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Public health risk assessment and interventions - Earthquake: Haiti - January 2010 (WHO, excerpts, edited)
Public health risk assessment and interventions - Earthquake: Haiti - January 2010 (WHO, excerpts, edited)
[Source Full PDF Document: LINK. EDITED.]
Public health risk assessment and interventions - Earthquake: Haiti - January 2010
Disclaimer:
This is an operational preliminary draft that will be subject to further review and update. The final draft will be available shortly.
Communicable Diseases Working Group on Emergencies, WHO headquarters
Communicable Diseases Surveillance and Response, Pan American Health Organization
WHO Country Office, Haiti
Communicable Disease Working Group on Emergencies (WHO/HQ)
Communicable Disease Surveillance and Response (AMRO/PAHO); WHO Office, Haiti.
Public Health risk assessment and interventions: Earthquake, Haiti
Disclaimer: This is an operational preliminary draft that will be subject to further review and update. The final draft will be available shortly. 16 January 2010
? World Health Organization 2010
All rights reserved.
The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers? products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.
For further information, please contact:
Disease Control in Humanitarian Emergencies
Department of Global Alert and Response
World Health Organization
1211 Geneva 27
Switzerland
Fax: (+41) 22 791 4285
cdemergencies@who.int
Acknowledgements
This public health risk assessment was jointly compiled by the unit on Disease Control in Humanitarian Emergencies (DCE), part of the Global Alert and Response Department (GAR) in the Health Security and Environment cluster (HSE), in collaboration with the Health Action in Crises (HAC) cluster at World Health Organization (WHO) Headquarters, and supported by the Department of Communicable Disease Surveillance and Response and the Emergency and Humanitarian Action unit in the WHO Regional Office for the Americas and the WHO Country Office of Haiti.
The risk assessment was developed by the Communicable Diseases Working Group on Emergencies (CDWGE) at WHO headquarters. The CD-WGE provides technical and operational support on communicable disease issues to WHO regional and country offices, ministries of health, other United Nations agencies, and nongovernmental and international organizations. The Working Group includes the departments of Global Alert and Response (GAR), Food Safety, Zoonoses and Foodborne Diseases (FOS), Public Health and Environment (PHE) in the Health Security and Environment (HSE) cluster; the Special Programme for Research and Training in Tropical Diseases (TDR); the Global Malaria Programme (GMP), Stop TB (STB), HIV/AIDS and Control of Neglected Tropical Diseases in the HTM cluster; Health Statistics and Informatics (HIS) in the Information, Evidence and Research (IER) Cluster; the departments of Child and Adolescent Health and Development (CAH), Making Pregnancy Safer (MPS), the department of Country Focus (CCO) in the Partnerships and UN Reform (PUN) cluster; Reproductive Health and Research (RHR), Immunizations, Vaccines and Biologicals (IVB) in the Family and Community Health (FCH) cluster; Violence and Injuries Prevention (VIP) and Nutrition for Health and Development (NHD) in the Noncommunicable Diseases and Mental Health (NMH) cluster; Clinical Procedures unit of Essential Health Technologies, (CPR/EHT) in HSS cluster, Health and Medical Services (HMS) and Security Services (SEC) in the General Management (GMG) cluster, and the cluster of Health Action in Crises (HAC) and the Polio Eradication Initiative (POL) and as a Special Programme in the Office of the Director General.
DCE gratefully acknowledges the current and previous collaboration and input of the disease-specific focal points of the CD-WGE, the WHO Regional Office for the Americas and the Country Office of the WHO Representative for Haiti, which have made the production of this profile possible.
Preface
The purpose of this public health risk assessment is to provide health professionals in United Nations agencies, nongovernmental organizations, donor agencies and local authorities currently working with populations affected by the emergency in Haiti, with up-to-date technical guidance on the major public health threats faced by the earthquake-affected population.
The topic areas addressed have been selected on the basis of the burden of morbidity, mortality and potential for increase in the area.
Public health threats represent a significant challenge to those providing health-care services in this evolving situation. It is hoped that this risk assessment will facilitate the coordination of activities between all agencies working among the populations currently affected by the crisis.
1. BACKGROUND AND RISK FACTORS
1.1 Event description
On 12 January 2010, at 16:53 local time (GMT 21:53hrs) an earthquake measuring 7.0 on the Richter scale occurred in Haiti. The epicenter of the earthquake was 17 km from the capital Port-au-Prince (population approximately 2 million). Aftershocks have been reported as high as 6.0. Approximately 3.5 million people live in earthquake-affected areas.
This is the strongest earthquake recorded in Haiti, a country that has already suffered years of humanitarian crisis and natural disasters including a series of hurricanes/tropical storms in 2008. The earthquake has inflicted significant damage, particularly affecting critical infrastructure including basic utilities (power, water, sanitation), transport, communication and health. Preliminary reports indicate many collapsed structures including hospitals and health centers in the Port-au-Prince area, with heavy loss of staff. The capacity to respond to this crisis has been severely compromised.
The transport infrastructure has been severely crippled, including damage to the airport and harbour.
Drinking water and sewer systems deemed functional before the earthquake are no longer usable.
Information about casualty figures is still provisional but reports indicate a significant loss of life. The UN mission and peacekeeping operations have also been severely affected.
Immediate health priorities include search and rescue for survivors trapped underneath the rubble, providing surgical/medical services to treat injured survivors, preventing wound infection and providing shelter, food, clean water and sanitation.
Internationally humanitarian aid is being offered presenting coordination challenges. Field hospitals are being deployed and once operational the number planned will be sufficient to meet the current needs.
