The Haiti Epidemic Advisory System (HEAS)

Acute Flaccid Paralysis: Port de Paix and Port au Prince, Haiti and Charlotte, North Carolina

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:

1. Verify the report with Medical Teams International (MTI);
2. Confirm that MTI reported the event to local Haitian public health authorities (MSPP);
3. Verify the Point(s) of Contact at the receiving hospital for the patient transferred from Port de Paix to Port au Prince
4. 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 [2010] 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 [2010] 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 [2010]. 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 
investigation).

Case 6: Male. 3 years old. Alive. Reported retrospectively during interview. Admitted to Beraca hospital sometime during the 2nd-3rd week of November [2010] 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 [2010] 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.

ACTIONS

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.

  Download Isolation and Characterization of Circulating Type 1 Vaccine-Derived Poliovirus from Sewage and Stream Waters in Hispaniola

Download Outbreak of Poliomyelitis in Hispaniola Associated with Circulating Type 1 Vaccine-Derived Poliovirus

 

 

WARNING FORECAST: POST-TOMAS CHOLERA AND OTHER INFECTIOUS DISEASE ACTIVITY

The HEAS thanks Dennis Sherrod of Alert1Weather.org, Dr. Eric Milstrey, and Mr. Lionel St. Pierre for their assistance with this report.

 Summary

 Increased cholera activity is expected following the anticipated passage of Tropical Depression Tomas across Haiti from Friday to Saturday.  Implications for the transmission of other infectious disease and risk to responders are discussed in this WARNING.

Meteorology

Tomas has decreased to a Tropical Depression as of this morning. The substantial drop in strength was unexpected and decreased concern for hurricane-related damage to the already devastated post-earthquake communities of Leogane, Port au Prince, and surrounding areas.

 The 1100 EDT update shows Tomas to have maximum sustained winds of 35 mph. Tomas has encountered an elongated low pressure system that has not allowed it to maintain typical tropical cyclonic characteristics. This translates to the storm is not being fed the energy to maintain much strengthening. Should this continue, the potential for Tomas to become a hurricane by the time it reaches Haiti will be low.

Current projections suggest Tomas may impact Haiti on the southwestern end as a Tropical Storm with winds in the 39-73 mph range. The same general track is forecast as stated yesterday, but with an initial arrival of this system across southwestern Haiti progressing slightly more north of northeast, possibly staying on the far western end of the country.

If this system stays on this same track and does not re-intensify, Haiti will be spared some of the stronger damaging winds.  Heavy rainfall amounts may still be expected across Haiti with amounts possible of 4 – 8 inches. This will still subject the area to flooding and possible mudslides all across the region.

As seen the last few days, the forecast from the various sources and forecast models have changed from day to day. Diligence is strongly recommended in preparing for this storm. This meteorological forecast may change again in the next several hours and throughout the next 2 days.

Implications For Cholera Transmission

Tropical countries endemic for cholera typically see increases in cholera transmission following flooding and seasonally after the peak of monsoon season.  We expect similar enhancement of transmission in Haiti, where a key difference exists: ongoing transmission and potential ecological establishment of a non-endemic pathogen in a naïve population and environment.  As with the introduction and spread of West Nile Virus in North America and the 2009 H1N1 influenza pandemic, aggressive transmission may be observed under these conditions.

 Ground observations indicate cholera has spread from the original epicenter in Artibonite to surrounding areas.  Much of the organized response effort mobilized to St Marc and areas along the Artibonite Valley, however little capacity has been extended to isolate rural areas now experiencing cholera transmission.  The result is while fatalities have been brought under control in Artibonite due to surged medical awareness and capacity, the rural areas are now experiencing the same pattern as pre-response St Marc:

-   abrupt appearance of cholera cases that suddenly overwhelm local capacity

-   abrupt documentation of fatalities

-   sudden geotemporal appearance of severe, fatal, and pervasive threat to the community results in the triggering of social outcry and anxiety

-   fear of civil unrest is triggered among non-Haitian responders

In effect, as areas such as St Marc become downgraded from an IDIS Cat 5 to an IDIS Cat 4, multiple new sites of IDIS Cat 5 events appear in rural areas.  Because many of these sites are outside of population- and resource-dense areas, detection and warning is time-delayed which in turns delays network sensitization and swarm mobilization to respond.

The appearance of Tropical Storm Tomas to the west of Haiti is expected to bring 200-mile wide bands of heavy rainfall that will cause flooding.  The below map (credit: ReliefWeb) provides an overview of flood prone areas of Haiti.  Given the complexity of documenting and responding to isolated poor rural areas now experiencing IDIS Cat 5 cholera, flooding will greatly exacerbate attempts to rapidly detect, report, and respond.  Heavy rainfall is expected to enhance the transmission of cholera in these areas.  Dispersal of evacuees from flooded areas is expected to facilitate the diffusion of cholera into areas not previously exposed to cholera and potentially overwhelm already-stressed Cholera Treatment Centers (CTCs) or naïve local clinics that have not yet seen cholera.  In these naïve areas, they have low stockade level of IV fluids and medications and post hurricane re-stockage from PaP will be delayed thus exacerbating health impacts. Isolated transmission of cholera to relief workers is expected.

