Showing posts with label Haiti. Show all posts
Showing posts with label Haiti. Show all posts

Sunday, June 15, 2014

Dealing With Uninvited Guests

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Aedes Albopictus – Asian Tiger Mosquito

 

# 8746

 

Yesterday Dr. Jen Halverson left a highly informative comment on my PAHO Chikungunya Update blog, which describes her impressions of the outbreak in Haiti, and is deserving of additional exposure.

 

The situation is Haiti is, as you said, very badly underreported. I got chikungunya (confirmed by testing in the US) on 5/14. I was one of the first cases among my friends. The vast majority of my ex-pat friends in Port au Prince have had it. Other cities are very affected as well. The majority of my Haitian friends and colleagues have already had it. My conservative estimate for Haiti is at least a million cases so far, and probably more. We will obviously never know the true numbers. I have been working in Haiti for 16 years (I'm an ER doctor) and I've never seen anything like this.

 

My thanks to Dr. Halverson for this sobering first hand report, and for the work she does under difficult conditions.  

 

Her account is all the more concerning as the rainy season in Haiti is really just getting underway. While tropical temps abound year-round, the rainy season runs from May through October, and can be greatly exacerbated by tropical storms and hurricanes which most often arrive in August and September. 

 

It is worth noting that this first Chikungunya outbreak began in late November of last year, after the end of the traditional rainy season, and has spread with remarkable efficiency during what are considered the driest 6 months of the year.

 

As you can see by the following CDC chart for Puerto Rico, dengue (which is spread by the same types of mosquitoes as Chikungunya), usually peaks in late September, during the height of the rainy season.   

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Given the Chikungunya outbreak in the Caribbean, public health departments here in Florida and around the United States, are urging people to be more diligent about removing breeding places for mosquitoes around their homes.

 

But it isn’t just outside the home where people need to check . . .  some mosquito species are perfectly capable of setting up light housekeeping inside the home as well.

 

While the Aedes aegypti has long been associated with spreading nasties such as yellow fever, dengue and Chikungunya, in 2005 a mutation in the envelope protein gene (E1-A226V) of the Chikungunya virus was credited with allowing Aedes Albopictus or `Asian tiger’ mosquito to transmit the virus efficiently (see A Single Mutation in Chikungunya Virus Affects Vector Specificity and Epidemic Potential). 

 

An important development in that the `Asian tiger’ mosquito is both well distributed around the world, and that it is a very aggressive daytime biter.  

 

While most often found outdoors, research has shown that the Ae. albopictus lives longer, may exhibit increased nighttime biting activity, and produces more offspring when living in an indoor environment (see PLoS One Indoor-Breeding of Aedes albopictus in Northern Peninsular Malaysia and Its Potential Epidemiological Implications).

 

Although this particular study was set in Malaysia, the Aedes albopictus mosquito has made extensive inroads in the rest of the world over the past 40 years, and is considered one of the top 100 worst invasive species according to the Global Invasive Species Database.

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Dark Blue indicates the A. Albopictus native range, while green indicates new introductions in last 40 years.

 

Having lived aboard a sailboat in the Florida keys around the Everglades,  I can assure you that well-fitted screens are your most important barrier against indoor mosquitoes.  Yet, despite your best efforts, some may still get inside. 

 

Since mosquito larvae can grow in as little as a tablespoon of water, it is important to consider indoor potted plants, and other places where stagnant water may exist, as well as outdoor breeding places.  Aedes mosquitoes have been been found breeding in such unusual places as Waterpiks, fridge trays, and seldom used toilets (according to the Miami Herald Mosquitoes carrying dengue fever can live indoors).

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Source - Mosquito Control Measures CHIK (2.0 MB PDF)

 

Given the risks posed by Chikungunya and dengue (and that of other mosquito borne diseases in the U.S., like WNV, EEE, & SLEV), it makes sense to take proactive mosquito prevention steps to protect you and your family.

 

So today would be a good day to go around and look for likely breeding places in, and around your home. This should become a weekly habit – at least during mosquito season.

 

And to help you with warding off these pests, we’ve an interactive insect repellant search engine developed by the EPA that will that will allow you to input your needs and it will spit out the best repellants to use.

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(click image to go to search engine)

 

And a final note, if you live in the United States (and this presumably is valid in other places as well), and you are seeing an unusual number of mosquitoes in your neighborhood, call your local mosquito control board and report it.  Quite often they will respond to your request by dispatching inspectors to look for, and eliminate, nearby breeding places.

Tuesday, August 21, 2012

Watching The Tropics

 

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# 6506

 

Although only a tropical depression at this time, the forecast is for TD#9 to intensify to storm strength later tonight (it would be named Isaac), and to hurricane strength by Thursday. 

 

The islands of Hispaniola and Cuba appear to be a greatest risk right now, but a northward curve may put Florida in its sights by early next week.

 

Among the most vulnerable populations along its forecast path are the hundreds of thousands of Haitians who remain in tent cities and improvised shelters following the 7.0 earthquake of early 2010.  Their plight was recently highlighted in a NYT’s article called Years After Haiti Quake, Safe Housing Is a Dream for Many.

 

Even if they are spared hurricane force winds, torrential rains can easily exacerbate the cholera outbreaks that are still ongoing, and can cause severe flooding, and devastating mud slides.

 

September is National Preparedness Month, but today’s forecast should serve as a wakeup call to all who live within range of hurricanes and tropical storms that one is wise not to wait to prepare.

 

Traditionally August is when the Atlantic hurricane season really begins to pick up steam, and that trend usually peaks in mid-September. 

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When it comes to getting the latest information on hurricanes, your first stop should always be the National Hurricane Center in Miami, Florida. These are the real experts, and the only ones you should rely on to track and forecast the storm.

