The Haiti Epidemic Advisory System (HEAS)

Rotavirus Diarrheal Syndrome- Report on the Dominican Republic From PAHO

Epidemiological Alert: Rotavirus Diarrheal Syndrome (23 March 2010)

Epidemiological Alerts In the past month there has been detecting the confirmed outbreaks of acute diarrhea caused by rotavirus in countries of the region. Dominican Republic showed an increase of 25% in 9 provinces. In Mexico, although the cases are distributed in 23 states, the largest percentage of these occurred in Chiapas (30%), Baja California (13%), among others. While in Guatemala were a total of 4,336 cases, of which 964 have been confirmed by laboratory.

http://new.paho.org/hq/index.php?option=com_content&task=view&id=2678&Itemid=1167

Cases of Diarrheal Disease Reported in Bellanton IDP Camp

Report Type: Surveillance Report

Location: Bellanton, Haiti

Disease Entity: Non-specified diarrheal disease

A survey carried out at the Bellanton IDP camp located just due west of Savane Blonde identified cases of non-specified diarrheal disease, vomiting, febrile illness, individuals with sore eyes and women with vaginal infections suspected to be caused from exposure to contaminated water.   The IDP camp at this location houses 580 families and is reported to be experiencing shortages of shelter-building material, food and clean water.

Medical Professional Reports Dehydration and Gastrointestinal Illness Primary Issue

Report Type: Surveillance Report

Location: Cite Soleil, Port-au-Prince, Haiti

Disease Entity: Non-specific gastrointestinal illness

On March 28th, reports from a physician based in a Cite Soleil area hospital indicate dehydration and gastrointestinal illnesses continue to be the primary cause of morbidity among earthquake survivors living in temporary shelters; however, mortality due to dehydration and gastrointestinal conditions has remained low.    Moreover, malaria cases are reported to be increasing as rainfall frequency and accumulation escalate.   The interviewed physician noted that there is still a shortage of diagnostic equipment and health professionals available in Port-au-Prince.

Preparing For A Possible Crisis: Pediatric Diarrheal Disease

Sent to the UN Cluster System and the broader Haiti responder community on 28 March @ 0538 GMT

Greetings,

The meteorological forecast for next week calls for thunderstorms beginning this Wednesday and lasting at least through the following Tuesday.  We will follow the forecasts closely as this time draws near.

We are all seriously concerned about an increase in diarrheal disease, specifically in children.  It has already been documented that diarrheal disease is a major cause of morbidity and mortality both before the earthquake and after.  We have observed apparent ‘bumps’ in diarrheal disease incidence following periods of sustained rainfall, however the epidemiological baseline remains unclear in terms of what is normal and expected for the Haitian population during the minor rainy season.  That said, we have maintained a WATCH status of alert for diarrheal disease in Haiti, and we expect to move this alert up to a WARNING with sustained rainfall.

The reason for this high level of concern is obvious to all of us who are working on the ground.  An extension of that concern may be seen when considering the fragile nature of the current ad hoc medical infrastructure in the quake-affected areas.  It is our assessment this infrastructure comprised mainly of volunteers is easily overwhelmed by a sudden influx of patients, particularly pediatric patients.  The higher the clinical acuity, the more easily it is to overwhelm.

To that end, we would like to encourage the following discussion from the responder community in Haiti:

Preparedness.  
Let us ask ourselves the difficult question of whether we are truly prepared if a substantial increase in diarrheal disease is observed across multiple locations?  Specifically, although Promess has a large supply of Pedialyte, is it enough?  What about oral and IV antibiotics?  IV fluids and kits?  How fast is this materiel able to be deployed throughout the IDP camps in response to reported outbreaks of diarrheal disease?  Is the application mechanism agile enough to handle a high volume of requests, even though coming from unregistered groups?  Have Haitian mothers been taught how to make oral rehydration salts (ORS) and how to use ORS solution proactively with their children?

