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Strengthening Global Health Systems: Haiti Between an Earthquake and a Cholera Outbreak

Strengthening Global Health Systems: Haiti Between an Earthquake and a Cholera Outbreak. Ezra J. Barzilay, MD Health Systems Reconstruction Office Centers for Disease Control and Prevention. USPHS Scientific and Training Sy mposium June 21, 2011.

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Strengthening Global Health Systems: Haiti Between an Earthquake and a Cholera Outbreak

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  1. Strengthening Global Health Systems: Haiti Between an Earthquake and a Cholera Outbreak Ezra J. Barzilay, MDHealth Systems Reconstruction OfficeCenters for Disease Control and Prevention USPHSScientific and Training Symposium June 21, 2011 Division of Global Disease Detection and Emergency Response Health Systems Reconstruction Office

  2. Haiti: Before the Earthquake

  3. Limited Public Health Infrastructure • Few trained epidemiologists • Limited cadre of public health professionals • Physician and nursing shortage • Limited laboratory capacity • Clinical care poorly linked to laboratory services Photo courtesy Mike Gerber

  4. Background Information Haiti-DR Border • Population 9.7 million • Lowest GDP in Western Hemisphere • 54% Living on <$1/day • 62% Adult literacy • 60% Lack access to basic healthcare • <5 mortality: 117 /1000 live births • 61 Years life expectancy • 98% Deforestation Photo by James Blair for National Geographic Photo by Chuck Holton 2006/8 UNICEF Statistics and WHO World Fact Sheet 2008 and 2005 World Bank Data and Statistics

  5. WASH* Deficiencies • 63% Access to improved water (2015 MDG = 73%) • 17% Access to improved sanitation (2015 MDG = 68%) *WASH – Water, Sanitation, and Hygiene 2010 WHO / UNICEF Joint Monitoring Program Statistics

  6. Global AIDS Program (GAP) in Haiti • CDC-Haiti office established by GAP in 2002 • By 2010, CDC-Haiti office has 45 locally employed staff (LES) • Funded by President’s Emergency Plan for AIDS Relief (PEPFAR) • $28M in 2004 • $125M in 2009 • Objectives are to support the Haitian Government to: • Achieve PEPFAR prevention, care and treatment targets • Strengthen public health systems • Strengthen laboratory systems and networks • Maximize unique government-to-government relationship with MSPP • Improve blood safety and availability • Carry out objectives by working with major partners

  7. January 12, 2010

  8. The Presidential Palace Photo from http://alchemipedia.blogspot.com/2010/01/republic-of-haiti-geography-caribbean.html Photo from http://www.boston.com/bigpicture/2010/01/earthquake_in_haiti.html

  9. Cathedral of Our Lady of the Assumption Photo by Garrett Crawford (http://www.flickr.com/photos/gc_photography/3563542680/in/set-72157618695654699/) Photo by Marco Dormino for the United Nations

  10. Typical Hillside Housing Photo by dalexfilms (http://www.flickr.com/photos/dalexfilms/4310956034/sizes/m/in/set-72157623167623601/) Photo by UK Department for International Development (DFID)

  11. Health Issues • ~230,000 dead • ~2,000,000 Internally Displaced Persons (IDPs) • Massive infrastructure destruction • Hospitals and clinics severely damaged • MSPP building destroyed • Severe overcrowding • Potential disease outbreaks • Water and sanitation • Lack of information • Impending rainy season Photo from United Nations (http://www.flickr.com/photos/un_photo/4293402594/)

  12. Public Health System Reconstruction

  13. Post-Earthquake Recovery • Led by Center for Global Health (CGH) • Launch reportable disease surveillance • National Sentinel Surveillance System (NSSS) • Internally Displaced Person Surveillance System (IDPSS) • Distribute rapid tests to support reportable disease surveillance • Typhoid (Tubex TF) • Malaria (CareStart) • Dengue (PanBio Duo Cassette) • Cholera (Crystal VC) • Shifting focus to technical assistance and capacity building Photos courtesy Mike Humphrys

  14. Long-Term Planning • Health Systems Reconstruction Office (HSRO) • New office created within CGH • Purpose to manage post-earthquake reconstruction activities • Funded by Congressional supplement • Maintain existing activities (GAP, HIV, etc.) • Develop Reconstruction Plan • Identify goals and objectives • Develop activities with input from Subject Matter Experts (SMEs) • Establish timeline for implementation • Collect baseline data and determine measurable outcomes

  15. CDC’s Plan for Reconstruction Activities • Category I: Cross-Cutting Public Health System Strengthening • EPI Training Program (FETP) • Surveillance Systems • Laboratory Systems • Category II: Disease Control Programs • Tuberculosis • Malaria Control • Lymphatic Filariasis • Immunization Program • Category III: Technical Assistance • Water, Sanitation, and Hygiene (WASH) • Nutrition • Maternal Health • Acute Febrile Illness

  16. The Outbreak • October 20, 2010 • Several hospitals in the Artibonite Department receive an influx of patients with profuse, acute watery diarrhea and vomiting • Most patients are adults who either work or reside in communities near the Artibonite River, about a 3 hour drive from Port au Prince • 1:00 pm MSPP and CDC notified – Teams sent to field to investigate

  17. Photo credit: Steve Grube

  18. The Outbreak • October 20, 2010 • 9:00 pm 10 stool samples arrive at LNSP; • Eight of 10 samples are Rapid Test positive

  19. The Outbreak • October 21, 2010 • 09:51 am growth of yellow colonies visible on TCBS media • 11:00 pm colonies on MH agar agglutinate in polyvalent O1 and Ogawa antisera • October 22 • Antimicrobial susceptibility testing initiated at LNSP • Isolates sent to CDC for confirmation & additional testing • October 23 • CDC cholera team deployed to Haiti • Isolates susceptible to tetracycline, ciprofloxacin, and resistant to tmp-smx, ampicillin, and nalidixic acid at LNSP

  20. Photo credit: David Snyder

  21. New Cases of Cholera and Overall Case Fatality Ratio, Haiti, 20 October 2010 - 20 April 2011

  22. 2010 Cholera Epidemic CDC/Haiti • Preventing deaths at the facility level • Preventing cases and deaths at the community level • Training in cholera case management at community level and at and health centers • Working collaboratively with ICDDR,B and MSF • Using science to direct prevention and control efforts • KAP study focusing on water, sanitation and hygiene practices • Case-control study of risk factors and protective behaviors • Monitoring the spread of disease – surveillance efforts

  23. Acknowledgements • Ministère de la Santé Publique et Population (MSPP) • Direction d’Epidémiologie, Laboratoire et Recherche (DELR) • LaboratoireNationale de Santé Publique (LNSP) • Pan American Health Organization (PAHO) • Centers for Disease Control and Prevention (CDC) Haiti • Centers for Disease Control and Prevention (CDC) Atlanta

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