 

The second official information source you should have bookmarked is your local Office of Emergency Management

 

Here you’ll be able to access local warnings, flood maps and evacuation information. To find it, you can Google or Yahoo search with your county/parish name and the words `Emergency Management’.

 

If you are on Twitter, you should also follow @FEMA, @CraigatFEMA, @NHC_Atlantic, @NHC_Pacific and @ReadydotGov.

 

NOAA’s NWS National Hurricane Center in Miami also has a Facebook page, where you can keep up with the latest tropical developments.

 

If you haven’t already downloaded the Tropical Cyclone Preparedness Guide, now would be an excellent time to do so. It is a short (12-page), easy to follow guide that will walk you through the basics of understanding (and surviving) hurricanes and tropical storms.

 

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Sunday, July 01, 2012

Media: Reports Of Cholera In Cuba

 

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Photo Credit  Wikipedia

 

# 6413

 

My thanks to Pathfinder, Gert van der Hoek, and Alert on FluTrackers for picking up and posting early media reports of what appears to be an outbreak of Cholera in Manzanillo, Cuba.

 

Two representative reports, with the first appearing last Thursday in Café Fuerte, which gives 50 people hospitalized, and two dead from the outbreak.  

 

Dos muertos y 50 hospitalizados por cólera en el oriente de Cuba  Por Café Fuerte

 

A translation of the article yields:

 

Two dead and 50 hospitalized for cholera in eastern Cuba Posted on Thursday, June 28, 2012 17:59

By Calixto R. Martínez *

Manzanillo, Granma. - Two people died and more than 50 remain hospitalized in the town of Manzanillo, in eastern Cuba, where authorities decreed a quarantine at the Provincial Hospital Surgical Clinic "Celia Sanchez."

 

Police and State Security agents guard the medical center, according to testimony given by residents in the cities of Manzanillo and Bayamo.

 

Although the government maintained total silence and the news has not spread in official media, the medical situation seems rather complicated.

(Continue . . )

 

 

 

A similar report (albeit with more cases) appeared on Friday in the El Nuevo Herald, a Spanish language daily paper published in Miami by McClatchy (and sister paper to the Miami Herald).  This is a machine translation, hence the mangled syntax.

 

 

Cholera Outbreak in Cuba

Juan Carlos Chavez

jcchavez@elnuevoherald.com

At least two dead and more than a hundred people hospitalized has stopped a cholera outbreak in the Cuban city of Manzanillo, Granma province. The health emergency was presented to half of the deals this week in The fisheries and Around the drain. Cuban government officials have not spoken officially about the situation.

 

"We have suspended sales of liquid ambulatory and have said that police have closed several palates (restaurants) as a precautionary measure," said Roberto de Jesús Guerra, director of Let's Talk Press news agency, based in Havana.

 

(Continue . . .)

 

While the source of this outbreak is not yet known, there is some media speculation that it may have been imported by returning medical and humanitarian relief personnel who served in Haiti during their recent (and ongoing) cholera epidemic.

Sunday, January 15, 2012

Referral: Crof On Cholera

 

 


# 6072

 

 

Crof, who has covered the Haitian cholera epidemic and subsequent local and international repercussions since the outbreak began, continues his exemplary coverage this weekend.

 

Fifteen months after it emerged, cholera continues to claim lives and exact a miserable toll on that impoverished Caribbean nation. 

 

You’ll find several new reports well worth reading this weekend on Crofsblog regarding a fresh outbreak in Pestel, including:

 

Haiti: Dr. John Carroll on cholera in Pestel, January 14, 2012 (updated)

 

Haiti: Cholera in Pestel so far

 

Haiti: More cholera news from Pestel

Saturday, October 29, 2011

EID Journal: Cholera In Haiti

 

 

# 5930

 

 

The first cholera epidemic in Haiti in more than a century has now been spreading for a full year, and according to a recent UN Radio report, The World Health Organization’s spokesman in Geneva, Tarik Jasarevic, gave the following update :

“As of 9 October 2011, the cumulative number of reported cholera cases was close to 470,000 of which 250,000 persons were hospitalized, and 6,595 persons had died. The exact figures could be found in the note at the back of the room. If current trends continued, they could expect another 75,000 cases by the end of the year, bringing the total cases to approximately 500,000 since the beginning of the epidemic.”

 

This ongoing tragedy comes on the heels of Haiti’s  2010 7.0 earthquake that claimed, by some estimations, more than 200,000 lives.

 

The November issue of the CDC’s  EID Journal devotes much of its content to this re-emerging disease threat.  Twenty-three articles, studies, and letters comprise this issue’s theme.

 

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THEME ISSUE: CHOLERA IN HAITI

 

Synopses

Lessons Learned during Public Health Response to Cholera Epidemic in Haiti and the Dominican Republic

J. W. Tappero and R. V. Tauxe

Safe water and sewage systems must be constructed to prevent future epidemics.

 

 

Rapid Development and Use of a Nationwide Training Program for Cholera Management, Haiti, 2010

R. V. Tauxe et al.

Rapid training of health care staff was followed by lower death rates.

Cholera—Modern Pandemic Disease of Ancient Lineage

J. G. Morris

Environmental triggers may lead to increases in Vibrio cholerae in environmental reservoirs, with spillover into human populations.

 

 

Considerations for Oral Cholera Vaccine Use during Outbreak after Earthquake in Haiti, 2010−2011

K. A. Date et al.

Many logistical and operational challenges prevented implementation of a vaccination campaign.

 

 

Research

Comparative Genomics of Vibrio cholerae from Haiti, Asia, and Africa

A. R. Reimer et al.

A strain from Haiti shares genetic ancestry with those from Asia and Africa.

 

Characterization of Toxigenic Vibrio cholerae from Haiti, 2010–2011

D. Talkington et al.

A virulent clone from Africa or southern Asia was likely introduced at a single time point.

