Tuberculosis in the aftermath of the 2010 earthquake in Haiti

Impact of Earthquakes on Lung Health

Earthquakes are catastrophic natural disasters that cause extensive damage to infrastructure and disrupt the lives of millions worldwide. Beyond the immediate physical and psychological damage caused by earthquakes, these events can significantly impact respiratory health. The inhalation of dust, smoke, particulates, toxic gases, and asbestos exposure can lead to various respiratory health pathologies. These include respiratory infections, exacerbations of pre-existing respiratory diseases, chest traumas, and pulmonary and venous thromboembolism. Longitudinal studies are necessary to assess the long-term respiratory health effects in affected populations. By addressing these knowledge gaps, future mitigation strategies and preparedness measures can be developed to minimize the respiratory health impacts of earthquakes and improve the well-being of affected communities. Robust building infrastructure and comprehensive earthquake preparedness are emerging as the most important determinants for not only mitigating building collapse but also significantly reducing the potential health impacts that follow. This comprehensive review aims to provide a systematic overview of the lung health impacts of earthquakes. It highlights the need for further research to identify specific pollutants, air contaminants, and environmental factors contributing to respiratory health issues following earthquakes.

The Impact of Earthquakes on Public Health: A Narrative Review of Infectious Diseases in the Post-Disaster Period Aiming to Disaster Risk Reduction

Earthquakes are among the most impressive natural phenomena with very high potential to set off a chain of effects that significantly affects public health through casualties and injuries. Related disasters are attributed not only to the strong ground motion and coseismic phenomena but also to secondary effects, comprising mainly landslides and tsunamis, among others. All these can create harsh conditions favorable for the emergence of infectious diseases that are capable of causing additional human and economic losses and disruption of the emergency and recovery process. The present study comprises an extensive narrative review of the existing literature on the earthquake-triggered infectious diseases recorded worldwide, along with their symptoms, causative pathogens, associated risk factors, most vulnerable population groups, and prevention strategies. Respiratory, gastrointestinal, and vector-borne diseases, as well as wound and skin infections, are mainly recorded among the earthquake-affected population. Measures for effectively preventing earthquake-triggered infectious diseases are also proposed. One of the widely proposed measures is the establishment of a proper disease surveillance system in order to immediately and effectively identify the pre- and post-disaster occurrence of infectious diseases. This approach significantly contributes to disease trends monitoring, validation of early warning, and support of the emergency response and recovery actions.

Health of Post-Institutionalized Haitian Children Adopted to the United States

OBJECTIVES

Haiti remains a principal placement country for intercountry adoptees to the United States. This project reports the health status of children adopted from Haiti arriving to the U.S. and compares them to intercountry adoptees from other regions.

METHODS

A retrospective chart review was conducted of adoptees placed in the U.S. from Haiti (n=87), age and sex matched with intercountry adoptees placed in the U.S. from Asia (n=87) and Latin America (n=87) between January 2010 and November 2019. Data on immunization status, contagious diseases, and nutrition and growth were analyzed via linear, logistic, and multinomial regression.

RESULTS

After adjusting for age, sex, and standardized height, children adopted from Haiti, compared to adoptees from Latin America and Asia, demonstrated a lack of immunity to hepatitis B (OR=5.89;6.87), increased immunity to hepatitis A (OR=0.38;0.30), infection by two or more parasites (OR=8.43;38.48), high lead levels (OR=23.79;7.04), and anemia (OR=15.25;9.18). Unexpectedly, children adopted from Haiti had greater standardized height (-1.28 vs. -1.82 and -2.13) and standardized weight (-0.32 vs. -0.57 and -1.57) than their counterparts from Latin America and Asia.

CONCLUSIONS

Children adopted from Haiti face complex medical challenges undoubtedly related to the country's low socioeconomic status (SES) and the impact of recurrent natural disasters and governmental neglect on public health infrastructure. Appropriate care is critical in preventing and avoiding transmission of infectious diseases in adoptees and family members. The high incidence of anemia and elevated lead levels may further exacerbate the developmental effects of early institutional deprivation.

Transmissibility of tuberculosis among students and non-students: an occupational-specific mathematical modelling

BACKGROUND

Recently, despite the steady decline in the tuberculosis (TB) epidemic globally, school TB outbreaks have been frequently reported in China. This study aimed to quantify the transmissibility of Mycobacterium tuberculosis (MTB) among students and non-students using a mathematical model to determine characteristics of TB transmission.

METHODS

We constructed a dataset of reported TB cases from four regions (Jilin Province, Xiamen City, Chuxiong Prefecture, and Wuhan City) in China from 2005 to 2019. We classified the population and the reported cases under student and non-student groups, and developed two mathematical models [nonseasonal model (Model A) and seasonal model (Model B)] based on the natural history and transmission features of TB. The effective reproduction number (Reff) of TB between groups were calculated using the collected data.

RESULTS

During the study period, data on 456,423 TB cases were collected from four regions: students accounted for 6.1% of cases. The goodness-of-fit analysis showed that Model A had a better fitting effect (P < 0.001). The average Reff of TB estimated from Model A was 1.68 [interquartile range (IQR): 1.20-1.96] in Chuxiong Prefecture, 1.67 (IQR: 1.40-1.93) in Xiamen City, 1.75 (IQR: 1.37-2.02) in Jilin Province, and 1.79 (IQR: 1.56-2.02) in Wuhan City. The average Reff of TB in the non-student population was 23.30 times (1.65/0.07) higher than that in the student population.

