The Haiti Epidemic Advisory System (HEAS)

Scattered Reports of Fatalities and Patient Surge in Central Haiti

We have been tracking reports over the last 10 days of patient surge and the now-classic and typical reporting of patients dying along the roads in the mountains of central Haiti.  Questions are being raised about the operational status of the St Marc hospital to receive some of this patient flow.  This is the same facility where the original first cases of cholera were reported.

Public health again nowhere to be found...

 

The Passing of a Hero: "Big Dave" Bompart

Today the HEAS is silenced in respect for the passing of "Big Dave" Bompart.  Our prayers are with his family.

 

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


Praecipio International is a charitable non-profit organization devoted to the promotion of operational biosurveillance worldwide.

Please Lift "Big Dave" Bompart Up In Prayer

It is with the greatest sadness the HEAS lifts up David Bompart "Big Dave" in worldwide prayer.  Big Dave was shot while transporting funds to an orphanage in Haiti.  He is a Christian, a hero, and an inspiration to us all for his tireless sacrifice for the People of Haiti.  Please take a moment to pray for Big Dave.

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


Praecipio International is a charitable non-profit organization devoted to the promotion of operational biosurveillance worldwide.

The Current and Future Status of Cholera in Haiti

Within the HEAS, a  serious discussion has ensued regarding the current and future status of cholera in Haiti, which began with a question from an outside agency:

 

 

• [From a major NGO seeking to implement major prevention efforts in Haiti] We know these predictions can be somewhat uncertain, but we would be grateful to hear your opinion as a medical actor on the ground.  Your first-hand knowledge about the infection patterns and the current pace of health and water sanitation interventions makes you well poised to help us see a few years ahead into the cholera epidemic.

 

• [From me to HEAS partners internationally recognized as cholera experts]  Guys, I could use your input and advice regarding the [above question] and would like to form a consensus opinion, if possible.

 

• The usual cholera epidemic attack rate (AR) among immunological susceptible populations is 2%.  This estimated attack rate considers only severe and some moderate cholera cases requiring hospitalization. Most of the total cases (95%)  are mild or asymptomatic and may not be detected by the surveillance system

 

• [My reply] Is this AR what you guys observed in Peru in '91?  Reason why I'm asking is we are dealing with a totally naive environment (albeit we are in a time period subsequent to first introduction [i.e. first wave]).

 

• Yes, this is what it was observed in the 1919 Latin America epidemic as well as  previous descriptions of cholera epidemics in Asia and Africa. I think that once cholera is established in the environment , all population is affected sooner or later if the water and sanitation conditions are not adequate. That is the case of Southeast Asia, over there the only susceptible population is small children with no antibodies against cholera.

 

• [My reply] This is a very important observation- we are still seeing a high percentage of adults affected versus kids- at least in the case of Pestel if I'm not mistaken.  So, the situation may be endemic in Port au Prince but still epidemic in the rural areas?

 

• There may be a few pockets of susceptible populations. Nevertheless, after cholera strikes, we have to be very careful with the diagnosis. During the last waves of the 1991epidemic, I went to investigate diarrheal diseases outbreaks that were wrongly diagnosed as cholera. Many of these outbreaks were disenteric amebiasis, E coli, salmonella, cryptosporidium, etc. It is time to start to invest some resources in confirming the outbreak agents.

 

• [My response] Right, copy.  That seems to have been the problem with the Pestel situation [i.e. public health officials delaying 72 hrs to respond because the situation in Pestel was not laboratory-confirmed cholera]- a bias that it was not due to cholera until lab confirmation proves otherwise.  If we had not intervened, people would have needlessly died.

 

... Later,

• I just checked the number of cases accumulated in Haiti until January 2012:
  
  The Ministry of Health has reported 524,861 cumulative cholera cases, 282,989 hospitalizations and 7,018 deaths, as of 8th january 2012. The overall fatality rate is 1.3 percent nationwide. The general trend is towards a decrease in the number of new cases and fatality
  *Source: Last report of MSPP as of 8 january 2012
  
  If we have a total population of 10 million inhabitants it looks like the 282,989 hospitalized cases (~2.8%) shows that the population is exhausted and the cholera epidemic may have  entered into a endemic patter of transmission.  If  somebody comes to deliver the vaccine or establishes any control strategy it will look as a very effective intervention,  just by being temporally associated with the development of immunity among the population.