 
 
Historical Reviews

Cholera in Haiti and Other Caribbean Regions, 19th Century

D. Jenson and V. Szabo

Epidemic cholera did not occur in Haiti before 2010.

 
Dispatches

Risk Factors Early in the 2010 Cholera Epidemic, Haiti

K. A. O’Connor et al.

 

Rapid Assessment of Cholera-related Deaths, Artibonite Department, Haiti, 2010

J. A. Routh et al.

 

Epidemic Cholera in a Crowded Urban Environment, Port-au-Prince, Haiti

S. E. Dunkle et al.

 

 

Toxigenic Vibrio cholerae O1 in Water and Seafood, Haiti

V. R. Hill et al.

Drug-Resistance Mechanisms in Vibrio cholerae O1 Outbreak Strain, Haiti, 2010

M. Sjölund-Karlsson et al.

 

Cholera Management and Prevention at Hôpital Albert Schweitzer, Haiti

S. Ernst et al.

 

Knowledge, Attitudes, and Practices Related to Treatment and Prevention of Cholera, Haiti, 2010

V. E. De Rochars et al.

 

Cholera Prevention Training Materials for Community Health Workers, Haiti, 2010–2011

A. Rajasingham et al.

 

Cholera in United States Associated with Epidemic in Hispaniola

A. E. Newton et al.

 

Travel Health Alert Notices and Haiti Cholera Outbreak, Florida, USA, 2011

M. U. Selent et al.

 

Multinational Cholera Outbreak after Wedding in the Dominican Republic

M. L. Jiménez et al.

 

Commentaries

Haiti in the Context of the Current Global Cholera Pandemic

E. T. Ryan

Letters

Preparing Health Care Workers for a Cholera Epidemic, Dominican Republic, 2010

C. Mendoza et al.

 

Understanding the Cholera Epidemic, Haiti

S. B. Pun

Etymologia

Etymologia: Cholera

N. Männikkö

Conference Summaries

Academic Consortia: Untapped Resources for Preparedness, Response, and Recovery—Examining the Cholera Outbreak in Haiti

L. M. Gargano et al.

Thursday, July 21, 2011

EID: Cholera In The U.S. Associated With Hispaniola Epidemic

 

 

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# 5707

 

 

Although endemic in many developing countries, due to our modern water and sewage treatment infrastructure, cholera is a rarely reported illness in the United States.

 

In the years between 1965 and 1990, there were only an average of 5 cases each year.

 

Starting in 1991, and running through 1994, a Cholera epidemic swept out of Peru infecting more than 1 million South Americans, and claiming nearly 10,000 lives.

 

During the height of that outbreak, the United States saw a 10-fold increase in cholera cases (n=53/yr), mostly from travelers returning from the afflicted region.

 

When the South American epidemic died down, so did the number of cases identified in the United States.  By the year 2000, the average number of yearly cases in the U.S. had dropped to 6, and most of those had a history of international travel.


Last October, when cholera appeared once again in the Western Hemisphere – this time in Haiti, and quickly spread into the Dominican Republic – concerns over another increase in domestic cholera cases were raised.

 

As expected, given the frequency and relative ease of travel between the United States and Haiti, an increase in the number of cholera cases in the United States was observed during the first six months of the epidemic.

 

Yesterday, the CDC’s EID Journal – in ahead of print dispatch – released a report summarizing the 23 known cases of Cholera that appeared in the U.S. in the wake of the Haitian epidemic.

 

All were associated with travel to Hispaniola (n=22) or the consumption of Haitian food (n=1), and no secondary transmission in the United States was observed.

 

Cholera in United States Associated with Epidemic in Hispaniola

DOI: 10.3201/eid1711.110808

 
Newton AE, Heiman KE, Schmitz A, Török T, Apostolou A, Hanson H, et al.  Emerg Infect
Dis. 2011 Nov;

EXCERPT

Six months after the Hispaniola cholera epidemic started in Haiti, 23 associated cases
were recognized in the United States. All cases were associated with recent travel to Hispaniola
or with consumption of seafood from Haiti.

 

The risk for cholera transmission in the United States is low because of improved water and sanitation, and there is no evidence of secondary
transmission. Florida, New York, and Massachusetts have the highest populations of persons of
Haitian or Dominican ancestry (6).

 

Most cases were reported from Florida, the state with the largest Haitian population. However, case-patients also resided in states with small Haitian and Dominican populations.

Travel between the United States and Haiti is straightforward; 4 US airports  offer daily direct flights from Florida and New York to Port-au-Prince. Many persons, including many of Haitian descent, traveled from the United States to Haiti to help with the response to the January 2010 earthquake in Port-au-Prince.

<SNIP>

Echoing the Latin American cholera epidemic in the 1990s, the number of US cholera cases has increased after the cholera epidemic in Hispaniola. Travelers to cholera-affected areas should be aware of the risk and should follow prevention measures to avoid infection.

 

In particular, travelers visiting friends or relatives may be at higher risk for travel-associated infection (7). Few case-patients had received cholera prevention education (educational materials available at www.cdc.gov/cholera/index.html); no cholera vaccine is licensed in the United States.

 

Until cholera in Haiti and Dominican Republic resolves, clinicians, microbiologists, and public health workers in the United States should be prepared for more cases in travelers returning from Hispaniola.

 

 

While obviously a public health concern, the good news here is that the primitive sanitary conditions needed to facilitate ongoing sustained transmission of cholera are largely absent in the United States.

 

International travel to developing countries  - whether for business, pleasure, or to assist in post-disaster recovery operations - has many rewards. The risks of contracting an illness like cholera – while not zero – with proper preparation are generally manageable.

 

As we saw advised earlier this week in MMWR: Dengue Among Travelers Returning from Haiti, international travelers should seek pre-travel health counseling to receive information about travel-related disease risks, and ways to prevent them.

