ARTICLE - UNCERTAINTY AND OPTIMISM

UNCERTAINTY AND OPTIMISM REIGN AS RELIEF EFFORTS IN HAITI CONTINUE
(Pediatric Supersite) - By Rob Volansky

Wound-related infections, TB raise concern among medical experts.

Six months after the earthquake that claimed hundreds of thousands of lives in Haiti, wave after wave of trauma-related infections resulting from amputations and surgeries performed in suboptimal conditions continue to plague specialists in all fields.

In addition, millions of people living in close quarters have shattered the tenuous control health officials had over tuberculosis, and these same conditions may be leading to increases in prostitution and sexual violence, which, health officials said, could lead to a spike in rates of HIV/AIDS and STDs. Lack of shelter and decimated infrastructure may also be contributing to increases in infections, ranging from vector-borne diseases to gastrointestinal diseases and respiratory infections. Children in particular were at the mercy of mosquitoes and unclean drinking water before the earthquake, and now are suffering doubly from treatable infections due to lack of treatment facilities. Infectious Diseases in Children spoke to a number of health experts with a range of experiences in Haiti, and the common theme was uncertainty.

Daniel Fitzgerald, MD, of the division of infectious diseases at Weill Cornell Medical College, spent extensive time in Haiti for several years before the earthquake through work with the Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO) organization.

But not all of the news is bad.

Beyond medicine, a spirit of togetherness among Haitians, medical personnel and volunteers is driving the effort past mere survival and into the realm of hope. Saving lives by any means necessary is no longer required, as medical tents and facilities have been mostly organized by specialty, and patients are being treated for conditions and released rather than spending weeks in acute care.

Despite this progress, with WHO and CDC surveillance data likely more than a year from showing any real effect, medical personnel are left to deal with devastating injuries and illnesses with few resources and, often, little information about the big picture.

Prevalent infections
Data from several organizations, including WHO and UNICEF, indicate that in addition to 220,000 deaths, the earthquake caused about 300,000 injuries and led to roughly 4,000 amputations.

“Trauma-related infections are a major problem,” Daniel Fitzgerald, MD, of the division of infectious diseases at Weill Cornell Medical College, said in an interview. Fitzgerald spent extensive time in Haiti for several years before the earthquake through work with the Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO) organization, which also has a strong relationship with Weill Cornell Medical College.

“We have seen hundreds of amputations, complicated fractures and external fixations. These surgeries were done urgently in less than optimal conditions and followed up with equally suboptimal postoperative care. Patients are coming back with malunions of bones needing recurrent surgeries due to infections.”

According to Dominique Bayard, MD, an internal medicine physician at Boston Medical Center and a first- generation Haitian-American, “soft tissue infections, especially in post-trauma and postoperative patients, are rampant. Patients are coming in to seek care after the infections have progressed significantly.”

The microbial laboratory at GHESKIO is improving, providing early insights into the etiology of certain infections. “At first, we were giving a broad spectrum of antibiotics,” Fitzgerald said.

“Because we did not know what the bugs were. Now our microbiology laboratory is functioning and we are seeing lots of S. aureus and some gram negative infections.”

HIV prevalence and access to antiretroviral therapy is also a concern.

“HIV prevalence rates have actually dropped to around 2% to 3% in Haiti,” Fitzgerald said. “However, with increases in homelessness and economic vulnerability after the earthquake, we do not know how it is going to play out.”

Women and young girls are in overcrowded temporary settlements where they do not even have four walls for shelter, according to Bayard, who added that showering and using the bathroom are also done in public venues. “Women felt vulnerable, and daily, several women reported being sexually attacked,” she said.

Robin Nandy, MD, MPH, senior health adviser for emergencies at UNICEF, said that severe damage to the UNICEF offices highlighted these vulnerabilities, particularly among children.

“We wanted to ensure a mechanism so children were not vulnerable to trafficking,” he said.

“Beyond any medical concerns, reuniting children with families was a top priority.”

Even after people have been found and relocated, access to treatment has been, at best, fractured and, at worst, stopped altogether.

The disaster has also caused interruptions in TB treatment. Fitzgerald said there were spikes in TB cases, even after groups of patients with the infection were isolated. The largest TB sanatorium collapsed, and treatment centers were also destroyed.

“It is not just in the medical facilities,” Fitzgerald said. “People are living on top of each other in these tent communities. It is very likely that a disease as communicable as TB will spread quickly in that environment.”

