BIOSURVEILLANCE UPDATE - 9

OPERATIONAL BIOSURVEILLANCE

FIELD NOTES FROM A MEMBER OF THE HEAS "SWARM RESPONSE"

From one of the HEAS partners, a frontline medical responder, sent to us on the 3rd. It highlights the challenges of managing the crisis and having effective situational awareness coupled to rapid response. This HEAS partner is an example of a "swarm response network", where they are autonomously filling in key gaps in verifying reports of cholera followed by activation of response should the need arise. This independence is a major strength of the HEAS.

We have a team in St Mark trying to help sustain their regular medical services which are always at risk of being lost with implementation of a cholera treatment centre if it uses your hospital. We have handed our rehydration centre in Villard over to the local nurses who we continue to employ for the week and then will hand over completely. They continue to see 55-60 patients per day with 1-4 needing IV treatment who they send to hospital. Most patients come from areas without roads or information who have been slow to 'hear the news' and who have little choice for water except the river.

We have had no more cases in Cite Soleil so far and none in Cabaret although they are reporting every case of regular diarrhea to us and we go verify the symptoms. We have not seen anything yet that concerns us. We are trying to secure a site in Cite Soleil for a CTC because we notice there is still no site listed on the health cluster's list of CTCs they publish daily. The church/school/clinic yard we work in is reluctant to let us treat cholera there, although i tell them there kids will be swimming in it inside or outside the gate regardless if it hits Cite Soleil.

We are holding a training session for the medical community of Cabaret commune Sunday afternoon to review and make available the treatment protocols and the educational material put out so far. We will also make call out lists of staff to work in CTCs in the area and have the city of Cabaret select where they will like a CTC site should they need it so we can help them set it up. We realize in talking to many Haitian medical providers that they do not access these sites and therefore have no knowledge of the protocols, the sensitivity testing, educational materials or the current updates of the situation. This means they have a difficult time responding to their own crisis...

REPORT OF OVERWHELMED HOSPITAL IN ST. MARC

While medical response in St Marc has been augmented with the support of Cholera Treatment Centers (CTCs), we have report of a hospital collapsing under the strain:

I got a call from a nurse in St. Marc last night. She was quite distraught in that they had run out of IV kits and the hospital (I don't know which one) was maxed out with patients. They didn't even have cups with which to give people ORS. Is it possible to put out to the HEAS group the need for IV kits in St. Marc? I am waiting to hear back from her which hospital she's in.
HEAS has activated swarm response to the query.

OUTBREAK AT SAULT D'EAU

We went out to Sault D'Eau (waterfalls in mountains 24km past Titanyen, 12 km from Mirebalais) this afternoon in response to reports of cholera deaths out there. There were 5 patients seen for clear cholera symptoms yesterday at the MSPP clinic. All required IV treatment. 1 was still in clinic today. There has been one death reported by the clinic since Monday. Interview revealed the single patient in clinic today had not left the area or participated in any weekend festivities in the falls. Apparently they do not drink from the river there, but have a capped spring and local springs, one from which she drank. The community says most sick people are from just outside town and at least 100 have gone straight to Mirebalais very sick with diarrhea and vomiting. Cases started Monday. Samples of the patient and of the river and water source from which she drank have been collected and will be sent to the national lab/CDC tomorrow.It seems what many feared would occur after the meeting of many at the falls this weekend has begun...

FLASH REPORT: CHOLERA IN GROS MORNE

From an HEAS Partner:

Back from Pendus. Left 12 staying at the clinic, at least 6 to be discharged tomorrow. The hospital here in town (Gros Morne) has two tents to hold overflow of cholera sick. 40 admissions today. There are lots of cases of anxiety.

FLASH REPORT: CHOLERA OUTBREAK/FATALITY IN BAS LIMBE/CAP HAITEN REGION

This message just came in this morning from one of the HEAS partners in Bas Limbe.

Key observations:

1. Rural areas continue to see transmission and adverse clinical outcomes due to lack of medical infrastructure or capacity to handle case loads

2. Smaller NGOs and personnel working in these environments are easily overwhelmed and thus vulnerable

3. The disparity and number of sites expected to report in a similar manner will overwhelm public health capacity to respond rapidly and proactively.

4. The forecast of tropical storm / hurricane with potential for flooding portends expanded transmission."I know you are crazy right now but I'm sorry to report that we have more V/D in the north and had a death yesterday in our village, he was from a small area called Mongoio.

This is the message I got from my staff. Our clinic is in Bord de Mer Limbe, 30 minutes north of Limbe, the region is known as Bas Limbe.

My staff had a total of 7 cases of V/D in the last 24 hours with profuse watery diarrhea. We have 2 other cases who are at home with severe sxs, but fear has started and no one will transport these people to the hospital. Already this morning we have 70 people lined up at our small clinic, and they are getting aggressive and upset. MSPP had sent a rep yesterday and are supposed to send a doctor today to help with the situation.

We are doing our own public education, and hopefully MSPP will send more support today. I'm going to send message out to MSPP myself about this situation.

My concern Jim is the fear...and the people becoming aggressive. Small villages can be just as bad or worse than cities.

Report of the patient:

He came in at 6;30 am (symptoms were 24 hours prior to presentation)
He was 25.
He came in with a day of diarrhea - started monday and he came in tuesday morning
We could not get his bp
He had vomitting and diarrhea all day
He received iv fluids
Was able to keep some oral fluids down
Gave him I.m. Ceftriaxon and oral cipro and flagggel aqnd doxyycyclen.
He had extra-intestinal worms on rib cage and felt as he had worms in his abdomen
His stool was mucous looking just liquid
At one point during the we thought we gave him too much iv fluids andhe had fluids in his lungs
He was very skinny, a sunken in face, malnutrition was obvious.
His skin was shrivelled.
We had enough supplies to give him iv fluids.
We no longer have supplies."

We posted an immediate request for personnel and materiel assistance to the now-500 member HEAS network.

Our advice to this HEAS partner was to be very careful about the nexus of cholera treatment and proximity to schools, markets, or recreation areas (i.e. soccer fields). We were concerned about the medical team's safety. This was the response:

"Thanks Jim.
I just sent a message to MSPP for the north. Apparently he was in the village yesterday and said he was going to send a "doctor" today but who knows what we will get.

I'm worried about my staff. They were up since 330 am and are taking the death quite hard. I've just got 3 docs there, but this is their first time in Haiti and they only arrived 5 days ago.
About aggression, we were treating patients in the school yesterday, so we've closed the school today to do cleaning. We do have a truck on standby as well and can transport to the hospital in Limbe.

Apparently when MSPP as around yesterday, they did take a sample from one person and it was positive for cholera. The also sent someone to the hospital, but they sent them to Cap Haitian, which is over 60 minutes away and not the nearby hospital in Limbe. Bon Samaritan is the local NGO hospital and there is a government hospital there as well.

I've asked MSPP in an email where they want me to send people as a referral centre. My staff also have their phone number on the ground.

Any support you can send would be great. I'm also going to send a message out to our Cap Haitian Health Network so that people are aware. My supplies are already down, but we are sending out a major public education campaign in home made ORS today.