1.2 Country context
Haiti is a Creole- and French- speaking Caribbean country with a total land area of approximately 27,750 square kilometres. It is the third largest country in the Caribbean. Haiti occupies the western third of the Island of Hispaniola, which it shares with the Dominican Republic (see Fig 1). The country has a tropical climate with some variation depending on altitude. There are two rainy seasons , April ? June and October ? November. Hurricane season is August/September.
In 2007 the population of Haiti was 9.7 million. It is the poorest country in the western hemisphere, and ranks 149/182 on the UNDP Human Development Index 2007. In 2001, 55% of the population lived in households that were below the extreme poverty line of US$ 1 per person per day.
Hospital and clinical facilities in Port-au-Prince have long been compromised by infrastructural deficiencies, electrical blackouts, water problems, and general impoverishment.
Water and sanitation are major issues in Haiti, with 45% of the population lacking access to safe water in 2009 and 83% of Haiti?s total population without access to improved sanitation (WHO/CCS).
In 2007, 47% of the population lacked access to basic health care, with the majority of the population seeking care from traditional healers. An estimated 40% of households experience food insecurity, manifested by low birth weight and nutrient deficiencies.
The health system in Haiti includes the public sector (Ministry of Public Health and Population and Ministry of Social Affairs); the private for-profit sector; the mixed non-profit sector (Ministry of Health personnel working in private institutions (NGOs) or religious organizations; the private non-profit sector (NGOs, foundations, associations); and the traditional health system. The Ministry of Public Health and Population encompasses 10 national bureaux and 4 coordinating units, addressing infectious and communicable diseases, EPI, nutrition, and hospital safety. There are 371 health posts, 217 health centres and 49 hospitals in Haiti. In 2009, there were >250 additional implementing partners in the health sector, further challenging health coordination (WHO/CCS).
2. IMMEDIATE PUBLIC HEALTH RISKS
2.1 Wounds and injuries
Earthquakes cause high mortality due to trauma. Wounds and Injuries will be numerous due to the initial impact of the earthquake and subsequent rescue and clean-up activities. Surgical needs are critically important during the first days and weeks. The majority of the injured are likely to have minor cuts and bruises, a smaller percentage will suffer from simple fractures, and a minority (but a significant number) will present with serious multiple fractures or internal injuries and crush syndrome requiring surgery, blood transfusion and other intensive treatment. These serious injuries are likely to overwhelm existing treatment capabilities, resulting in further delays. A significant number of burns have also been reported, requiring specific burns care.
Risk of wound infection and tetanus are high due to the difficulties with immediate access to health facilities and delayed presentation of acute injuries. Gangrene is a complication of wound contamination, and prompt wound treatment is critical for its prevention. Gangrenous wounds should be managed aggressively, with surgical removal of gangrenous tissue. There is no risk of transmission of gangrene to unaffected persons.
Low vaccination coverage among one year-old children (DTP3 53% at one year in 2007, see Table 1), and waning tetanus immunity in adults increases the likelihood of morbidity and mortality from tetanus. (For additional information, see section 4, Wounds and injuries, and Child health in emergencies: Pocket book of hospital care for children).
2.2 Water/sanitation/hygiene-related and foodborne diseases
The displaced populations in Haiti are at high risk from outbreaks of water, sanitation, and hygiene and foodborne-related diseases, as well as foodborne diseases, due to reduced access to safe water and sanitation systems. Disruption of usual water sources and contamination of water by damaged sewage infrastructure may result in unsafe drinking water being consumed, increasing the risk of exposure. Salmonella typhi (causing typhoid fever), hepatitis A and hepatitis E are present and have epidemic potential. Cholera is not endemic in Haiti. Diarrhoea is already a major contributor to the high rates of under-five mortality; WHO estimates that diarrhoea accounts for 16% of under-five deaths in Haiti. Leptospirosis is endemic in Haiti (see section 2.5 Vector-borne and zoonotic diseases).
2.3 Diseases associated with crowding
Population displacement can result in overcrowding in resettlement areas, raising the risk of transmission of certain communicable diseases that are spread from person-to-person through respiratory droplets such as measles, diphtheria and pertussis (see section below on vaccine-preventable diseases), and acute respiratory infections or ARI. This risk is increased with inadequate ventilation. Overcrowding can also increase the likelihood of transmission of meningitis, waterborne and vector-borne diseases in the weeks and months following the earthquake.
Acute respiratory infections. ARIs include any infection of the upper or lower respiratory tracts. A major concern is acute lower respiratory (ALRI) tract infection (pneumonia, bronchiolitis and bronchitis) in children under five. WHO estimated in 2000 that 20% of under five deaths in Haiti were caused by pneumonia. Low birth weight, malnourished and non-breastfed children and those living in overcrowded conditions are at higher risk of acquiring pneumonia. Infants of less than six months of age, who are not breastfed, have an increased risk of dying from pneumonia that is five times higher than in infants who are exclusively breastfed for the first six months.
Early detection and case management of pneumonia and other common illnesses, guided by the Integrated Management of Childhood Illness (IMCI), will prevent unnecessary morbidity and mortality in children under five years of age. It is recommended that trained health care workers refer to the national IMCI guidelines during and after the emergency.
Pandemic influenza A (H1N1) 2009 is currently circulating in Haiti. It is transmitted from person to person as easily as normal seasonal flu by exposure to infected droplets expelled by coughing or sneezing or via contaminated hands or surfaces. (For additional information, see section 4, Pandemic influenza A (H1N1) 2009).