 

With each naïve site seeing abrupt, unexpected appearance of cholera will be the opportunity for social outcry and civil unrest.

Other Infectious Disease Activity

Diarrhea, dengue, malaria, and leptospirosis pose the greatest risk to in Haiti after Hurricane Tomas. Diarrhea risk will be immediate and substantial. Peer-reviewed literature has demonstrated increased West Nile virus activity following Hurricane Katrina and therefore should be considered as well in Haiti.  Persons in contact with rivers, streams, or standing water will be at risk for leptospirosis. The already poor sanitation very likely will be further degraded by the storm.  Bacterial and protozoal diarrhea rates could more than double among those relief personnel consuming local food, water, or ice. Typhoid fever and hepatitis A could cause a small number of cases among unvaccinated personnel.

Torrential rainfall will suppress malaria and dengue risk for 3 to 4 weeks by destroying vector breeding sites. Initially, malaria and dengue cases are expected to be rare but risk will rise as mosquito populations rebound. In the absence of countermeasures, increased numbers of cases are possible in areas of historical transmission; in densely populated urban areas, dengue rates could increase within weeks.  The fact that winter and the drier season is approaching should limit transmission however.

Risks from other infectious diseases are largely unchanged.

Additional Information

Port Au Prince: IDP camps: Flood and Landslide Risk (as of 19 Feb 2010)

Haiti: Slope Analysis and Historical Floods (as of 2 Mar 2010)

Haiti: Multi-Hazard Risk, Major Disasters and Severity (1998 - 2010)

 

 

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.

Cholera Laboratory Confirmed in Haiti

We now have laboratory confirmation from a separate, highly credible source the epidemic is due to cholera, serovar pending.

We continue to await official notice from WHO/PAHO or MSPP.

 

 

WARNING: Possible IDIS Category 5 Diarrheal Disease Event in Artibonite Valley, Haiti

We have indications of an infectious disease event in Haiti (Artibonite Valley) rated now at a possible IDIS Category 4 infectious disease event transitioning to a Category 5, defined as:

IDIS Category 4. Infectious disease event associated with social disruption. Category 4 events highlight when organized response has occurred, yet significant social disruption has been documented.

IDIS Category 5. Infectious disease event associated with disaster indicators.

Key observations as of the date/time of this message:

• Non-routine occurrence of diarrheal disease, described by Dr. Claude Surena, President of the Haitian Medical Association, as "according to the results of the analysis carried out in the laboratory it is cholera" to AFP. 
• We note, however, that true laboratory-confirmed cholera has not been reported since the early 1990s and thus are skeptical of etiology being true cholera.
• Photographs and direct observations from St Nicholas Hospital in St Marc and comments from Surena indicate the hospital is overwhelmed and now in the process of divesting patients to other clinics for treatment- indicative/suggestive of local medical capacity collapse; photographs show multiple patients on IV therapy ORS is being used and is being mobilized.
• PROMESS aware, however logistics status unknown.
• Local infrastructure to respond in Artibonite is severely limited, with evidence of poor information sharing and alerting capacity. Public health resources are much more limited than in Port-au-Prince.
• Significant community anxiety noted; indigenous Haitians claiming the presence of "cholera" and surging advice via Twitter for proper food and water handling / sanitation precautions.
• International NGOs are mobilizing, and the UN Clusters are mobilizing around the issue such as WASH and Health.
• Statements to-date/time from WHO/PAHO and MSPP emphasize no laboratory confirmation.
• Tremendous and abrupt international sensitization as evidenced by Twitter and HEAS web portal hit counts.

We wish to emphasize the purpose of Infectious Disease Impact Scale (IDIS) is a heuristic mechanism to contextualize emerging indicators pertaining to possible infectious disease events possibly evolving to crises and perhaps disasters. Therefore, while we are confident the event is a true diarrheal disease event, we are unable to verify if it is truly due to cholera or that it is truly a Category 4-5 event as of the time / date of this report.  

What we are implying is immediate closer scrutiny and verification is required.

 

The HEAS Advisory System Module was de-activated in June following the last SitRep.  Given the current situation, the HEAS will be reactivated to provide support.

 

Diarrheal Disease in Artibonite

We have been tracking both Twitter and French media reports of an "outbreak" of diarrheal disease thought to have killed approximately 40 individuals and caused "genuine panic". This is the official comment from PAHO:

To date there is a suspected outbreak of diarrhea in the Artibonite. The Department of Public Health and Population (MSPP) has sent an investigation team on St Marc and Mirebalais and awaits the results. At this point there is no declaration of emergency or official confirmation of an outbreak.

