BIOSURVEILLANCE UPDATE - 8

OPERATIONAL BIOSURVEILLANCE

USS IWO JIMA IS HEADING TO HAITI

U.S. Southern Command directed USS Iwo Jima (LHD 7) to steam toward Haiti today in preparation for the forecasted arrival of tropical storm Tomas.

Large Wasp-class ships, such as Iwo Jima (LHD 7), resemble small aircraft carriers with the ability to conduct air and naval operations. 8 CH-46 Sea Knight, medium-lift, dual-rotor helicopters, 2 MH-60 Knight Hawk helicopters and 2 amphibious landing craft units (LCU's) are on Iwo Jima to support relief and quickly move staffs and cargo making it an ideal platform to support logistics during humanitarian disasters.

1,600 military and civilian medical, engineering, aviation, logistical and other support personnel are embarked aboard Iwo Jima, including U.S. Navy engineers, a contingent of 500 Marines with logistical-support expertise, volunteers from the U.S. Public Health Service and various non-governmental organizations (NGOs), as well as medical, dental and engineering professionals from Europe, North America and South America.

TROPICAL STORM TOMAS PROJECTED THROUGH HAITI AS POSSIBLE CATEGORY 2 HURRICANE

As of Tuesday, Tropical Storm Tomas is remaining on basically the same path as has been previously forecast. It is currently approximately 300 miles south of Jacmel, Haiti.

Maximum sustained winds have increased to approximately 50 mph with gusts to 65 mph. It will start a more northwestward track late this evening through tomorrow when it is forecast to begin the northeastward track we do not want.

Forecast projections again show the strength at a possible Category 2 Hurricane with sustained winds between 96 and 110 mph at landfall sometime Friday, November 05, 2010.

Current forecast models are all in agreement of the general forecast track. Current model forecast show a potential landfall track near the southwestern side of Haiti, moving northeastward across the country, west of PAP, exiting the country near Cap Haiten.

Remember, this is only a projected path at this time and it could and will possibly very well change in the next two days. The landfall track is for informational and reference purposes at this time.

Rainfall amounts across Haiti could range from 4 to 8 inches in a period from Friday through Saturday.

Updates will follow on Wednesday, unless conditions warrant an updated forecast before that time.

CHOLERA OUTBREAK: MAISSADE-HINCHE AREA

A Cholera Treatment Center (CTC) is being stood up in response to the abrupt presentation of 40 patients beginning two days ago to the hospital in Hinche from the Maissade region. MSPP is engaged with PIH, JPHRO, Medishare, and others, and the Hinche CTC will be operational by tomorrow. The Mirebalais CTC should be ready by Thursday or Friday.

HEAS SITREP 11.1.10

SUMMARY

As of Friday, October 29th, PAHO has reported more than 4,700 cases and more than 330 fatalities (apparent case fatality rate approximately 7%). PAHO was unable to report updated statistics because MSPP had not released them on Monday, Nov 1st. Statistics quoted by the media over the weekend indicate fatalities approaching 340. If approximately 25% of cholera cases are clinically apparent, then a highly conservative estimate places the true case count at nearly 19,000. We estimate the case counts to be closer to 40,000 based on the level of under-reporting and rural transmission occurring in areas not being serviced by responders. Cholera epidemics often follow a waxing and waning pattern of transmission and therefore can be unpredictable.

KEY UPDATES
Further evidence of cholera transmission in Cite Soleil has not been reported, which is a key sentinel site for the greater Port au Prince area. Vigilance and sensitization for cholera in Cite Soleil has been elevated to the maximum extent possible.

We are aware of 12 confirmed cases of cholera reported within PAP but not publicly reported by officials.

Suspect case samples have been sent from Leogane to LNSP for processing, indicative of a high index of suspicion and a highly sensitized local surveillance grid.

Field teams operating in Artibonite have reported back today that the true case counts are far higher than is officially reported due to the following factors:

1. Evidence of pervasive transmission throughout the Artibonite region along rivers and tributaries. Seeding of tributaries has been reported, which again strongly raises the question of ecological establishment, and a "rolling" pattern of transmission from village to village downriver has been reported.

2. Rural community transmission is “off the grid” and often have little to no access to safe drinking water or sanitation- conditions that existed prior to the earthquake.

3. Lack of appropriate infrastructure to support situational awareness and strongly suspected political interference to report accurate case counts.

4. Little presence of public health officials or epidemiologists in rural areas.

The Health Cluster has, to some degree of success, mobilized medical response (Cholera Treatment Centers, CTCs) for key patient catchment sites such as St Marc and Arachaie with surge capacity created in PAP, Carrefour, and Leogane. However, rural transmission continues in areas distant from these CTCs. Laboratory diagnostic capacity is severely limited and localized to main patient catchment areas, limiting an ability to rapidly confirm and plan intervention at sites throughout the countryside. We recommend a high index of suspicion and to not wait for official confirmation to respond.

The major rainy season normally peaks in October and persists through November. The prospect of Tropical Storm Tomas gaining strength to become a Category 1 hurricane before causing potential damage and heavy rain in Haiti further complicates attempts to gain control of the epidemic.

STATUS OF THE BIOSURVEILLANCE GRID

The U.S. Centers for Disease Control and Prevention have officially declined to provide funding and operational collaboration to the 400+ overlapping social networks of responders represented by the HEAS. This represents the second time CDC has declined to fund and participate. 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 Internally Displaced Persons Syndromic Surveillance system (IDPSS) has once again been resurrected by CDC in support of MSPP to provide situational awareness response support.

This system collapsed several times and was unable to produce actionable early warning during the post-quake period. The IDPSS did not provide early warning of the current cholera epidemic and has not provided continuous situation reports or data outputs to the response community.

CDC has decided to activate a cholera-specific surveillance system predicated on commune reporting through mobile teams. It is unlikely this approach will reach operational maturity quickly enough to enable proactive and strategic response. Without integrative collaboration, both the IDPSS and the cholera-specific surveillance systems will provide only a partial view into the crisis and will not promote maximally efficient deployment of surveillance and response resources.

CONCLUSION

Current evidence of under-reporting particularly from rural areas and case foci that appear and disappear without on-site public health evaluation, lack of timely situational awareness reports from public health, and refusals to interface with medical responders indicate an overwhelmed public health capacity complicated by political sensitivities.

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