Meningococcal disease is spread from person to person through respiratory droplets from infected people. Transmission is facilitated by close contact and crowded living conditions.
Tuberculosis (TB) is still among the leading causes of morbidity and mortality. Haiti has the highest TB incidence in the Western hemisphere. In 2007, the estimated number of TB cases was 35 000 with an incidence of 147 cases per 100 000 population. Mortality rate from all forms of TB was 71/100 000 population in 2007. Among new cases, 23% were HIV positive. The estimated prevalence of MDR among all new cases is 1.8% (WHO, TB country profile). Haiti has adopted the DOTS strategy, with services provided through the National TB Programme (NTP).
TB control in Haiti involves a significant number of NGOs. Treatment is available in 198 health facilities, including four sanitaria. The objectives of the NTP (that are in line with the WHO global targets: at least 70% TB case detection rate and at least 85% treatment success rate) have not yet been met. Indeed, the detection rate of smear-positive TB cases was 47% in 2007 and the treatment success rate was 81% in 2006.
In the acute phase of this emergency, the potential interruption of all treatments for chronic diseases (including TB, HIV, diabetes, etc.) and loss of patient follow-up is likely to be a significant problem. It is therefore essential that strong collaboration is established between health workers responding to the emergency and the established NTP services. The other aspects of TB control can be addressed once emergency and basic health care have been re-established. Pages 95 to 97 of the guideline TB care and
control in refugee and displaced populations highlights the TB control issues that should be considered in situations of natural disasters (see section 4, Tuberculosis).
2.4 Vaccine-preventable diseases and routine immunization coverage
Tetanus has a high case-fatality rate of 70?100% without medical treatment and is globally underreported. The incubation period is usually three to 21 days. A shorter incubation period is associated with severe disease and a worse prognosis. Reports from the national authorities, WHO and UNICEF indicate a 53% Diphtheria? tetanus? pertussis, 3rd dose (DTP3) coverage (2007) among one year old children in Haiti.
Appropriate management of injured survivors should be implemented as soon as possible to minimize future disability and to avert avoidable death following the earthquake. All wounds and injuries should be scrutinized as Clostridium tetani spores present in the soil can infect trivial, unnoticed wounds, lacerations and burns. Health-care workers operating in disaster settings should be alerted by the occurrence of cases of dysphagia (difficulty in swallowing) and trismus ("lockjaw" or tonic contraction of jaw muscles), often the first symptoms of the disease.
Appropriate management of injured survivors should be implemented as soon as possible to minimize future disability and to avert avoidable death. Patients should systematically receive prophylactic antibiotics and tetanus toxoid vaccine if non-immune, together with tetanus immune globulin if the wound is tetanus-prone. (See sections 3.1 Case management and 3.3 Immunization; for additional information, see section 4, Tetanus; Wounds and injuries.)
Measles, diphtheria, pertussis and polio. In populations with low vaccination coverage, the crowding associated with displacement may increase the risk of outbreaks from measles, pertussis, and diphtheria. Measles infection has not been confirmed in Haiti since 2001. Reports from the national authorities, WHO and UNICEF indicate 58% measles vaccine coverage among one year old children (2007), resulting in an increased risk of measles outbreaks. Diphtheria outbreaks occurred in Haiti in 2004, 2005 and 2009; 3rd dose (DTP3) coverage (2007) among one year old children in Haiti is reported as 53%. Polio has been eliminated in Haiti. Coverage (OPV3) among one year old children (2007) is 52%.
Hepatitis A is a liver infection caused by the hepatitis A virus (HAV), and transmitted by the faecal-oral route. (See sections 2.1 Water/sanitation/hygiene-related and foodborne diseases and 3.4 Immunization)
Table 1. Routine vaccination coverage at one year of age, 2007, Haiti
[Antigen - % coverage*]
* Official country estimates reported to WHO/UNICEF, 2007
2.5 Vector-borne diseases and zoonotic diseases
Dengue / dengue haemorrhagic fever (DHF) is a viral disease transmitted by the Ae. aegypti mosquito which is endemic in Haiti. High transmission rates of all four dengue viruses have been reported from Haiti, with transmission occurring mainly during April/May through November. Dengue causes a severe influenza-like illness. A potentially lethal complication called dengue haemorrhagic fever can sometimes occur. Epidemics of dengue can occur cyclically in 3-5 year intervals. (For additional information, see section 4, Dengue).
Malaria is a serious issue in Haiti. Malaria risk, which is exclusively due to P. falciparum, exists throughout the year in the entire country, including coastal and border zones. Risk in the main urban areas of Port-au-Prince is considered to be very low but may increase in the current emergency situation.
Chloroquine can be used for treatment, as no P. falciparum resistance to chloroquine has been reported. Displaced populations may be at an increased risk of malaria and dengue due to an increased exposure to vectors among displaced populations who lack adequate shelter. (For additional information, see section 3.4, Case management)
Human rabies transmitted by dogs is a priority disease in Haiti. Rabies control is a priority, and a dog mass vaccination campaign was undergoing at the time of the earthquake. There may be an increased risk of rabies transmission from animal bites following the earthquake.
Leptospirosis is endemic in Haiti. Infection in humans may occur indirectly when the bacteria comes into contact with the skin (especially if damaged) or the mucous membranes. It can also result from contact with moist soil or vegetation contaminated with the urine of infected animals.
Lymphatic filariasis is endemic throughout the island and transmitted by the night-biting Culex quinquefasciatis mosquito. Displaced populations without adequate shelter may be at increased of bites from these mosquitoes. LLINs offer some protection against mosquito vectors.
