CHOLERA AND POST-EARTHQUAKE BULLETIN #24

HaitiHealth Cluster Bulletin Cholera and Post-Earthquake Response in Haiti - #24
Report
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Pan American Health Organization, World Health Organization
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HIGHLIGHTS

A vulnerability analysis was carried out based on information provided by the MSPP, PAHO/WHO, and health partners, while taking into account combined risk factors from Health and WASH sectors. In addition, aspects such as population density, camps, access to water and sanitation, attack rate, mortality, and socioeconomic status were taken into account to evaluate the risks. Based on this analysis, it is reasonable to expect the first outbreaks in the Departments of West (including Port-au-Prince), South and South East, whereas Jeremie, Cap Haitien, and Port de Paix have been identified as highly vulnerable localities as well. Financial gaps for response to potential outbreaks are observed with MSPP and certain NGOs whose cholera funds are expiring.

Several donors (ECHO, USAID) have indicated that new funds to respond to potential cholera outbreaks are available.

The number of new cholera cases nationwide continues to decrease. The number of new cases in Northeast, Center, Port-au-Prince, North, Northwest, Artibonite, West, Nippes and Grande Anse departments are stable or decreasing. However, cases in South and South-East are increasing, potentially confirming the above mentioned vulnerability analysis.

REPORT

The Ministère de la Santé Publique et de la Population (MSPP) and PAHO, the Regional Office of the World Health Organization (WHO) for the Americas, coordinate the Health Cluster. MSPP Cluster Contacts: Dr. Claude Surena; Dr. Jean Hugues Henrys; PAHO/WHO Contacts: Dr. Juan Carlos Gustavo Alonso; Dr. Josep Vargas

Health Cluster partners are asked to contribute to this bulletin with information on
needs and activities as well as corrections to content, by emailing
hai.clustersante@paho.org (subject heading: Health Cluster Bulletin).

For useful information on meetings, guidelines, and CTC, CTU, and health facility locations, visit: http://haiti.humanitarianresponse.info.

Dear health partners,

At the start of the rainy season, we observe an upsurge in cholera outbreaks. The Health Cluster is continuously gathering information regarding the response capacity and short and medium term plans of health actors, and coordinating responses in
outbreak areas. We appreciate our partners‟ and other health actors‟ efforts in response to these outbreaks.

SITUATION OVERVIEW

On 17 April 2011, the cumulative number of reported cholera cases was 285,931, including 4,870 deaths. The observed cumulative incidence of cholera cases since the beginning of the outbreak was of 27.3 per 1,000 inhabitants, ranging from 5.2 per 1,000 in the Department of South-East to 40.8 per 1,000 in the Department of Artibonite.

Overall, the number of medical staff from health partners has been reduced in most CTCs and CTUs. Medical staff has been trained and employed in the CTUs established in health centers. NGOs are mostly phasing out due to the decrease in cholera cases or due to the lack of funding. However, health partners continue to support regular training and refreshment courses for local medical staff, maintain a surveillance system to monitor the evolution, and assess of the potential need to reactivate their response.

Partners in Health (PIH) / Zanmi Lasante (ZL) were victims of acts of violence following the publication of the second round legislative elections in Belladere in Center Department. On April 21, arson claimed the life of a PIH staff member, while other staff and their family members were wounded in the attacks. The hospital where PIH was working has been evacuated and PIH staff members as well as the Cuban Medical Brigades have left Belladere. Despite the recent acts of violence that have occurred, PIH remains committed to serving their communities in an impartial manner.

The French Red Cross has completed its cholera activities this week. A final evaluation of the cholera emergency activities will be conducted and disseminated shortly.

Irregular payment of salaries to local health staff continues to represent major risks that can jeopardize the response capacity at local and departmental level in case of sudden increase in the number of cholera cases or any other major outbreak. Certain UN agencies and NGOs are able to provide temporary incentives as a short term alternative. However, it is expected that the MSPP ensures payment of salaries.

The WASH sector remains of paramount importance. The chlorination of water systems and water trucks to the metropolitan areas has been a huge progress, despite the challenges that this method still faces. There needs to be attention to the private companies and alternative treatment systems being used so as not to have resurgence within the urban areas. In rural areas, the treatment of water remains an unresolved challenge.

An upsurge in cholera outbreaks in isolated areas has been observed in different parts of the country. In these circumstances, in addition to the need for heightened vigilance, there must be verification of alerts and strengthened coordination to provide a rapid response. It is of paramount importance to increase efforts to facilitate access to drinking water and sanitation throughout the country as well as to strengthen hygiene and health promotion at community level through community health workers and brigadiers to keep number of cases under control.

