On January 9th, an astute HEAS community member discovered a YouTube video of a patient being transported by ground and fixed wing aircraft by GlobalDIRT from Beraca Hospital in Port de Paix to a hospital in Port au Prince. In the video, they referred to ascending paralysis suspected to be caused by an infectious agent, where 2 other patients with similar symptoms had died. This prompted immediate engagement of the HEAS to:
- Verify the report with Medical Teams International (MTI);
- Confirm that MTI reported the event to local Haitian public health authorities (MSPP);
- Verify the Point(s) of Contact at the receiving hospital for the patient transferred from Port de Paix to Port au Prince
- Notify PAHO/WHO and the US Centers for Disease Control and Prevention given the suspicion of possible poliovirus activity
The HEAS then issued an advisory to the nearly 1,100-member HEAS community on Jan 11th to sensitize them to be vigilant for additional cases. Haitian Ministry of Health (MSPP)-approved reporting criteria for Acute Flaccid Paralysis case reported were shared. In the advisory, it was noted the last case of wild viral infection in Haiti was reported in 1989, and natural disease was declared eradicated as of 1991. However, Acute Flaccid Paralysis (AFP) had been reported every year in Haiti since at least 1998.
This HEAS advisory resulted, minutes later, in a report from an HEAS community member of a 12 year old girl that was recently medivac'd to Charlotte, North Carolina and admitted to the PICU with respiratory failure secondary to ascending paralysis. HEAS team members then verified this report with the involved Charlotte hospital and updated CDC and PAHO with the point of contact there. Medical staff of the involved hospital were unaware of the context of concern until the HEAS contacted them.
Another HEAS member reminded the community of the 2000-2001 outbreak of Vaccine-Derived PolioVirus Type 1 (VDPV), as described in the below attachments to this post, where Kew et al reported:
From 12 July 2000 to 31 July 2001, a total of 123 AFP cases were reported in the Dominican Republic, 13 of which have been confirmed as polio by isolation of poliovirus type 1 from either the patients or their healthy contacts... In Haiti, 33 AFP cases were investigated between 28 August 2000 and 31 July 2001. Seven additional cases associated with circulating type 1 VDPV were found in 2001. Two patients died of bulbar poliomyelitis. Only one patient had a record of receiving three doses of OPV. All others were unvaccinated (11 patients), incompletely vaccinated (7 patients), or had an unknown vaccination status (2 patients).
Kew et al reported the outbreak was caused by a vaccine strain (OPV) poliovirus that had reverted and "at least four different enteroviruses recombined with the type 1 VDPV during its circulation in Hispaniola". Kew later reported to WHO that VDPVs share the following similarities with wild type polioviruses:
- Capacity for sustained person-to-person transmission
- Significant paralytic attack rate
- Critical attenuating sites reverted/recombined out
- Highly neurovirulent in transgenic mouse model
- “Non-vaccine-like” antigenic properties
- Replicates at 39.5 C
- Undergoes recombination with NPEVs during circulation
An additional property should be pointed out as well: lethality. Kew et al reported the outbreak was successfully contained by a vaccination campaign with OPV.
Vinje et al (see attached) conducted an environmental survey and discovered:
Of the 23 positive samples, 10 tested positive for poliovirus type 1, 7 tested positive for poliovirus type 2, 5 tested positive for poliovirus type 3, and 1 tested positive for both poliovirus type 2 and type 3. By sequence analysis of the complete viral capsid gene 1 (VP1), a 2.1%–3.7% genetic sequence difference between 7 type 1 strains and Sabin type 1 vaccine strain was found. Phylogenetic analysis showed that these viruses are highly related to cVDPV isolated from clinical cases and form distinct subclusters related to geographic region.
Based on this background information, the HEAS questioned the assumption that VDPV in Hispaniola was truly eradicated. Specifically, the HEAS questioned the validity of declaring a country polio-free if VDPV was still circulating and causing disease indistinguishable from that caused by wild type poliovirus. Either way, this historical context became the focus of concern and urgency to resolve diagnostic uncertainty about the reported cases.