2.6 Other public health risks and considerations
Corpses. It is important to convey to all parties that corpses do not represent a public health threat. When death is due to the initial impact of the event and not because of disease, dead bodies have not been associated with outbreaks. Standard infection control precautions are recommended for those managing corpses. (For additional information, see section 4, Management of dead bodies).
Malnutrition is a problem in all provinces in Haiti, particularly for children under five years old. Under-nutrition is an important underlying factor contributing to childhood mortality rates, and has also been linked to impaired cognitive development.
Prevalence of acute malnutrition among children under five is an area of serious concern, having doubled in 5 years: national prevalence of acute malnutrition was 4.5% in 2000 (DHS 2000) and 9.1% in 2005 (DHS 2005). From 2000-2007, 41% infants less than 6 months old were exclusively breastfed.
The earthquake-affected populations are at an increased risk of moderate and severe acute malnutrition especially in vulnerable groups such as young children, pregnant and lactating women and older persons. This risk is linked to lack of access to appropriate and adequate food, and to increased cases of diarrhoeal diseases and reduced access to health and nutrition services.
Additionally, the risk may be increased by lack of support for mothers or caretakers for breastfeeding, relactation, appropriate complementary feeding. Uncontrolled donations of infant formula and other breast-milk substitutes can increase morbidity and mortality in infants and young children. (For additional information, see section 4, Malnutrition).
Key reproductive health interventions are ensuring safe delivery (access to basic and comprehensive emergency obstetric care ), clinical management of sexual violence, prevention of HIV transmission and provision of contraceptives to meet demand. These interventions are critical components of the Minimal Initial Service Package (MISP) for reproductive health, which is implementation in the acute phase of an emergency. (For additional information, see section 4, Reproductive Health in Emergencies)
Sexually transmitted infections (STIs) including human immunodeficiency virus (HIV). Haiti is affected by a generalized HIV epidemic. An estimated 120 000 people in Haiti are living with the virus (UNAIDS, WHO 2005). From the 2008 Universal Access report 2008, the Ministry of Health and Population estimated there were 47 health centres (7%) providing antiretroviral treatment in Haiti, with over 19 000 undergoing treatment with antiretroviral treatment (ART). The emergency response should ensure a minimum package of HIV prevention, treatment and care services, including the strengthening of standard precautions, with the provision of gloves, sterile needles and syringes, and safe waste disposal management in health services. Additional services should include provision of condoms, education and prevention messages, and post-exposure prophylaxis for occupational exposure and survivors of rape.
Needle and syringe exchange programmes should be maintained. Efforts should be made to ensure that HIV/AIDS patients receiving ART do not have their treatment interrupted and that ART is provided for the prevention of mother-to-child transmission of HIV.
During emergencies, vulnerable people may be subjected to situations that substantially increase their exposure to STIs, including HIV. Risk factors include massive displacement of people from their homes, women and children left to fend for themselves, prevalence of domestic violence, social services overwhelmed or destroyed, and a lack of means to prevent HIV infection, such as clean needles, safe blood transfusions and availability of condoms. (For additional information, see section 4, Gender and Gender-based violence and HIV/AIDS).
Skin infections occur not only due to overcrowding but also as a result of a lack of water and reduced hygiene. Infestations (e.g. scabies, lice ? associated with typhus) are also common and require treatment once they occur.
Noncommunicable diseases (NCDs) are recognized as an important health concern in Haiti. Chronic conditions, including cancer, cardiovascular disease including hypertension, diabetes, chronic respiratory disease and neuropsychiatric disorders, account for an increasing proportion of the disease burden. This group of diseases places a substantial burden on health services and an impoverishing drain on families and communities. The priorities during the acute phase of this emergency are to minimize treatment
interruptions.
Environmental risks may exist from damaged hazardous installations such as industrial facilities, damaged oil and gasoline depots, warehouses that stockpile agro-, industrial or other chemicals as well as damaged technical equipment (e.g. transformers, medical equipment with radiological sources). Most of Haiti's industry is located around Port-au-Prince. Health workers should look out for patients' symptoms that may be consistent with chemical intoxication, especially skin irritation and chemical burns.
Poor management of waste, including health-care waste, can potentially expose health-care workers, waste handlers, patients and the community at large to infection, toxic effects and injuries as well as increasing the risk of polluting the environment. (For additional information, see section 4,
Environmental health in emergencies, UNEP/OCHA Environmental Risk Identification).
Carbon monoxide poisoning is a risk if petrol-driven generators are used in enclosed spaces. Care should be taken to ensure adequate ventilation where generators are used.
Interrupted power supply. As a result of extended power supply interruption, food is likely to have been spoiled and could become a possible source of disease if consumed. Routine vaccine stocks and the cold chain are also likely to have been compromised.
Drug and equipment donations. Inappropriate donations of medicines, medical equipment and medical supplies can be minimized by donors adhering to the interagency guidelines (for additional information, see section 4, Drug donations). In general, the key principles are :
(See section 4, Drug donations)
Disposing of pharmaceuticals should be by high temperature incineration (i.e. above 1200?C). Such incineration facilities, equipped with adequate emission control, are mainly found in the industrialized world. The cost of disposing of hazardous waste in this way ranges from US$ 2000 to US$ 4000 per ton.
Staff health. (See Section 6)
(...)
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[Source Full PDF Document: LINK. EDITED.]