Sunday, July 17, 2011

MMWR: Dengue Among Travelers Returning from Haiti

 

 

# 5697

 

 

Last summer, the CDC issued a Health Advisory via their HAN (Health Alert Network) in order to inform health care providers of the possibility of seeing Dengue Fever in returning visitors from areas where the virus is being seen.

 

This is an official
CDC HEALTH ADVISORY

Distributed via Health Alert Network
Sunday, July 25, 2010, 22:35 EDT (10:35 PM EDT)
CDCHAN-00315-2010-07-25-ADV-N

Increased Potential for Dengue Infection in Travelers Returning from International and Selected Domestic Areas

Summary

Dengue virus transmission has been increasing to epidemic levels in many parts of the tropics and subtropics. Travelers to these areas are at risk of acquiring dengue virus and developing dengue fever (DF) or the severe form of the disease, dengue hemorrhagic fever (DHF).

 

The return of locally acquired dengue fever to Florida in 2009 - after an absence of 6 decades - was no doubt due to repeated introductions of the virus by travelers coming from countries where the virus is endemic.

 

You can find the CDC MMWR report on the reemergence of Dengue in Key West HERE.

 

In Travel-Associated Dengue Surveillance --- United States, 2006—2008, also published last summer, the MMWR came out with a new report on Travel Associated Dengue in the United States.

 

This surveillance pre-dates the Key West outbreak, and as the study reports, `Clinically recognized cases of travel-associated dengue likely underestimate the risk for importation because many dengue infections are asymptomatic or mildly symptomatic’.

 

 

Worldwide, the explosive growth of Dengue – when combined with our highly mobile society – provides ample opportunities for this mosquito borne virus to travel to new regions.

 

Dengue’s success is well illustrated by the following graph from the World Health Organization.

 

Average annual number of dengue cases reported to the World Health Organization - has steadily increased since the 1950s, with 908 cases average reported between 1950 and 1959 and 968,564 cases average reported annually between 2000 and 2007.

What this graph doesn’t indicate is another doubling of dengue cases has taken place over the past 5 years.  

 

 

All of which serves as prelude to Friday’s MMWR release, which looked at the incidence of Dengue fever in travelers returning from Haiti last fall.  You can read the entire report at the link below.

 

 

Dengue Virus Infections Among Travelers Returning from Haiti --- Georgia and Nebraska, October 2010

Weekly

July 15, 2011 / 60(27);914-917

 

The gist, however, is that of 28 travelers who had recently returned from spending 7-11 days in Haiti, 7 (25%) showed laboratory evidence of recent DENV infection.

 

As the report explains:

 

All 28 travelers were asked to participate in a survey using a 53-item questionnaire to collect information regarding demographics, medical and travel history, pretravel preparations and knowledge, mosquito-avoidance practices while in Haiti, and illnesses during and after travel. Twenty-five (89%) travelers participated: 21 by telephone or in-person interviews, two by proxy, and two by self-administration.

 

Based on this questionnaire, 90% had a pre-travel health care appointment and 57% researched travel advice on the Internet. 95% reported having pre-travel knowledge about infectious diseases in Haiti, and 48% stated they were aware of the dangers of Dengue.

 

Despite these opportunities for awareness, only 24% reported using mosquito repellent several times a day.

 

Moreover, no statistically significant association was found between acquiring a dengue infection and pre-travel knowledge or mosquito-avoidance practices.

 

The editorial note concludes by saying:

 

All travelers to Haiti should seek pretravel health counseling, preferably 4--6 weeks before travel, receive information about risks for DENV infection, and employ recommended mosquito-avoidance practices.

 

Clinicians evaluating travelers with febrile illness who recently have returned from Haiti or other DENV-endemic areas are encouraged to consider dengue in their differential diagnosis, submit specimens for laboratory testing, and report cases of dengue expeditiously to local or state health departments

 

Whether you are tramping through the tropics where Dengue is endemic, or simply strolling through your neighborhood when mosquitoes are active, this advice from the Florida health department remains worth heeding.

 

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Saturday, June 04, 2011

Haiti: Unwelcome Rains & An OCHA Update

 

 

 

# 5601

 

 

With the Atlantic Tropical Storm season now underway the islands of the Caribbean are entering a six-month rainy season that will likely last until November.

 

Scores of tropical waves come off the African coastline and march across the Atlantic between June and November, or low pressure areas form over the warm tropical waters, and most years a dozen or more spin up to become hurricanes or tropical storms.

 

Even without the damaging winds of full blown hurricanes, tropical rains can have a heavy impact – and no island is more at risk than Hispaniola, which is shared by Haiti and the Dominican Republic.

 

Aside from the yearly summer threats of localized flash floods and mudslides (due to rampant deforestation), Haiti and the Dominican Republic are both dealing with a cholera outbreak. 

 

An outbreak that could easily be exacerbated by heavy rainfall.

 

With inadequate (often non-existent) water and sewage treatment capabilities on the island - heavy rains wash sewage from open pits, septic drain fields, and latrines into rivers - which are used for bathing and drinking water. 

 

As bad as the outbreak of Cholera has been, it arguably might have been worse if it had not started in October - near the end of last year’s rainy season.

 

This morning’s 8am NHC tropical weather outlook has a persistent rain maker with a moderate potential for development nearly stationary south-west of Haiti. 

 

Heavy rains, flash floods, and mudslides are forecast for portions of Haiti, The Dominican Republic, Jamaica, and Southern Cuba.

 

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Computer models are uncertain where this patch of disturbed weather will go, as steering winds are light and variable. Although it’s early in the season, this area will be watched for development.

 

 

Via Reliefweb, we’ve an OCHA humanitarian Bulletin – dated June 3rd – which covers the cholera situation, the aftermath of last year’s earthquake, tsunami & seismic threats, flooding, and other vulnerabilities in Haiti. 