Early Warning and Situational Awareness.  
Formal public health surveillance currently consists of filling out forms and submitting them to the Haiti Ministry of Health once per week, with a developing network of sites to support laboratory testing.  To augment this process, we would like to strongly encourage cluster members to not only fill out these forms but also engage in routine information sharing about events.  This is referred to as “informal surveillance”, and we offer the following Google group, the “Haiti Epidemic Advisory System” and the InSTEDD-supported SMS/text messaging alert system called Geochat to facilitate communication among us.  In this Google group we will be sharing insights into what to look for and examples of informal surveillance in action.  Please note this group is only for ground-based Haiti responders.  The link to the Google group may be found here, and instructions for how to sign up for the SMS/text messaging Geochat service is found on the group website:
http://groups.google.com/group/haiti-epidemic-advisory-system?hl=en

Response.  
If we are prepared and we are sharing warning information and situational awareness, are we then prepared as a community to respond?  Response in this context may become quite challenging, particularly if the roads become more difficult to travel on due to rain and slides.  Further, if we do not have adequate supplies coupled to agile logistical distribution, we will not be empowered as a responder community to respond.  Imagine multiple sites say in Port-au-Prince that may or may not have on-site medical personnel who may or may not have enough supplies to respond to a crisis of diarrheal disease.  We need to confront these questions as a community and make sure we are able to answer them before a crisis occurs.

We are here to facilitate this process and assist in a positive outcome for Haiti’s children.  It is acknowledged this is a substantial and complex challenge, and we may see the deaths of children despite everything we attempt to prevent it.  Here we encourage an exploration of all possible options proactively before the crisis is thrust upon us unprepared.

Cheers,

Jim

---

James M. Wilson V, M.D.
Executive Director, Praecipio International
Haiti Epidemic Advisory System (HEAS)
Petionville-Port au Prince, Haiti

Widely Acknowledged Concerns About the Coming Rainy Season and the Status of Early Warning in Haiti

A comprehensive acknowledgment by multiple international agencies of the multiple situation reports and ground assessments by the Haiti Epidemic Advisory System was finally published by The Lancet.  Our high level of concern and EMERGENCY APPEAL remains valid.

International agencies acknowledged the following:

1. Singular concern about diarrheal disease, with potential for "explosive epidemics" [CDC]
2. Acknowledgment that children (7 of them reported, with an unknown additional number likely not reported) have died of diarrhea since the earthquake [Haiti Ministry of Health]
3. "The [sanitation] needs are overwhelming" [UNICEF]
4. Sphere standards have not been met [UNICEF]
5. "We're very concerned about the rainy season... [and] contamination of the water supply; latrines can overflow, [and] people continue to defecate in the open" [International Organization for Migration]
6. The initial formal epidemiological surveillance system was "flawed". [CDC]  CDC asserts the updated system has been improved and is "nimble".  This is an overestimate at this point in the process.  It is highly unlikely the system will be able to produce effective tactical early warning to support large scale rapid response efforts directed to diarrheal disease in less than 30 days.  This concern was echoed vocally by the Epi SubCluster participants at last week's meeting.

The consistent challenge for public health is an understanding and operational acceptance of the sociology of warning- particularly under crisis or disaster conditions.  As we have shown during the emergence of the H1N1 pandemic, informal crisis communications defies bureaucratic and formal constructs for information sharing. 

In 2009, the American Red Cross and the Mississippi Department of Health implemented an informal disease surveillance system after Hurricane Katrina to provide situational awareness for 43 shelters and over 3,500 evacuees (see attached).    They concluded,

The surveillance system used direct verbal communication between shelter staff and hotline managers to enable more rapid reporting, mapping, investigation, and intervention, far beyond the capabilities of a more passive or paper-based system.  It also allowed for immediate feedback and education for staff unfamiliar with the diseases and reporting process.  Replication of this program should be considered during future disasters when health surveillance of a large, disseminate shelter population is necessary.

This is clearly the case in Haiti, as we have shown repeatedly through the Haiti Epidemic Advisory System.

The other issue at hand is the high level of programmatic technical focus by CDC and others towards vectorborne disease.  This has readily been acknowledged to be a backseat issue to the imminent threat of pediatric infectious disease as a potential social disruptor and crisis generator in Haiti.  The reason for this bias remains unclear.

We remain seriously concerned about the worsening risk parameters, lack of an effective early warning system, and lack of appropriate prioritization of preparedness and rapid response in Haiti.  A combination of informal and formal approaches to surveillance is required immediately.

Download Mississippi's Infectious Disease Hotline- a Model for Disaster Response

Emergency Appeal: Haiti Epidemic Warning and Rapid Response

FOR IMMEDIATE RELEASE

Emergency Appeal: Haiti

Epidemic Warning and Rapid Response

Praecipio International, a non-profit organization that tracks disease outbreaks globally, is planning to re-deploy to Haiti to assist in curbing unfolding infectious disease crises as the rainy season begins.   The founders of Praecipio International have extensive public health experience and led the same analytical team from Veratect Corporation that first detected and warned of the potential crisis evolving in Mexico in spring of 2009 that was later confirmed by the World Health Organization to be the H1N1 influenza pandemic.