Public health risk assessment and interventions - Earthquake: Haiti - January 2010
Disclaimer:
This is an operational preliminary draft that will be subject to further review and update. The final draft will be available shortly.
Communicable Diseases Working Group on Emergencies, WHO headquarters
Communicable Diseases Surveillance and Response, Pan American Health Organization
WHO Country Office, Haiti
Communicable Disease Working Group on Emergencies (WHO/HQ)
Communicable Disease Surveillance and Response (AMRO/PAHO); WHO Office, Haiti.
Public Health risk assessment and interventions: Earthquake, Haiti
Disclaimer: This is an operational preliminary draft that will be subject to further review and update. The final draft will be available shortly. 16 January 2010
? World Health Organization 2010
All rights reserved.
The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers? products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.
For further information, please contact:
Disease Control in Humanitarian Emergencies
Department of Global Alert and Response
World Health Organization
1211 Geneva 27
Switzerland
Fax: (+41) 22 791 4285
cdemergencies@who.int
Acknowledgements
This public health risk assessment was jointly compiled by the unit on Disease Control in Humanitarian Emergencies (DCE), part of the Global Alert and Response Department (GAR) in the Health Security and Environment cluster (HSE), in collaboration with the Health Action in Crises (HAC) cluster at World Health Organization (WHO) Headquarters, and supported by the Department of Communicable Disease Surveillance and Response and the Emergency and Humanitarian Action unit in the WHO Regional Office for the Americas and the WHO Country Office of Haiti.
The risk assessment was developed by the Communicable Diseases Working Group on Emergencies (CDWGE) at WHO headquarters. The CD-WGE provides technical and operational support on communicable disease issues to WHO regional and country offices, ministries of health, other United Nations agencies, and nongovernmental and international organizations. The Working Group includes the departments of Global Alert and Response (GAR), Food Safety, Zoonoses and Foodborne Diseases (FOS), Public Health and Environment (PHE) in the Health Security and Environment (HSE) cluster; the Special Programme for Research and Training in Tropical Diseases (TDR); the Global Malaria Programme (GMP), Stop TB (STB), HIV/AIDS and Control of Neglected Tropical Diseases in the HTM cluster; Health Statistics and Informatics (HIS) in the Information, Evidence and Research (IER) Cluster; the departments of Child and Adolescent Health and Development (CAH), Making Pregnancy Safer (MPS), the department of Country Focus (CCO) in the Partnerships and UN Reform (PUN) cluster; Reproductive Health and Research (RHR), Immunizations, Vaccines and Biologicals (IVB) in the Family and Community Health (FCH) cluster; Violence and Injuries Prevention (VIP) and Nutrition for Health and Development (NHD) in the Noncommunicable Diseases and Mental Health (NMH) cluster; Clinical Procedures unit of Essential Health Technologies, (CPR/EHT) in HSS cluster, Health and Medical Services (HMS) and Security Services (SEC) in the General Management (GMG) cluster, and the cluster of Health Action in Crises (HAC) and the Polio Eradication Initiative (POL) and as a Special Programme in the Office of the Director General.
DCE gratefully acknowledges the current and previous collaboration and input of the disease-specific focal points of the CD-WGE, the WHO Regional Office for the Americas and the Country Office of the WHO Representative for Haiti, which have made the production of this profile possible.
Preface
The purpose of this public health risk assessment is to provide health professionals in United Nations agencies, nongovernmental organizations, donor agencies and local authorities currently working with populations affected by the emergency in Haiti, with up-to-date technical guidance on the major public health threats faced by the earthquake-affected population.
The topic areas addressed have been selected on the basis of the burden of morbidity, mortality and potential for increase in the area.
Public health threats represent a significant challenge to those providing health-care services in this evolving situation. It is hoped that this risk assessment will facilitate the coordination of activities between all agencies working among the populations currently affected by the crisis.
1. BACKGROUND AND RISK FACTORS
1.1 Event description
On 12 January 2010, at 16:53 local time (GMT 21:53hrs) an earthquake measuring 7.0 on the Richter scale occurred in Haiti. The epicenter of the earthquake was 17 km from the capital Port-au-Prince (population approximately 2 million). Aftershocks have been reported as high as 6.0. Approximately 3.5 million people live in earthquake-affected areas.
This is the strongest earthquake recorded in Haiti, a country that has already suffered years of humanitarian crisis and natural disasters including a series of hurricanes/tropical storms in 2008. The earthquake has inflicted significant damage, particularly affecting critical infrastructure including basic utilities (power, water, sanitation), transport, communication and health. Preliminary reports indicate many collapsed structures including hospitals and health centers in the Port-au-Prince area, with heavy loss of staff. The capacity to respond to this crisis has been severely compromised.
The transport infrastructure has been severely crippled, including damage to the airport and harbour.
Drinking water and sewer systems deemed functional before the earthquake are no longer usable.
Information about casualty figures is still provisional but reports indicate a significant loss of life. The UN mission and peacekeeping operations have also been severely affected.
Immediate health priorities include search and rescue for survivors trapped underneath the rubble, providing surgical/medical services to treat injured survivors, preventing wound infection and providing shelter, food, clean water and sanitation.
Internationally humanitarian aid is being offered presenting coordination challenges. Field hospitals are being deployed and once operational the number planned will be sufficient to meet the current needs.
1.2 Country context
Haiti is a Creole- and French- speaking Caribbean country with a total land area of approximately 27,750 square kilometres. It is the third largest country in the Caribbean. Haiti occupies the western third of the Island of Hispaniola, which it shares with the Dominican Republic (see Fig 1). The country has a tropical climate with some variation depending on altitude. There are two rainy seasons , April ? June and October ? November. Hurricane season is August/September.
