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Published Date: 2010-03-07 13:00:03
Subject: PRO/AH/EDR> Disease situation, post-earthquake - Haiti (02)
Archive Number: 20100307.0750

DISEASE SITUATION, POST-EARTHQUAKE - HAITI (02)
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A ProMED-mail post
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International Society for Infectious Diseases
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Date: 5 Mar 2010
From: James Wilson
<iceaxe5@gmail.com>

5 Mar 2010 Notes -- Petionville and immediate area
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Staying with the Jenkins Penn Haiti Relief Organization (J/P HRO),
who are coordinating the integrated humanitarian relief effort at
Petionville. This includes the 82nd Airborne, HP, Demira (German
NGO), Save the Children, International Medical Corps (IMC),
MSF-Holland, Oxfam, and Catholic Relief Services (CRS), and the
smaller NGO and unaffiliated individuals cycling through the J/P HRO
camp. J/P HRO has been running "Strike Teams" out to locations such
as Cite Soleil. There is no UN [United Nations] or other major NGO
[non-governmental organization] presence in Petionville. The Centers
for Disease Control and Prevention (CDC) was recently here describing
how to fill out the formal medical surveillance forms.

At the foot of the hill below us lies an IDP [internally displaced
persons] camp with an estimated 80 000 people, which I surveyed this
evening. There is raw sewage everywhere, as evidenced also by the
odor. Haitians are cooking in the open, and there is music and
children playing everywhere and much singing. The overall mood is not
one of depression but of happy resilience. It was truly remarkable to see.

One thing that impressed me was the mud. It is a slimy clay, owing to
periodic rainfall seen here over the last couple of days. It is
pouring rain as I'm typing this now. The clay is so slippery, it is
very hard to walk on -- you worry about losing your step and falling.
The vehicles cannot make it up the very mild slope even in 4-wheel
drive now, never mind how it might be with sustained rains. Catholic
Relief Services indicated some of the roads were already too
dangerous for the food supply trucks.

Multiple nurses with ICU [intensive care unit] and ED [emergency
department] training (one of whom was a Haitian-American), a
physician assistant, several EMTs [emergency medical techicians] and
medics, physicians (both US and native Haitian) were interviewed. I
specifically avoided "leading the witness" in the process to allow
them to express their concerns and observations without bias.

There is zero laboratory capability here. All diagnoses are clinical
and are influenced by prior exposure to the diseases seen. Syndromic
diagnoses are prevalent as a result. Culturally, the Haitians call
"fever" anything that hurts them. They also have a heightened sense
of mortality right now, which explains the high psychosomatic illness
being seen -- likely PTSD [post traumatic stress disorder].

No trauma presentations have been seen in the last 2 weeks. Overall,
responders estimate 50-80 percent of all visits they see are
psychosomatic. There is a social driver here [--] Over The Counter
(OTC) medications are expensive here: 3 days' salary buys 6
[acetaminophin tablets].

The responders unanimously indicated effective biosurveillance and
early warning was "far more important than anything we are doing, we
need prevention at this point." They are all very concerned with
flooding bringing an increase in infectious disease, including the
Haitian health care providers. People stopped me repeatedly to
express their concerns and share their observations.

Infectious diseases seen at Petionville, Freres, and Cite Soleil include:

- At least 50 percent of the children have diarrhea -- unable to
ascertain what the actual baseline is, and the Haitian physicians
cannot articulate this either. The Haitian-American nurse, with years
of experience working in Haiti, strongly believes the prevalence is
unusual and non-routine. The Haitian physicians indicate they
typically see increases of diarrhea, acute respiratory disease (i.e.,
colds), and malaria after flooding. Four out of 40 responders in this
camp had to be placed on an IV [intravenous medication drip] for
diarrhea / dehydration. Approximately one-third of them have had some
form of gastroenteritis while here, treated immediately with Cipro
[ciprofloxacin] which appears to take care of the problem. Problem
was suspected to be related to use of Haitian workers to prepare camp meals.

- Viral meningitis at Mas Villa, a 47 y/o woman, seen 2 weeks ago
and transferred out for intensive care

- All clinical forms of syphilis have been seen

- Active TB -- 2 kids, 2 adults plus one fatality and 5 additional
cases seen by the Haitian physicians; drug resistance profile unknown

- One child with typhoid. Typhoid is seen sporadically and
occasionally in small clusters according to the Haitian physicians.

- Suspected case of dengue fever in Cite Soleil

- No pandemic influenza reported by anyone, and the responders have
seen pH1N1 infection in the states. The Haitian physicians indicated
no influenza epidemic has occurred yet in Haiti, which is an
important point I need to follow up on.

- Bloody diarrhea seen in a baby one week ago that required
treatment with IV Cipro plus 4 additional pediatric cases in the last
week -- bloody diarrhea in children is not a typical finding
according to the Haitian docs

- Pneumonia, etiology unknown seen in multiple patients, had one
responder develop a left lower lobe pneumonia, etiology unknown

- Chickenpox outbreaks of usually 5 people at a time

- Tremendous prevalence of yeast infection, vaginitis, and UTIs

- Very high worm burden

- Very high lice and scabies burden

- No tetanus or gangrene

- No measles, however see below for vaccination status. According to
Haitian physicians, measles is typically seen in July, August, and
September in Haiti. This is the 1st time I've seen a seasonality to
measles expressed for Haiti.

Vaccination status is a serious issue. The Red Cross apparently came
to vaccinate, but they provided vaccinations at a time when the
majority of the IDP camp inhabitants had already left to seek work
during the day. It also happened to be raining that day. It was
strongly felt by the Haitian health care providers that pre-education
was needed for the entire camp because when word spread about sore
arms and the occasional post-vaccination fever, very few showed up
for the 2nd day of vaccinations. Red Cross left the area, leaving a
best estimate only 20 percent of the population vaccinated. No one
knows if or when they will be back.

