HEAS SitRep 12.8.10

• On December 3rd, MSPP reported 91,770 hospital visits for cholera, 43,243 of which were admitted, and 2,071 fatalities as of that day. These retrospective statistics continue to represent gross underestimates of the true caseload and fatalities seen in Haiti thus far.
  • The greatest discrepancies in reporting are observed in the difficult to reach mountainous, rural areas. There are currently no credible statistics to account for these communities, which are thought to represent nearly 2/3 of Haiti by land area.
  • The election period may have disrupted official reporting.
  • Precipitation is forecasted for this weekend, particularly for the southern peninsula, which may result in enhancement of transmission. We hypothesize the dry period experienced by much of the country post-Tomas has inhibited transmission.

• The HEAS is primarily concerned with under-represented areas experiencing “first contact” sudden patient surge and high daily clinical mortality. We do not use the public health case fatality rate, which is defined as the number of individuals infected that die divided by the number of individuals infected. Instead, the daily clinical mortality is a reflection of psychosocial burden on the affected community, where it is calculated as the number of fatalities for a given disease observed by a given clinic divided by the number of admissions for that disease to the clinic. If five patients are admitted and those five patients all die, then the daily clinical mortality is 100%. This is representative of high and acute psychosocial impact to both the clinic staff and surrounding community as rumor of the event spreads. It is also representative of clinic capacity in terms of ability to exploit pre-event warning, pre-event education and training, materiel preparedness, and peri-event personnel and materiel capacity. It is an important marker for emergency response deployment. Below is an example at the departmental level, that of “first contact” daily clinical mortality:

 

• When considered by department, the most recent Haitian Ministry of Health (MSPP) statistics published as of December 4th highlight key areas experiencing “first contact” mortality.

• The below figure represents the departments (Grand Anse, Nippes, Sud, Sud-Est, and Nord-Est) that are of greatest concern to the HEAS. These areas were forecasted to be the next “battlefront” by the HEAS; this forecast is now validated. These are sites experiencing either “first contact” patient surge high clinical mortality. WASH and Health Cluster resources are largely concentrated and in the process of mobilization for Jacmel and Les Cayes, however the situation remains highly dynamic. The rural mountainous areas of the southern peninsula are reporting cholera, however evaluation of these areas has been limited. The HEAS is most concerned about the status of Sud-Est due to its geographic isolation from the remainder of the country. As mentioned above, rain is forecasted for the coming weekend, with higher precipitation expected for the southern peninsula. This will likely exacerbate epidemic control efforts due to enhancement of transmission and inhibition of response mobilization.

• The next category of departments represent sites where there has been active and persistent transmission, hospitalizations, and moderate, persistent clinical mortality. Nord-Est is the only department in this category at-present:

• The final category represents sites where there has been active and persistent transmission, hospitalizations, and low but persistent clinical mortality. This category effectively represents the remainder of the country:

• The below figures highlight the results of 37 directly participating HEAS partners, two large social networks including the HEAS, 802 point to point email communications (with a daily peak of 284 emails), and a time delta between HEAS notification of Request For Emergency Assistance and materiel & personnel arrival on-site of 3 and 5 days, respectively.  In the social network plex figures, each colored diamond represents a separate HEAS partner, and the larger inverted triangles represent two large social networks, one of which is the HEAS itself.

The Borgne Emergency Ad Hoc Cholera Treatment Facility, Nov 22nd. 

• The reality of HEAS alert and response operations resides in a now well-established pattern of reporting. Communities along paved roads, which includes coastal areas, valleys, and mountain passes are the first to report cases followed later by observation that mountain rural communities above are the source of more critically ill cases. These cases are more ill upon arrival due to the multiple-hour trek by foot required to reach the nearest CTC / CTU. As reported before by the HEAS, many of these communities were caught completely by surprise having not even heard there was cholera in the country. These mountain rural communities represent approximately 2/3 of Haiti by land area and are extremely difficult to access, often only allowing access by foot or helo drop. Many do not have helo landing zones. The current national response effort does not contemplate accessing these difficult to reach areas. The HEAS continues to receive many requests for emergency assistance from these sites, however it is likely we are observing gross under-reporting. The below figure highlights the regions of concern from this perspective and reflects a substantially more challenging view of where response assets are versus the broader evolving need. Red areas indicate rural sites of greatest concern to the HEAS, followed by orange and yellow areas, respectively.

• Conservative estimates suggest more than 360,000 cases of cholera in Haiti to-date, the majority of which were subclinical. This is based on the 1 clinically apparent : 3 subclinical case ratios quoted by PAHO.

• In some areas of Haiti, we have had confirmation that in-patient statistics are under-reported by as much as 400%. In many areas of Haiti, we are documenting outbreaks that are not being accounted for in the official statistics. We therefore estimate the upper bound of estimated total (subclinical and clinically apparent) case counts to be one million. From a practical operations point of view, these estimates are academic, and we do not believe it likely the case counts are one million but rather closer to 500,000 total. The bottom line is the epidemic continues to spread without restraint.

• Initial conservative PAHO projections used an attack rate of 2% of a total estimated Haiti population of 10 million to estimate 200,000 total clinically apparent infections, the true community load will be closer to 800,000 if subclinical infections are counted. We will exceed these estimates well before the peak of the epidemic.

• We err on the side of over-estimating because this is a "virgin soil" epidemic and expected to aggressively spread throughout Hispaniola.

• We are now pursuing answers to the question of uptake by indigenous zooplankton and spread along oceanic currents that pass west of the Gonave Gulf, which is where the Artibonite River discharges, north and west along the northern Cuban coastline and north to the waters east of Florida.

• We assess the elections on the 28th facilitated further spread. To what degree remains uncertain.

• Multiple healthcare worker infections have been reported on the ground in Haiti with one report of a worker returning to the United States infected.

• There will be more cases in the United States; we believe it likely more cases are inside the US unreported.  Implications for the United States are non-significant.

• It is clear both the Health and WASH Cluster activities are unable to keep up with the speed and breadth of cholera transmission.

• Civil unrest triggered by announcement of the election results last night forced the closure of PAHO operations today.

• The entire HEAS surveillance / response grid is now overwhelmed and lacks the agility enjoyed in the beginning of the disaster. To meet this crisis, we are attempting to ascertain additional levels of funding and expertise.