Post-earthquake Haiti: A Tinderbox for Disease

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As an infectious disease research fellow at the UC Berkeley
Center for Infectious Disease and Emergency Readiness (CIDER)
and at UCSF, I conduct research using computer models to
better predict and control infectious diseases. However,
since late January, I have been working at Hôpital de
l’Université d’état d’Haiti, the public university hospital
in Port-au-Prince and the largest hospital in Haiti.

I have been running a tuberculosis (TB) ward and also serve as an infectious disease consultant for the doctors here, who are primarily trained in surgery, emergency, or critical care medicine. These consultations have included evaluations of infections caused by earthquake trauma, post-orthopedic surgical infections, and tetanus—as well as infections caused by the disruption of infrastructure and destruction of housing, such as typhoid, untreated TB, and varicella.

Much of my day is spent caring for TB patients. I provide care in a tent where the temperature is usually 90 to 100 degrees Fahrenheit. Many patients arrive critically ill, with longstanding TB and oxygen saturations in the 60s and 70s, which is much lower than one would ever see in a chronically ill patient in the United States. Managing these patients has been challenging. There is some laboratory capacity, but most decisions are made solely based on clinical evaluation. Sometimes my job is simply to make sure I have managed my patients’ fluid status and avoided heat stroke. I also make sure they have enough food and water, which is difficult as the hospital can run out of food for up to a day at a time. The resources are intermittent. We have dialysis, but usually

do not have oxygen, and too many patients die for want of oxygen. Although we have been able to find enough TB drugs to treat the known and clinically apparent TB cases, we do not have the basic diagnostic tests (e.g., AFB sputum smears) to evaluate questionable TB cases. Many of my TB patients are HIV-infected, and they are disproportionately younger women.

This raises substantial concerns about the long-term effects of this disaster on the public health infrastructure. Haiti faced the largest per capita burden of TB before the earthquake. Now there is the risk for increased spread without the infrastructure to manage daily treatment, the follow-up for sputum clearance (an indicator of infectiousness), and the management of TB medications to avoid the spread of anti-TB drug resistance.

At the moment, Haiti has very little general antibiotic drug resistance overall. So I have been encouraging doctors to use medicines which we think of as “weak” in the United States, but which are actually more powerful when the bacteria are not resistant. So we can use penicillins and cephalosporins, and we do not need Vanco or expensive broad-spectrum antibiotics commonly used in the United States.

My work here has highlighted the need for immediately addressing infectious diseases in a disaster response. There are patients who have extensive, complex surgeries and then develop infections because of inadequate basic postoperative care. Some of these patients develop tetanus following these surgeries. Tetanus could have been prevented if there had been enough tetanus globulin or enough tetanus vaccination throughout the population before the earthquake. Moreover, we are seeing more cases of epidemic diseases, such as typhoid and varicella, which are spreading through the tightly packed tent cities of hundreds to thousands of people, where displaced persons have been sheltered.

With my background in infectious disease mathematical modeling, I keep thinking of how the density of the populations in tent cities creates the perfect kindling for transmission and disease outbreaks. I also begin wondering how the selection pressure of the antibiotics brought by expatriate doctors will affect the development and spread of drug resistance long term. This would be one legacy we do not want to leave behind. end of line

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