 

Our main focus in Haiti is to spearhead the creation of an early warning disease surveillance network to complement existing formal systems.

The onset of continuous rainfall in Haiti poses an immediate health threat to individuals residing in IDP camps.  Floodwaters trigger the overflow of pit latrines bringing raw sewage flow into the camps contaminating local water sources.  Contact with raw sewage greatly increases the chance of exposure to waterborne pathogens that cause diarrheal disease.  Prior to the January 12th earthquake, diarrheal disease was already a leading cause of illness and death for children in Haiti.  Now, both children and adults living in temporary shelters with inadequate hygiene are facing a substantial increased risk for diarrheal disease due to the environmental conditions, which will only worsen as the rainy season unfolds in Haiti.

 

The medical infrastructure in Haiti consists mainly of volunteer and non-profit groups who are themselves transitional – some groups are pulling out of Haiti and some are rotating entire teams of medical personnel every week. This ad hoc infrastructure is both limited and easily overwhelmed.  Because of these conditions, rapid identification of diarrheal disease hot spots when they emerge is critical, so that aid can be moved quickly to prevent further spread of disease and exhaustion of medical resources.   Praecipio International is currently actively engaged in addressing these needs.  Initial action includes stockpiling pharmaceuticals and medical supplies for emergency distribution, deploying personnel to evaluate at-risk populations, and expanding the current information network between ground responders to improve overall disease reporting and response efforts.

 

Dr. Jim Wilson, Executive Director of Praecipio International has been in Haiti in recent weeks working with the Jenkins-Penn Haiti Relief Organization to directly evaluate residents of IDP camps in the Port-au-Prince area and provide medical assistance to those in need.  During the past two months, Praecipio has been providing continual situational awareness for infectious disease activity among earthquake survivors and anticipatory assessments of expected disease threats.

 

Praecipio International has maintained a WATCH status for Haiti beginning within weeks of the earthquake and believe this status will elevate to a WARNING in less than 30 days with the coming rains. Action is immediately required to mitigate unnecessary loss of life among earthquake survivor populations.

 

Praecipio International has issued an Emergency Appeal for the following operational actions over the next 3 months, to begin immediately:

 

1. Continue building a disease reporting network to support early warning of diarrheal disease hot spots in partnership with the Haiti Ministry of Health;

 

2. Continue to stockpile medications and medical supplies to support a possible large-scale diarrheal disease response; and

 

3. Deploy Intercept Teams throughout Port-au-Prince to provide ground assessment support and medical countermeasures to responders dealing with surges in diarrheal disease.

 

This Emergency Appeal requires US$125,000 for the Praecipio International team to return to Haiti for 3 months to continue expanding the informal disease surveillance system and disease prevention efforts underway as the rainy season begins.

 

Summary Findings of Ground Assessment in Haiti: Immediate Action Required

Method:

Length of evaluation: 5 MAR - 19 MAR.  In-person assessments of random orphanages, IDP camps, and health facilities; focused interviews of Haitian authorities, CDC personnel, USAID representatives, U.S. DOD personnel, WHO/PAHO team leads, senior medical personnel for the International Federation of the Red Cross, senior leadership of the American Red Cross, Senior Medical Lead for World Vision, Ground Medical Lead for Samaritan’s Purse, medical personnel with Doctors Without Borders, a multitude of responders from unaffiliated NGOs and volunteer groups, the Haitian business community, and prominent ex-pat community members.

Results:

• The majority of shelter provided in IDP camps consisted of sheets and lumber covered in tarps.

• Although water supply was often chlorinated to levels above US drinking standards, there were several sites identified where the contractor had not chlorinated the water. Further, it was noted by the IFRC that the Bangladesh protocols were not in place.  Closed-lid water containers were rarely observed at water distribution sites.

• Hand washing stations were not available in the majority of locations.  Hygiene education programs were not implemented throughout.

• Pit latrines were dug, however it was discovered quite quickly that 30 minutes of heavy rain floods the pits and runs raw sewage through the camps.  This video, taken by the IFRC shows the damage caused by a typical rainfall.

• CDC’s epidemiology team is focused on supporting the Haiti National Public Health Laboratory and formal medical surveillance. They have deployed SMEs for malaria and dengue control but acknowledged a lack of prioritization for diarrheal disease. There was no debate from their end which was considered a bigger risk of triggering a crisis: diarrheal disease.  CDC acknowledged more data to inform surveillance efforts was welcomed, including informal surveillance approaches. While formal medical surveillance, data quality issues aside, provided some information on infectious disease morbidity, public health did not yet have a clear assessment of the leading infectious causes of mortality. They emphasized they work in Haiti at the bequest of the Haitian government and take their lead in public health intervention.