Some health care officials said they are concerned about increased malaria and dengue.

“It has been my experience that most children in Haiti likely have had dengue by age 5,” Fitzgerald said. “I can only imagine what the data look like now.”

Access to clean water is limited, and all of the experts reported increases in gastrointestinal illnesses, particularly infections causing diarrhea in children.

“Diarrhea was already prevalent before, and now it is heightened by lack of clean drinking water and the breakdown of the primary care system,” Fitzgerald said.

There remains a threat of outbreaks of vaccine-preventable diseases such as measles, diphtheria, tetanus, but health officials said they hope that their immunization response following the earthquake will help minimize the risk of such outbreaks.

WHO and CDC surveillance programs have helped to monitor, detect and respond to outbreaks of communicable diseases. Diarrhea and other infections are present as many of these conditions are endemic in Haiti, but so far there has not been a major outbreak.

Health officials credited emergency response and ongoing surveillance and response mechanisms for this, however they noted, ongoing vigilance is required, especially as hurricane season approaches. Haiti could experience further population displacement and increased vulnerability of these populations to communicable diseases.

Response efforts
Nandy explained the current approach of the Ministry of Health to vaccinations in Haiti, supported by WHO, UNICEF and other agencies including NGOs like MSF and the Red Cross.

“We want to change the culture of vaccines in Haiti. We started with an emergency vaccination campaign for measles and diphtheria, pertussis and tetanus targeting the affected population, particularly those residing in overcrowded temporary settlements. Once the initial campaign is over, we hope to use the investment in the campaign as a platform to revitalize immunization services in Haiti. This will include rehabilitating the cold chain and vaccination distribution systems and enhancing their capacity to introduce new vaccines into the immunization schedule, particularly Haemophilus influenza B and pneumococcal vaccines,” he said. “So, while doing immediate relief programs, we are working toward setting up for longer-term interventions.”

The U.N. Office for the Coordination of Humanitarian Affairs (OCHA) has developed a “cluster” approach to the earthquake response, according to Nandy. This is a part of the humanitarian reform process, started in 2005, and assigns lead agencies for each sector within a humanitarian response to ensure predictability and coordination of efforts. WHO leads the health cluster, which means it is responsible for the coordination and oversight of health activities, from vaccination programs to ART administration.

“This approach was initiated early in the emergency response and was critical because there were more than 300 organizations and agencies working on health issues alone,” Nandy said.

Paul Delonnay, MD, is an anesthesiologist at Boston Medical Center who was born in Port-au-Prince and studied medicine there. He returned to his alma mater days after the earthquake because he “had to do something,” he said. His initial work dealt mainly with amputations to prevent tetanus, gangrene, sepsis and other tissue infections, but he said the problems go far beyond anything that a laboratory could handle.

“Many of these people do not have any concept of a microbe,” he said. “They cannot imagine that a microorganism can make you sick. They do not realize that clear water does not mean it is clean.”

Rebuilding infrastructure
Fitzgerald has been back to Haiti several times since January, and he said he feels a similar shock each time he returns and sees the flood of people living in tents or on the street.

“They have nothing to go back to,” he said. “Their home is gone. Their job site is gone. They have nothing.”

Fitzgerald said the public health care system in Haiti was fragile before the disaster and is virtually non-existent now.

There is much talk of rebuilding the systemic and medical infrastructure of Haiti, but whether this talk will translate into sustainable action remains to be seen.

“From what I understand, before the quake, there was $50 million coming into the country, now there is $100 million,” Delonnay said. “There were [nongovernmental organizations], there were volunteers. But this is a country that has a chronic disaster situation. The earthquake was just a flare-up.”

Delonnay said despite the overwhelming force of international aid, the response of the Haitian government and people will ultimately determine the fate of Haiti. He remains hopeful, adding that perhaps the distress of the earthquake can be used as a teaching moment.

Barbara McLean, MN, RN, CRNP, CCRN, is an independent critical care nurse who has made a career of working in developing countries and disaster situations. She said education is necessary to rebuild the infrastructure in Haiti, and the rebuilding process goes beyond brick and mortar.

Barbara McLean
“These are people who speak three or four languages. We need to facilitate opportunities,” she said. “If it is possible to start a medical university or nursing school, we should do it. We have the volunteers to run them for now, so we should capitalize. There needs to be a system to teach the Haitian people how to help themselves.”