Precautions were taken to the hospital of St. Mark, or most of the patients are hospitalized, received the necessary medical equipment to meet needs during the coming days. PAHO / WHO is working closely with the MSPP, PAHO expert participates in meetings of the situation room of the national laboratory, PAHO epidemiologist working with the national team tomorrow morning and will travel there with the director of medical United Nations. If needs PROMESS has the stock of essential medicines to meet the request.

We have seen no information or indication of sudden / abrupt inundation of medical infrastructure or report of public evacuation, however patients are hospitalized. A diagnosis of cholera is highly unlikely given it has not been reported in Haiti for many years. Lab results, as stated above, are pending.

Lymphatic Filariasis in Haiti: Translocation Implications For The United States

In a previous post, we identified possible increases in filarial transmission in Haiti.  At this time, it remains unclear if this is acute lymphatic filariasis, a true outbreak, or reporting bias following sensitization to look for the disease.  Sources have indicated Haiti may be entering the beginning of a cycle of increased transmission activity- this requires confirmation.  Particularly in regards to humanitarian workers and indigenous Haitians returning or visiting the United States, the potential to see introductions of acute lymphatic filariasis should be entertained. 

Melrose and Leggat (2005, see attached) highlight cases where substantial infection and clinical manifestation of acute lymphatic filariasis was observed in military forces serving in endemic areas.  Estimates of exposure in the Pacific Theater during World War II, for instance, suggested over 38,000 naval personnel were exposed, with over 10,000 diagnosed with the disease.  During a deployment in Samoa, 70% of exposed personnel were infected.  In one impressive example, more than 2,500 servicemen were medically evacuated to Klamath Falls, Oregon for treatment over a 17-month period.  Melrose and Leggat provide examples of infection rates among deployed personnel where, in one case, rates were high enough to withdraw entire units from service in the middle of the war to the US for treatment.  

While elephantiasis is a common visual presentation of lymphatic filariasis that comes to mind to most clinicians who have had little experience with the disease, diagnostic criteria for acute lymphatic filariasis is more broad and non-specific (from Melrose and Leggat per their reference to Hodge et al, the manuscript of which is not found in PubMED):

Involvement of the genitalia

• episodes frequently follow periods of manual labor
  
• testicular pain is the most common complaint the pain may radiate up the spermatic cord or may appear first in the lower abdomen and radiate down the spermatic cord to the testicle
  
• the spermatic cord and epididymis are thickened and indurated but the vas deferens is not involved
  
• acute hydrocele is often present
  
• pain in the medial aspect of the thigh on the affected side may be present
  
• scrotal edema is often present
  

Involvement of the superficial lymphatic vessels of the extremities

• pain in the extremity radiating distally is the usual complaint
  
• pain may be noticed first in the proximal lymph nodes
  
• the affected extremity becomes edematous
  
• a definite "red streak" characteristic of acute lymphangitis appears proximally. The affected lymphatic vessel is palpable, and usually only a single vessel is involved
  
• there is increased local heat
  
• the lesion extends centrifugally
  
• resolution begins proximally and extends centrifugally the lymph nodes draining the affected area are enlarged and tender
• severe constitutional manifestations are usually absent
  

A recent review by Manguin et al (see attached) have highlighted the potential for co-transmission of malaria and filariasis leveraging the same mosquito vectors, a compelling thought when contemplating the evolving phenomenon of dengue re-emergence in Florida and the Gulf states and potential for re-emergence of malaria and/or lymphatic filariasis.  Malaria cases have been identified in the US, with occasional instances of autochthonous transmission (as with dengue).  Evidence suggests transmission of filarial worms by mosquitoes is an inefficient process compared to malaria, and infection requires prolonged exposure to filariasis-endemic areas.  It is more likely to observe translocation of single cases from Haiti versus autochthonous transmission in the US.  However given the difficulty in sensitizing clinical suspicion to adjust differential diagnoses, current access to treatment provided by CDC (see prior post), and lack of preventive prophylaxis in the US, we propose identification of translocation and autochthonous transmission may be challenging, especially in local unsensitized communities within the US. 

Download Lymphatic Filariasis- Disease Outbreaks in Military Deployments From World War II

Download Co-transmission of malaria and filariasis

HEAS Downgrades Alert Levels for Diarrheal Disease and Pandemic H1N1 in Haiti

HEAS has downgraded the alert levels for diarrheal disease to an ADVISORY and pandemic H1N1 to non-disruptor status.

Dengue Advisory Issued in the US for Relief Workers Returning From Haiti

CDC issued an advisory on April 27th for dengue infection among relief workers traveling from Haiti to the United States. 