 

 

Humanitarian Bulletin (06 May - 3 June 2011)

UN Office for the Coordination of Humanitarian Affairs

Download PDF (488.68 KB)

OVERVIEW

• Cholera alerts on the rise, including in Port-au-Prince

• Les Palmes and Nippes highly vulnerable to flooding

• Survival strategies of vulnerable households exhausted in some areas

• Specific needs of disabled and older IDPs overlooked

 

(EXCERPTS)

 

The number of weekly hospitalizations nationwide has increased from an average 1,700 to 2,600, reports PAHO in its latest bulletin dated May 27.

 

The South-East, Grande Anse, South and West are the departments most affected by outbreaks of cholera with a surge over the past three weeks in the number of daily alerts received from partners in the field. In the South-East department, the number of hospitalization has tripled over the past two weeks, with some of the cases coming however from neighboring West Department.

 

From 21-23 May, a significant increase of cases in
Port-au-Prince metropolitan area has also been
reported. As of 2 June, close to 2,000 cases and
13 deaths had been reported.

 

Some donors including ECHO and USAID have indicated the availability of new funds to respond to further cholera outbreaks.

 

 
PAHO is noting that it is too early to say whether there is a change in the tendency of the epidemic. The rise in the number of alerts might be due to the closure of Cholera Treatment Units (CTUs) and Centers (CTCs), resulting in the accumulation of cases in other health infrastructures still open.
 

 

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Saturday, May 07, 2011

EID Journal: Understanding Haiti’s Cholera Outbreak

 

 

# 5543

 

 

 

There’s an old story about a guy who fears his wife may be cheating on him, so he he hires a private detective to follow her.

 

A couple of days later the detective brings him pictures of her meeting with a strange man in a bar, driving together to a sleazy motel, and the two of them going into a rented room and pulling the shades.

 

The husband sighs and says, “Always that element of doubt . . . ”

 

Which pretty much sums up the recent UN report on the origins of Haiti’s Cholera outbreak, which has killed nearly 5,000 individuals (a story well reported by Crof) and sickened a quarter of a million.

 

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SourceOCHA as of April 25th, 2011

 

 

The report acknowledged:

 

  • Haiti had been free of cholera for decades
  • The strain that showed up in October was closely matched to the strains found in Southeast Asia, including Nepal
  • That Nepali peacekeepers (MINUSTAH) arrived in Mirebalais shortly before the outbreak began
  • The sanitation conditions at the Mirebalais MINUSTAH camp were not sufficient to prevent contamination of the Meye Tributary System with human fecal waste.

 

The report further admits that Cholera was undoubtedly introduced by someone visiting from Southeast Asia.

 

The evidence does not support the hypotheses suggesting that the current outbreak is of a natural
environmental source. In particular, the outbreak is not due to the Gulf of Mexico strain of Vibrio cholerae, nor is it due to a pathogenic mutation of a strain indigenously originating from the Haitian environment.

 

Instead, the evidence overwhelmingly supports the conclusion that the source of the Haiti cholera
outbreak was due to contamination of the Meye Tributary of the Artibonite River with a pathogenic
strain of current South Asian type Vibrio cholerae as a result of human activity. 

  

They conclude, however by saying that:

 

The precise country from where the Haiti isolate of Vibrio cholerae O1 arrived is debatable.

 

Preliminary genetic analysis using MLVA profiles and cholera toxin B subunit mutations indicate that the strains isolated during the cholera outbreak in Haiti and those circulating in South Asia, including Nepal, at the same time in 2009-2010 are similar. 

 

Always that element of doubt.

 

The UN report goes on to reference 9 factors that contributed to the outbreak – mostly relating to poor sanitary conditions in Haiti, a lack of immunity, and the virulence of the strain – and then states:

 

The Independent Panel concludes that the Haiti cholera outbreak was caused by the confluence of circumstances as described above, and was not the fault of, or deliberate action of, a group or individual.

 

The source of cholera in Haiti is no longer relevant to controlling the outbreak. What are needed at this time are measures to prevent the disease from becoming endemic.

 

 

Incongruously, while painting a picture that strongly suggests the Nepali troops were a likely source of the outbreak, this UN report goes to great lengths not to state it as actual fact.

 

In fairness, it is probably impossible to know – with absolute certainty – whether the Nepali peacekeepers brought cholera into Haiti. The evidence may be strong, but it is circumstantial.

 

Which, frankly, describes the data from most epidemiological investigations.  

 

Obviously this is a diplomatic hot potato, and this UN report does what it can to try to move forward, rather than assign blame.

 

And one can certainly sympathize with the MINUSTAH troops – there to do humanitarian work in a difficult environment with primitive sanitary facilities  – who may have inadvertently (and unknowingly) introduced cholera into the country.

 

As the saying goes, `No good deed goes unpunished’.

 

This week we’ve a another report (published online ahead of print) from the CDC’s EID Journal which is a bit more direct in its assessments.

 

 

Piarroux R, Barrais R, Faucher B, Haus R, Piarroux M,
Gaudart J, et al. Understanding the cholera epidemic, Haiti. Emerg Infect Dis. 2011 Jul; [Epub ahead of print]

 

Abstract (Excerpts)

After onset of the cholera epidemic in Haiti in mid-October 2010, a team of researchers from France and Haiti implemented field investigations and built a database of daily cases to facilitate identification of communes most affected.

 

Several models were used to identify spatio-temporal clusters, assess relative risk associated with the epidemic’s spread, and investigate causes of its rapid expansion in Artibonite Department.

 

<SNIP>

 

Our findings strongly suggest that contamination of the Artibonite and 1 of its tributaries downstream from a military camp triggered the epidemic.

