Sunday, February 7, 2010

U.S. to Blame for Lack of Access to Pediatric Critical Care, Experts Say

A ProMED-mail post

ProMED-mail is a program of the
International Society for Infectious Diseases

Date: Tue 2 Feb 2010
Source: Haiti: Operational Biosurveillance [edited]

Haiti Epidemic Advisory System
The UN Health Cluster [the Global Health Cluster, under the leadership
of the World Health Organization, is made up of more than 30
international humanitarian health organizations that have been working
together over the past 2 years to build partnerships and mutual
understanding and to develop common approaches to humanitarian health
action. See
is now sending teams of individuals to assess various areas of Haiti.
Over 246 responder organizations signed up as part of the Health
Cluster, and reports of activities were requested from all of them.
However only 46 reports were received. This implies an operational
distraction towards the immediate priorities of food, water,
sanitation, and shelter provision to the refugees, among other more
urgent priorities. As a result, situational awareness for infectious
disease events remains limited and heavily depending on
non-traditional surveillance methodologies.

Diarrheal illness
Current reports indicate an active trend of increasing incidence in
the IDP [? internally displaced persons] camps. Periodic rainfall
predicted this week [week of 1 Feb 2010], with sustained rains in the
PAP [Port au Prince] area anticipated beginning in March.
Precipitation may further compromise indigenous water sources and
exacerbate what limited sanitation is available.

Pandemic H1N1
Current reports indicate an active trend of increasing respiratory
disease in the IDP camps. There has been no formal evaluation or
laboratory confirmation of pH1N1 [pandemic H1N1] to our knowledge.
Advisory issued on 2 Feb [2010] based on the observation that patient
transfers for ventilator beds has been extremely difficult,
particularly in regards to pediatric beds. Those at risk for severe
clinical outcomes from pH1N1 infection include children and pregnant
women. Further, we have documented in multiple countries adverse
clinical outcomes seen in indigenous peoples with poor access to
adequate healthcare, as is the case in Haiti. With the coming rains in
March to encourage crowding in IDP camps, the potential for outbreaks
is moderate. No evidence of pandemic vaccine deployment campaigns by
responding agencies in Haiti. Potential to see serious pediatric
illness requiring pediatric intensive care and ventilatory capabilities.

Extremely difficult to assess actual risk under present conditions.
Prudence suggests a conservative, vigilant, and proactive posture.
Prior post detailed risk factors for Artibonite Valley, which
historically has seen a peak of human cases in the May-June time frame.

Risk for outbreaks is moderate with the coming sustained rains in
March. Vector breeding sites will increase, as will the potential for
dengue transmission. Heaviest transmission typically seen in the later
half of the year. We have not seen plans yet for mosquito nets
provided to IDP camps.

Pediatric mortality in Haiti
We have been following multiple reports of a commonly observed problem
with disasters in undeveloped or developing countries: lack of
specialized care for children. Specifically, lack of access to
pediatric critical care services.

"On most days, at least one patient died, usually a child."
"It's ridiculous how many kids die from diarrhea, and it's going to
get worse with all the people crowded together... When the rains come,
it could be a slaughter."

"A 15-year-old got gangrene 3 days after being told she would be
heading to Miami for medical care. On Friday, she lost the lower half
of one leg and the foot on the other. Another 14-year-old, whose name
frenzied doctors can't recall, died on Tuesday."

"[Another woman] is still waiting to leave. The quake ripped the skin,
muscles and tendons off her leg. She has to be completely sedated
every time her dressing is changed."
"These are not optimal conditions... This is a dirty, grassy hospital.
It is not the Johns Hopkins ICU."

Lack of access to pediatric critical care stems from several problems:

1. Lack of field-capable pediatric critical care resources that
includes neonatal capabilities

2. Limited capability at military facilities on the ground in Haiti

3. State of Florida blocking transfers from Haiti to appropriate
facilities, claiming lack of financial reimbursements

4. Political sensitization around alleged abduction of children by
missionaries at the Dominican Republic border

5. HHS [? USA Department of Health and Human Services] criteria for
patient transfer claimed to be rigid, "case by case", and inflexible.

6. DHS [? USA Department of Homeland Security] blocking admission to
the United States for patients without paperwork, visas, etc. where a
significant portion of these children are without guardians, parents,
or paperwork.

From a pediatric point of view, we have been primarily concerned
about diarrheal disease, respiratory disease, dengue, and malaria as
primary killers of children during this time. The reasoning for this
prioritization is due to relative ease in control. Vaccination
campaigns are already underway for diphtheria, tetanus, and pertussis.
We would assume given the public health and medical personnel's
publicized concerns about measles they will extend coverage to include
measles. However the disruptors mentioned above have the ability to
spread quickly and kill many children under the present conditions,
and especially during the rainy season due to the difficulty in
gaining effective control.

It has been suggested at the UN Health Cluster that formation of the
IDP camps represents a better sanitary situation than the slums of
Port au Prince. While that may be the case for a short time, a
combination of crowding, pressure on limited and undeveloped
sanitation capacity, and the coming rains will rapidly put this idea
to the side.

Haiti's children remain at serious risk. Lack of access to appropriate
care and appropriate public health intervention will ensure continued
high fatality rates in the weeks to come.

Cubans engaged in vector control
Cuban anti-vector specialists have cleared areas from rats and
rodents, have fumigated them and implemented measures to control
vectors. However, the demand of these tasks is beyond their
possibilities, in view of the prevailing hygienic situation. This is
the 1st time we've seen a dedicated effort to conducting a vector
control campaign, albeit likely of limited value due to the sheer
magnitude of the problem.