We had received reports of dengue infection in military and civilian relief workers returning to the US in February.  At that point, it was an issue easily handled at the physician-patient level.  Speculation suggests the timing of this particular advisory may reflect a concern not only of seeing more cases in returning relief workers but seasonal mosquito emergence in the US- particularly Aedes aegypti and Aedes albopictus. 

The salient concern here is whether returning dengue-viremic relief workers, if bitten by US-endemic mosquitoes, could trigger localized outbreaks.  Key West, Florida just experienced this problem this past fall, so there is some sensitivity to this issue.  This will be an increasing concern as ambient air temperatures optimize in July for most of the US (and people spend more time outdoors exposed to mosquito bites).  The southern states will be expected to reach temperature optimization sooner in the season.

Given reports of increased malaria activity, there is a broader range of potential infectious diseases to consider as well when seeing ill patients returning from Haiti.

Increase in Pandemic H1N1 Cases Reported in Cuba: Implications for Elevating the Alert Level in Haiti

The National Influenza Virus Labs of the Tropical Medicine Institute Pedro Kouri, Cuba have announced the identification of 93 new cases of pandemic H1N1 and have decided to initiate a vaccination campaign.  The Cubans have indicated an increase in cases over the last 5 weeks.

We have maintained an ADVISORY for pandemic H1N1 in Haiti for several weeks due to the following concerns:

1. A consistently retracting medical infrastructure due to funding struggles, now overlapping with a specific strategy to hand off assets to the Haitian medical community; this is a very fragile medical infrastructure that is easily overwhelmed. Even more so when considering (a) pediatric (b) critical care. The question of critical care availability for pregnant mothers represents and additional consideration. 
2. The potential for outbreaks of pH1N1 in overcrowded, unhygienic, and unsanitary IDP camps during sustained rains. Rains encourage higher contact rates among families. We saw this phenomenon in post-flood emergencies in Taiwan’s refugee centers following typhoons. We assess outbreaks of pH1N1 will present as focal outbreaks as opposed to a grid-wide abrupt surge of cases as seen in the temperate zone countries. That said, the potential for patient surge to the limited hospitals able to provide care and overwhelm them is very real.
3. The potential that, while the vast majority of pH1N1 cases are self limited and easily managed, there are a very small number of ventilators and associated pediatric equipment with trained pediatric staff who know how to manage children on ventilators present in-country. It would not take many severe cases to overwhelm this capacity. 
4. We are dealing with a malnourished population with limited to no access to medical care. During the pandemic, we tracked multiple reports of poor community outcomes among socially isolated indigenous peoples in Brazil, Peru, Panama, Costa Rica, Alaska, Canada, and the US.  A small cluster of bad clinical presentation or fatalities provoked social behaviors such as the so-called “panic evacuation” and social outcry pitting communities against local officials- especially if fatalities were observed among children or pregnant mothers. This tended to be a localized phenomenon when it happens, however we are always monitoring for contributing triggers for civil unrest in this tenuous situation in Haiti. 
5. Currently, there has been an increase in acute respiratory infections reported in Haiti of low mortality.  It is unknown to what extent this represents active pandemic H1N1 transmission.  PCR testing for pH1N1 is available in Haiti but underutilized by medical responders.  The few samples submitted were negative for H1N1 in prior weeks.  Unknown what the current status is.

Caveats:

1. Herd immunity status for pH1N1 in Haiti is unknown. As recently as December 2009, the Dominican Republic reported cases.
2. There has long been this assumption those of African descent are not affected by pandemics to the same extent as non-Africans. I contest that assumption because we have seen disruptive epidemics of A/H3N2, for instance (see attached manuscript). The stats in the 2002 epidemic of A/H3N2 in Madagascar: 30,304 cases, 754 fatalities (estimated CFR 2%). In one district, 54% of all fatalities due to acute respiratory infection (i.e. suspicious for A/H3N2) were children less than 5 years of age. These kinds of stats, if projected to Haiti, would pose a challenge to the tenuous medical infrastructure. We believe under reporting of influenza in Africa is an artifact of social sensitization- those living in Africa and other impoverished environments are distracted by infectious disease associated with far more gravitas such as malaria or HIV. Influenza is not deadly enough to provoke local commentary and hence does not show up quickly in surveillance. During the 2009 H1N1 pandemic, we saw what we strongly suspected to be pH1N1 in southern Sudan, DRC, Uganda, and western Kenya passing from north to south. Buried in the noise of other non-medical social issues of higher acuity.
3. When conducting a ground assessment, we did not find a single ex-pat, Haitian authority or physician, or anyone else in Haiti who declared a pandemic wave had indeed passed through the country.

We are now considering evaluating whether to elevate the alert level for pandemic H1N1 in Haiti.