 

 

You’ll find a detailed analysis of the outbreak and its spread in this paper, along with arguments that asymptomatic carriers of cholera would have been unlikely to shed enough V. cholerae in their stools to have sparked the outbreak.

 

They believe that at some point, `symptomatic cases occurred inside the MINUSTAH camp’. A point that, to my knowledge, has never been conceded by the Nepali contingent.

 

From the Discussion section the authors give their rationale for the importance of determining the origin of the outbreak:

 

Determining the origin and the means of spread of the cholera epidemic in Haiti was necessary to direct the cholera response, including lasting control of an indigenous bacterium and the fight for elimination of an accidentally imported disease, even if we acknowledge that the latter might secondarily become endemic.

 

Putting an end to the controversy over the cholera
origin could ease prevention and treatment by decreasing the distrust associated with the widespread suspicions of a cover-up of a deliberate importation of cholera (15,16).

 

Demonstrating an imported origin would additionally compel international organizations to reappraise their procedures. Furthermore, it could help to contain disproportionate fear toward rice culture in the future, a phenomenon responsible for important crop losses this year (17).

 

Notably, recent publications supporting an imported origin (7) did not worsen social unrest, contrary to what some dreaded (18–20).

 
Our epidemiologic study provides several additional arguments confirming an importation of cholera in Haiti.

 

There was an exact correlation in time and places between the arrival of a Nepalese battalion from an area experiencing a cholera outbreak and the appearance of the first cases in Meille a few days after.

 

The remoteness of Meille in central Haiti and the absence of report of other incomers make it unlikely that a cholera strain might have been
brought there another way.

 

 

An accompanying editorial appears (Dowell SF, Braden CR. Implications of the introduction of cholera to Haiti. Emerg Infect Dis. 2011 Jul; [Epub ahead of print]))

 

It states, in part:

 

For Haiti, the future course of the cholera epidemic is difficult to predict, especially given the chronic degradation of water and sanitation infrastructure over many years and the acute disruption from the earthquake in Haiti in January 2010 (6).

 

Improving water and sanitation infrastructure is clearly the most effective and lasting approach to prevent the spread of cholera in countries where it is endemic as well as in those that are currently cholera-free.

 

Simple enough sounding solutions, but terribly difficult to implement in an impoverished, earthquake wracked, and dysfunctional nation like Haiti.

Sunday, February 06, 2011

The `Other Reason’ For Traveler’s Vaccinations

 

 


# 5292

 

 

Most travelers think of vaccinations as being important protection for the recipient, particularly when visiting regions where rare, or exotic diseases (like Yellow Fever or Meningococcal Meningitis) might be encountered.

 

But as a statement by PAHO reminds us, routine vaccinations against common communicable diseases (ie. polio, rubella, measles, pertussis) are needed to protect the people who live in the countries where western travelers visit.

 

And today, nowhere is that more important than on the fragile earthquake and cholera ravaged island of Haiti, where the last thing they need is another imported disease threat to deal with.

 

 

 

PAHO/WHO Urges Travelers to Get Vaccinated Before Entering Haiti

 


Immunization is needed to ensure that infectious diseases are not imported into Haiti

Washington, DC, February 4, 2011 (PAHO/WHO)
– The Pan American Health Organization/World Health Organization (PAHO/WHO) is urging all international travelers to Haiti to get up-to-date on their vaccines, to ensure they do not unknowingly import infectious diseases into Haiti.

 

The recommendation follows recent epidemiological investigations of two disease outbreaks in Haiti, one involving suspected polio and the other, suspected measles. The investigations were carried out by Haiti’s Ministry of Health with support from PAHO/WHO and the U.S. Centers for Disease Control and Prevention (CDC).

 

The first investigation concerned four cases of paralysis in cholera patients in the coastal city of Port-de-Paix. Laboratory tests have ruled out polio as the cause of the illnesses. However, as a precaution, polio vaccine is now being included in vaccination campaigns against diphtheria and measles in the area. No cases of indigenous wild polio have been reported in Haiti since polio was declared eradicated from throughout the Americas in 1994.

 

The second investigation involved a case of measles in the 8-month-old child of a U.S. volunteer who traveled from her home in Pennsylvania to Haiti in late December. The baby developed measles after returning to the United States on Jan. 7, followed by two siblings who also developed the disease. Four of the family’s six children were unvaccinated.

 

<SNIP>

Infectious diseases including measles and polio can be carried and transmitted even by individuals who do not have symptoms themselves. Because of the risk of importing disease, PAHO strongly recommends that all individuals planning to go to Haiti make sure they have been vaccinated against measles, rubella, polio and other vaccine-preventable.

Monday, January 31, 2011

Haiti: Charting The Cholera Epidemic

 

 


# 5272

 

 

I’ve not done a lot on the Cholera outbreak in Haiti over the past few weeks, simply because Crofsblog has been extraordinarily dedicated to the story since it began.  And for daily coverage of Haiti, that’s the site to visit.

 

But from time to time - when I’ve thought I could add some value - I’ve posted on the outbreak, including:

 

MMWR: Haiti Cholera Update
Haiti: The Progression Of An Epidemic
Haiti: Updated Cholera Outbreak Map
 

Sixty days ago I posted some graphics showing the progression of the Cholera Epidemic through the end of November.  At the time, the mortality rate was listed at 2.2%.

 

image

These are just reported numbers, of course. The real numbers are likely much higher.   Also, a great many more people are assumed to be asymptomatic carriers of the bacteria.

 

Today OCHA has posted a freshly updated map, and chart of the epidemic’s progress, hosted by Reliefweb.  You can download the map in its entirety at the link below, but I’ve excerpted a couple of interesting segments to highlight.