There is a substantial malnutrition and vitamin deficiency problem
here. Multiple cases here in camp of pica in children. There has been
a major problem identified with mothers of newborns not producing
breast milk due to stress, lack of food, dehydration, and other
factors. As a result, the responders have seen mothers trying to give
babies straight water and mashed rice and beans -- both of which are
likely contaminated and horrible for the baby's electrolyte
maintenance. Without the immune protection offered by breast milk, it
is easy to see why the babies have diarrhea... And why fatal outcomes
have been seen.

The responders have seen a problem with inappropriate wound
management, where [amoxicillin clavulanate]is being overused, and it
is causing diarrhea. The majority of the wounds seen are granulating
with no evidence of infection and thus do not require antibiotics.
Same problem with doxycycline being used to treat malaria, where they
are seeing diarrhea in these patients suspected to be caused by the
antibiotic itself.

In terms of available pharmaceuticals, the entire camp ran out of
oral rehydration salts long ago (they were in high demand), no iron,
no vitamins, no perinatal vitamins. High demand for abendizole for
pinworms, cipro, and ceftriaxone for STDs [sexually transmitted
diseases]. I will look into this more deeply at a later date.

There is an environmental health professional here who is testing the
water supply provided by Oxfam. Normal acceptable levels for free
chlorine in US tap water is 0.3 ppm. Testing of the water supply
provided to the locals here indicates a level of 0.5 ppm, however
variability has been noted. There is no formal water quality control
or testing program here. That said, it was the impression of the
environmental health professional that public education campaigns for
proper handling of treated water and hand washing should be a top
priority now. He was skeptical if it was feasible to implement this
given the strong cultural bias to litter and not adhere to proper
sanitation practices.

In regards to formal medical surveillance encouraged by the CDC here
a few days ago, the overwhelming response was the responders did not
have the time to go through elaborate forms, the forms were not
translated to either French or Kreyol [Creole], and the Haitians
themselves did not appear to fully understand the definition of the
field entries. The Haitians were eager to participate in formal
surveillance but the responders were not.

In cross-checking our last SitRep of 1 March 2010 [see below], I
believe we are going to have to adjust the assessment based on the
poor vaccination coverage in the face of the rains.

--
James Wilson, MD
<iceaxe5@gmail.com>

[ProMED-mail would like to thank Dr. Wilson for sharing this
information with our subscribers.

There is a website with a blog titled "Haiti: Operational
Biosurveillance that is available at
<http://biosurveillance.typepad.com/haiti_operational_biosurv/>. The
main page provides links to specific reports on the current
identified health issues identified related to the post-earthquake
health situation in Haiti. Included in this is are the Haiti Epidemic
Advisory System (HEAS) Situation Reports (SitRep's) that appear to be
issued on a weekly basis, with the most recent available report dated
1 Mar 2010 and can be found at
<http://biosurveillance.typepad.com/haiti_operational_biosurv/2010/03/haiti-epidemic-advisory-system-heas-sitrep-updated-1-mar.html>
[this moderator suspects this is the SitRep referred to above in Dr.
Wilson's 1st hand report on the situation]. The reports are a
conglomeration of reports from the variety of responding groups
including NGOs and the UN Health Cluster.

According to the CARICOM report available on the ReliefNet website,
as of 23 Feb 2010, approximately 1.3 million persons in Haiti are
living in spontaneous settlements (see
<http://www.reliefweb.int/rw/rwb.nsf/db900sid/MUMA-83A2S7?OpenDocument&rc=2&emid=EQ-2010-000009-HTI>
for full update report as of 3 Mar 2010).

The observations in the above 1st hand report are not unexpected
observations following a major disaster event -- the identification
of disease transmission of diseases that have previously been known
to be endemic in the country, and increases in diseases associated
with crowded living conditions and disruption in the routine health
infrastructure in an area. The challenges mentioned in the
vaccination efforts on the part of the relief organizations are
similar to challenges that governments have faced when planning
vaccination campaigns -- the need to plan vaccination sessions on
days and times of days when children and their caretakers are
available, and the need to set up vaccination posts near to places of
work/congregation of caretakers with the target aged children.

With respect to pandemic H1N1 transmission, a review of the various
reports available suggests that there has not been actual testing for
the influenza virus, so definitive information on the presence or
absence of the virus and its association with the respiratory
illnesses seen is not available.

According to reports from other areas involved in the relief effort
(outside of Petionville), cases of tetanus have been seen.

ProMED-mail has posted separate reports associated with specific
disease events (see references below on malaria, tuberculosis and
meningococcal disease) that have been reported on.

Of note is the identified major component associated with probable
post traumatic stress disorder (PTSD). There is an excellent review
of PTSD following disasters. Galea S, Nandi A, Vlahov D. The
Epidemiology of Post-Traumatic Stress Disorder after Disasters.
Epidemiol Rev 27 (1): 78-91. (2005) (full article available at
<http://epirev.oxfordjournals.org/cgi/content/extract/27/1/78>. The
supplemental tables referred to in the text are available at
<http://epirev.oxfordjournals.org/cgi/data/27/1/78/DC1/1>.). Webtable
2 shows a summary of studies addressing the incidence of PTSD
following disasters ranging from 37 to 59.4 percent among survivors
and 13.9 to 15 percent among rescue workers/first responders. The
observations in the 1st-hand report along with prior studies
emphasizes the need for mental health specialists to be an integral
part of the relief effort once the initial acute traumatic and
medical issues are addressed. - Mod.MPP]

See Also