Public health authorities subsequently sent a team to investigate the apparent case cluster at Beraca Hospital and discovered an additional four suspect cases:
Summary of the interview with Dr Mozart Cherubin (Hospital Director) and Dr. Vilton, Beraca Hospital, Commune La Pointe, Port-de-Paix. Interview held on 12 Jan 2011
- Cases presented to Baraca Hospital, Commune de La Pointe, Port-de-Paix
- Cases were 1st admitted to the CTC [cholera treatment center] for cholera treatment.
- Cases 1-4 were in hypovolemic shock when admitted.
- During this interview they corrected previous version about hospital discharge: only case 3 was discharged.
- For those who died, death certificates are not available [for us to see] (They were not admitted to the CTC so the death registration is in the main hospital and not the cholera [treatment center - CTC])
- All cases presented similar symptoms of paralysis within 72 hours of recovery.
- Symptoms consisted of: ascending bilateral flaccid paralysis leading to difficulty in speech, loss of consciousness and then respiratory distress. Paralysis was highlighted in cases 2, 3 and 4, while hypotony was the main symptom for cases 6 and 7.
- All cases were treated with ORS [oral rehydration salts], Ringers lactate, dextrose 5 percent or saline solutions, and doxycycline (oral) in adults; erythromycin (oral) in children. The severe cases were also treated with ceftriaxone IV [intravenous] (this is sure for case 3, but during the interview they said that 5 severe cases were given ceftriaxone -- they could be cases 1,2,4, and 5). Case 5 was also treated with dexamethasone. At some point during the interview they mentioned the use of metroclopramide for cases with severe vomiting, but denied its administration to these cases. No clinical history available to check treatments. All this information was provided orally.
- Medicines and RL, etc are provided by different organizations. (MSPP/ PROMESS, MTI, MSH/USAID).
- All cases died except cases 4, 6 and 7.
- Both doctors said that they have never seen similar cases. For the last 10 years, only 2 diagnoses of GBS [Guillain-Barre Syndrome] have been made in this hospital (they were a 1 [year old] and a 4 [year old])
- Among the cases reported, cases 2, 3 and 4 cluster in time and seem to fit the same clinical presentation. Case 1 may also belong to this cluster but the reporting doctor was not sure. As for case 5, reporting doctor was dubious. Cases 6 and 7 may be subject to recall bias. They have heard about the 12 [year old] female transferred to Charlotte (USA) but didn't know where she came from. [She came from Petionville. -HEAS]
- They were questioned regarding particular diets or food that may have been given to these cases. They discarded this possibility. They mentioned fish (tetrodotoxin?) is not usually given to sick people.
There are no similar cases among family members. They were reluctant to talk about traditional practices.
Case 1: Female. 5-6 years old. Died. Admitted at the beginning of November  to Beraca Hospital's CTC with cholera. Severe clinical presentation. Recovered and was about to be discharged when she
started with asthenia, hypotonic in both legs which rapidly evolved into an ascending, generalized flaccid paralysis, respiratory distress and died within 24 hours. Address unknown: somewhere in Port de Paix or Sant Louis du Nord. This case was notified retrospectively after death.
Case 2: Male. 17 years old. Died. Admitted at the beginning of December  to Beraca Hospital's CTC with cholera. Also severe clinical presentation. Recovered in 3-4 days, when he started with
hypotonic paralysis in both legs, which evolved in 24 hours to paralysis of both arms, weak voice, severe dysarthria. Conscious until death 48 hours after clinical presentation of paralysis. Date of
death: [13 Dec 2010]. Diagnosed as GBS. Address unknown: somewhere in Lavaud. He was treated with IV [intravenous] potassium after paralysis onset.
