BIOSURVEILLANCE UPDATE - 17

OPERATIONAL BIOSURVEILLANCE

Current official stats are more than 16,700 cases and 1,034 fatalities.

In some areas of Haiti, we have confirmation that in-patient statistics are under-reported by as much as 400%. In many areas of Haiti, we are documenting outbreaks that are not being accounted for in the official statistics.

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 60k cases shedding pathogen into the environment. We believe the true statistic to be closer to more than 100k based on the degree of under-reporting. It is extremedly difficult to estimate the true scale of this epidemic now. This is a grossly uncontrolled, uncontained epidemic of cholera that has exceeded public health capacity to investigate and assess every site reported and every sample received.

As noted by HEAS one week ago and today officially acknowledged, cholera is in the Dominican Republic. We expect to see medical clinic inundations inside DR in the near future.

"FIRST CONTACT" EFFECT ON CHOLERA MORTALITY IN HAITI

Official statistics are often quoted in terms of total aggregated case counts and total aggregate deaths at the national or departmental level. For example, as of today, there have been 16,700 cases and 1,034 fatalities with a case fatality rate-apparent of 6.2%. From an operational perspective, this yields little information to guide rapid medical support deployment.

Once we have been sensitized to report of sudden inundation of a clinic with suspect cholera cases, subsequent examination of epidemiological data offers insight into how a clinic is progressing. Acquisition of epidemiological data usually happens several days after "first contact" with cholera due to the operational distraction of managing the sudden influx of patients. Progess is determined by effective management of the balance between patient demand, medical response resources (i.e. personnel and materiel), and positive adaptation over time of processes, procedures, and experience to streamline efficient diagnosis and care of the patients.

Clinics experiencing "first contact" with cholera are usually observed to have dramatically high daily mortality as they adapt to the sudden challenge.

This is particularly true for clinics unprepared or staffed with personnel with little experience recognizing and treating cholera, as is was the case in the Cap Haitien region.

It is notable that Cap Haitien experienced later surge than Plaisance and Limbe and was better resourced when they experienced first contact, which may explain the lower daily mortality.

This is a strong argument for near-real time, network-centric situation awareness as facilitated by the HEAS. At the Plaisance and Limbe facilities, daily mortality declined despite an increase in case counts. At the Cap Haitien facility, however, we are concerned about the persistenly high daily clinic mortality. MSF is mobilizing to assist them now.

The argument for prior experience and forewarning is further supported by examination of the data from MSF cholera treatment centers in Port au Prince, where daily clinic mortality has not breached 10%. MSF as an organization has experience treating cholera in other parts of the world and also was sensitized by a combination of their experience in Artibonite and sensitization to warnings issued about the entry of cholera into Port au Prince.

UPDATE - CAP HAITIEN: CUT OFF FROM MEDICAL SUPPORT / IDIS CAT 5

UPDATE: MSF is mobilizing support but were delayed due to the violence. They are expected to resume mobilization as soon as possible. We have indication the violence has died down for the time being and remain hopeful the situation can be stabilized to enable proper medical support.

With the incendiary rioting in Cap Haitien city, much of the mobilization efforts to support medical response in the greater Cap Haitien region have either stalled or been diverted to other regions. Responders now hesitate due to regional security concerns. This was the much-feared outcome of any violence triggered by allegations of accidental introduction of cholera by Nepalese UN forces to Haiti. When patient demand exceeds medical personnel or materiel supply, increased daily mortality is observed:

We are seriously concerned about the well being of the citizens in the Cap Haitien region and fear the situation will now result in a disproportionately high mortality rate as patient demand continues to exceed medical capacity in the region.

EMERGENCY SITUATION DECLARED IN ST LOUIS DU NORD (IDIS CAT 5)

Medical responders are still struggling to cope with clinic inundation that began on Nov 7th in St Louis du Nord, now down to 24 hrs of supplies left as relayed by an HEAS partner:

... [clinic] currently has approximately 24 hours worth of supplies to continue fighting the cholera in their area (St. Louis Du Nord 19.931698,-72.72063 ) and are forced to ration the supplies they do have (i.e.-make decisions about who gets to live & die).

There is a field right near their compound that can accommodate the landing of a helicopter if someone is so inclined as to fly supplies in (they are reporting their area is currently quiet & safe), but they need to get replenishment of the following at a minimum as soon as possible:

Ringers solution, IV Potassium Chloride,Ampicilan & IV Zofran,Azithromycin & Doxy, caths 20, 22 & 24 gauge, diapers (all sizes), CUPS, body bags

Helicopter landing information:
UN has landed a helicopter many times, so it works for helo. Coordinates for helo landing field are: 19.929822,-72.716081...

St Louis du Nord remains rated at an IDIS Cat 5. The HEAS network was mounting response via C-130 Hercules transport to Cap Haitien to support the entire region, however civil destabilization of Cap Haitien has cut off access to support and inhibited other responders' willingness to deploy in. HEAS is in the process of contacting emergency responders now.

TWO SUSPECT CHOLERA CASES IN FOND DES NEGRES

We are already aware of one laboratory confirmed cholera case in Les Cayes with a negative travel history from Nov 8th. If the cases in Fond des Negres are confirmed, it will imply a large area of concern in the southern peninsula.