ARTICLE - BIOSURVEILLANCE REPORT

HAITI: OPERATIONAL BIOSURVEILLANCE

(http://biosurveillance.typepad.com/haiti_operational_biosurv/)

SURVEILLANCE REPORTS
10/22/2010

FLASH REPORT: SECOND SUSPECT CHOLERA FATALITY REPORTED IN LAFITO/LAFITEAU

An HEAS partner has indicated a second fatality has been reported in Lafito/Lafiteau, Haiti, a town in proximity to the ad hoc "Camp Obama" settlement and, miles down the road, Cite Soleil.

Separate HEAS partners based on the ground in Cite Soleil have indicated no apparent cases of cholera in Cite Soleil, however they have been sensitized to watch for illness. HEAS partners are presently in St Marc and have indicated the fatalities more than likely exceed 150, and "hundreds" of patients have overwhelmed St Nicholas Hospital.

We would like to emphasize the southern leading edge of the epidemic appears to be Lafito/Lafiteau, with an immediate potential opportunity for containment prior to entry into Port au Prince. This is a point of hope, however it still remains possible cholera has already entered Port au Prince. Immediate response presence to evaluate conditions in Lafito/Lafiteau, "Camp Obama", and Cite Soleil is strongly encouraged.


PROSPECTS FOR RAPID CONTAINMENT OF EPIDEMIC LEAD EDGE

Significant concern regarding potential spread of cholera in Cite Soleil and onward to Port au Prince now. Comment from an HEAS partner:

I am not an epi person but wouldn't it make sense to concentrate the initial hygiene efforts in the affected areas but also in the buffer zone between Port au Prince and Patient Zero of the West Department (Lafito)? I am using the same logic as in creating a firebreak in a burning forest.

One possible advantage for managing the situation: almost all human traffic from St. Marc. travels up and down the narrow corridor along the coast. the only other option is to cut across to Mirebalais and head south. Ergo, if it things get out of hand in the Artibonite and Central Plateau, containment becomes a more manageable proposition.

SUSPECTED CHOLERA FATALITY IN LAFITEAU, IN PROXIMITY TO PORT-AU-PRINCE (UPDATED)

An HEAS partner has reported the following:

We have reportedly had one death from acute watery diarrhea and vomitting over the course of a single day in Lafiteau on Ntl Rte #1 km25. The woman had been to a local market and became sick at home and died within the day. Can't confirm the cause.

This is concerning to two key reasons:

Immediate proximity to Port-au-Prince (see map), and
Possible contamination of market products and subsequent facilitated spread through market transactions

We assess the situation is evolving to a Cat 5 event. Immediate, regionalized response is required.

UPDATE from an HEAS Partner:

From an HEAS Partner: Lafito (to use the Kreyol spelling) and the adjoining community of Titayen are in a desert area of the coastal plain north of PauP. We did a study of the area in 2004 and there are only four water sources of which only one is considered potable. The others have very high salinity.Most of the people in the area walk to the mission school which has water trucked in to their compound. It would be interesting to know which market the woman visited. There is one at the crossroads in Titayen but I would suspect that she was shopping in Cabaret just to the north. This would indicate a greater buffer zone between the local source contamination and Port-au-Prince.

The next major populated areas moving South are Croix-des-Bouquets and, if turning right shortly after leaving Titayen, Cite Soleil. If they start seeing cases in Cite Soleil, then the genie is out of the bottle and containment will be all but impossible.

10/21/2010
WASH CLUSTER MOBILIZATION TO RESPOND IN ARTIBONITE

Per DINEPA- note concern for potential spread of the epidemic to Port-au-Prince:

Dear WASH partners,
The latest information obtained from the Artibonite Department indicates that potentially fatal cases of acute watery diarrhoea are spreading. Faced with this public health situation, MSPP, DINEPA, local Government Authorities, the WASH Cluster, and various WASH partners agencies are initiating an intensive response. In order to ensure that this swift response is well coordinated, DINEPA and the WASH Cluster have called for a coordination meeting to be held tomorrow, October 22 at the Office of Société des Eaux de Saint-Marc (SESAM) at 12:00 hrs midday. The aim of the meeting is to clarify strategies and activities to contain or prevent the spread of cases of acute watery diarrhea. Additional WASH capacity is needed in the following areas:

- Assisting medical teams establish essential WASH services for the treatment of patients.

- Systematic treatment of all drinking water sources in all regions at the source and household level with chlorine (or chlorine solutions).

- Mass distributions of soap.

- Promotion of clear hygiene messages (to be quickly finalized between WASH and Health).

For the forthcoming coordination meeting, WASH agencies are asked to share their capacity for an immediate response (both in terms of materials and human resources) in relation to the four specific points above. Coordination and division of the WASH response will be established with local authorities based on capacities, existing geographical locations, and needs on the ground.

Faced with this situation in Artibonite, DINEPA and the WASH Cluster are also particularly concerned with the situation in the metropolitan area of Port - au Prince in particular sites with populations affected by the earthquake of 12 January. As such, DINEPA and WASH Cluster recommend all WASH agencies working in displacement sites and neighbourhoods in the metropolitan area immediately follow these priority measures to reduce public health risks.

