BIOSURVEILLANCE REPORT - 14

OPERATIONAL BIOSURVEILLANCE

Current official stats are more than 9,971 cases and 643 fatalities.

In some areas of Haiti, we have confirmation that in-patient statistics are under-reported by as much as 400%.

There is no question of under-reporting. If we assume the case counts are 1/4 the true community load, then we now have nearly 36k cases shedding pathogen into the environment. We believe the true statistic to be closer to more than 50k based on the degree of under-reporting. This is an uncontrolled, uncontained epidemic of cholera that has exceeded public health capacity to investigate and assess every site reported and every sample received.
Evidence now suggests the epidemic has crossed the border into the Dominican Republic, which was expected.

HOPITAL ALBERT SCHWEITZER: EPIDEMIOLOGICAL DATA

We thank our colleagues for sharing this important information from the world-renowned Hopital Albert Schweitzer. Of particular note is the bimodal peak of the epidemic curve, likely reflective of waxing and waning transmission in the patient catchment area of HAS along the Artibonite River, particularly as transmission is seen in rural areas. It is clear epidemic activity in this area of Haiti has not ceased.

CAP HAITIEN, BAS LIMBE, LIMBE: IDIS CAT 5

The Cap Haitien / Bas Limbe / Limbe region is now assessed to be an IDIS Cat 5. Medical response grid failure is imminent without immediate intervention.

From an HEAS partner:

I made a visit to both Limbe hospitals yesterday and brought more supplies to Bord de Mer Limbe clinic (Haiti Village Health) where I ended up staying night due to huge volumes of rain and assisting with cholera patients here. Even with the rain (likely causing many to never make it) clinic is seeing 5-10 patients a day. 6 to the hospital this morning one of whom died. Late last night we were at (Hospital) Bon Samaritan which is overflowing with patients. The last two days had been crazy and they were hoping to set up a second tent today to accommodate increased patient load. The situation at the other Limbe hospital (Government hospital St Jean) was worse. We brought a patient there only to discover that a huge tent and building full of patients was being attended by no one. There was no doctor or nurse present, dry IV bags, and when we asked how a doctor could be reached no one really knew. All patients from the clinic are now being routed to Bon Samaritan after stabilization with IV or oral fluid and the hospital has said to send them along no problem.

Also had another report from Clinic Ebenezer who said they were overrun with patients and on their last box of saline. Staff have been overwhelmed and they are looking for nurses.

I think that things are not great at the hospital (St Michel) or at the gymnasium where they are putting the suspect cholera cases. I had thought that MSF was all set up, but they still won’t be for a couple of days apparently. There have been a number of deaths in the community around FSM (Fort St Michel), and I understand people don’t want to stay at the gymnasium. I also understand that they are treating people at Milot. I have been in touch with people from the Baptist Convention Hospital in Quatier Morin, about possibly opening a ward there. I have been speaking with contacts in PAP and they are hoping to send more supplies and staffing but many more are needed, as you can see how the spread is happening.

CHOLERA IN CAZALE

From an HEAS partner:

The clinic in Cazale started seeing suspected cholera cases yesterday. Stool samples have been sent to the capital for confirmation. They have only seen a few cases so far, and have adequate supplies and personnel. I will update if this changes. Cazale is located about 5 miles inland (up in the mountains) from Cabaret. Many of their patients walk for 6+ hours to get to them, so people often show up in pretty bad shape. Their first patient required 7.5 L of LR and 3 L of ORS before he urinated.

CHOLERA TRANSMISSION RISK IN SOUTHEAST HAITI

[Our tremendous thanks to UNDP DINEPA for sharing this crucial information.]Colleagues,
Since 2006 UNDP and DINEPA (before SNEP) work together in a program of water supply and sanitation department on the Southeast. Since 2008 the program has begun a comprehensive inventory and a survey of the sector throughout the EPA Southeast.

Result of this work we (UNDP DINEPA) have developed maps by county (10 cards) that represent the theoretical risk of transmission of cholera in all localities (approximately 900 locations / homes) in the south-east from the water drinking. We hope the map will be useful for planning actions. At the end ofthis week a similar card on the department Centre will be available. Maps of South-east will be improved during the week with data we have on the hydrographic network, schools, health facilities and roads. Attached herewith the 10 cards.

