BIOSURVEILLANCE UPDATE - 20

OPERATIONAL BIOSURVEILLANCE

Current official stats are more than 23,377 cases and 1,344 fatalities. This includes more than 1,618 cases in Port au Prince with over 77 fatalities.

We note large discrepancies between HEAS partner information and officially reported statistics, reflective of official under-reporting.

Conservative estimates therefore suggest nearly 95,000 cases of cholera in Haiti to-date, the majority of which were subclinical.

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. We therefore estimate the upper bound of estimated total (subclinical and clinically apparent) case counts to be nearly 375,000.

Although PAHO projections use an attack rate of 2% of a total estimated Haiti population of 10 million to estimate 200,000 total clinically apparent infections, the true community load will be closer to 800,000 if subclinical infections are counted.

We err on the side of over-estimating because this is a "virgin soil" epidemic and expected to aggressively spread throughout the country and across the border into the Dominican Republic.

We are now pursuing answers to the question of uptake by indigenous zooplankton and spread along oceanic currents that pass west of the Gonave Gulf, which is where the Artibonite River discharges, north and west along the northern Cuban coastline and north to the waters east of Florida.

It is likely the elections will facilitate the spread of the epidemic due to population mixing.

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

As expected, Florida has reported a case of cholera in a returned traveler. There will be more cases in the United States; we believe it likely more cases are inside the US unreported.

Implications for the United States are neglible.

PETITE RIVIERE DE NIPPES: FIRST SUSPECT CASES OF CHOLERA

From an HEAS partner:

Yesterday, our clinic reported its first cases of suspected cholera. Of the three patients we treated, two were travelers from the Artobonite department which is the center of the outbreak. Based on the experience in the rest of Haiti, we expect to see many more cases over the next several weeks.

UPDATE: MILOT

From an HEAS partner:

As of Friday November 19th, we had received 214 patients with cholera at the CTC at Hopital Sacre Coeur in Milot. 160 have been discharged,12 died [CFR-apparent 5.6%], 42 are now in the quarantine area. We anticipate that the number of cholera patients will increase drastically this week now that the road between Cap Haitien and Milot has reopened.

UPDATE: CAZALE

From an HEAS partner in Cazale. The HEAS issued an alert for this site on Nov 10th.

We are located in Cazale. A rural village outside of Cabaret. We have been receiving cholera patients since Nov 9th. The community of Cazale has donated a house and we have 25 cots set up to receive patients. Since Nov 9th we have received 251 cases. Many of these we are giving ORS. We just wanted to touch base with you and let you know that we are here. We continue to receive patients each day but so far have not had all the beds full.

FLASH REPORT: CHOLERA IN MORON AND JEREMIE, SOUTHERN PENINSULA

We had received indications of cholera's spread to the Les Cayes area, with one laboratory-confirmed case on Nov 8th. This was not publicly acknowledged by officials at that time. Then, on Nov 16th, we received report of suspect cases in Fond des Negres.

Now we have report of suspected and confirmed cholera with fatalities in Jeremie and Moron.

We are now working under the assumption the southern peninsula is experiencing local transmission of cholera:

We've had several cases of cholera at St. Antoine's Hospital in Jeremie. As of Saturday afternoon there were 8 patients, 7 clinical and 1 confirmed. One rumored death in Moron. They're setting up tentsfor a CTC outside of the hospital.

FIRST CONTACT: ZABRIKO / FORGE

We now have reports of first contact mortality in Forge and the Zabriko area. HEAS partners are attempting to gain clarity in regards to emergency need.

FIRST CONTACT: ANSE ROUGE AND TERRE NEUVE

From an HEAS partner, with thanks to Citizen Action Team... here we present yet another example of first contact effect:

Anse Rouge has approximately 37,000 residents but also services parts of Terre Neuve, raising the number to about 42,000. Article 29 Organization's base is in Second Section Commune Anse Rouge, which has four physical health clinics. One is the ILODEP clinic sponsored by Parole et Action, the other three are community clinics which have no paid staff and have not received supplies since July, the last time that A29 secured supplies for distribution to the clinics. There is no doctor or nurse in second section Commune Anse Rouge. There is rumored to be a doctor present in the City of Anse Rouge at the tent clinic (in first section Commune Anse Rouge) at the site of the old hospital that burnt down last year. This clinic is between a 2 to 8 hour walk for people in Second Section Commune Anse Rouge and there are virtually no taptaps or cars in the region.

Cholera first entered Second Section Commune Anse Rouge about two weeks ago with cases coming in from people who had been in Gonaives. In second Section Commune Anse Rouge, we had five cases last week. The La Source Chaude clinic, which is the main clinic for the second section and is run by a volunteer nurse auxillary, closed its doors for fear of cholera. All five cholera victims died. A29's coordinator lobbied regional MSPP to re-open the clinic, which the volunteer nurse auxillary has now done, but there are currently no supplies (IV's, hydration fluids, antibiotics) to treat patients. Thus, more patients have arrived at the clinic, receive a cholera diagnosis, and then die. By the time the patients arrive at the clinic they have been too far along to respond to ORS, so IVs are needed. There are very few cars in the region so it is difficult to get patients to the City of Anse Rouge clinic, which as of yesterday was also out of IVs and rehydration fluids. As of yesterday, at least five more cholera patients found transport from Second Section Commune Anse Rouge to the City of Anse Rouge clinic in the first section. Two more died at the La Source Chaude clinic in Second Section. Five new patients had arrived at the La Source Clinic yesterday.