In 2007 the population of Haiti was 9.7 million. It is the poorest country in the western hemisphere, and ranks 149/182 on the UNDP Human Development Index 2007. In 2001, 55% of the population lived in households that were below the extreme poverty line of US$ 1 per person per day.
Hospital and clinical facilities in Port-au-Prince have long been compromised by infrastructural deficiencies, electrical blackouts, water problems, and general impoverishment.
Water and sanitation are major issues in Haiti, with 45% of the population lacking access to safe water in 2009 and 83% of Haiti?s total population without access to improved sanitation (WHO/CCS).
In 2007, 47% of the population lacked access to basic health care, with the majority of the population seeking care from traditional healers. An estimated 40% of households experience food insecurity, manifested by low birth weight and nutrient deficiencies.
The health system in Haiti includes the public sector (Ministry of Public Health and Population and Ministry of Social Affairs); the private for-profit sector; the mixed non-profit sector (Ministry of Health personnel working in private institutions (NGOs) or religious organizations; the private non-profit sector (NGOs, foundations, associations); and the traditional health system. The Ministry of Public Health and Population encompasses 10 national bureaux and 4 coordinating units, addressing infectious and communicable diseases, EPI, nutrition, and hospital safety. There are 371 health posts, 217 health centres and 49 hospitals in Haiti. In 2009, there were >250 additional implementing partners in the health sector, further challenging health coordination (WHO/CCS).
2. IMMEDIATE PUBLIC HEALTH RISKS
2.1 Wounds and injuries
Earthquakes cause high mortality due to trauma. Wounds and Injuries will be numerous due to the initial impact of the earthquake and subsequent rescue and clean-up activities. Surgical needs are critically important during the first days and weeks. The majority of the injured are likely to have minor cuts and bruises, a smaller percentage will suffer from simple fractures, and a minority (but a significant number) will present with serious multiple fractures or internal injuries and crush syndrome requiring surgery, blood transfusion and other intensive treatment. These serious injuries are likely to overwhelm existing treatment capabilities, resulting in further delays. A significant number of burns have also been reported, requiring specific burns care.
Risk of wound infection and tetanus are high due to the difficulties with immediate access to health facilities and delayed presentation of acute injuries. Gangrene is a complication of wound contamination, and prompt wound treatment is critical for its prevention. Gangrenous wounds should be managed aggressively, with surgical removal of gangrenous tissue. There is no risk of transmission of gangrene to unaffected persons.
Low vaccination coverage among one year-old children (DTP3 53% at one year in 2007, see Table 1), and waning tetanus immunity in adults increases the likelihood of morbidity and mortality from tetanus. (For additional information, see section 4, Wounds and injuries, and Child health in emergencies: Pocket book of hospital care for children).
2.2 Water/sanitation/hygiene-related and foodborne diseases
The displaced populations in Haiti are at high risk from outbreaks of water, sanitation, and hygiene and foodborne-related diseases, as well as foodborne diseases, due to reduced access to safe water and sanitation systems. Disruption of usual water sources and contamination of water by damaged sewage infrastructure may result in unsafe drinking water being consumed, increasing the risk of exposure. Salmonella typhi (causing typhoid fever), hepatitis A and hepatitis E are present and have epidemic potential. Cholera is not endemic in Haiti. Diarrhoea is already a major contributor to the high rates of under-five mortality; WHO estimates that diarrhoea accounts for 16% of under-five deaths in Haiti. Leptospirosis is endemic in Haiti (see section 2.5 Vector-borne and zoonotic diseases).
2.3 Diseases associated with crowding
Population displacement can result in overcrowding in resettlement areas, raising the risk of transmission of certain communicable diseases that are spread from person-to-person through respiratory droplets such as measles, diphtheria and pertussis (see section below on vaccine-preventable diseases), and acute respiratory infections or ARI. This risk is increased with inadequate ventilation. Overcrowding can also increase the likelihood of transmission of meningitis, waterborne and vector-borne diseases in the weeks and months following the earthquake.
Acute respiratory infections. ARIs include any infection of the upper or lower respiratory tracts. A major concern is acute lower respiratory (ALRI) tract infection (pneumonia, bronchiolitis and bronchitis) in children under five. WHO estimated in 2000 that 20% of under five deaths in Haiti were caused by pneumonia. Low birth weight, malnourished and non-breastfed children and those living in overcrowded conditions are at higher risk of acquiring pneumonia. Infants of less than six months of age, who are not breastfed, have an increased risk of dying from pneumonia that is five times higher than in infants who are exclusively breastfed for the first six months.
Early detection and case management of pneumonia and other common illnesses, guided by the Integrated Management of Childhood Illness (IMCI), will prevent unnecessary morbidity and mortality in children under five years of age. It is recommended that trained health care workers refer to the national IMCI guidelines during and after the emergency.
Pandemic influenza A (H1N1) 2009 is currently circulating in Haiti. It is transmitted from person to person as easily as normal seasonal flu by exposure to infected droplets expelled by coughing or sneezing or via contaminated hands or surfaces. (For additional information, see section 4, Pandemic influenza A (H1N1) 2009).
Meningococcal disease is spread from person to person through respiratory droplets from infected people. Transmission is facilitated by close contact and crowded living conditions.