Good work and good day.
Ovidio López-IbáñezDraft EPA SoutheastEnvironment UnitUNDP-Haiti
Maps attached below.
Download AnseaPitre
Download Bainet
Download BelleAnse
Download BelleAnse
Download CayesJacmel
Download CotedeFer
Download GrandGosier
Download Jacmel
Download LaVallee
Download Marigot
Download Thiotte

PORT DE PAIX: 20 FATALITIES REPORTED

CAP HAITIEN: 165 HOSPITALIZATIONS AND 7 FATALITIES REPORTED

GONAIVES AT IDIS CAT 5

We have multiple sources reporting 60 fatalities in Gonaives both in medical facilities and out in the community over the span of 48 hrs. This is an instance where timely warning coupled to rapid medical response surge was not successful. The mayor of Gonaives reported people were forced to walk to the hospital because taxis refused to transport them. He was quoted as saying, "Patients have died on the way to the hospital, the bodies are wrapped in blankets and placed near the cemetery in the city." The transport of these bodies were observed by locals, who now have mounted protests over the handling of the situation. At this point, establishment of a CTC is in development.

LA POINTE: CHOLERA REPORTED, WITH COMMUNITY ANXIETY NOTED

We have report of community anxiety due to cholera patient demand placed on the BERAKCA Hospital in La Pointe. As a result of a Request For Assistance, HEAS is mobilizing response assets to support the community. La Pointe is flanked on both sides of the coast by communities that have already reported cholera.

HEAS SITREP 11.9.10

SUMMARY

Current official stats are more than 9,500 cases and 583 fatalities. In some areas of Haiti, we have confirmation that in-patient statistics are under-reported by as much as 400%.

There is no question of under-reporting. If clinically apparent case counts are assumed to be 1/4 the true community load, then nearly 36k cases are shedding pathogen into the environment. We believe the true statistic to be closer to more than 50k based on the degree of under-reporting. This is an uncontrolled, uncontained epidemic of cholera that has exceeded public health capacity to investigate and assess every site reported and every sample received.

Substantial political interference and resultant lack of proper coordination at the Health Cluster and WASH levels continues to severely compromise timely reporting of information critical to save lives. This has been a problem since the earthquake in January 2010. Haitian officials have declared the cholera epidemic to be an issue of national security, which may further contribute to political interference in information sharing.

Evidence now suggests the epidemic has crossed the border into the Dominican Republic, which was expected.

KEY UPDATES
Cholera has now seeded the Haitian environment in more sites than can be properly assessed.

Evidence of community transmission is present in multiple sites such as the northwest, greater Port au Prince area, and strongly suspected in the southern peninsula. Transmission modes include waterborne, food contamination, and human-to-human contact.

Transmission in the original epicenter of the epidemic along the Artibonite River has decreased substantially and shifted to surrounding rural areas, extending to the northern coast. As feared, cholera transmission in communities along the coastal highway between St Marc and Cite Soleil likely resulted in dozens of indigenous cases now identified in Cite Soleil, with dire implications for Port au Prince. Multiple confirmed cases without travel history to Artibonite have been documented in both Cite Soleil and Port au Prince, and hundreds more suspect cases have been declared inside Port au Prince. Significant political interference prevents full clarity of the situation inside the city. As of this report, HUEH and other major medical centers inside Port au Prince are stable and able to handle the patient flow.

Sporadic, unconfirmed rumor suggests cholera has reached Carrefour, however this information is treated with a high degree of uncertainty. Eventual confirmation in Carrefour is expected.

Other areas have reported cholera such as Grand and Petit Goave; confirmed or not, this would not be unexpected. All suspect cholera cases tested in Leogane have reportedly been negative, however it would not be unexpected to see confirmation in the very near future. Suspect cholera cases have been reported in Les Cayes, Jacmel, and several other rural communities in the southern peninsula. We assess it is highly likely the epidemic has indeed extended to the southern peninsula.

The issue of “suspected” versus “confirmed” reporting and decision points for action have been hotly debated inside the HEAS community. As was observed in the United States during the 2009 H1N1 influenza pandemic, the number of samples collected is disproportionate to the ability of LNSP to process them in a timely fashion and publicly declare confirmation status. The entire nation is now sensitized to report cholera, however many have never seen cholera before.

This implies means the false positive rate is likely increased. Diarrheal disease not due to cholera is caused by a wide variety of other endemic pathogens and is seen this time of year during the major rainy season. All of this acknowledged, hesitation to verify or assume “cholera until proven otherwise” may mean the difference between 1 and 10 fatalities for a given community. This is a tremendous challenge to the HEAS community.

We find that the pattern of reporting, particularly with rural villages in the north with minimal baseline medical capacity, initial IDIS ratings reach Category 5 and then are quickly downgraded to Cat 4 once medical response is mobilized and responders become habituated to clinical care for cholera patients. Much of Artibonite Valley is now rated at IDIS 3 or lower.

Port au Prince is currently rated at IDIS Cat 1 to 3, depending on the specific site, with strong potential to reach Cat 5 in the coming days. Cite Soleil is likely to reach Cat 5 conditions before Port au Prince.