These measures should be carried out purely as preventive measure and care should be taken not to generate alarm or cause panic:

- Ensure that all water supplies, particularly those distributed by water truck, are chlorinated to at least 0.5mg/l free chlorine residual.

- Clean and disinfected all community latrines and their surroundings with chlorine-containing products several times per day.

- Ensure access to soap.

- Intensify hygiene promotion efforts in particularly hand washing with soap, the importance of safe drinking water, and the dangers of open defecation.

DINEPA and the WASH Cluster reminds all partners that any case of acute watery diarrhea must be referred to health structures without delay.

Additional information will be communicated on a regular basis to the WASH partners.

HAITI EPIDEMIC ADVISORY SYSTEM SITREP: 21 OCTOBER

NOTE: The Advisory System has been reactivated now to support the current cholera epidemic.

Mission Objective. Our objective is to identify those infectious diseases that may abruptly overwhelm the ad hoc medical infrastructure or be perceived by the Haitian public to be unusual or unexpected. In other words, identification and prioritization of those infectious diseases that may become a crisis or disaster.

Biosurveillance Grid Status. HEAS has now been reactivated in light of the current cholera epidemic.

Social Order-Health Security Nexus. Findings from other countries suggest massive social disruption potential during epidemics of cholera. As with any infectious disease crisis or disaster, provokation of social outcry and challenge to established authority may occur.

Meteorology. Haiti is currently in the midst of the majory rainy season, which is expected to persist through November, having peaked in October.

Medical Response Grid Status. Should an infectious disease crisis become manifest, the risk of inundation and overwhelming medical logistics during a rapid response campaign has remained high since the earthquake. This concern is magnified in the context of the current major rainy season. Current observations of the cholera epidemic in Artibonite validate this assessment, as reports indicate hospital capacity has been exceeded and patients are being diverted to other clinics (see below).

Current Advisories and Situation Status.

OP NOTES - DISRUPTORS

Cholera. The current situation is UNSTABLE. Current monitoring indicates a rapidly evolving situation, and we have indications of an infectious disease event due to cholera 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 that laboratory-confirmed cholera has not been reported since the early 1990s
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; we expect official statements soon

Tremendous and abrupt international sensitization as evidenced by Twitter and HEAS web portal hit counts

Transition of this event to a Category 5 is expected at this point; immediate international response is required.

OPERATIONAL DEFINITIONS

Infectious disruptor agent. An infectious disease capable of triggering crisis or disaster conditions.

Infectious disease crisis: time-sensitive, non-routine organization-level decisions that may affect a local community’s activities of daily living. It is more common such decision-making falls within the roles and responsibility of a public health institution than a public or private hospital or individual healthcare provider. This becomes a community level decision-making activity in countries where there is no public health capacity. The majority concern here is pediatric diarrheal disease in Haiti.

Infectious disease disaster: when crisis mode decision making by public health officials or institution fails to control the situation, either from an informational or response perspective and substantial social disruption associated with features of community disintegration occurs as a result. The term "community disintegration" refers to the dissolution of a community as a social unit. This is classically exemplified by the evacuation of a village due to an uncontrolled epidemic. Ebola is the archetype disruptor capable of generating this kind of social response in undeveloped areas of Africa. We do not consider any of the infectious disease in Haiti to represent potential disasters.

Warning. Indication of increasing incidence of an infectious disruptor agent, with alignment of optimized conditions to support transmission.

Watch. Indication of increasing incidence of an infectious disruptor agent, without alignment of optimized conditions to support transmission.

Advisory. Presence of an infectious disruptor agent reported.

Infectious Disease Impact Scale (IDIS). The IDIS is a model that serves as a guide to understanding the impact of acutely disruptive infectious disease events through the lens of disaster sociology. Up to this point, event descriptors of infectious disease events have focused on use of terms like "outbreak" and "epidemic". This is problematic in the operational setting when valid epidemiological data is often sparse or unreliable. Here we consider a different perspective that focuses on the interface between an infectious disease hazard and indigenous vulnerability.

IDIS Category 0. Unreported infectious disease event. Daily, routine infectious diseases are handled at this level, and provision of warning about these diseases is not deemed 'relevant'.

IDIS Category 1. Reported infectious disease event. The typical Category 1 infectious disease event reported by a community reflects a sensitivity to public health or medical significance. No other significant features indicative of immediate public health or medical infrastructure impact, public anxiety, or civil unrest triggered by the event are noted.

IDIS Category 2. Infectious disease event associated with routine organized response. Category 2 events often reflect locally well-known diseases that nevertheless generate a demand for organization-level time-sensitive action. This action is local routine.

IDIS Category 3. Infectious disease event associated with non-routine organized response. Category 3 events are essentially the beginnings of a community crisis.

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.

IDIS Category 6. Infectious disease event associated with apocalyptic indicators.

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.