Transcript Zoonotic Disease Issues During the 2010 Haiti Earthquake Response In collaboration with HSI Dr Megan Hlusko, DVM, MSc (International Veterinary Development) Veterinarians Without Borders-Vétérinaires Sans.

Zoonotic Disease Issues
During the 2010 Haiti Earthquake
Response
In collaboration with HSI
Dr Megan Hlusko, DVM, MSc (International Veterinary Development)
Veterinarians Without Borders-Vétérinaires Sans Frontières Canada
COPEH- Canada member
Zoonotic Disease Issues
During the 2010 Haiti Earthquake
Response
Video © HSI 2010, F Loftus
My call, my mission
The second deployment with HSI.
MY MISSION:
animal health, animal welfare,
human-animal interactions,
Long-term veterinary needs.
Called: Tuesday January 26th
Deployed: Thursday January 28th.
Today’s presentation
During my deployment,
where did I perceive risk for zoonotic
disease transmission?
From before deployment until I arrived at home,
and possibly afterwards…
International
aid
workers
International
animal
population
Haitian
Population
Haitian
animal
population
“Preparations” for deployment
The RISKS prior to deployment
Lack of awareness of pre-disaster situation of
affected country.
Unpreparedness to protect ones personal health.
Unpreparedness to respond to a disaster
situation.
All of these situations put the people & animals
that we work with at risk.
“Preparations” for deployment
•The poorest country in the Americas
1st thing first- Where am I going?
•About 80% of the pop estimated to be living in
Howinto
prepare for an
poverty
2003.
emergency deployment,
natural
•Most Haitiansa live
on $2disaster,
or less per day.
in a developing country?
•Haiti has 50% illiteracy and over 80% of college
graduates from Haiti have immigrated,
mostly to the United States.
•60% live of Subsistence farming
“Preparations” for deployment
•Half of the children in Haiti are unvaccinated and
just 40% of the population has access to
basic health care.
•Even prior to the 2010 earthquakes,
approx 1/2 the causes of deaths attributed
to HIV/AIDS, resp infections, meningitis
and diarrheal diseases, including cholera
and typhoid, according to WHO.
“Preparations” for deployment
•90% of children suffer from waterborne and
intestinal parasites.
•Approx 5% Haiti's adult pop is infected with HIV.
•TB in Haiti- more than ten times as high as those
in other Latin American countries.
•Some 30,000 people in Haiti suffer each year
from malaria.
“Preparations” for deployment
Disease outbreaks are
more likely to occur when disasters hit
poor and developing countries:
“HEALTH” is more fragile, “RISK” is greater.
Disease agents are already present,
risk factors will become greater when a
catastrophic natural disaster changes
demographics, necessary resources & immunity.
“Preparations” for deployment
2nd- What can I prevent?
The idea is to go healthy & remain healthy…
Vaccines (Rabies, tetanus,
hepatitis A & B,
meningitis A & C,
poliomyelitis,diphtheria)
Antibiotics (Gastro x, bites etc.)
Anti-malarial
Equipment & supplies / Team
“Preparations” for deployment
Disaster preparedness
(necessity & risk)
We must be prepared to helpOur expertise are not enough*.
Wang-Brown, 2005
Disaster means:
Lack of resources (diagnostics)
Different methodology (ddx)
Lots of unexpected
Lots of emotions…
The “WORLD” rushes to Haiti
Internationally volunteers with an array of experties
are providing relief aid in many forms.
Major problems:
Death & Injury
Displaced populations
Food & resource shortages
Disrupted water, waste & sanitation
Lack of infrastructure (medical & housing)
*** Not all Zoonotic diseases are an immediate
concern- fatal ones are though.
Zoonoses in Haiti:
As a veterinarian
Animal health, disease & injury
*** Public health & agriculture
*** Shared risks (zoonoses) & agents
Predict unexpected risks
Remember 60% live of Subsistence farming,
DOGS are vectors…
EPIDEMICS are not only a human health risk but
a question of livelihood and potential for
re-building once the catastrophe has “passed”.
Zoonoses in Haiti:
As a veterinarian
Direct / Indirect & vector transmission
*** Unknown transmission
Fatal vs “QUIET” (“Usually” asymptomatic)
RISK FACTORS – effect degrees of morbidity &
eventually mortality of a zoonotic agent.
Photo © HSI 2010 K Milani
At risk populations:
Haitians (victims and non-victims)
International aid community in Haiti
Animal populations (including livestock)
International community at large
Shared Risks
Human Health
Outcome
(infection)
SHARED
RISK
Animal
reservoir
Animal Health
Outcome
(Symptomatic or
detectable
infection)
Vector density,
competence
Pathogens
Environmental factors
(climate, landscape change, population density …)
Rabinowitz & al. 2008
Zoonoses in Haiti:
Pre-earthquake situation
Confirmed Zoonoses in humans in Haiti:
According to OIE/WHO WAHID Interface
Rabies
Anthrax
Leptospirosis
Salmonellosis
Bovine tuberculosis
Porcine cysticercosis
Echinococcosis/hydatidosis
N. w. screwworm (C. hominivorax)
Zoonoses in Haiti:
Pre-earthquake situation
CONFIRMED Zoonoses in humans in Haiti:
Is this list complete ?