 

Haiti: Cholera Cumulative Cases since October 2010 (as of 24 Jan 2011)

Map of 'Haiti%3A%20Cholera%20Cumulative%20Cases%20since%20October%202010%20(as%20of%2024%20Jan%202011)'

  • Date: 27 Jan 2011
  • Type: Natural Disaster
  • Keyword(s): Epidemic; Health; Natural Disaster; Affected Population
  • Format:

    map.pdfPDF *, 1218 Kb

 

 

In addition to depicting the spread of the epidemic in a series of maps, this release also charts the number of cases and fatalities. 

 

While 4000+ deaths is obviously a tragedy, the CFR (case fatality ratio) has dropped considerably over what was first reported back in October (roughly 8%).  

 

image

image

 

A goodly portion of this drop can no doubt be attributed to better surveillance and the counting of less severe cases, which may not have been included in the earliest numbers. 

 

Some of it, however, is undoubtedly due to the ramped up response by numerous relief agencies to the crisis.

 

 

Even assuming the vagaries of surveillance and reporting out of Haiti, and the likely undercounting of fatalities (and total cases), these numbers indicate that progress is being made.

 

That earthquake ravaged Port-au-Prince is running under a 1% mortality rate is actually quite remarkable.

 

And the (roughly) 2% CFR outside of the capital is noteworthy as well, given the pre-existing disease burdens and poor health care infrastructure that exists in rural Haiti.

 

While the cholera situation in Haiti can hardly be described as good, thankfully, it does appear that some progress is being made.

 

For some background on other diseases plaguing Haiti, you may be interested an a blog I wrote last November:

 

Haiti: Three Non-Cholera Health Threats

Wednesday, December 08, 2010

MMWR: Haiti Cholera Update

 

 

 

# 5128

 

The CDC’s MMWR (Morbidity & Mortality Weekly Report) at irregular intervals offers dispatches – usually reports from the field – regarding ongoing infectious disease outbreaks around the globe.  


The last MMWR update on the cholera epidemic in Haiti came on October 29th (see MMWR Dispatch: Cholera Outbreak In Haiti).

 

Today’s (December 8th) update is reported by the Ministry of Public Health and Population, Haiti. Pan American Health Organization. CDC

 

Since this is a lengthy dispatch, I’ve only reproduced the opening couple of paragraphs.

 

Follow the link to read the entire dispatch, and the editorial comments that follow.

Update: Outbreak of Cholera --- Haiti, 2010

Dispatch

December 8, 2010 / 59(Dispatch);1-5

The first cholera outbreak in Haiti in at least a century was confirmed by the Haitian National Public Health Laboratory on October 21, 2010 (1). Surveillance data through December 3, provided by the Haitian Ministry of Public Health and Population (MSPP), indicated that the outbreak had spread nationwide and that cases of cholera and cholera-associated hospitalizations and deaths had climbed rapidly in November. As of December 3, MSPP reported 91,770 cases of cholera from all 10 departments and the capital city of Port-au-Prince; 43,243 (47.1%) patients had been hospitalized, and 2,071 (2.3%) had died. A rapid mortality assessment in Artibonite Department found that deaths occurred as rapidly as 2 hours after symptom onset and identified important gaps in access to life-saving treatments, including oral rehydration solution (ORS). Urgent activities are under way, and additional efforts are imperative to reduce cholera mortality by expanding access to cholera treatment and to reduce cholera transmission by improving access to safe water and adequate sanitation.

 

A nationwide cholera surveillance system has been established in Haiti. Hospitals and clinics send daily case counts to local MSPP officials; aggregate data are sent on to department-level officials and then to central government officials. A case of cholera is defined as profuse, acute, watery diarrhea in a resident of a department in which at least one case of cholera has been laboratory-confirmed by isolation of Vibrio cholerae from culture of a stool specimen. A hospitalized case occurs in a patient admitted to a health facility (i.e., a hospital or cholera treatment site) for at least one night. A cholera death is the death of a person with illness that meets the case definition for cholera. Any cholera death that occurs in a health facility, regardless of whether the decedent was admitted overnight, is considered a cholera hospital death. MSPP posts daily and cumulative tallies of cholera reports on a public website; tallies are stratified by department and age group (aged <5 years and all ages).* Since November 16, nonhospitalized cases have been posted in addition to hospitalized cases.

(Continue . . . )

Thursday, December 02, 2010

Haiti: The Progression Of An Epidemic

 

 

# 5108

 

 

A truly illuminating look at the relentless spread of cholera in Haiti comes today via a series of maps released by OCHA that show the geographic and numerical case load progression of the illness from October 20th through November 29th.

 

As with most epidemics, the increases in the beginning are small, but they quickly explode.

 

Some of that may be due to limited surveillance and reporting during the first couple of weeks.  But as more and more people become carriers, the actual spread of the illness accelerates rapidly.

 

 

image

 

These are just reported numbers, of course. The real numbers are likely much higher.   Also, a great many more people are assumed to be asymptomatic carriers of the bacteria.

 

A series of maps shows how this outbreak started in one department (Haiti is divided into 10 Departments), and in a matter of a couple of weeks spread to 5, then 7, and finally all 10 departments.

 

 

image

image

image

 

You can download the entire graphic from ReliefWeb.

 

Haiti: Cholera Cumulative Cases since 20 October 2010 (as of 29 Nov 2010)

Map of 'Haiti%3A%20Cholera%20Cumulative%20Cases%20since%2020%20October%202010%20(as%20of%2029%20Nov%202010)'

  • Date: 01 Dec 2010
  • Type: Natural Disaster
  • Keyword(s): Affected Population; Epidemic; Health; Natural Disaster
  • Format:

    map.pdfPDF *, 1344 Kb

  • Source(s):
    - United Nations Office for the Coordination of Humanitarian Affairs (OCHA)

Thursday, November 25, 2010

Haiti: Updated Cholera Outbreak Map

 

 

 

# 5090

 

 

A week ago I posted a map prepared by OCHA showing the extent of the Haitian cholera outbreak as of November 17th, 2010.

