates.  As a point of example, in 2002, Madagascar experienced an outbreak of A/H3N2.  From August to September, authorities documented 30,304 cases and 754 fatalities from 13 of 111 health districts and 4 of 6 provinces.  Most of the illnesses occurred in rural areas, and an estimated 95% of cases were not reported. 

We assess if pH1N1 were to pose a problem in the coming minor rainy season, it would present as focal outbreaks that would be difficult to control.

Dengue.  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 and are aware of vector control meetings involving MENTOR and other NGOs.

Gastrointestinal Anthrax.  We have ground truthed this assessment with the country veterinarian.  Cutaneous anthrax is not a concern because it is a baseline in rural areas with a well understood peak in May and June.  Occasional cases are seen in PAP and other urban areas. 

The main concern is gastrointestinal anthrax which is a concern if mass slaughter of livestock occurs in the midst of a serious food crisis.  We expect the risk to be worthy of note if the food security situation deteriorates to levels seen during the mid-1990s food crisis.  Haitians do not consume high quantities of beef, and in urban areas the beef they do consume is imported. 

Op Notes- Other Infectious Disease of Public Health Concern

Vaccine-Preventable Disease.  Our ground assessment of vaccination status suggests a different vaccine coverage than previously assumed based on reporting from responsible NGOs.  The Haiti Ministry of Health regulates all vaccination activity in the country and has asked for a cessation of vaccination activity by mid-April.  We are unclear why there is an imposed deadline.  It is debatable what the true vaccination coverage is in many of the IDP camps and other poor areas of PAP such as Cite Soleil.  This concern is significant enough to adjust our projections in the assessments.

Waterborne Disease.  Diarrheal disease, including typhoid, is covered above under "Disruptors" and is a major concern. 

There continues to be an assumption cholera will be a serious problem in Haiti with the onset of the rainy season.  The true risk of cholera is assessed to be neglible 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. 

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 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.  We are concerned about adherence of proper infection control standards to protect responders.  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.

With the onset of the current short period of hot and dry conditions, upper respiratory disease has been seen with increased frequency but with few cases of mortality.  Several of the responders in our camp have bronchitis.

Other.  Rabies as a risk has declined significantly because the Ministry of Agriculture, in conjunction with NGO partners such as ARCH estimate a 70-75% vaccination coverage among free roaming companion animals in PAP.

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.