Source: Slopjop
¶ The aftermath effects of the earthquake continue in Haiti, even if other events seem to have supplanted the topic in the news. The conditions in the Internally Displaced Person (IDP) camps continue to deteriorate and disease has now become a primary concern (and point of intervention) for the various members of the response networks. There is an abundance of life-threatening diarrheal disease and a significant shortage of oral rehydration medications. In particular, this places infants and children at increased risk.
¶ Additionally, the ‘silent population’ of Haiti (as I like to call them) are those individuals who previously fled the destruction of the urban centers to stay with family in more rural regions. A previous post, “Dearth of Haitian Agricultural Baseline Information“, I wrote about this population and included a map of the areas which received the most migrants. Recent reports from Haiti highlight the serious and continued degradation of the public health infrastructure, which appears to be straining, if not overwhelming, international medical responders. If this is the case in areas with access to medical facilities, what is the disease burden and current status of the ‘silent population’ – those who migrated to rural areas? Is there a potential for them to have carried infectious disease with them, after their short stay in post-quake urban areas?
¶ How can we assess, monitor and provide services to this, now inflated, rural population? How do we identify the effects such a population growth has had on an already infrastructure-strained rural population? What are the public health risks associated with degraded (or non-existent) food security measures, animal disease and zoonotic pathogens? At what point are societal limitations, such as aversion to eating meat from a diseased animal, overcome by malnutrition and disease? What are the risks to special groups, such as children and pregnant women, with such things as milk consumption and zoonotic disease exposure? As discussed in the post, “A Framework for One Health Monitoring in Haiti“, the situation in the urban centers requires a timely and holistic approach to disease monitoring for development of targeted interventions. With regard to the ‘Silent Population’, do we continue to ignore this gap (group) or institute a system that can not only assess the situation, but also provide information and direct assistance to more remote regions?
¶ A colleague, Jim Wilson MD, (Biosurveillance blog, twitter: @iceaxe5) is currently in Haiti conducting assessments of the international public health infrastructure, risk conditions for disease outbreaks, and in a ‘One Health’ mindset, has interviewed veterinary professionals about public health issues. Below is an excerpt of an email Jim sent regarding conditions he has monitored in Haiti. I have only posted his correspondence regarding veterinary public health topics – my response follows his comments.
¶ Jim’s Write-ups:
***Update for 11 March 2010***
My turn to be ill. Spent some quality time on a cot yesterday morning…
I met with Max Millien, the country’s Chief Veterinarian, to get his thoughts on the disease risk situation in an effort to calibrate our assessments. In Haiti, there are an estimated 800k pigs, 700-800k cattle, and >2M goats- more than any other Caribbean country. Thirty years ago Haiti exported meat, including rabbit meat, via the Haiti-America Meat Company. But an American bought carpets at the market made with livestock hair and contracted inhalation anthrax- this brought the whole exportation market to a halt.
Max disagreed somewhat with [previous veterinarian], saying the anthrax vaccination levels, a yearly process in Haiti, now stand at much less than 40%. Because of the recent focus on Teschovirus, they are behind on vaccination for classical swine fever. Theft of livestock is a major problem in Haiti, particularly with livestock that migrate from Haiti to DR, where Dominicans will confiscate the animals- implication being any livestock disease in Haiti is likely to be found in DR as well. Tagging was initiated for pigs because of the classical swine fever concern; tagging for cattle is about to begin.
Rabies is the top concern in regards to zoonotic disease in post-earthquake Haiti. There were 29 fatalities recorded in the Americas in 2006, of which 11 were in Haiti. Rabies is an underreported disease in Haiti. In collaboration with other groups like ARCH, an overall vaccination coverage of >75% has been achieved in Port-au-Prince. Dog tagging and tracking remain challenges. Mongoose and bats are the main reservoirs.
Gastrointestinal anthrax is the next concern. Human and animal anthrax is underreported in Haiti, and it is believed the more serious cases go undetected in the rural areas because the animal or human dies before reaching care. Attempted sale of anthrax-infected meat does occur occasionally at baseline. When asked if intestinal anthrax is a concern if the food security situation destabilizes, Max indicated yes. The risk to Port-au-Prince is low because most meat is imported, and consumer demand is relatively low. Poultry is in higher demand. If access to food gets to the point of that seen in the mid-90s embargo, there will be cause for concern with a primary emphasis on rural followed by the urban areas. If gastrointestinal anthrax appears in Haiti, Max believes there will be diagnostic confusion because there is no laboratory diagnostic capability and physicians will not be pre-sensitized to look for it.
Jim’s Previous Update:
A field veterinarian who works closely with the Chief Veterinarian of Haiti and has been working Haiti for 26 years in both small and large animal medicine provided information on animal disease in Haiti. Veterinary laboratories in Haiti are able to perform serologies for avian influenza and classical swine fever but no other viral diseases. They are also able to perform fecals and salmonella diagnostics. According to the veterinarian, rabies and anthrax are the top disease concerns considering the current post-earthquake conditions and the intersection with human health.