Case 3: Female. 36 years old. Died. She was a nurse/auxiliare working at Beraca's CTC. She was admitted to the same CTC with cholera, mid-December . Also severe clinical presentation. After
recovery, she was discharged (a Monday), went home and on Wednesday afternoon couldn't move her legs. She was admitted to hospital on Wednesday night (22 Dec 2010) with paralysis. She rapidly developed ascending paralysis with difficult speech, respiratory distress, and coma and died on Sun 26 Dec 2010. She had fever at the end and was diagnosed of respiratory infection and treated with ceftriaxone IV. No similar cases amongst family members. She has 3 children aged 15, 13, 12 [years old]. Stool samples from these children have been requested. Address: La Pointe (nearby Beraca hospital).
Case 4: Male. 34 years old. Alive. Initially admitted for cholera at Abricot CTC, 18 hours later [he] was admitted to Beraca CTC with diarrhea and vomiting (on [27 Dec 2010]). Severe clinical presentation
with hypovolemic shock. Day before date of discharge, started with pain in his legs (mainly in the left leg). The following day he couldn't stand up and was completely paralyzed within hours.
Transferred to PaP on 02 Jan 2011(alive). Diagnosed as GBS. Address: St Louis du Nord.
Case 5: Male. 85 years old. Died. Referred to Beraca hospital from other health facility for cholera complications and flaccid paralysis. Has been reported retrospectively after death (and during our
Case 6: Male. 3 years old. Alive. Reported retrospectively during interview. Admitted to Beraca hospital sometime during the 2nd-3rd week of November  with cholera. Presented generalized hypotony,
swollen abdomen (not sure at what moment, during or after the cholera episode). Clinical symptoms lasted for 3-4 days. Was treated with potassium and B complex with full recovery. Address: Port-de-Paix.
Case 7: Male. 6 years old. [Alive] Admitted last week of November/beginning of December  to Beraca Hospital's with hypothonia. Had been treated for cholera in another CTC (Abricot?, Gaspin?) Recovered in 72 hours. Address unknown.
Note: There is another case reported by informal sources (HEAS) regarding a 12-year-old female transferred from PaP to Charlotte (USA) with a similar clinical description (generalized flaccid paralysis, respiratory distress). Her department of origin is unknown.
A sampling kit with laboratory forms was left at the hospital.
- Doctors were requested to take samples from the 3 children of case 3.
- They were also requested to notify immediately to DSNO and PAHO-alerts any incoming case of paralysis and to take samples.
On January 14th, more HEAS members stepped forward to relate their experience treating VDPV cases during the 2000-2001 outbreak in Haiti, and on the following day an HEAS member (a physician working in Haiti) reported the following:
After the earthquake in Jan, I had a young man, 16-18yo, die of acute flaccid paralysis but had no idea at that time the [Haitian] govt reported such things. We spent a long time trying to sort out what part of spinal cord might have given him an ascending flaccid paralysis causing death from respiratory failure over the course of about 24hrs and could not come up with a medical, physicological answer except [Guillan-Barre]. Polio never entered my brain. He had a fracture in his lower leg and had a spinal anesthetic which resolved but he came back the next day complaining of weakness and trouble breathing. This was [in] Fermate.
To the best of our knowledge, this last reported case has not been evaluated.
Several key observations were made during this warning sequence and is a useful case study in operational biosurveillance:
- Warning was driven purely by human recognition- no technical apparatus was used to alert humans and no alert was issued through any national reporting or syndromic surveillance system. In other words, traditional public health surveillance methodologies failed to report this important event.
- Warning was used as a successful community-sensitizing process that facilitated spread through different communities of interest. Medical staff in Charlotte, North Carolina would have been completely unaware and working under the assumption of Guillain-Barre Syndrome without situational awareness provided through HEAS-mediated social networking.
- Initial reporting of this event was delayed and potentially compromised the safety of Haitian medical staff at Beraca Hospital, the ground and air transport teams, and medical staff at the receiving hospital in Port au Prince.
- HEAS community engagement not only provided detection of the initial case cluster of concern but also subsequent cases, historical context, and engagement with the appropriate authorities.
- Precautionary infection control procedures and community sensitization to report similar cases were activated independently and in compliment to public health action. These measures remain in place pending forensic epidemiological and laboratory investigation, which may or may not yield definitive results.
- Despite recent reports of "confirmed polio", laboratory testing remains PENDING as of the date of this post.