A29 launched a public education and prevention campaign two weeks ago at the region's two largest public markets (the City of Anse Rouge and the La Source Chaude markets). Information is spread by megaphone regarding prevention of cholera, treatment and how and when to make ORS.

As a result of the outbreak in Gonaives, people are afraid to go to Gonaives for fear of contracting cholera. This puts the entire region in a precarious position as most of the region's supplies are procured in Gonaives (rice, oil, gas, everything). Commune Anse Rouge produces shallot and sourghum and pwa congo but no other crops in sufficient quantity to meet people's basic dietary needs - everything comes from Gonaives. There have been reports that one of the first two cholera victims in the region, when being shut out by the clinic and the community, deliberately polluted the drinking water source in Kay Felip, causing the other three people (of the initial five people) to contract cholera.

There is a lot of panic and fear as a result, which could all easily be assuaged with the presence of a qualified doctor or nurse and some cholera medical supplies. A29 is currently engaged in efforts to secure supplies and transport for cholera treatment from PAP but has met with great challenges thus far. A29 is also attempting to engage medical teams to bring support to the region, which almost never receives such assistance because of its isolated location NW of Gonaives.

MERCERON: SUSPECT CASES REPORTED

The finding of suspect cases and fatalities in Merceron would not be a surprise given previously reported activity in the region. HEAS community partners are attempting to verify this reporting and assess status of emergency need.

BORD DE MAR / LIMBE: CHOLERA CASES RISING

From an HEAS partner:

One fatality reported so far, which is good. The medical team now has experience treating cholera patients, which improves the daily mortality stats.

NOTES FROM THE EPICENTER: WE ARE OUT OF ... EVERYTHING

I am sad to report that things have worsened significantly and in 3 camps (St. Marc being the hardest hit that I have seen yet) have 76 known cholera deaths and 1,709 confirmed cases. The death toll of 76, I received yesterday from [REDACTED] was the count over approximately (the last) ten days in one camp. There are many more deaths from other camps and although some of us traveling to the rural areas are trying to remain in contact, it is nearly impossible.

We are out of ORS - oral rehydration solution, pedialyte, IV fluids and tubing -- everything. The situation in the tent camps/cities is already full of unspeakable horrors and now for those with cholera the sight is just gruesome. The rural camps, hardest hit by cholera are in the worst situation because there is NO relief aid presence and no UN presence.

During this last trip it would take almost 5 hours to drive from St. Marc back to Port au Prince to try and secure supplies. We are purchasing ORS, water, and pedialyte (now absent from stores because we are buying so much of it). [REDACTED] gave me 10 cases of pedialyte and some other supplies, which is all they could afford because they feared an outbreak in Port au Prince.

Finally, after running out of medications, fluids, etc. and being turned away from most all sources for medical supplies, including the UN, there was no way to help those suffering from cholera. It was simply too difficult to watch another baby die of dehydration and I came home to recover from the worst week I'd experienced in Haiti since the earthquake. I cannot begin to explain how much worse the situation is in Haiti and how there is very little coordination of any relief aid or the NGO's.

The following is the mission statement of the UN for its mission in Haiti. It is not being carried out now during this cholera outbreak and has not been carried out since the earthquake, which is more than a failure to the Haitian people.

"The mission of the United Nations Office for the Coordination of Humanitarian Affairs (OCHA) is to mobilize and coordinate effective and principled humanitarian action in partnership with national and international actors."

I have shared all my findings with the CDC in order to give them as much data as I can gather for their investigators. I have also given our findings to the MOH and OCHA - mainly for informational purposes because I've given up the hope of obtaining necessary supplies. I wish the news was better and sadly the deaths will continue because there is little to no support available for those providers in rural areas.

There is very little available in the way of supplies even in the larger cities now facing patients with cholera. I am contacting organizations here at home to try and get the ORS, which comes in small packets, donated so I can take it back on my next trip.

BORGNE: DISTRESS CALL TO THE HEAS

From an HEAS partner:

Just received word from Borgne, Haiti in the north that they are overwhelmed with cholera cases, including fatalities. It is a very remote region in the mountains and there is only a small community hospital backed by a small NGO that I usually work with, but I am presently in Port au Prince. They have no resources. They need cots, IV fluids, and ORS. They claim to have not much support. Can anyone help?

We are attempting to verify need and query for resources. It is likely this coastal town, as with many of the other northern coastal towns, is seeing patients coming in by foot from the mountains seriously ill. Upon arrival, they are often near-death.

ST MICHEL DE L'ATALAYE: 25 FATALITIES AND 125 OVERWHELMING CLINIC WITH ONE NURSE

Report of 25 fatalities and 125 patients abruptly overcrowding a clinic staffed with one nurse is a typical story of the rural areas of Haiti that are grossly under-resourced by the current response effort. The HEAS is attempting to verify need and clarify reports of a CTC being on-site.