 

• [My response] What if these numbers are an underestimate given the 2/3 rural mountainous / unreached / poorly reported areas of Haiti?  Are we able to consider this?  Thank you for the discourse.

 

• I agree. Indeed, there must be an underestimation of the number of cases. The 2% attack rate is based on similar or even less sensitive surveillance systems. If the number of cholera cases is greater, again , this means that most of the Haitian population is immune. The sadness  of this history is that we did not concentrated all our efforts in saving the lives. To achieve this level of natural immunity with more than 7,000 deaths is a failure. At this point water interventions will be strongly associated with no cholera cases, latrines will be strongly associated with no cholera cases, voodoo bone powders will be strongly associated with no cholera cases. The colloquium of this disaster is the return of UN "experts" to say that their presence has been the key factor in stopping the epidemic.

 

 

 

A Moment of Quiet Introspection Following the Disaster in Pestel

Today we received the final assessment of the cholera disaster (IDIS Cat 5) in Pestel and surrounding communes:

Below is a summary of the cases of cholera logged in the Pestel commune.  

---------------------------------------------------------------------------------------------------------------------------------

Incidence of Cholera in Pestel Commune

October 2011 --> 115
November 2011 --> 118
December 2011 --> 126
January 1-12 --> 86 cases

***Assessment by Miriam, Harvest House, Dr. Phillipe January 9-12***
***Cholera eduction/ Aqua tabs + ORS distribution implemented***
Global DIRT assistance January 12-14

1/13 --> 7
1/14 --> 5
1/15 --> 1
1/16 --> 4
1/17 --> 11  (1 death)
1/18 --> 5
1/19 --> 3
1/20 --> 3
1/21 --> 0
1/22 --> 7
1/23 --> 4  (2 deaths)
1/24 --> 0
1/25 --> 3
1/26 --> 3
1/27 --> 4
1/28 --> 0
1/29 --> 3
1/30 --> 3

Total January = 152

Morbidity:
December 1 - January 12 --> 59 deaths
January 12 - 30 --> 3 deaths

 

This was our response:

Clarification: is this solely for Pestel and NOT the surrounding villages as well?  We had report of as many as several hundred cases and 70 fatalities in the region as opposed to just Pestel.  IN THE LEAST, it shows yet again what happens when emergency response occurs- you blunt the fatality rate.

Their response to our question:

These are the cases of cholera which presented to the 4 CTCs (Tozia, Dereveaux, Pela, Pavillon,  Pestel).  I wish you could have heard the stories and seen the faces of the people in Grand Anse.  Then you see how many lives were saved and how many we're affected by the cholera.

 

 

 

Operational Highlights of the HEAS

Our team was interviewed by a major international press organization this afternoon, and they asked about key achievements of the HEAS.  The following was provided as a list of highlights:

1.  HEAS performance / forecasting functions the first 150 days post quake

2.  Our first public statement regarding reports of severe diarrheal disease in Artibonite (ie cholera)

3.  Our first public report of linking the UN Nepalese base in Mirebalais to the cholera disaster (this was actually an update, posted a couple of hours after the initial report).  This was the first public report describing probable attribution for the cholera disaster in Haiti.

4.  Referral to the Paul Keim (a member of the NSABB, the same panel reviewing the controversial studies on avian influenza) study proving the link to Nepal

5.  First case of acute flaccid paralysis identified.  It remains our belief Vaccine-Derived PolioVirus (VDPV) Type 1 continues to transmit in Haiti.  What is required to disprove this belief is a comprehensive field investigation by a neutral third party.

6.  11th case of acute flaccid paralysis identified

7.  Field ops: description of HEAS warning-response ops in rural mountainous areas of Haiti, note the report on Borgne as an excellent example

8.  Intercept Team field ops reports from Belle Fontaine (Dec 10-12th and Jan 12-13th)

The reporter asked us what we thought about cholera transmission now in Haiti.  Our response was cholera continues to transmit in the rural, mountainous 2/3 of Haiti's landmass difficult to appreciate by the major NGOs and officials based in the 1/3 of Haiti that is urbanized.  There is little question the highest fatality rates and destructive social outcomes are observed in these rural areas.  Case fatality rates still reported by officials represent underreporting and bias towards areas of Haiti with the best access to health care. 

We also emphasized the HEAS did all of this for less than $20,000 US.