What if we were to look closely,
at less glamorous zoonoses,
the “QUIET” ones ?
Zoonoses in Haiti:
Post-earthquake situation
Where have the risks of infection changed;
ie. Where SHOULD we look ?
A. Due to massive population displacements:
The tent-cities,
The outlying communities.
B. Due to death & injury:
The hospitals
Zoonoses in Haiti:
Tent city #1
CLEAR Presence of animals
ABSOLUTE Public health concerns
80 % OF CAMPS HAVE
NO HEALTHCARE
INSTITUTIONS,
no HIV TXTs, NO TB TXTs.
Zoonoses in Haiti:
The tent cities - ANIMALS
Presence of animals:
Not an easy question for earthquake victims
“When push comes to shove”
Photo © HSI 2010 K Milani
-presence of stray & owned animals
(dogs, pigs, goats, RATS, +- poultry, +- cats)
-animals are in rough condition
(parasitism, maternal wasting, symptomatic)
-shared environment with humans
-reports of bites & risky interactions
(during individual “animal control”)
Zoonoses in Haiti:
The tent cities - WORK
Team work:
-Handle animals & protect (* animal behavior)
-Examine & assess (* ddx)
-Know protocols
-Resourcefulness
+ access, families, discussions, education
- draw attention to selves & animals, leads to
animal handling, agression…
Photo © HSI 2010 K Milani
Zoonoses in Haiti:
The tent cities - PEOPLE
At risk individuals:
Children / Elderly
Pregnant & lactating women
Immuno-compromised (HIV)
Malnourished (protein-energy)
Injured (non-attended)
Alcoholism / substance abusers
Animal care workers
MORBIDITY CHANGES WITH IMMUNE
STATUS & POSSIBILITY OF TRANSMISSION
(FOR BOTH HUMANS & ANIMALS)
Zoonoses in Haiti:
The tent cities – PUBLIC HEALTH
Public Health:
Environmental health:
water, sanitation, hygiene & vectors.
-overcrowding
-poor water supply
-Inadequate hygiene & sanitation
-Poor water & excreta disposal
Results in increased risk of disease
transmission, due to proximity, poor
hygiene & presence of animals .
Photo © HSI 2010 K Milani
Zoonoses in Haiti:
The tent cities – PUBLIC HEALTH
SPHERE PROJECT MINIMAL STANDARDS
LATRINES
SHOULD BE 1/20 PPL
BUT WAS 1/200++ = 3 670 latrines
Goal for END MARCH was 1/100;
would be 13 000 more
For END JUNE 1/50;
would be 21 000 more
Zoonoses in Haiti:
The tent cities – FECAL ORAL
MAJOR cause for concern:
(after informal questionnaire & observation)
*** The FECAL-ORAL ROUTE of transmission
is a critical point of concern.
HAND-WASHING BECOMES AN
OPTIONAL PRACTICE;
REASON: not enough water & what
is available is dirty anyway.
THE consequences can be HUGE.
Zoonoses in Haiti:
The tent cities – THE DOGS
CLINICAL SIGNS
Diarrhea, wasting, poor fur condition / alopecia,
neurological, weakness, lameness,
respiratory distress … death.
DIFFERENTIAL DIAGNOSIS:
Helminthes: Nematodes (Toxocara canis), hookworms,
cestodes (Echinococcosis; Dipylidium caninum)… Bacterial:
Campylobacteriosis, Salmonellosis, Bartonellosis,
Leptospirosis, Brucellosis, Mycobacteriosis, Coxiellosis…
Protozoa: Cryptosporidiosis, Giardiasis, Toxoplasmosis...
External parasites: fleas, lice, dermatophytosis… Viral:
Influenza, Lymphocytic choriomeningitis, Rabies...
Zoonoses in Haiti:
The tent cities – THE DOGS
RABIES, LEPTO, PLAGUE, ANTHRAX…
CAMPYLO. , GIARDIA, CRYPTO. !!!
MALNOURISHED CHILD + INTER PARASITES + X
= MORBIDITY +- MORTALITY FROM DIARRHEA
NO ORT, NO MEDICAL ATTENTION
Mid FEB 2010
UNICEF
7 deaths < 5 yrs
To DIARRHEA
Zoonoses in Haiti:
The tent cities - RABIES
RABIES:
Presence of Rabies in Haiti
Humans are bitten
Vaccination efforts were interrupted…
FROM: ZOONOSES AND COMMUNICABLE DISEASES
COMMON TO MAN AND ANIMALS, PAHO
Zoonoses in Haiti:
The tent cities - RABIES
Preliminary surveillance
assessments from January to May
2010, based upon clinical signs
alone, suggest as many as
17 possible human rabies cases...
Cases are underreported.