• All of the NGOs or non-public health personnel interviewed indicated they were concerned about diarrheal disease with the coming rains. Seasoned field personnel from MSF/Doctors Without Borders acknowledged formal medical surveillance was not helpful for early warning, and they welcomed the idea of informal surveillance approaches. They were quite concerned about the prospect of diarrheal disease with the coming rains. These thoughts were shared by all other groups encountered.

• There was no evidence of a specific large-scale preparedness plan to respond to epidemic diarrheal disease. There was no evidence of a rapid response capability to deploy countermeasures (i.e. oral rehydration salts, antibiotics, IV fluids) to ‘hot spots’ reporting substantial increases in diarrheal disease.  The Promess warehouse was now charging for many of their medications- it was not apparent how well (if) it would function logistically in an emergency response scenario represented by an epidemic of diarrheal disease. It was acknowledged they have a large stockpile of Pedialyte, however it remains debatable how fast that stockpile could be mobilized in the context of an emergency response.

• There was minimal surge capacity in the ad hoc medical grid in PAP.  This medical grid is comprised mainly of individuals and groups of responders who in many instances rotate entire teams of medical personnel, including the Chief Medical Officer, every one to two weeks which impairs any attempt to have operational continuity.  Sign-off between rotating teams was a challenge. The medical grid functions without situational awareness or anticipation of patient surge and universally asked for situational awareness for infectious disease events. Due to funding constraints, this vulnerability will increase with contraction of available medical resources as responders depart Haiti. The possible departure of the University of Miami team, for example, would close the only functioning NICU in Port-au-Prince and the main PICU used for receiving transfers of critically ill children.

• Based on open source records dating back to the 1950s, Haitian society has rioted after flooding, with cited concerns of lack of shelter, access to safe drinking water and food, and increased risk of disease. These times have occurred within the context of political instability. It may be argued now is such a time. It is a general sentiment on the ground there are discrepancies between funding provided to Haiti versus what was actually made available to the Haitian public. We question what might happen if diarrheal disease reaches uncontrolled levels during the minor rainy season and how the Haitian public might react if children died at levels unusual even for Haitian society.

Action:

Praecipio International considers the situation to represent an imminent emergency for Haiti:

1. Diarrheal disease is preventable
2. Diarrheal disease is a major killer of children if unchecked
3. An uncontrolled epidemic of pediatric diarrheal disease, with unusual levels of mortality, may become an important contributing factor to civil unrest
4. Immediate deployment back to Haiti to initiate a plan of action is required
5. An Emergency Appeal will be presented by Praecipio International
   

Health Beliefs Related to Diarrhea in Haitian Children

A compelling study done by Kirkpatrick and Cobb (1990, see attached), addressed the question of Haitian mothers' beliefs about diarrhea in their children.  Eighty-three Haitian women were interviewed at a sugar cane field in Dominican Republic, where they lived and worked.  At the time, the authors considered it safer to conduct the study in the DR versus Haiti due to political and civil instability at the time.

The authors quoted a study by Pons (1986) that 40% of the children found among sugar cane workers were markedly malnourished.  A prior post here highlighted OCHA's recent findings of malnutrition.

Summary findings were as follows:

1. Diarrheal disease was named the top threat to children's health by Haitian mothers.
2. Primary causes of diarrhea named by Haitian mothers were water, food, and microbes.
3. 38% of Haitian mothers indicated they would STOP breastfeeding if their child had diarrhea.

Bullet #3 is of singular concern, as it reveals a belief we occasionally saw at the Petionville IDP camp- that mothers would cease breastfeeding or attempt to supplement feeds with straight water +/- rice and mashed beans.  We were concerned about contaminated water and food exacerbating an already ill child's condition.  We found it imperative mothers were taught to continue to breastfeed as much as possible, with Pedialyte supplementation as needed with close follow up at the clinic.

Haitian awareness that 1) diarrheal disease is a threat to the safety of the children and 2) sources and causes of diarrheal disease involve the water supply is important to note for the current situation in Haiti, where the Haitian public is aware of the shortfalls in aid and the imminent threat the coming rains represent.  A review of open source material dating back to the 1950s suggests public awareness that flooding brings problems with access to shelter, safe water, food, and protection from disease led to rioting in times when there was political instability.  We assess diarrheal disease in Haiti to represent a potential non-routine, unexpected excession of morbidity and mortality... in other words, a potential crisis in the next 30-60-90 days.  This is the reason for the standing WATCH that has been posted.