The closest site reporting cholera to the border with the Dominican Republic (DR) is approximately 10 miles and is not on a major roadway. That said, 3 suspect cases have been reported with positive travel history from Haiti to DR, and no acknowledgement has been provided to-date by DR officials. We assess it is highly likely cholera is inside DR’s borders. The HEAS has coordinated with DR officials to provide situational awareness to enable preparedness.

The major rainy season normally peaks in October and persists through November. We assess the pass-through of Hurricane Tomas provided environmental enhancement of cholera transmission due to flooding. We expect to see continued effects for the next several days.

STATUS OF THE BIOSURVEILLANCE GRID

The HEAS is a community of more than 600 online and offline ground medical responders, international experts in cholera ecology, operational biosurveillance analysts, meteorologists, veterinarians, sanitation specialists, and public health officials. The membership includes international NGOs, IGOs, UN, US agencies, and private citizens with specific, relevant expertise.

The HEAS Mid Action report, based on the initial 150 days of operations post-earthquake, displays the power of operational biosurveillance-facilitated distributive networking for early warning and rapid response. The HEAS community has now evolved into a self-regulating body that processes tactical event warning and forecast information to prompt verification and rapid “swarm” medical response activities. It is the largest group of its kind operating in Haiti.

CONCLUSION
The cholera epidemic in Haiti proceeds in an uncontrolled, uncontained fashion and will likely encompass all of Haiti within a matter of weeks. Ecological establishment will be pervasive regardless of ongoing response efforts.

Efforts to improve access to safe drinking water and sanitation are as challenging as they were post-quake, and now additional vast areas of Haiti will require similar attention. It is unlikely effort will be mobilized quickly enough to forestall the spread of cholera. Public health intervention in the areas of education, hygiene, and training of medical responders will continue to be important. However, the default operational position now is not to prioritize effort to prevent spread but to prevent or mitigate unnecessary fatalities. The HEAS is narrowly focused on early, actionable warning coupled to “swarm” medical response. We have observed time deltas between warning and imminent healthcare facility collapse can be as short as 24 hrs. The HEAS has encouraged high false positive rate reporting to ensure communications with involved medical facilities and staff can be established and resources mobilized quickly enough should they be required. This process has already assisted several overwhelmed facilities and likely prevented unnecessary loss of life.

It is notable the function of the HEAS, as facilitated by operational biosurveillance analysts, is distinct from public health operations with a different focus, scope, and operations tempo.

Although complimentary information sharing between the two communities would likely be more productive than maintaining a separation of operations, we have found public health involvement aside from consultative input to be largely irrelevant. This is a similar observation to what was observed during the 2009 H1N1 influenza pandemic and likely reflects a well-understood lack of agility in public health function during rapidly evolving infectious disease crises and disasters.

The HEAS coordinates with other foreign nations about the situation in Haiti. As discussed above, DR will likely be the second country in the region to experience epidemic conditions. It is difficult to anticipate the next involved country thereafter. Advisories were sent by the HEAS to key elements of the United States medical community on 10/21, 10/22, and 11/4 in an effort to sensitize clinical awareness for travelers or patients transferred from Haiti. The discovery of cholera in travelers or patients from Haiti inside the United States will not be unexpected.

Continued independent "smart swarming", utilizing distributive networks for situational awareness, is strongly recommended with an expectation for a protracted period of response operations.

Eventual regionalization of cholera in the Caribbean is a strong possibility but not a certainty if the pandemic of the early 1990s is a guide.

ST MARC REGIONAL CASE COUNTS SUBSTANTIALLY DECREASED

We now have reports from HEAS partners in Villard and Pont Sonde that, as with the majority of the St Marc region, cholera case counts are substantially decreased now:

[Villard] We have collected numbers from our "UTC" in Villard, (just north of Pont Sonde and St Mark) and number of patients saturday was 10, Sunday was 2. They called to say that, after the rains, a few more were sick 'from time to time' but that it is all. This is down from 35/d last week and a peak of approx 115/d.

[Pont Sonde] Thankfully, we have had no deaths at the clinic and the number of cases has dropped dramatically.

MORE CHOLERA IN PORT AU PRINCE WITHOUT TRAVEL HISTORY FROM ARTIBONITE

From HEAS partner:

We have now 2 more patients who have rapid tested positive for cholera 01 at Hospital Bernard Mevs. One is 41 year old woman who lives in Salt in La Plain in a house, also has not travelled outside of her area in over a year. The other is a 33 year old woman who lives in a tent city not 10 minutes from Hospital Bernard Mevs that is called Cite Renord. Her water source is apparently a communal water source; she also has not traveled. This water source in this tent city should likely be investigated.