The Haiti Epidemic Advisory System (HEAS)

Performance of the HEAS in the First 150 Days Post-Earthquake

In recent weeks, Praecipio International completed its “Haiti Mid-Action Report,” which outlines and evaluates actions by the Praecipio International Intercept Team, Haiti Epidemic Advisory System (HEAS) and related activities during the first 150 days post-earthquake (January 13 – June 11, 2010). This report highlights key successes and shortfalls so that our organization and partners may learn and improve upon operational surveillance tactics and strategies from our experience in Haiti.

Below are excerpts from the Praecipio International Haiti Mid-Action Report. For access to the full transcript or questions regarding the report, please contact Dr. Jim Wilson at jim.wilson@praecipiointernational.org.

Excerpt 1

Within minutes of notification of the earthquake by the Global Disaster Alert and Coordination System, the Intercept Team initiated online source scanning in English and other relevant languages, such as French and Spanish, to gain an initial understanding of infectious disease events reported in the affected areas of Haiti. We then conducted a search of peer-reviewed literature for relevant baseline knowledge of disease activity in Haiti. Shortly thereafter, on 15 January, the Intercept Team made the following initial assessment in the earthquake’s immediate aftermath available to the public:

• Large-scale epidemics are not typically triggered by earthquakes;

• Seasonal endemic diseases are still observed such as malaria and dengue, which may complicate response; and,

• Corpses do not typically trigger epidemics.

Based on our initial assessment, we drafted a biosurveillance assistance strategy for Haiti, focusing on infectious diseases capable of generating crisis. Given the deteriorated state of Haiti’s healthcare infrastructure after the earthquake, our work was intended to provide first responders in Haiti with information that might allow them to identify and respond to diseases representing the most significant threat as quickly as possible.

Excerpt 2

A key component to our response in Haiti was fostering an independent and peer-accepted open forum for an exchange of critical information through the HEAS. We engaged two approaches to foster the HEAS network:

1. The team approached individuals and organizations on the ground, in listservs, and in online forums that spontaneously formed during the response effort. We provided information and access to the team collaboratively. This openness encouraged multi-lateral communication about infectious disease events.

2. The team invited interested individuals and groups to a HEAS-specific forum. The Intercept Team served as moderator promoting information exchange between participants. This resulted in cross-migration of interested parties into the HEAS forum where focused dialog about live infectious disease events could occur.

Excerpt 3

After establishing the Haiti Epidemic Advisory System (HEAS), the team eventually fused and contextualized open source and trust network information into the following formats:

• Critical Information Requirements.

• Tactical Reports.

• Advisories.

• Situation Reports (“SitReps”)

The release of HEAS Situation Reports was driven by receipt of credible information to indicate a change in risk status and advisory levels, or substantive updates regarding contextual information.

Over the 150 day post-earthquake time period evaluated in the Haiti Mid-Action Report, Praecipio International provided forecasting and early warning for numerous infectious diseases that were issued through SitReps. The table below provides time deltas (in days) for early warning provided by Praecipio International for specific infectious disease activity in Haiti.

 

The HEAS remains active today and is currently serving as a key platform for information exchange regarding the ongoing cholera crisis in Haiti.

FLASH REPORT: Cholera In Cite Soleil

As evidenced in multiple reports by the HEAS, a clear route of cholera transmission from Artibonite existed along the coastal highway from Arachaie to Lafito to, potentially, "Camp Obama" and (of greater concern) Cite Soleil.  As feared, cholera has now been reported in Cite Soleil in a case without a travel history from Artibonite Valley:

The clinic in Cite Soleil treated a patient this morning that presented at the clinic with rice water diarrhea and vomiting. It is the considered diagnosis of the tropical medicine experienced physician at the clinic that this is cholera.
 
 It was further determined that this individual had not traveled outside of Cite Soleil. It is of very great concern that the case history proved that this patient has not been away nor does she ever travel from her home in Cite Soleil.  This transmission occurred in Cite Soleil.
 
Also of great concern, because of efforts to clear rubbish and garbage from the water courses the contaminated soil that lines these channels is being spilled onto the banks which serve as the paths leading into the heart of this overcrowded area of the city.  The Cite Soleil is seeing a sharp rise in diarrheal illness most probably associated with the spillage of what constitutes raw sewage along the afore described paths.
 
While these later described patients that are presenting to the clinic with diarrhea do not have symptoms consistent with a diagnosis of cholera this trend, a rapid increase in cases of diarrheal illness, portends a disaster if cholera now in the area crosses the epidemic threshold!!!  Two days of rain will make this almost inescapable.
 
Please remember that the first case reported above is separate. The symptoms of that patient matched word for word the WHO accepted case description for cholera.

The team considers this a priority alert for Port-au-Prince worthy of immediate investigation.

Updated Case Counts And Implications For Sustained Transmission

From our perspective, we agree with PAHO's recent statement today about the epidemic and while we all would like to be hopeful, we are reminded of the recent 2008-2009 epidemic of cholera in Zimbabwe.  Responders there were lulled into a false sense of security as the epidemic waned, only to be badly disappointed as the epidemic continued onward to produce 98,424 suspected cases and 4,276 deaths (Case Fatality Rate of 4.3%) from August 2008 to June 2009 that were officially reported. Fifty-five out of 62 districts in all 10 provinces had been affected, according to the World Health Organization.

Currently we are seeing 4,147 cases officially reported, with 292 deaths.  We assume PAHO is reporting these as separate groups of people, where the total number of cases reported is actually 4,147+292= 4,439.  If we generally assume that only 25% of cases display clinically apparent illness, we conservatively assume then there has been at least 17,756 infected people to-date.  This is a truly alarming number of people, especially when considering 1) this is likely the result of under-reporting and 2) a large percentage of these infected individuals could be shedding pathogen into the environment for weeks post-infection.