We have advocated repeatedly here for the immediate activation of our ground team to support preparedness, early warning, and rapid response activities in Port-au-Prince.  It will become important for the Haitian public to be made aware everything possible is being done to protect their children.

Download Haitian Beliefs About Diarrhea in Children

Ominous Indicators of Infectious Disease Threat to Children in Haiti

In a 22 March assessment by OCHA (see attached below), several key findings support our concern for pediatric health in Haiti.  Below are the direct quotes from OCHA:

• Female headed households are more food insecure than male headed households (60% vs 45%).  Women are the primary caregivers for children.
• 6% of children 6 - 59 months have a MUAC (mid-upper arm circumference) <125 mm (moderate and severe wasting).
• 1.3% of children 6 - 59 months have a MUAC <115mm (severe wasting).  This is comparable or slightly higher than the situation before the earthquake.
• The low MUAC appears to be linked with having had diarrhea in the previous two weeks.

• The average of people per latrine are 411 people/latrine, with ranges from 66.8 people/latrine to 941 people/latrine, with 33% (7/21) of the sites without any latrines.
• 86% (18/21) of the sites had regular water provision.
• 86% (18/21) of the sites had regular health provision.
• 71% (6/21) of the sites report mosquitoes to be a problem, while only 9% (2/21) of the sites reported malaria cases.  Note there is an error with the first part of this statement- 6/21 equals 28%, not 71%.  Malaria mimics many other diseases; laboratory confirmation and a full epidemiological assessment is needed to validate this statement.  Open containers serving as mosquito breeding sites in the IDP camps with the coming rains pose a serious challenge to vector control in the coming months.  See our prior post showing pictures of these containers littering the drainage areas in an IDP camp.
• In the priority areas, a total of 4,275 latrines is needed in order to assure 50 people/latrine, and a total of 10,687 in order to assure Sphere standards.  Sphere standards have not been achieved yet in Haiti.
• 9% (2/21) of the sites have at least some improved ventilated pit latrines, 28% have some mobile toilets, while the rest of the sites are equipped with basic pit latrines.  This translates to the majority of sites having pit latrines.  Pit latrines are easily flooded with rain, as described here previously.
• 57% (8/14) of the sites with latrines have clean facilities, with only one site being able to provide hand washing facilities.  Hand washing is a major preventative step towards inhibiting the spread of diarrheal disease.
• 23% (5/21) of the sites have had any health education activities, with 0% of the sites having health education signs.

• In Cite Soleil, less than 28% of respondents received aid from relief organizations at the time of the survey.  Current aid distribution methods have been ineffective in reaching most people.
• There is a lack of sanitation (latrines), lack of follow up medical care...

Essentially, OCHA's findings support our assessments here, that we face a potential crisis of diarrheal disease that threatens the lives of children in Haiti in the next 30-60-90 days.

Download 220310 HAITI HA Key Findings No.1

Premature Congratulations For Conquering Outbreaks of Diarrhea

A recent media announcement by CARE International claims outbreaks of diarrheal disease have been avoided through the provision of safe drinking water, sanitation facilities, and hygiene education campaigns.

This is a premature assessment, as the rainy season has not begun in earnest yet, and laboratory diagnostics show a clear burden of diarrheal agents in Haiti.  Current disease surveillance efforts in Haiti are not operationally mature enough to rapidly identify "outbreaks" or "epidemics" of any disease because no one understands the denominator (i.e. the baseline of disease) yet.  We suspect outbreaks have indeed occurred based on pediatric fatalities reported due to dehydration and diarrhea during a period of rain that later ebbed during a period of hot, dry days seen a week ago.

Degradation of water quality begins after leaving the spigot, and we observed the majority of people carrying water with open buckets and running hands under the water at the spigot.  In other words, Bangladesh water handling containers and protocols were not observed.  Hand washing stations are not located throughout the IDP camps, and hygiene campaigns need to overcome decades (perhaps centuries?) of ingrained cultural behavior.  As we have described multiple times here, raw sewage flows easily through the camps with but a short period of rainfall. 

In summary, complacency is a dangerous state of mind.  As pointed out here and in multiple other forums and sources, there remains a discrepancy of what has actually been achieved at the level of the victims in Haiti, a gap that may reveal itself as a crisis of diarrheal disease in less than 30 days.  Preparedness is key.