Date: Tue 2 Feb 2010

Source: Haiti: Operational Biosurveillance [edited]

<http://biosurveillance.typepad.com/haiti_operational_biosurv/>

Haiti Epidemic Advisory System
------------------------------
The UN Health Cluster [the Global Health Cluster, under the leadership of the World Health Organization, is made up of more than 30 international humanitarian health organizations that have been working together over the past 2 years to build partnerships and mutual understanding and to develop common approaches to humanitarian health action. See <http://www.humanitarianreform.org/humanitarianreform/Default.aspx?tabid=75>] is now sending teams of individuals to assess various areas of Haiti. Over 246 responder organizations signed up as part of the Health Cluster, and reports of activities were requested from all of them. However only 46 reports were received. This implies an operational distraction towards the immediate priorities of food, water, sanitation, and shelter provision to the refugees, among other more urgent priorities. As a result, situational awareness for infectious disease events remains limited and heavily depending on non-traditional surveillance methodologies.

Diarrheal illness
-----------------
Current reports indicate an active trend of increasing incidence in the IDP [? internally displaced persons] camps. Periodic rainfall predicted this week [week of 1 Feb 2010], with sustained rains in the PAP [Port au Prince] area anticipated beginning in March. Precipitation may further compromise indigenous water sources and exacerbate what limited sanitation is available.

Pandemic H1N1
-------------
Current reports indicate an active trend of increasing respiratory disease in the IDP camps. There has been no formal evaluation or laboratory confirmation of pH1N1 [pandemic H1N1] to our knowledge. Advisory issued on 2 Feb [2010] based on the observation that patient transfers for ventilator beds has been extremely difficult, particularly in regards to pediatric beds. Those at risk for severe clinical outcomes from pH1N1 infection include children and pregnant women. Further, we have documented in multiple countries adverse clinical outcomes seen in indigenous peoples with poor access to adequate healthcare, as is the case in Haiti. With the coming rains in March to encourage crowding in IDP camps, the potential for outbreaks is moderate. No evidence of pandemic vaccine deployment campaigns by responding agencies in Haiti. Potential to see serious pediatric illness requiring pediatric intensive care and ventilatory capabilities.

Anthrax
-------
Extremely difficult to assess actual risk under present conditions. Prudence suggests a conservative, vigilant, and proactive posture. Prior post detailed risk factors for Artibonite Valley, which historically has seen a peak of human cases in the May-June time frame.

Dengue
------
Risk for outbreaks is moderate with the coming sustained rains in March. Vector breeding sites will increase, as will the potential for dengue transmission. Heaviest transmission typically seen in the later half of the year. We have not seen plans yet for mosquito nets provided to IDP camps.

Pediatric mortality in Haiti

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

We have been following multiple reports of a commonly observed problem with disasters in undeveloped or developing countries: lack of specialized care for children. Specifically, lack of access to pediatric critical care services.

"On most days, at least one patient died, usually a child."

"It's ridiculous how many kids die from diarrhea, and it's going to get worse with all the people crowded together... When the rains come, it could be a slaughter."

"A 15-year-old got gangrene 3 days after being told she would be heading to Miami for medical care. On Friday, she lost the lower half of one leg and the foot on the other. Another 14-year-old, whose name frenzied doctors can't recall, died on Tuesday."

"[Another woman] is still waiting to leave. The quake ripped the skin, muscles and tendons off her leg. She has to be completely sedated every time her dressing is changed."

"These are not optimal conditions... This is a dirty, grassy hospital. It is not the Johns Hopkins ICU."

Lack of access to pediatric critical care stems from several problems:

1. Lack of field-capable pediatric critical care resources that includes neonatal capabilities

2. Limited capability at military facilities on the ground in Haiti

3. State of Florida blocking transfers from Haiti to appropriate facilities, claiming lack of financial reimbursements

4. Political sensitization around alleged abduction of children by missionaries at the Dominican Republic border

5. HHS [? USA Department of Health and Human Services] criteria for patient transfer claimed to be rigid, "case by case", and inflexible.
6. DHS [? USA Department of Homeland Security] blocking admission to the United States for patients without paperwork, visas, etc. where a significant portion of these children are without guardians, parents, or paperwork.

From a pediatric point of view, we have been primarily concerned about diarrheal disease, respiratory disease, dengue, and malaria as primary killers of children during this time. The reasoning for this prioritization is due to relative ease in control. Vaccination campaigns are already underway for diphtheria, tetanus, and pertussis. We would assume given the public health and medical personnel's publicized concerns about measles they will extend coverage to include measles. However the disruptors mentioned above have the ability to spread quickly and kill many children under the present conditions, and especially during the rainy season due to the difficulty in gaining effective control.

It has been suggested at the UN Health Cluster that formation of the IDP camps represents a better sanitary situation than the slums of Port au Prince. While that may be the ase for a short time, a combination of crowding, pressure on limited and undeveloped sanitation capacity, and the coming rains will rapidly put this idea to the side.

Haiti's children remain at serious risk. Lack of access to appropriate care and appropriate public health intervention will ensure continued high fatality rates in the weeks to come.

Cubans engaged in vector control
--------------------------------
Cuban anti-vector specialists have cleared areas from rats and rodents, have fumigated them and implemented measures to control vectors. However, the demand of these tasks is beyond their possibilities, in view of the prevailing hygienic situation. This is the 1st time we've seen a dedicated effort to conducting a vector control campaign, albeit likely of limited value due to the sheer magnitude of the problem.