Zoonoses in Haiti:
The tent cities - LEPTOSPIROSIS
LEPTOSPIROSIS:
Presence of Lepto in Haiti
Clean water is hard to come by…
urine + run-off + water use
FROM: ZOONOSES AND COMMUNICABLE DISEASES
COMMON TO MAN AND ANIMALS, PAHO
Zoonoses in Haiti:
The tent cities - LEPTOSPIROSIS
LARGE OUTBREAKS AFTER:
-FLOODING in Puerto Rico (Sanders, 1996),
Hawaii (Gaynor et al., 2007) & Laos (Kawaguchi et al, 2008)
-EARTHQUAKE in Japan (Aoki et al, 2001)
HAITI ICTERIC FEBRILE SYNDROME
12 700 cases reported January to June 2009
Zoonoses in Haiti:
The tent cities
The Analysis:
Agents are the same or similar to
pre-earthquake situation.
Risk factors for transmission are greater:
Poor public health
Poor immunity
Proximity
Overlapping human & animal niche
The RISK:
Transmission, MORBIDITY & possible mortality
Zoonoses in Haiti:
Outlying villages
CLEAR Presence of animals
LACK of Resources to meet demands
Photo © HSI 2010 K Milani
Photo © HSI 2010 K Milani
Zoonoses in Haiti:
Outlying villages - ANIMALS
Presence of animals…
Dogs, +- cats, goats, poultry,
pigs, cattle, horses, donkeys
Fend for themselves- turned out to “graze”
Resources do not allow one to feed animals
Deaths reported, unknown cause…
Lack of awareness:
“Dead animals can still be a
food-source for the family”
Ex. Jacmel
Zoonoses in Haiti:
Outlying villages - PEOPLE
Presence of animals…
Also a presence of an influx of population.
Resources were already scarce before EQ
(including medical, veterinary, food, supplies…)
International aid is NOT directed towards the
“non-victims” in the surrounding villages.
604 215 PEOPLE FLED TO RURAL PROVINCES IN THE DAYS
AFTER THE Eqs (Lancet, March 10)
Zoonoses in Haiti:
Outlying villages - WORK
Multiple species to examine
Human aid is also necessary
Any aid is aid.
Photo © HSI 2010 K Milani
The care of a veterinarian is far more
interesting than no care at all…
Photo © HSI 2010 K Milani
Possibility for “cross-contamination”
Rules of asepsis …
(And HIV…)
Zoonoses in Haiti:
Outlying villages - ANTHRAX
ANTHRAX
Presence of Anthrax in Haiti
Sick animals present in the environment,
are possibly shedding agents,
Some are dying,
but can still be considered a food source.
FROM: ZOONOSES AND COMMUNICABLE DISEASES
COMMON TO MAN AND ANIMALS, PAHO
Zoonoses in Haiti:
Outlying villages
The Analysis:
Resources are limited
Population pressure worsens conditions
Attention must be re-directed from subsistence
farming to survival.
Lack of awareness re zoonotic dx
The RISK:
Greater susceptibility to zoonotic agents,
due to further malnutrition &
resulting weakened immunity.
Problems go unnoticed & un-reported.
Zoonoses in Haiti:
The temporary hospitals
NO ANIMALS present
PRESENCE of zoonotic disease
HIGH traffic area
SUB-OPTIMAL sanitization
Zoonoses in Haiti:
The temporary hospitals
NO ANIMALS present BUT…
Shoes & boots
12 hours of veterinary work in the field prior to
my overnight hospital shift
Little sanitary control in & out of hospital
MYSELF:
32 hour day
Instant nurse – with very few doctors
Files are minimal
Quarantine is non-present
Contagious diseases ARE present
Zoonoses in Haiti:
The temporary hospitals
Presence of zoonotic disease
“Sentinels” for disease:
TB
Scabies
Other non-dx conditions (GI, liver …)
HIGH traffic area
Families & caregivers come and go
No separation of sick and well
Victims of EQ & other pre EQ conditions
VOLUNTEER TENT & no records of aid workers
Zoonoses in Haiti:
The temporary hospitals
THE RISK:
Disease dissemination towards:
Outlying populations, including tent cities
International aid-workers
Animal populations via livelihood
Possibly international communities
*** Methicillin- Resistant Staphylococcus
Aureus Infection
Zoonoses in Haiti:
Going HOME – USA & CANADA
Packing up
Border crossings (me & the dogs)
Back to work
Personal Health
“Follow-up” with Haiti…
Now what ?
Zoonoses in Haiti:
Now & as time passes
There are an abundance of “opportunities” for
zoonotic disease transmission.
At this point it is difficult to say whether risks of
epidemics are greater due to the conditions that
the earthquakes magnified,
“except” MALARIA
(from 30 000 cases a yr, to 200 000 in 2010)
PAHO March 2010
Zoonoses in Haiti:
Now & as time passes
Historically natural disaster do not necessarily
result in epidemics, but Haiti suffered higher
death tolls, more destruction then “usual”,
under already sub-optimal conditions.
Historically,
CHRONIC DISEASE ISSUES
ARE NOT WELL REPORTED
LEISHMANIA IN ALGERIA (2003 EQ)…
PNEUMONIC PLAGUE IN W CHINA ?
However present reports & conditions in
Haiti give us reason to continue
surveillance:
RAINS
MALARIA CASES
TENT CITIES BECOME SHANTYTOWNS
Photo © HSI 2010 K Milani