 

At the time, there were close to 19,000 confirmed cases and more than 1,100 deaths.

 

Today, OCHA and ReliefWeb have published a new map, updated through November 23rd.  They now list 25,000 hospitalized, and more than 1,400 fatalities.

 

Follow the links to view the full sized maps.

 

 

HAITI: Cholera Outbreak (as of 23 Nov 2010) - Location Map

 

 

Map of 'HAITI%3A%20Cholera%20Outbreak%20(as%20of%2023%20Nov%202010)%20-%20Location%20Map'

  • Date: 25 Nov 2010
  • Type: Natural Disaster
  • Keyword(s): Epidemic; Health; Affected Population
  • Format(s):

    EP-2010-000210-HTI_1125.pdfPDF *, 163 Kb


    EP-2010-000210-HTI_1125.jpg JPG, 71 Kb

  • Source(s):
    - United Nations Office for the Coordination of Humanitarian Affairs - ReliefWeb
    - United Nations Office for the Coordination of Humanitarian Affairs (OCHA)
  • Related Document:
    - Haiti: Cholera Situation Report #20 - 23 November 2010
    - Haiti: Cholera Outbreak in Haiti, 2010
  • Tuesday, November 23, 2010

    Declan Butler On Haiti’s Cholera Epidemic

     

     

     


    # 5083

     

     

    A lot of my readers are no doubt familiar with Nature News senior reporter Declan Butler for, among many accomplishments, his early work in bringing the avian flu story to the public.

     

    But Butler is hardly a Johnny one-note. He holds a PhD in marine biology from the University of Leeds, and writes on a variety of scientific issues.

     

    Today he brings us background and sobering analysis of the potential impact of the cholera epidemic on Haiti’s population over the next year or so.

     

    A hat tip to David Dobbs for retweeting this link.

     

    I’ve just posted his lede.

     

    Follow the link to read it in its entirety.  As with practically anything Butler writes, this is highly recommended.

     

     

    Cholera tightens grip on Haiti

    Those tackling the epidemic are struggling to keep pace with an escalating crisis.

    Declan Butler

    As cholera rampages through Haiti, some epidemiologists are warning that the country could face more than half a million cases over the coming year. Yet tracking and treating the disease is proving increasingly difficult as civil unrest grips the county.

    (Continue. . . )

    Monday, November 22, 2010

    Haiti: Inextricably Intertwined Disasters

     

     

     

    # 5078

     

     

     

    Long before cholera broke out in the tent cities, and decades prior to the devastating 7.0 Port-au-Prince earthquake, Haiti endured some of the highest rates of poverty and disease in the western hemisphere.

     

    A little more than a week ago, in Haiti: Three Non-Cholera Health Threats, I wrote about the toll that Malaria, Cyptosporidium, and Acute Respiratory Infections took on that population.

     

    Today, from IRIN PlusNews (hat tip Sharon Sanders at FluTrackers), we have a couple of feature articles on TB and HIV, and how they – along with the earthquake and the cholera epidemic - are inextricably intertwined in the cascading crisis in Haiti.

     

    First a report on the additional threat that cholera places on the 2.2% of Haiti’s population (roughly 120,000 people) who have HIV. 

     

    HAITI: HIV-positive people especially vulnerable to cholera


    PORT-AU-PRINCE, 22 November 2010 (PlusNews) - As the death toll from the cholera epidemic sweeping through Haiti surpasses 1,000, with more than 19,000 confirmed cases, health officials say people living with HIV are especially vulnerable.

     

    Only about 25 percent of people infected with cholera develop symptoms - mainly watery diarrhoea and vomiting - but people already weakened by illness, malnutrition or pregnancy are particularly at risk.

     

    "[People living with HIV] are very much at risk because they already have a weakened immune system," explained Hanz Legagneur, director of the Ministry of Public Health in the country's West Department.

     

    (Continue . . .)

     

     

    Next a report on how the living conditions in the 1,300 refugee camps for the survivors of the earthquake – many of whom are crowded into communal tents - are ripe for the spread of Tuberculosis.

     

     

    HAITI: Combating TB in Port-au-Prince's tent cities


    Photo:
    Tamar Dressler/IRIN

    Thousands are still living in tiny tents in the capital, Port-au-Prince

     

    PORT-AU-PRINCE, 17 November 2010 (PlusNews) - Health workers in Haiti are concerned about the spread of tuberculosis (TB) in the tent cities that have housed more than one million people since the massive earthquake in January.

     

    "With the quake this became an emergency," said Macarthur Charles, a doctor with Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), one of the largest HIV- and TB-focused NGOs in Haiti.

    (Continue . . .)

     

     

    Although accurate numbers are impossible to obtain, field reports (well covered on a daily basis by Crofsblog) seem to suggest a higher than expected fatality rate among cholera patients in this epidemic.

     

    Not so surprising given the existing burden of disease in Haiti, long-standing fragmentary health care services, poverty and neglect, and the devastation from January’s earthquake.

     

    Disasters all. 

     

    And all no doubt factors that conspire to severely compound the effects of this cholera epidemic.

     

    And they also make solutions that much harder to find.

    Thursday, November 18, 2010

    Cholera Outbreak Map Of Haiti

     

     

    # 5069

     

     

    Although Crofsblog  is doing most of the heavy lifting when it comes to blogging about the cholera outbreak in Haiti (and if you aren’t following him, why not?) – I ran across this map published by ReliefWeb today, and thought it would help put things in better perspective.

     

    Follow the links to download larger versions of this graphic.

     

     

    HAITI: Cholera Outbreak (as of 17 Nov 2010) - Location Map

    Map of 'HAITI%3A%20Cholera%20Outbreak%20(as%20of%2017%20Nov%202010)%20-%20Location%20Map'