Tuberculosis (TB) is still among the leading causes of morbidity and mortality. Haiti has the highest TB incidence in the Western hemisphere. In 2007, the estimated number of TB cases was 35 000 with an incidence of 147 cases per 100 000 population. Mortality rate from all forms of TB was 71/100 000 population in 2007. Among new cases, 23% were HIV positive. The estimated prevalence of MDR among all new cases is 1.8% (WHO, TB country profile). Haiti has adopted the DOTS strategy, with services provided through the National TB Programme (NTP).
TB control in Haiti involves a significant number of NGOs. Treatment is available in 198 health facilities, including four sanitaria. The objectives of the NTP (that are in line with the WHO global targets: at least 70% TB case detection rate and at least 85% treatment success rate) have not yet been met. Indeed, the detection rate of smear-positive TB cases was 47% in 2007 and the treatment success rate was 81% in 2006.
In the acute phase of this emergency, the potential interruption of all treatments for chronic diseases (including TB, HIV, diabetes, etc.) and loss of patient follow-up is likely to be a significant problem. It is therefore essential that strong collaboration is established between health workers responding to the emergency and the established NTP services. The other aspects of TB control can be addressed once emergency and basic health care have been re-established. Pages 95 to 97 of the guideline TB care and
control in refugee and displaced populations highlights the TB control issues that should be considered in situations of natural disasters (see section 4, Tuberculosis).
2.4 Vaccine-preventable diseases and routine immunization coverage
Tetanus has a high case-fatality rate of 70?100% without medical treatment and is globally underreported. The incubation period is usually three to 21 days. A shorter incubation period is associated with severe disease and a worse prognosis. Reports from the national authorities, WHO and UNICEF indicate a 53% Diphtheria? tetanus? pertussis, 3rd dose (DTP3) coverage (2007) among one year old children in Haiti.
Appropriate management of injured survivors should be implemented as soon as possible to minimize future disability and to avert avoidable death following the earthquake. All wounds and injuries should be scrutinized as Clostridium tetani spores present in the soil can infect trivial, unnoticed wounds, lacerations and burns. Health-care workers operating in disaster settings should be alerted by the occurrence of cases of dysphagia (difficulty in swallowing) and trismus ("lockjaw" or tonic contraction of jaw muscles), often the first symptoms of the disease.
Appropriate management of injured survivors should be implemented as soon as possible to minimize future disability and to avert avoidable death. Patients should systematically receive prophylactic antibiotics and tetanus toxoid vaccine if non-immune, together with tetanus immune globulin if the wound is tetanus-prone. (See sections 3.1 Case management and 3.3 Immunization; for additional information, see section 4, Tetanus; Wounds and injuries.)
Measles, diphtheria, pertussis and polio. In populations with low vaccination coverage, the crowding associated with displacement may increase the risk of outbreaks from measles, pertussis, and diphtheria. Measles infection has not been confirmed in Haiti since 2001. Reports from the national authorities, WHO and UNICEF indicate 58% measles vaccine coverage among one year old children (2007), resulting in an increased risk of measles outbreaks. Diphtheria outbreaks occurred in Haiti in 2004, 2005 and 2009; 3rd dose (DTP3) coverage (2007) among one year old children in Haiti is reported as 53%. Polio has been eliminated in Haiti. Coverage (OPV3) among one year old children (2007) is 52%.
Hepatitis A is a liver infection caused by the hepatitis A virus (HAV), and transmitted by the faecal-oral route. (See sections 2.1 Water/sanitation/hygiene-related and foodborne diseases and 3.4 Immunization)
Table 1. Routine vaccination coverage at one year of age, 2007, Haiti
[Antigen - % coverage*]
- (BCG) bacille Calmette?Gu?rin - 75
- Diphtheria? tetanus? pertussis, 3rd dose - 53
- MCV (measles-containing vaccine) - 58
- Polio, 3rd dose - 52
* Official country estimates reported to WHO/UNICEF, 2007
2.5 Vector-borne diseases and zoonotic diseases
Dengue / dengue haemorrhagic fever (DHF) is a viral disease transmitted by the Ae. aegypti mosquito which is endemic in Haiti. High transmission rates of all four dengue viruses have been reported from Haiti, with transmission occurring mainly during April/May through November. Dengue causes a severe influenza-like illness. A potentially lethal complication called dengue haemorrhagic fever can sometimes occur. Epidemics of dengue can occur cyclically in 3-5 year intervals. (For additional information, see section 4, Dengue).
Malaria is a serious issue in Haiti. Malaria risk, which is exclusively due to P. falciparum, exists throughout the year in the entire country, including coastal and border zones. Risk in the main urban areas of Port-au-Prince is considered to be very low but may increase in the current emergency situation.
Chloroquine can be used for treatment, as no P. falciparum resistance to chloroquine has been reported. Displaced populations may be at an increased risk of malaria and dengue due to an increased exposure to vectors among displaced populations who lack adequate shelter. (For additional information, see section 3.4, Case management)
Human rabies transmitted by dogs is a priority disease in Haiti. Rabies control is a priority, and a dog mass vaccination campaign was undergoing at the time of the earthquake. There may be an increased risk of rabies transmission from animal bites following the earthquake.
Leptospirosis is endemic in Haiti. Infection in humans may occur indirectly when the bacteria comes into contact with the skin (especially if damaged) or the mucous membranes. It can also result from contact with moist soil or vegetation contaminated with the urine of infected animals.
Lymphatic filariasis is endemic throughout the island and transmitted by the night-biting Culex quinquefasciatis mosquito. Displaced populations without adequate shelter may be at increased of bites from these mosquitoes. LLINs offer some protection against mosquito vectors.