EPIDEMIOLOGICAL SURVEILLANCE
Indicator-based component

• On 17 April 2011, the cumulative number of reported cholera cases was 285,931, including 4,870 deaths. The observed cumulative incidence of cholera cases since the beginning of the outbreak was of 27.3 per 1,000 inhabitants, ranging from 5.2 per 1,000 in the Department of South-East to 40.8 per 1,000 in the Department of Artibonite (Figure 1).

The overall observed case fatality ratio was 1.7%, ranging from 0.8% in Port-au-Prince to 8.0% in the South-East department. Since the beginning of the outbreak, at least 88.5% of the reported cases were observed among individuals aged 5 years or more (252,972 out of 285,931 individuals for whom the age is known).

Of the total number of reported cholera cases as of 17 April 2011, 53.9% (154,041) has been hospitalized since the beginning of the outbreak (Figure 2).

EVENT-BASED COMPONENT (ALERTS)

The number of daily alerts received from partners in the field is slightly increasing. The alerts are now also reflecting hazards other than cholera and cholera hot spots in remote areas, including rainy season, elections, and phasing out of CTCs and CTUs. It also includes calls by health authorities and partners involved in surveillance activities for heightened attention at the health care facility and community level.

WASH (ENVIRONMENTAL HEALTH)

Poor access to water and sanitation infrastructures remain the principal challenge that needs to be overcome in order to improve health conditions of the population. Less than 50% of the total population has access to drinking water and only 16% of homes have latrines. In health care centers, the lack of access to safe water is still an unsolved problem that contributes to the expansion of water related diseases, like cholera. Currently, PAHO is identifying and executing water and sanitation projects in health care centers, including health care waste management.

A workshop was organized in Jacmel to introduce a UNFPA/PAHO-supported survey in 12 health care centers regarding sanitary conditions. The survey has already been completed, and many MSPP personnel from Nippes and South-East departments were invited to discuss the observed results. Some initiatives were identified and several projects in health care centers will be carried out over the coming weeks.

MENTAL HEALTH & TOBACCO

The WHO-AIMS evaluation is in its final phase of data gathering and evaluation report drafting. The preliminary results have been shared with the Mental Health Working Group.

The working group that formulates the Mental Health Policy and the National Plan remains dynamic. This group consists of the MSPP, PAHO/WHO, national and international mental health actors and several experts from universities (Toronto, and Montreal). The drafting of the national policy document is currently being finalized and the working method for the mental health national strategic plan has been established.

The main themes that should be included in the plan have been selected on the basis of the preliminary results of the WHO-AIMS evaluation. Sub-thematic working groups will be appointed to develop the different aspects of the future plan, which are:

- Mental Health in Primary Health Care
- Community-based Psychosocial Services
- Preparedness and Response to Mental Health in emergencies
- Mental Health and disability issues
- Mental Health in Prisons
- Mental Health and Addiction
- Mental Health and traditional health practitioners,
- Psychiatric Care in Hospitals, and
- Human Resources / Training and Research

A workshop on the National Strategic Plan for Mental Health will be organized in Port au Prince at the end of June 2011, with the members of the Mental Health Working group and other key actors.

The list of essential psychotropic medicines for the country is being finalized and the proposal will be submitted to the MSPP for discussion during the essential medicines validation workshop.

The 59th Congress of the Haitian Medical Association, which was held in Port au Prince on the 19th April 2011, included a presentation of “Tobacco and Lung Cancer in Haiti”.

HEALTH PROMOTION

A Health Promotion Plan is being drafted with the Health Promotion Directorate of the MSPP. This plan aims to contribute to the improvement of the health status and well-being of all Haitian people, increase their level of awareness and accountability for people‟s health in the communities, and to reduce inequalities in Health matters.

On the 19th of April, the MSPP organized a workshop regarding the CAP survey that was carried out by ARCA, a local company, at the request of MSPP and UNICEF. This study that focused on the three first months that followed the outbreak of the epidemics aims to provide a better understanding of the fight against cholera performed in the country, will contribute to the drafting of new communication strategies for the future. The main objective of this workshop was to harmonize the Health Promotion messages and radio-TV spots.

The Hygiene Promotion sub-cluster is currently submitting to the MSPP for validation a WOW – practices Framework document for hygiene and WASH promotion. This document contains the results of the lessons learned workshop with regard to hygiene promotion in Haiti that was held in 2010.

REPRODUCTIVE HEALTH

On 18 to 20 April 2011, PAHO/WHO, UNFPA and UNICEF representatives jointly visited Nippes department, visiting institutions that participate in the joint reproductive health project. The structures visited are part of the SOG (Free Obstetric Care) program or are candidates to become part of it. Together with the departmental representatives of the MSPP, the representatives visited health facilities in Miragoane, Paillant, Petite Riviere des Nippes, Anse a Veau, Petit Trou des Nippes. The meetings enabled the visitors to obtain fruitful exchanges and discuss issues such as arrears in salary payment and communication issues between partners. The three UN partners will join forces in order to search for solutions to improve maternal and neonatal health of the Haitian population.