Rabies
The veterinarian indicated that as a result of USDA- and NGO-funded vaccination, as well as other agricultural infrastructure initiatives in Haiti, more than 75% of cats and dogs in Port-au-Prince have been vaccinated for rabies. He indicated there is still a high prevalence of rabies in Les Cayes. In addition, there are mongooses in Haiti that are an important reservoir for rabies virus in the wild.
Anthrax
The veterinarian discussed the potential risk of anthrax infection in humans and noted that in the past, outbreaks in livestock typically affect cattle, goats, or sheep and can be as large as 200 animals involved in an outbreak with no concurrent human infection. When anthrax is present in the human population, the bulk of recognized human infections are cutaneous, with a seasonal peak in May – June. Given these observations, the veterinarian surmised that there could be some indigenous human immunity in Haiti. However, he believes there may be a bias in recognized human clinical forms of anthrax in Haiti, because undeclared gastrointestinal, pulmonary, and meningitic cases may not survive long enough to reach a healthcare provider in rural areas. Similarly, he believed livestock probably die too quickly to be processed in the field and brought to market, so to see diseased meat in the markets is uncommon.
- Farmers occasionally try to sell anthrax-infected meat at markets; however, the local population avoids diseased meat and well understands the risks. That said, there is little food quality control and enforcement in Haiti. The veterinarian considers gastroenteric anthrax of low potential risk in Port-au-Prince, but of increasing risk in the rural areas. He lived in Haiti during the embargo of the mid 1990s and believes the current food security situation is nowhere near as bad as it was then.
- Current national anthrax vaccination coverage in Haitian livestock was estimated to be no more than 40%; cattle, goats, and sheep are vaccinated but not pigs.
- Known anthrax hot spots include Dessalines / Artibonite Valley, Anse Rouge, Limbe, and in the mountains around Les Cayes – there was a suspicious goat die-off there in the recent past. They have rarely observed pigs to be infected; porcine infection is thought to be largely subclinical.
Other Entities of Interest
An abortion storm was recently reported among goats in a rural area outside of Leogane – the veterinarian suspects leptospirosis as the cause. He is concerned about the human health risks due to the increasing problem of rat infestation. He has no laboratory capability to test for leptospirosis in animals, which he suspects is under-diagnosed as with human cases. He has not heard of large outbreaks of leptospirosis in Haiti.
Low pathogenic / subclinical influenza A (H1N2) is also present in Haiti, first detected in Dominican Republic.
The veterinarian raised the recent concern regarding Teschovirus, which appeared abruptly and unexpectedly in Saint Marc last year. The origin of the virus is unknown, given the low volume of pig importation to Haiti. As with Newcastle’s disease and classical swine fever, Teschovirus does not produce clinically significant illness in humans.
In our conversation last night, you also mentioned the myriad of livestock that are present in the camp as well as in the city. Could this population face the same challenges when faced with maintaining their animals and being in close proximity under the current conditions?
Our assessment of the current animal health situation is they are getting containment of the rabies concern, and anthrax will not be a significant concern until the food security situation gets to the point where starvation is observed on a broader basis.
¶ My response:
Great update and thanks for including some of the vet public health aspect. The abortion storm in goats has me a little concerned due to the number of zoonotic pathogens causing abortion in small ruminants – especially an abortion storm. Without being able to necropsy the animals or have additional information as to during what term the abortions occurred, some other zoonotic diseases of concern (other than lepto) come to mind.
- Campylobacter fetus (and C. jejuni) – can cause abortion storms and is transmissible to humans via secretions (e.g. consumption of unpasteurized milk).
- Chlamydophila abortus (formerly Chlamydia psittaci) – also causes abortion storms and has caused infection in humans – there are case reports of pregnant women becoming infected and subsequently aborting
- Toxoplasma gondii - depending on the number of cats in the area, might be a concern for human transmission – also causes abortion storms
- Q Fever – can be transmitted via contact (and inhalation) – also causes abortions
As you can see, there are human public health risks associated with small ruminant abortions, from consumption of milk, to direct contact with fetal/gestational materials. This is in addition to other standard risks with ruminants (in particular with a lack of sanitation) such as Cryptosporidium. While there might be host immunity with the human population, due to the stressors of recent events, this could potential pose a risk.
One of my concerns on the veterinary public health side regarding disease surveillance, is the population of people who migrated from urban centers back to more rural areas to stay with family. Did they bring disease with them if they were in the urban centers for some time prior to leaving? With the added number of mouths to feed, will the local inhibition to eat contaminated meat and/or feed unpasteurized goat milk to children be degraded? In a sense, without some sort of surveillance capability and an ability to target different populations for monitoring and intervention, will this be a ‘silent population’ of disease?
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