2.6 Other public health risks and considerations
Corpses. It is important to convey to all parties that corpses do not represent a public health threat. When death is due to the initial impact of the event and not because of disease, dead bodies have not been associated with outbreaks. Standard infection control precautions are recommended for those managing corpses. (For additional information, see section 4, Management of dead bodies).
Malnutrition is a problem in all provinces in Haiti, particularly for children under five years old. Under-nutrition is an important underlying factor contributing to childhood mortality rates, and has also been linked to impaired cognitive development.
Prevalence of acute malnutrition among children under five is an area of serious concern, having doubled in 5 years: national prevalence of acute malnutrition was 4.5% in 2000 (DHS 2000) and 9.1% in 2005 (DHS 2005). From 2000-2007, 41% infants less than 6 months old were exclusively breastfed.
The earthquake-affected populations are at an increased risk of moderate and severe acute malnutrition especially in vulnerable groups such as young children, pregnant and lactating women and older persons. This risk is linked to lack of access to appropriate and adequate food, and to increased cases of diarrhoeal diseases and reduced access to health and nutrition services.
Additionally, the risk may be increased by lack of support for mothers or caretakers for breastfeeding, relactation, appropriate complementary feeding. Uncontrolled donations of infant formula and other breast-milk substitutes can increase morbidity and mortality in infants and young children. (For additional information, see section 4, Malnutrition).
Key reproductive health interventions are ensuring safe delivery (access to basic and comprehensive emergency obstetric care ), clinical management of sexual violence, prevention of HIV transmission and provision of contraceptives to meet demand. These interventions are critical components of the Minimal Initial Service Package (MISP) for reproductive health, which is implementation in the acute phase of an emergency. (For additional information, see section 4, Reproductive Health in Emergencies)
Sexually transmitted infections (STIs) including human immunodeficiency virus (HIV). Haiti is affected by a generalized HIV epidemic. An estimated 120 000 people in Haiti are living with the virus (UNAIDS, WHO 2005). From the 2008 Universal Access report 2008, the Ministry of Health and Population estimated there were 47 health centres (7%) providing antiretroviral treatment in Haiti, with over 19 000 undergoing treatment with antiretroviral treatment (ART). The emergency response should ensure a minimum package of HIV prevention, treatment and care services, including the strengthening of standard precautions, with the provision of gloves, sterile needles and syringes, and safe waste disposal management in health services. Additional services should include provision of condoms, education and prevention messages, and post-exposure prophylaxis for occupational exposure and survivors of rape.
Needle and syringe exchange programmes should be maintained. Efforts should be made to ensure that HIV/AIDS patients receiving ART do not have their treatment interrupted and that ART is provided for the prevention of mother-to-child transmission of HIV.
During emergencies, vulnerable people may be subjected to situations that substantially increase their exposure to STIs, including HIV. Risk factors include massive displacement of people from their homes, women and children left to fend for themselves, prevalence of domestic violence, social services overwhelmed or destroyed, and a lack of means to prevent HIV infection, such as clean needles, safe blood transfusions and availability of condoms. (For additional information, see section 4, Gender and Gender-based violence and HIV/AIDS).
Skin infections occur not only due to overcrowding but also as a result of a lack of water and reduced hygiene. Infestations (e.g. scabies, lice ? associated with typhus) are also common and require treatment once they occur.
Noncommunicable diseases (NCDs) are recognized as an important health concern in Haiti. Chronic conditions, including cancer, cardiovascular disease including hypertension, diabetes, chronic respiratory disease and neuropsychiatric disorders, account for an increasing proportion of the disease burden. This group of diseases places a substantial burden on health services and an impoverishing drain on families and communities. The priorities during the acute phase of this emergency are to minimize treatment
interruptions.
Environmental risks may exist from damaged hazardous installations such as industrial facilities, damaged oil and gasoline depots, warehouses that stockpile agro-, industrial or other chemicals as well as damaged technical equipment (e.g. transformers, medical equipment with radiological sources). Most of Haiti's industry is located around Port-au-Prince. Health workers should look out for patients' symptoms that may be consistent with chemical intoxication, especially skin irritation and chemical burns.
Poor management of waste, including health-care waste, can potentially expose health-care workers, waste handlers, patients and the community at large to infection, toxic effects and injuries as well as increasing the risk of polluting the environment. (For additional information, see section 4,
Environmental health in emergencies, UNEP/OCHA Environmental Risk Identification).
Carbon monoxide poisoning is a risk if petrol-driven generators are used in enclosed spaces. Care should be taken to ensure adequate ventilation where generators are used.
Interrupted power supply. As a result of extended power supply interruption, food is likely to have been spoiled and could become a possible source of disease if consumed. Routine vaccine stocks and the cold chain are also likely to have been compromised.
Drug and equipment donations. Inappropriate donations of medicines, medical equipment and medical supplies can be minimized by donors adhering to the interagency guidelines (for additional information, see section 4, Drug donations). In general, the key principles are :
- drug and medical equipment donations should not be a priority;
- donated drugs and medical equipment should explicitly address the expressed official needs of the recipient country;
- donated drugs must be on the national list of registered drugs;
- donated drugs must be labelled in English or the national language;
- the date of expiration of the drugs must be no less than one year from arrival in the country.
(See section 4, Drug donations)
Disposing of pharmaceuticals should be by high temperature incineration (i.e. above 1200?C). Such incineration facilities, equipped with adequate emission control, are mainly found in the industrialized world. The cost of disposing of hazardous waste in this way ranges from US$ 2000 to US$ 4000 per ton.
Staff health. (See Section 6)
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