BIOSURVEILLANCE UPDATE - 7

OPERATIONAL BIOSURVEILLANCE

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.

UPDATED CASE COUNTS AND IMPLICATIONS FOR SUSTAINED TRANSMISSION

From our perspective, we agree with PAHO's recent statement today about the epidemic and while we all would like to be hopeful, we are reminded of the recent 2008-2009 epidemic of cholera in Zimbabwe. Responders there were lulled into a false sense of security as the epidemic waned, only to be badly disappointed as the epidemic continued onward to produce 98,424 suspected cases and 4,276 deaths (Case Fatality Rate of 4.3%) from August 2008 to June 2009 that were officially reported. Fifty-five out of 62 districts in all 10 provinces had been affected, according to the World Health Organization.

Currently we are seeing 4,147 cases officially reported, with 292 deaths. We assume PAHO is reporting these as separate groups of people, where the total number of cases reported is actually 4,147+292= 4,439. If we generally assume that only 25% of cases display clinically apparent illness, we conservatively assume then there has been at least 17,756 infected people to-date. This is a truly alarming number of people, especially when considering 1) this is likely the result of under-reporting and 2) a large percentage of these infected individuals could be shedding pathogen into the environment for weeks post-infection.

There are a number of factors in play to explain the apparent high CFR:

1. CFRs are often inflated at the front-end of outbreaks and epidemics in general, especially when dealing with an area of limited infectious disease warning capability, because the social bias in reporting up to a national level is driven by fatalities or the most severe clinical outcomes.

2. Once the clinical entity (i.e. cholera) is recognized to be the etiological agent, extrapolations for the true infectious disease load in community may then be calculated for a truer estimate (such as we've proposed above).

3. Once social sensitization has been achieved through a warning process such as we have achieved, reminders for clinical diagnosis are also distributed which actually alters the probability of clinical diagnosis for milder cases. This means your reported case count may migrate a bit over time.

Bottom line, our team remains on maximum alert and are concerned about the potential for ecological establishment and introduction to other nations in the Caribbean.

EXPANSION OF CHOLERA AND THE TEMPERING OF HOPE

We, like the rest of the responder community, have dared to hope containment may be possible at various junctures of this crisis. We noted recent reporting of cases seen in Limbe and Plaisance, where Limbe is a 15 minute drive from Cap Hatien, and are reminded this situation is still very much in flux and unlikely to resolve soon. One of the HEAS partners who was close to the recent 2008 massive epidemic of cholera in Zimbabwe noted that responders there also had indication of a stabilizing or slowing down of transmission, only to be horribly disappointed as tens of thousands were infected. While we keep hoping Haiti will "get a break", we simply cannot allow ourselves to stand down for a moment. This remains an IDIS Category 5 event that is very much in-play. And the question of ecological establishment remains an open one as well.

CONTEXT: ANTI-CLINIC PROTEST IN ST. MARC

We previously noted a protest that erupted in St Marc over the creation of a cholera treatment facility, and we have been provided with several important points of context:

MINUSTAH was not directly involved in the creation of the treatment center but was providing security for MSF personnel by request.

The chosen site of the facility was across the street from a school; and
Was a community soccer field

The latter two points are crucial for the following reasons:

We have come to realize over the years that for communities coping with a high level of threat perception, especially during unexpected or non-routine infectious disease events, protection of children becomes an exquisitely sensitive nexus of concern that may lead to social outcry and even violence.

Communities under collective stress such as is readily observed in St Marc have a high demand for coping outlets such as recreation and access to religious services, for example. Compromised access to such outlets is actually a key indicator that prompts us to monitor for civil unrest.

If the community in question is already experiencing tension such as the negative MINUSTAH-Haitian public dynamic, then these issues become all the more important to monitor... and avoid.
At some point following conclusion of this disaster response effort it would be a prudent activity to review these kinds of observations to better inform response activities in the future.

ANTI-CLINIC PROTEST IN ST. MARC
Media reported on students protesting the activation of a cholera treatment center in St. Marc managed by MSF.

This is clearly a community education issue. Such community anxiety is very common when dealing with a pathogen previously unknown to a community or not in recent generational memory. We have seen the various manifestations of community anxiety for years in many different cultures under many different scenarios- from Ebola to the 2009 influenza pandemic. It relates to community coping mechanism when dealing with a non-routine, unexpected perceived threat, particularly one perceived difficult to control.