Haiti Cholera Update #12

As of 9 Novemeber 2011, MSPP (Ministère de la Santé Publique et de la Population) reports 11,125 cases of cholera and 724 deaths.  The hospital mortality rate is 3,9%. Cholera promptly treated has a mortality rate of 1-2%. HaitiLibre reports that there are now 278 confirmed cases of cholera in Port-au-Prince, and 10 deaths. In the outlying regions as well as in the Artibonite, the website reports, the situation is becoming dire:

The epidemic is spreading each day a little more in Gonaives, agglomeration of more than 300,000 inhabitants : for the single day of November 8, 460 people presented themselves for consultation at the hospital in Raboteau when they were 360 the day before and 104 the day before. The epidemic is becoming out of control in these areas. The ACF [Action Contre la Faim] said that the focus of the international community in Port-au-Prince and the lower Artibonite, although it is important, is detrimental to other affected areas.

In the Artibonite, the center of the epidemic, OCHA, MINUSTAH, the government and humanitarian partners report that with the increasing workload, more medical staff with more experience is needed urgently as well as medical supplies supplementary, including at least 1,200 body bags according to an official report.

The Haiti Epidemic Advisory System (HEAS) gives this analysis in its layest sitution report:

Cholera has now seeded the Haitian environment in more sites than can be properly assessed. Evidence of community transmission is present in multiple sites such as the northwest, greater Port au Prince area, and strongly suspected in the southern peninsula. Transmission modes include waterborne, food contamination, and human-to-human contact.

Transmission in the original epicenter of the epidemic along the Artibonite River has decreased substantially and shifted to surrounding rural areas, extending to the northern coast. As feared, cholera transmission in communities along the coastal highway between St Marc and Cite Soleil likely resulted in dozens of indigenous cases now identified in Cite Soleil, with dire implications for Port au Prince. Multiple confirmed cases without travel history to Artibonite have been documented in both Cite Soleil and Port au Prince, and hundreds more suspect cases have been declared inside Port au Prince. Significant political interference prevents full clarity of the situation inside the city. As of this report, [9/11/10 --- ed.]  HUEH and other major medical centers inside Port au Prince are stable and able to handle the patient flow.

The issue of “suspected” versus “confirmed” reporting and decision points for action have been hotly debated inside the HEAS community. As was observed in the United States during the 2009 H1N1 influenza pandemic, the number of samples collected is disproportionate to the ability of LNSP to process them in a timely fashion and publicly declare confirmation status. The entire nation is now sensitized to report cholera, however many have never seen cholera before. This implies means the false positive rate is likely increased. Diarrheal disease not due to cholera is caused by a wide variety of other endemic pathogens and is seen this time of year during the major rainy season.  All of this acknowledged, hesitation to verify or assume “cholera until proven otherwise” may mean the difference between 1 and 10 fatalities for a given community. This is a tremendous challenge to the HEAS community.

[snip]

Conclusion

The cholera epidemic in Haiti proceeds in an uncontrolled, uncontained fashion and will likely encompass all of Haiti within a matter of weeks.  Ecological establishment will be pervasive regardless of ongoing response efforts.

Efforts to improve access to safe drinking water and sanitation are as challenging as they were post-quake, and now additional vast areas of Haiti will require similar attention.  It is unlikely effort will be mobilized quickly enough to forestall the spread of cholera. Public health intervention in the areas of education, hygiene, and training of medical responders will continue to be important. However, the default operational position now is not to prioritize effort to prevent spread but to prevent or mitigate unnecessary fatalities. The HEAS is narrowly focused on early, actionable warning coupled to “swarm” medical response.  We have observed time deltas [i.e. change --- ed.] between warning and imminent healthcare facility collapse can be as short as 24 hrs. The HEAS has encouraged high false positive rate reporting to ensure communications with involved medical facilities and staff can be established and resources mobilized quickly enough should they be required. This process has already assisted several overwhelmed facilities and likely prevented unnecessary loss of life. [Emphasis mine]

Médecins san frontières reports on conditions in PAP:

It’s a really worrying situation for us at the moment. All of the hospitals in Port-au-Prince are overflowing with patients and we’re seeing seven times the total amount of cases we had three days ago.In the slum of Cite Soleil, located in the north of the city, yesterday we recorded 216 separate cases of cholera arriving at the hospital, while the total number recorded just 5 days ago was 30. Patients are coming from everywhere, throughout the city, slums and wealthier areas. At the moment we have 400 beds set aside for the stabilization and rehabilitation of patients and we’re hoping to get that up to 1,000 by the end of the week.

But we are really worried about space. If the number of cases continues to increase at the same rate, then we’re going to have to adopt some drastic measures to be able to treat people. We’re going to have to use public spaces and even streets. I can easily see this situation deteriorating to the point where patients are lying in the street, waiting for treatment. At the moment, we just don’t have that many options.

We’re looking for alternative spaces, but you have to remember what the situation in Port-au-Prince is like. Since the earthquake, every available space that wasn’t damaged has been filled by camps where people are living in extremely precarious conditions. Just to find an empty area in this city is a major logistical challenge, so for us to find room to treat people is very complicated.

James Wilson at Haiti: Operation Biosurveillance has produced a useful timeline of the epidemic, from Case 0 to the report from MSF: “All the hospitals in Port-au-Prince are overflowing.”

Dominican authorities prepare to reopen the trans-national markets closed by the epidemic.