Sepsis, gangrene, tetanus, and lack of pediatric intensive care
"They returned to their respective hospitals in [the States] over the
weekend after sweating through 20-hour shifts in a 150-bed hospital
north of Port-au-Prince crammed with 400 patients. They slept on the
floor, helplessly watched many Haitians die in their care, and used
cardboard, ironing boards, and anything else they could find as
makeshift operating tables.

The 1st patient, a 13-year-old boy, came to the hospital with a
mangled leg after he was rescued from beneath a pile of rubble. The
doctors pinned his leg back together using prosthetics and tools they
had brought with them; during the surgery, he was awake and singing.
Later, a mother came to the hospital carrying her unconscious 2-week
old baby, a girl infected with sepsis. The surgeons resuscitated her
but were without a pediatrician. They then tried bringing the baby and
her mother to a nearby US Navy ship, only to find they did not have
the proper physician there, either. They eventually boarded a UN
ambulance, roaming across treacherous roads to a main Haitian
hospital, only for the baby to die upon arrival." - medical response
team from California.

"The conditions are really dire, but we have no choice. Each procedure
has to be carried out that day, to avoid the onset of gangrene.
Fortunately I have everything I needed for anaesthetics and pain
management. The pharmacy was in another building that hadn't been
destroyed. It's complicated and frustrating not having all the
equipment at hand. I saw a tetanus case, a child of 10 years. She was
convulsing on the 1st day, and stiff, with spasms, by the 2nd. Tetanus
is hard to treat if you're not properly equipped. You need to
administer a sedative to relax the patient, and then monitor her
really closely, as her breathing can stop. This patient was on oxygen,
and we monitored her as best we could, but it was a hit-and-miss
affair. We needed a properly equipped intensive care unit, where there
weren't so many risks. The worst, the most annoying thing, was that we
had breathing apparatus in the cargo plane, but as we'd been delayed,
it wasn't yet installed." - pediatric anesthesiologist with MSF
[Medecins Sans Frontieres].

Raw field response conditions in Haiti
Email from Alison Thompson sent to her parents in Sutherland Shire
(Sydney) on 24 Jan 2010. Subject: Hell in Haiti

"Hi mum and dad -- I won't be around when they announce my award on
[26 Jan 2010]. I am with Sean Penn, Diana Jenkins, Oscar, and 15
doctors embedded in the US 82nd Airborne (USA) Division. Dante would
describe it as hell here. There is no food and water and hundreds
dying daily. The aid is all bottlenecked and not reaching here.

The other day I assisted with amputation (holding them down) while
they used a saw to cut a young boy's leg off with no pain killers.
Today I went with a strike force and army patrol in hummers into the
streets and walked 5 miles through the camps set up on every street
corner. Sewage and bodies stench is everywhere. As I attend to a
patient 30 people crowd around me and it's hard to breath. I nearly
fainted today as the sewage smell went straight down my throat. I went
white and dizzy but couldn't sit down as sewage is running through the
streets. There is much infection and it feels like the job is too big.
No antibiotics anywhere

"Good news, today our New York doctors evacuated 18 patients with
spinal injuries out to Miami and we're all so excited. Our MASH unit
[US Mobile Army Surgical Hospital] is in the 82nd's air base
overlooking a refugee camp of over 50 000 people. The refugees start
singing Christian songs at 4 am and line up for food until the army
hands it out at 8 am (that's if there is any food). On the 1st night I
was in the nearby jungle camping under the stars with my team and woke
up to the beautiful music drawing me to them. I thought it was a
church and we went to find it and came across the 82 Airborne camp and
the refugee camp. (That's how we ended up here, as it wasn't safe to
stay where we were even though we had our own security force). We are
totally self sufficient with food, gas, and medicines and have a
private donor (Diana Jenkins who was a refugee in camps in Bosnia as a
child -- her family died of starvation in the camps.) Sean Penn is
here purely as a volunteer and is cutting through bureaucracy to get
aid moving and food water and medicines to the people. There is no
agenda but to save lives. Helicopters fly overhead and it feels like
Viet Nam. That night 50 000 people sung me to sleep and they sing
every night for the world to save them. There is always hope but she's
not here right now.

Alison xxx"

Communicated by:
James Wilson, MD
Executive Director
The Global Institute For Disruptive Events (GuIDE)

More reports of typhoid & tetanus
From a team of 15 San Francisco Bay Area physicians: treated cases of
tetanus and typhoid fever.

From a team of physicians from Yale-New Haven Hospital: treated a
6-year-old girl with typhoid peritonitis.

[These reports from the field give a vivid picture of the scale of the
disaster caused by the earthquake in Haiti. Hundreds of thousands of
people are displaced, many with injuries sustained in the earthquake,
acute infections, or chronic illnesses, all in immediate need of
shelter, food, clean water, sanitation, and medical care.

WHO has issued a public health risk assessment to facilitate the
response of those aiding the earthquake-affected population in Haiti,
available at

Haiti and the Dominican Republic occupy the Caribbean island of
Hispaniola in the Greater Antillean archipelago. A
HealthMap/ProMED-mail interactive map of Hispaniola can be found at
. - Mod.ML]

[Gideon (Global Infectious Disease & Epidemiology Network) is
providing a free download of "Infectious Disease of Haiti". It is
available at
. -

[see also:
Tuberculosis - Haiti: post-earthquake 20100207.0409
Meningococcemia, fatal - Dominican Republic ex Haiti 20100206.0401
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