On December 1st, the Haiti Health Cluster reported 77,208 hospital visits for cholera, 34,248 of which were admitted, and 1,751 fatalities as of November 27th. These continue to represent gross underestimates of the true caseload and fatalities seen in Haiti thus far. The below represents areas of specific concern and active monitoring by the HEAS:
Red- where we continuously receive emergency requests for assistance due to "first contact" high mortality and have facilitated several mobile emergency responses. Currently, we have report that MSF’s facilities are overrun with patients with no auxiliary staff. We are expecting overflow surge into surrounding clinics that are already struggling. Both the Cap Haitien and NW regions are seriously strained, with the NE region becoming increasingly problematic to manage. Little situational awareness is provided for the remote mountainous regions. We suspect very high mortality for those villages at >3 hrs walking distance from the nearest medical facility able to support cholera treatment.
Orange- where we occasionally receive notification of "first contact" high mortality but confirmation is difficult; we suspect there is far greater mortality in these mountains but it goes unreported because of very low NGO presence and difficulty of access. As mentioned above, we suspect very high mortality for those villages at >3 hrs walking distance from the nearest medical facility able to support cholera treatment.
Yellow- where we have confirmed cholera activity at multiple sites throughout the southern peninsula, however the majority of international response is focused on PaP, Artibonite, and recently the north… the south is left relatively untouched in terms of response. As with the orange areas, we suspect far more activity that is what reported because of very low NGO presence. We also note very large time lags in official reporting from this area. The southern peninsula is the next ‘battlefront’, where we expect the 'war' to go very badly given the low availability of response assets.
Case fatality rates such as the most recent Health Cluster report of 3.6% (in-hospital) is representative of gross national level aggregation of information available to officials, which represents a substantial bias towards CTC/CTUs staffed by experienced teams such as MSF. What is not reflected is the continually documented "first contact" pattern of daily clinical mortality seen by rural communities and urban environments such as Gonaives several weeks ago reported by officials do not reflect the true impact of cholera at the community level. The daily mortality we have documented on multiple occasions may range from 10 to 100%. We often see sudden overwhelming of local capacity to the point of back-loading corpses for burial, having run out of body bags.
Conservative estimates suggest more than 300,000 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 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. 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.
The below represents the USAID view of the situation, which highlights multiple areas of mismatch between emergency need and CTC/CTU placement. The HEAS is working with PAHO to close these gaps.
The below represents the WASH view of the situation, which also does not completely agree with our situational awareness (see below notes):
It is clear both the Health and WASH Cluster activities are unable to keep up with the speed and breadth of cholera transmission.
Donor fatigue continues to impair response efforts, as does periodic civil unrest. There is a significant lack of volunteerism from the international medical community, where levels of volunteerism observed post-quake are not observed currently. The response grid is in jeopardy of collapse without additional assistance.
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.
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