Ezra J. Barzilay, MDHealth Systems Reconstruction Office
Centers for Disease Control and Prevention
USPHS Scientific and Training SymposiumJune 21, 2011
Strengthening Global Health Systems:
Haiti Between an Earthquake and a Cholera Outbreak
Division of Global Disease Detection and Emergency ResponseHealth Systems Reconstruction Office
Haiti: Before the Earthquake
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
Background Information 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 Chuck Holton
Photo by James Blair for National Geographic
Haiti-DR Border
2006/8 UNICEF Statistics and WHO World Fact Sheet 2008 and 2005 World Bank Data and Statistics
WASH* Deficiencies 63% Access to improved water (2015 MDG = 73%) 17% Access to improved sanitation (2015 MDG =
68%)
2010 WHO / UNICEF Joint Monitoring Program Statistics
1990 2000 20080
10203040506070
Water Sanitation
*WASH – Water, Sanitation, and Hygiene
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
January 12, 2010
Photo from http://www.boston.com/bigpicture/2010/01/earthquake_in_haiti.html Photo from http://alchemipedia.blogspot.com/2010/01/republic-of-haiti-geography-caribbean.html
The Presidential Palace
Photo by Garrett Crawford (http://www.flickr.com/photos/gc_photography/3563542680/in/set-72157618695654699/)
Photo by Marco Dormino for the United Nations
Cathedral of Our Lady of the Assumption
Photo by dalexfilms (http://www.flickr.com/photos/dalexfilms/4310956034/sizes/m/in/set-72157623167623601/)
Photo by UK Department for International Development (DFID)
Typical Hillside Housing
Health Issues ~230,000 dead ~2,000,000 Internally Displaced Persons
(IDPs) Massive infrastructure destruction
Hospitals and clinicsseverely 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/)
Public Health System Reconstruction
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
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
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
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
18Photo credit: Steve Grube
The Outbreak October 20, 2010
9:00 pm 10 stool samples arrive at LNSP; Eight of 10 samples are Rapid Test positive
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
Photo credit: David Snyder
23
New Cases of Cholera and Overall Case Fatality Ratio, Haiti, 20 October 2010 - 20
April 2011
26
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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
2010 Cholera EpidemicCDC/Haiti
Acknowledgements
Ministère de la Santé Publique et Population (MSPP) Direction d’Epidémiologie, Laboratoire et Recherche
(DELR) Laboratoire Nationale 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