There are a number of factors in play to explain the apparent high CFR:
 
1.  CFRs are often inflated at the front-end of outbreaks and epidemics in general, especially when dealing with an area of limited infectious disease warning capability, because the social bias in reporting up to a national level is driven by fatalities or the most severe clinical outcomes.

2.  Once the clinical entity (i.e. cholera) is recognized to be the etiological agent, extrapolations for the true infectious disease load in community may then be calculated for a truer estimate (such as we've proposed above).

3.  Once social sensitization has been achieved through a warning process such as we have achieved, reminders for clinical diagnosis are also distributed which actually alters the probability of clinical diagnosis for milder cases.  This means your reported case count may migrate a bit over time.

Bottom line, our team remains on maximum alert and are concerned about the potential for ecological establishment and introduction to other nations in the Caribbean.

Updated PAHO Situation Map

Download EOC-Haiti-Cholera-SitRep5-26102010ENG

Expansion of Cholera and the Tempering of Hope

We, like the rest of the responder community, have dared to hope containment may be possible at various junctures of this crisis.  We noted recent reporting of cases seen in Limbe and Plaisance, where Limbe is a 15 minute drive from Cap Hatien, and are reminded this situation is still very much in flux and unlikely to resolve soon.  One of the HEAS partners who was close to the recent 2008 massive epidemic of cholera in Zimbabwe noted that responders there also had indication of a stabilizing or slowing down of transmission, only to be horribly disappointed as tens of thousands were infected.  While we keep hoping Haiti will "get a break", we simply cannot allow ourselves to stand down for a moment.  This remains an IDIS Category 5 event that is very much in-play.  And the question of ecological establishment remains an open one as well.

Context: Anti-Clinic Protest in St Marc

We previously noted a protest that erupted in St Marc over the creation of a cholera treatment facility, and we have been provided with several important points of context:

1. MINUSTAH was not directly involved in the creation of the treatment center but was providing security for MSF personnel by request.
2. The chosen site of the facility was across the street from a school; and
3. Was a community soccer field

The latter two points are crucial for the following reasons:

1. We have come to realize over the years that for communities coping with a high level of threat perception, especially during unexpected or non-routine infectious disease events, protection of children becomes an exquisitely sensitive nexus of concern that may lead to social outcry and even violence.
2. Communities under collective stress such as is readily observed in St Marc have a high demand for coping outlets such as recreation and access to religious services, for example.  Compromised access to such outlets is actually a key indicator that prompts us to monitor for civil unrest.

If the community in question is already experiencing tension such as the negative MINUSTAH-Haitian public dynamic, then these issues become all the more important to monitor... and avoid.

At some point following conclusion of this disaster response effort it would be a prudent activity to review these kinds of observations to better inform response activities in the future.

Anti-Clinic Protest in St Marc

Media reported on students protesting the activation of a cholera treatment center in St Marc managed by MSF. 

This is clearly a community education issue.  Such community anxiety is very common when dealing with a pathogen previously unknown to a community or not in recent generational memory.  We have seen the various manifestations of community anxiety for years in many different cultures under many different scenarios- from Ebola to the 2009 influenza pandemic.  It relates to community coping mechanism when dealing with a non-routine, unexpected perceived threat, particularly one perceived difficult to control.

OCHA Situation Map For Artibonite and Centre

Below and attached is a superb map of the response effort ongoing in Artibonite and Centre.  BRAVO to the OCHA mapping team and well done.

Download OCHA Cholera in Artibonite and Centre 10.26.10

 

UPDATE 2: Community Outcry Blaming Nepalese MINUSTAH Deployment in Mirebalais For Cholera Epidemic

In a previous post, we noted local community concern about Nepalese MINUSTAH troops possibly being the source of the cholera epidemic.  We emphasized that such claims need to be investigated properly, and sources indicate testing is in process.  MINUSTAH has issued a statement that clarifies the sanitation handling practices of the deployment in question.  We encourage the readers to read the statement.  Test results will be conveyed as soon as possible.

Activation of the International Health Regulations

This is the first documented cholera epidemic in the Caribbean in many years, since the last pandemic of the early 1990s.  WHO's recent declaration that travel restrictions from Haiti will not be required raises serious questions of whether spread in the region is truly unlikely. Despite the WHO official's comment:

"There is no need to close the borders or restrict travel or trade because a neighbouring country has cholera. This is what we say for all cholera outbreaks worldwide."

This would imply this is an ordinary outbreak / epidemic of cholera.  It is not, and it represents a key epidemiological change for the Carribean region that should be monitored closely.

The Dominican Republic has closed its borders, however it is generally believed the border is highly porous.  Should the epidemic continue, we expect to see cases there eventually.  Jamaica is on high alert, as are other countries in the region.  While we do not want to cause further damage to Haiti's economy, the question of international travel restrictions should be re-examined at frequent intervals given the volume of multi-national responders flying in to assist. 

Several days ago, the HEAS posted an advisory to several key medical communities in the United States to prompt diagnostic awareness and to ask a travel history.  Most physicians in the United States have never seen a case of cholera, and prompt recognition is key to effective treatment.  The disease is easily treated, with very low mortality if the patient is managed appropriately.  Translocation of this disease to developed countries will not result in a large outbreak. 

Translocation of cholera to developing or undeveloped areas of the Caribbean, Mexico, Central or South America would likely present in a similar manner as seen in Haiti.