Moving forward
Fitzgerald said the relief effort is a marathon, not a sprint — a statement that most individuals and organizations agree with.

“Following an emergency like this there is sometimes an expectation that every problem will be addressed at the same time and at the same pace,” Nandy said. “However, this is unlikely to happen due to lack of resources and practical considerations, particularly human resources. The energy and enthusiasm are good, but we need to prioritize activities carefully and ensure adequate resources to meet goals. We need to work in a layered manner, linking the immediate response to longer term goals and accept that different goals will require different timelines.”

Nandy said the health cluster is tackling various facets of health care. “As we pass the 6-month mark, we are supporting activities on multiple fronts, linking immediate needs to longer term development goals,” he said. “Trauma care and postoperative programs for amputees are coming up to speed. In addition to vaccine programs, we are trying to ensure availability of primary health care and get HIV patients back on ART. The Water Sanitation & Hygiene (WASH) and nutrition clusters, led by UNICEF and closely related to the health cluster, are working to ensure adequate water, sanitation and nutritional interventions, respectively, in order to prevent and minimize the impact of infectious diseases.”

Although medication is not in terribly short supply, there are not enough infectious diseases specialists who can appropriately prescribe antibiotics, McLean said, adding that almost every patient she encounters has an infection. She encourages all infectious diseases clinicians to visit Haiti.

“If weeks go by without an ID specialist present, the use of antibiotics runs rampant,” she said.

“When an infectious disease person comes in, the antibiotic mix almost always changes.”

The threat of resistance is often present where antibiotic use is prevalent, but Fitzgerald said that under-treatment, not over-treatment, remains the key concern.

“My facility had plenty of HIV medication, but we could only dispense about 2 weeks worth of supply at a time,” Bayard said. “Without consistent access and monitoring by one physician, I suspect things will get worse.”

Despite these obstacles, optimism remains, albeit grounded in harsh realities.

At one point, Delonnay said he was on the street taking photographs, and a woman went into labor near the tent where she and her family were living. “I had to jump in because nobody was there at first,” he said.

“The umbilical cord was wrapped around the infant’s neck. Suddenly some nurses arrived and resuscitated the baby, with almost nothing. The baby lived.”

Fitzgerald and Nandy said public-private partnerships will be key given the scale and influence of the private sector in Haiti.

“We have been encouraged by willingness of private nonprofits and [nongovernmental organizations] to work with the Haitian government, and vice versa,” Fitzgerald said.

“We need to do whatever we can to ensure that some positives come from this terrible disaster and we all must understand that given the magnitude of the disaster, we will only achieve so much in the short term and will need to invest in Haiti for the long haul,” Nandy said.

For more information:

Please visit the WHO website: http://new.paho.org/disasters/index.php?option=com_content&task=view&id=1088&Itemid=906

Perspective
I went with a team from Hopkins to the hospital at the University of Port-Au-Prince 10 days after the earthquake hit. I have worked in emergency medicine and disaster situations for 20 years, and this was as bad as could possibly be. To have such a devastating event happen in a place with so little infrastructure made it a legitimate worst-case scenario.

About one-third of the cases we were dealing with were directly earthquake-related, but we also had people coming in up to 2 weeks out who had not received any care as yet.

The infectious diseases we were dealing with included acute infections, long-term complications from fractures or amputations and complications relating to HIV or TB. We had a decent supply of antibiotics, but we kept running out of antimalarials because we were treating malaria presumptively. We had no way of diagnosing it.

There was a lab at the facility, but it was extremely backed up and took hours to get results back.

We were seeing between 400 and 500 patients a day and did not have time to wait.

TB was of particular concern, but with space so limited, our ‘isolation’ procedure was to simply put them on beds we had set up under a tree outside the tent. There was no other place to put them.

Strangely enough, the good news in all of this, now that we are 6 months down the line, is that a lot of the dire predictions about large-scale outbreaks of infectious diseases simply have not come to pass. Everyone from casual observers to media outlets to clinicians, myself included, thought that by this point, we would be seeing overwhelming incidence of malaria and diarrheal disease, among other things. It has been very gratifying that that has not yet happened.

–Tom Kirsch, MD, MPH Director of Operations, Department of Emergency Medicine, Johns Hopkins Medicine, Johns Hopkins Bloomberg School of Public Health