SITUATION BY DEPARTMENT

In the sections situation by departments, the following information is presented:

(i) trends of the cholera epidemic (number of reported hospitalized cholera cases by week of reporting, from 8 November 2010 to 17 April 2011; source: MSPP, http://www.mspp.gouv.ht/site/index.php#);

(ii) trends and figures provided by the PAHO/WHO Teams at Departmental level; (iii) alerts regarding public health events received since the publication of Issue 23 of the Health Cluster Bulletin, published on 15 April 2011.1

1 Source routine surveillance data: Ministère de la Sante Publique et de la Population (MSPP), http://www.mspp.gouv.ht/site/index.php#, as of 28 February 2011.

Note: Data presented should be interpreted cautiously as these are continuously corrected and updated (e.g. for some weeks, the cumulative number of cases may be lower than in the previous week; incomplete reports in some departments). Also there might be discrepancies between data presented in this section and those provided by partners and PAHO-WHO Teams deployed at Departmental levels and presented in the dedicated section.

Data provided by the Directions Departmental de Sante and partners to the PAHO/WHO Teams in the field.

Source event based information: alert scheme currently maintained by the Pan-American Health Organization / World Health Organization in Haiti.

NORTHWEST

The overall trend of cholera activity is decreasing.

Hotspots in the department include:

12 April 2011 - In Port de Paix, a suspected case of Acute Flaccid Paralysis was observed in a 7 year old girl at the Immaculate Conception Hospital in Port-de-Paix.

Action - Information was disseminated and samples have been taken and sent to the lab. The MSPP team of the department is investigating.

NORTH

The overall trend of cholera activity is stable or descending in the different localities. Activities are now focusing on the set up of community brigades and the identification of health structures that can care for cholera patients.

Hotspots in the department include:

7 April 2011 - The number of suspected cases of cholera increased in Plaisance and now varies between 11 and 13 per day.

Action - A team from the department, strengthened by CDC, was deployed to Plaisance by April 13, to explain the increase.

NORTHEAST

The overall trend of cholera activity is decreasing.

Hotspots in the department include:

14 April 2011 - An increase in cases of diarrhea in the commune of Mombin-Crochu (17 cases per day) coming from Bois-de-Laurence, and 16 cases per day in Sans-Souci.
Three community deaths were observed in these localities.

Action - Merlin sent a team to the CTU in Mombin-Crochu. PAHO/WHO remains on standby to provide supplies or carry out WASH activities if needed.

ARTIBONITE

The overall trend of cholera activity is stable.

Hotspots in the department include:

8 April 2011 - In St. Marc, three suspected measles cases have been notified at St. Nicolas hospital, concerning one child and two family members.

Action - The field team and EPI unit of PAHO/WHO have warned the Direction Departementale, and MSPP representatives have taken samples that were sent to the LNSP.

18 April 2011 - Significant increase in new patients in the CTC at the Albert Schweitzer Hospital of Deschappelles. The current census includes 17 adults and 2 children.

Action- a PAHO/WHO Field Team has been deployed to verify the situation in the commune.

18 April 2011 - St Michel de la Attalaye: IMC has requested support from other partners since the number of cholera cases in St. Michel is continuous to vary. They receive over 120 cases per week.

CENTER

The overall trend of cholera activity is stable with small peaks in the last week.

Hotspots in the department include:

8-10 April 2011 - Communes de Cerca La Source, Thomassique and Lascahobas: From 2-10 April 2011, the CTU of Savanette received 58 hospitalizations and 3 institutional and 8 community deaths were notified. Nearly all patients come from Raspadou. The situation in the CTU is difficult due to a lack of personnel, space, medication, materials and motivation. On 13 April, the personnel of the CTU in Savanette went on strike. Cholera victims have been buried without disinfection, which may have caused contamination of a nearby water source.

Action - After verification of cholera increase in Thomassique (approx. 25 cases) and in Savanette, this information was communicated to UNICEF and other partners. PAHO/WHO and UNICEF are providing the necessary supplies and ensuring the payment of the staff of the CTU. On 14 April, CMB has carried out hygiene promotion sessions, and distributed ORS and Aquatabs. A solution for the financial problems of the CTU is urgently required. PAHO/WHO is providing the necessary materials and rehabilitating the CTU because the tents had been destroyed by strong rain. A tent for 12 beds has been installed.

15 April 2011 - In Mirebalais, an increase in the number of cases of acute diarrhea was observed and patients were hospitalized in the CTC of Mirebalais and received the diagnosis "cholera‟.

Action - The CMB is sensitizing the personnel of the CTC with regard to the need for appropriate diagnostics. Samples should be taken in order to establish the etiological diagnostic of the diarrhea.