Sepsis, gangrene, tetanus, and lack of pediatric intensive care
---------------------------------------------------------------
"They returned to their respective hospitals in [the States] over the weekend after sweating through 20-hour shifts in a 150-bed hospital north of Port-au-Prince crammed with 400 patients. They slept on the floor, helplessly watched many Haitians die in their care, and used cardboard, ironing boards, and anything else they could find as makeshift operating tables.

The 1st patient, a 13-year-old boy, came to the hospital with a mangled leg after he was rescued from beneath a pile of rubble. The doctors pinned his leg back together using prosthetics and tools they had brought with them; during the surgery, he was awake and singing. Later, a mother came to the hospital carrying her unconscious 2-week old baby, a girl infected with sepsis. The surgeons resuscitated her but were without a pediatrician. They then tried bringing the baby and her mother to a nearby US Navy ship, only to find they did not have the proper physician there, either. They eventually boarded a UN ambulance, roaming across treacherous roads to a main Haitian hospital, only for the baby to die upon arrival." - medical response team from California.

"The conditions are really dire, but we have no choice. Each procedure has to be carried out that day, to avoid the onset of gangrene. Fortunately I have everything I needed for anaesthetics and pain management. The pharmacy was in another building that hadn't been destroyed. It's complicated and frustrating not having all the equipment at hand. I saw a tetanus case, a child of 10 years. She was convulsing on the 1st day, and stiff, with spasms, by the 2nd. Tetanus is hard to treat if you're not properly equipped. You need to administer a sedative to relax the patient, and then monitor her really closely, as her breathing can stop. This patient was on oxygen, and we monitored her as best we could, but it was a hit-and-miss affair. We needed a properly equipped intensive care unit, where there weren't so many risks. The worst, the most annoying thing, was that we had breathing apparatus in the cargo plane, but as we'd been delayed, it wasn't yet installed." - pediatric anesthesiologist with MSF [Medecins Sans Frontieres].

Raw field response conditions in Haiti
--------------------------------------
Email from Alison Thompson sent to her parents in Sutherland Shire (Sydney) on 24 Jan 2010. Subject: Hell in Haiti

"Hi mum and dad -- I won't be around when they announce my award on [26 Jan 2010]. I am with Sean Penn, Diana Jenkins, Oscar, and 15 doctors embedded in the US 82nd Airborne (USA) Division. Dante would describe it as hell here. There is no food and water and hundreds dying daily. The aid is all bottlenecked and not reaching here.

The other day I assisted with amputation (holding them down) while they used a saw to cut a young boy's leg off with no pain killers. Today I went with a strike force and army patrol in hummers into the streets and walked 5 miles through the camps set up on every street corner. Sewage and bodies stench is everywhere. As I attend to a patient 30 people crowd around me and it's hard to breath. I nearly fainted today as the sewage smell went straight down my throat. I went white and dizzy but couldn't sit down as sewage is running through the streets. There is much infection and it feels like the job is too big. No antibiotics anywhere

"Good news, today our New York doctors evacuated 18 patients with spinal injuries out to Miami and we're all so excited. Our MASH unit [US Mobile Army Surgical Hospital] is in the 82nd's air base overlooking a refugee camp of over 50 000 people. The refugees start singing Christian songs at 4 am and line up for food until the army hands it out at 8 am (that's if there is any food). On the 1st night I was in the nearby jungle camping under the stars with my team and woke up to the beautiful music drawing me to them. I thought it was a church and we went to find it and came across the 82 Airborne camp and the refugee camp. (That's how we ended up here, as it wasn't safe to stay where we were even though we had our own security force). We are totally self sufficient with food, gas, and medicines and have a private donor (Diana Jenkins who was a refugee in camps in Bosnia as a child -- her family died of starvation in the camps.) Sean Penn is here purely as a volunteer and is cutting through bureaucracy to get aid moving and food water and medicines to the people. There is no agenda but to save lives. Helicopters fly overhead and it feels like Viet Nam. That night 50 000 people sung me to sleep and they sing every night for the world to save them. There is always hope but she's not here right now.
-----------------

Communicated by:

James Wilson, MD

Executive Director

The Global Institute For Disruptive Events (GuIDE)

jim.wilson@gifde.org
===================
More reports of typhoid & tetanus
----------------------------------
From a team of 15 San Francisco Bay Area physicians: treated cases of tetanus and typhoid fever. From a team of physicians from Yale-New Haven Hospital: treated a 6-year-old girl with typhoid peritonitis.

[These reports from the field give a vivid picture of the scale of the disaster caused by the earthquake in Haiti. Hundreds of thousands of people are displaced, many with injuries sustained in the earthquake, acute infections, or chronic illnesses, all in immediate need of shelter, food, clean water, sanitation, and medical care.

WHO has issued a public health risk assessment to facilitate the response of those aiding the earthquake-affected population in Haiti, available at <http://www.who.int/diseasecontrol_emergencies/publications/haiti_earthquake_20100118.pdf>.

Haiti and the Dominican Republic occupy the Caribbean island of Hispaniola in the Greater Antillean archipelago. A HealthMap/ProMED-mail interactive map of Hispaniola can be found at <http://healthmap.org/r/00Yo>. - ProMed Mod.ML]

[Gideon (Global Infectious Disease & Epidemiology Network) is providing a free download of "Infectious Disease of Haiti". It is available at <http://www.gideononline.com/blog/2010/01/28/e-book-the-infectious-diseases-of-haiti-by-gideon/>. - ProMed Mod.LM]