Cholera Epidemic in Haiti: A Threat to the Western Hemisphere? Dr. Daphne B. Moffett Health Systems Reconstruction Office 26 May 2011

Transcription

1 Cholera Epidemic in Haiti: A Threat to the Western Hemisphere? Dr. Daphne B. Moffett Health Systems Reconstruction Office 26 May 2011

2 Cholera Outbreak October 19, 2010 : MSPP Alert Increase in cases of acute watery diarrhea Severe dehydration and death among all age groups No history of epidemic cholera in Haiti October 20, 2010 : Positive Rapid Test LNSP receives specimens 8 are positive for V. cholerae O1 by rapid test October 22, 2010 : Culture Confirmation LNSP isolates Vibrio cholerae serogroup O1, serotype Ogawa, biotype El Tor Within 4 days of patients presenting Rapid response and identification possible because of existing PEPFAR platform and ongoing post-eq public health response

3 2010 Haiti Cholera Response Director s Update Brief 08 MAR 2011 For Internal/Official Use Only (FIUO/FOUO)----Sensitive But Unclassified (SBU) - NOT FOR FURTHER DISTRIBUTION

4 First Culture Confirmed Case by Department Ouest 23 Oct Nord 25 Oct Sud 10 Nov Nippes 18 Nov October November Artibonite 21 Oct Centre 24 Oct Nord- Ouest 26 Oct Nord-Est & Sud- Est 14 Nov Grande Anse 19 Nov

5 2010 Haiti Cholera Response Director s Update Brief 08 MAR 2011 For Internal/Official Use Only (FIUO/FOUO)----Sensitive But Unclassified (SBU) - NOT FOR FURTHER DISTRIBUTION 5

6 Total (n=302,401) and Hospitalized (n=162,651) Cholera Cases by Day Haiti, Oct 20, 2010 May 10, 2011

7 Total Cholera Deaths (n=5,234) by Day Haiti, Oct 20, 2010 May 10, 2011 Date

8 Cumulative Total Cholera Cases, Haiti, Oct 20, 2010 May 10, 2011 Date

9 Notice of Cholera in Dominican Republic 9

10 Confirmed Cholera Cases in the US Outbreak-Associated 9 confirmed cases: FL (7), VA (1), and NC (1) All with recent travel to Haiti 8 culture confirmed; 1 seropositive Age 9-84 (median=53); 44% female PFGE: 8 match Haiti isolate by PFGE Reported travel purposes: o Visiting relatives (3)* o Business (2)* o Medical relief work (2) o Unknown (2) o Moved to US (1) *One patient reported both visiting relatives and business travel 10

11 Travel and Onset Dates of Confirmed Imported Cholera Cases Case 1 T-HAN distribution began Case 2 Case 3 Case 4 Case 5 Case 6 Case 7 Case 8 Travel dates * Illness onset date Note: Travel dates missing for case #2 and #3 Case 9 8/30 9/19 10/9 10/29 11/18 12/8 12/28 1/17 11

12 Information for Travelers Arriving in US from Haiti 12

13 Initial Migration and Quarantine Issues Considered Guidance to Travelers Travelers to Haiti avoid nonessential travel to Haiti, 5 basic prevention messages Travelers returning to US from Haiti watch for symptoms, seek immediate medical care for diarrhea Travelers to the Dominican Republic risk low, but take precautions Guidance for Air Crews and Customs & Border Protection Officers Risk of person-to-person transmission low CDC is not denying boarding to ill passengers under its regulatory authority Recommends airlines consider denying boarding to visibly ill travelers Some airlines are electing to screen their passengers prior to boarding Recommends airlines should stock ORS and how to disinfect aircraft 13

14 KAP Study of Travelers from Haiti: Cholera T-HAN 14

15 Cholera Travel Health Alert Notice (T-HAN) Background T-HANs distributed during SARS & H1N1 outbreaks Prevent spread of communicable disease Inform travelers to seek medical care based on symptoms Inform physicians of communicable disease risk No formal evaluation of impact on travelers health 20 Dec 2010: Cholera T-HANs at Miami, Fort Lauderdale, New York City (JFK), and San Juan airports Peak holiday travel season Customs and Border Protection (CBP) at Passport Control distribute to travelers arriving from Haiti 4 languages: English, Haitian-Creole, French, Spanish >32,000 distributed since Dec 20 15

16 CDC Cholera T-HAN 16

17 Purpose: Assess KAP among arriving travelers from Haiti regarding effectiveness of T-HAN as a communication tool Jan 2011: Survey conducted at Miami airport Approximately half of Haiti-to-US daily flights Up to 900 passengers per day Travelers interviewed in Customs and Immigration area Voluntary minutes after receiving T-HAN 5 questions Cholera T-HAN Survey Methods 17

18 Cholera T-HAN Survey Questionnaire Responses Total Passengers = 1348 Total % Travelers surveyed Male Received T-HAN Read T-HAN Go to doctor if diarrhea: Very likely Likely Not likely Very likely to go to doctor RR 95% CI AOR* 95% CI Read T-HAN * Adjusted for sex, US origin 18

19 Cholera T-HAN Survey Impact of T-HANS Survey A higher proportion of travelers who read the T-HAN very likely to go to a doctor Since 20 Dec, interviews of cholera cases in US indicated T-HAN prompted medical visit 1 of 3 confirmed cases 1 of 2 suspected cases* Resource intensive Expensive to print Need to partner with CBP to distribute Cholera outbreak in Haiti likely to continue for extended time * 2 nd suspect case would not have received T-HAN 19

20 Cholera T-HAN Survey Recommendations Continue T-HAN distribution through Feb Transition to travel health poster in airport arrival areas Continue physician education to raise awareness Epi-X, MMWR, COCA Continue Haitian community education in US Radio & social media messages, press releases, town hall meetings 20

21 Cholera Cases and Outbreak (as of 8 March 2011) Dominican Republic Cholera cases 470 lab-confirmed cases (first confirmed on October 31, 2010) Four confirmed cholera-related deaths Active transmission in eight of 32 provinces Cholera outbreak associated with wedding attendance Cases among ~540 attendees at a wedding held 22-Jan lab-confirmed cases reported from three countries--us: NYC (3), MA (4), Venezuela (38)*, DR (19) ~70 suspected cases reported in three countries TX (1 new case- state DHS confirmed) NY (1 case confirmed) Case-control study in Venezuela, DR, Spain, and US DR MOH is leading the study and analysis PAHO is coordinating efforts between Venezuela and DR CDC EISO involved in case interview 21

22 WHO Collaborating Center for Implementation of IHR National Surveillance and Response Capacity WHO-CDC Capacity Development Disease detection and response Training in field epidemiology and laboratory methods Pandemic influenza preparedness Human health-animal health interface Health Communication and Information Technology Laboratory systems and biosafety

23 Who is responsible?

24 Independent Panel Review of Cholera Outbreak in Haiti--recommendations Prevention strategies for UN personnel from cholera endemic areas deploying to non-cholera endemic areas Use of on-site fecal waste treatment systems at UN installations Examination of use of cholera vaccines (for emergency responders and in post-outbreak areas) Prioritize UN and GOH investments in WASH 24

25 Considerations Closing the borders Firmly held beliefs History Blame and economic responsibility Potential retribution against infected population or index case Communication strategies that work