WEST

The overall trend of cholera activity is stable with a slight decrease.

PORT-AU-PRINCE

The overall trend of cholera activity is stable and slightly decreasing.

Hotspots in the department include:

14 April 2011 - A suspect case of AFP was notified at the General Hospital in a 4 year old boy.

Action - the department authorities of the MSPP are investigating the case.

17 April 2011 - Possible cholera outbreak with 7 suspect cases at orphanage Foyer d‟Orelph (Croix des Bouquets) that assist 53 children.

Action - Notification has been sent to MSPP and departmental epidemiologists for verification and action if needed.

28 April 2011 - A sharp increase occurred (84 cases in two days) in Potineau, in Cornillon Commune.

Action - A team consisting of PAHO/WHO and ALIMA staff has been deployed to the area.

SOUTHEAST

The overall trend of cholera cases is increasing.

Hotspots in the department include:

10-18 April 2011 - Increased number of cholera cases in the CTU in Thiotte, with 90 patients during the busiest day and 2 community deaths. Most cases come from Grand Gosier, where there is no CTU since there has never been a cholera problem. The cases originate from Domas (including the deaths), Bodarie and Boulay communes.

Action - PAHO/WHO, Save the Children and OCHA assessed the situation in Thiotte and provided supplies. Save the Children, who manages the CTU, is hiring more personnel, MSPP has sent nurses and PAHO/WHO is assisting with funding. A WASH team has been deployed to investigate the source of infection, likely from a river source. Awareness activities are underway, together with supply of ORS, Aquatabs, soap, jerry cans etc. The Cuban Brigade sent a team to Domas, to treat patients in their homes and provide prevention activities. One of the biggest problems is the disposal of dead bodies. Due to a political conflict, dead bodies from the CTU are not transported to Grand Gosier. Mediation is ongoing.

13 April 2011 - Rise in community deaths (3 deaths in children under 5 years old) notified in Bainet. Within 4 days, there were 5 community deaths.

Action - Verification has been carried out by Save the Children, but rise is not considered a peak. Save the Children is monitoring the situation.

13 April 2011 - In Jacmel prison, some 25 suspected cases of Tuberculosis have been observed. The St. Michel hospital in Jacmel refuses to attend to these prisoners without certificates that cost 100 gds each stating that they need medical care.

Action - Field team is assessing means to pay for the tests and medical certificates. The prison is in need of medical supplies.

15 April 2011 - End of March, there were rumors of 25-30 cholera cases with 5 fatalities in Côtes de Fer. Since the peak of March, there have been very few cholera cases, probably due to the sensitization activities. Plan Haiti is building a CTU, but lack of funds will likely to prevent them from opening.

18 April 2011 - In Peredo (Marigat area), the dispensary received their first cases in over 2 weeks, coming from Savanne du Bois. A pregnant woman died in the community from a suspected case of cholera.

Action - The MSPP is monitoring.

NIPPES

The overall trend of cholera activity is stable.

Hotspots in the department included:

25 April 2011 - Increase in cholera cases in Baraderes. 52 cases were seen, 22 hospitalized and 3 deaths.

Action - PAHO/WHO along with PAH ensured that enough cholera supplies were given to the health centre in Baraderes. So far, health facilities have enough supplies and enough bed capacity.

SOUTH

The overall trend of cholera activity is increasing.

Hotspots in the department included:

17-23 April 2011 - The trend of cases was going downward in the department of South but as of last week, it is going upward again. During the week of 17-23 April, 341 cases were seen with 241 hospitalizations in the South, mostly originating from Les Cayes: (215 cases seen, 163 hospitalized cases and 2 deaths).

Action - PAHO/WHO along with PAH ensured that enough cholera supplies were given to IMC in les Cayes. So far, health facilities have enough supplies and enough bed capacity, but this situation might change at the end of the month as curative services suppliers, IMC and British Red Cross, will pull out of cholera activities completely.

GRANDE ANSE

The overall trend of cholera activity is stable.

Hotspots in the department include:

15 April 2011 - In Moron, rumors mention over 30 new cholera cases.

Action - an MdM team went to Moron, and observed an increase of cases, all coming from Moron. Merlin is ensuring case management.

15 April 2011 - Surveillance data are missing for several centres, since CTC/CTU staff have not been paid since several months. For the moment, the staff is going to work but this situation may not last much longer.

18 April 2011 - In Pestel, an important water shortage (and lack of rains) has been observed, in addition to an absence of WASH activities.

25 April 2011 - In Marfranc, an increase in cases has been observed.

Action - MdM provided supplies.

25 April 2011- In Chambellan, 2 patients died out of 9 hospitalized between the 20th and 24th April.

A list of most frequently-used acronyms related to the response to cholera in Haiti is available at
http://new.paho.org/hq/index.php?option=com_docman&task=doc_download&gid=11788&Itemid=