CONCLUSIONS

The transmissibility of MTB remains high in the non-student population of the areas studied, which is still dominant in the spread of TB. TB transmissibility from the non-student-to-student-population had a strong influence on students. Specific interventions, such as TB screening, should be applied rigorously to control and to prevent TB transmission among students.

Seminar Lessons: Infectious Diseases Associated with and Causing Disaster

Disasters such as the magnitude-9 Great East Japan Earthquake occur periodically. We considered this experience while developing measures against a predicted earthquake in the Nankai Trough. This report includes a summary of 10 disastrous infectious diseases for which a countermeasures seminar was held. Thirty-five speakers from twenty-one organizations performed the lectures. Besides infectious diseases, conference topics also included disaster prevention and mitigation methods. In addition, the development of point-of-care tests, biomarkers for diagnosis, and severity assessments for infectious diseases were introduced, along with epidemics of infectious diseases affected by climate. Of the 28 pathogens that became a hot topic, 17 are viruses, and 14 out of these 17 (82%) are RNA viruses. Of the 10 seminars, the last 2 targeted only COVID-19. It was emphasized that COVID-19 is not just a disaster-related infection but a disaster itself. The first seminar on COVID-19 provided immunological and epidemiological knowledge and commentary on clinical practices. During the second COVID-19 seminar, vaccine development, virological characteristics, treatment of respiratory failure, biomarkers, and human genetic susceptibility for infectious diseases were discussed. Conducting continuous seminars is important for general infectious controls.

Community health workers in humanitarian settings: Scoping review

Background

There is a need for greater understanding of experiences implementing community-based primary health care in humanitarian settings and of the adjustments needed to ensure continuation of essential services and utilization of services by the population, and to contribute to effective emergency response. We reviewed the evidence base on community health workers (CHWs) in humanitarian settings, with the goal of improving delivery of essential services to the most vulnerable populations.

Methods

We conducted a scoping review of published and grey literature related to health and nutrition services provided by CHWs in humanitarian settings. Extracted data from retained documents were analyzed inductively for key themes.

Results

Of 3709 documents screened, 219 were included in the review. Key findings from the literature include: 1) CHWs were often able to continue providing services during acute and protracted crises, including prolonged periods of conflict and insecurity and during population displacement. 2) CHWs carried out critical emergency response activities during acute crises. 3) Flexible funding facilitated transitions between development and humanitarian programming. 4) Communities that did not have a locally-resident CHW experienced reduced access to services when travel was limited. 5) Community selection of CHWs and engagement of respected local leaders were crucial for community trust and acceptance and high utilization of services. 6) Selection of local supervisors and use of mobile phones facilitated continued supervision. 7) Actions taken to maintain supplies included creating parallel supply chains, providing buffer stocks to CHWs, and storing commodities in decentralized locations. 8) When travel was restricted, reporting and data collection were continued using mobile phones and use of local data collectors. 9) CHWs and supervisors faced security threats and psychological trauma as a result of their work.

Conclusions

To achieve impact, policy makers and program implementers will have to address the bottlenecks to CHW service delivery common in stable low-income settings as well as the additional challenges unique to humanitarian settings. Future interventions should take into account the lessons learned from years of experience with implementation of community-based primary health care in humanitarian settings. There is also a need for rigorous assessments of community-based primary health care interventions in humanitarian settings.

Identification of TB space-time clusters and hotspots in Ouest département, Haiti, 2011-2016

BACKGROUND

Haiti has the highest incidence rate of TB in the Western Hemisphere, with an estimated 170 cases per 100,000 in 2019. Since 2010, control efforts have focused on targeted case-finding activities in urban areas, implementation of rapid molecular diagnostics at high-volume TB centers, and improved reporting. TB analyses are rarely focused on lower geographic units; thus, the major goal was to determine if there were focal areas of TB transmission from 2011 to 2016 at operational geographic levels useful for the National TB Control Program (PNLT).

METHODS

We created a geocoder to locate TB cases at the smallest geographic level. Kulldorff's space-time permutation scan, Anselin Moran's I, and Getis-Ord Gi* statistics were used to determine the spatial distribution and clusters of TB.

RESULTS

With 91% of cases linked using the geocoder, TB clusters were identified each year. Getis-Ord Gi* analysis revealed 14 distinct spatial clusters of high incidences in the Port-au-Prince metropolitan area. One hundred retrospective space-time clusters were detected.

CONCLUSION

Our study confirms the presence of TB hotspots in the Ouest département, with most clusters in the Port-au-Prince metropolitan area. Results will help the PNLT and its partners better design case-finding strategies for these areas.

Treatment success for patients with tuberculosis receiving care in areas severely affected by Hurricane Matthew - Haiti, 2016

BACKGROUND

On October 4, 2016, Hurricane Matthew struck southwest Haiti as a category 4 storm. The goal of this study was to evaluate the impact of the hurricane on tuberculosis (TB) services and patient outcomes in the three severely affected departments-Sud, Grand'Anse, and Nippes-of southwest Haiti.

METHODS

We developed a standard questionnaire to assess a convenience sample of health facilities in the affected areas, a patient tracking form, and a line list for tracking all patients with drug-susceptible TB registered in care six months before the hurricane. We analyzed data from the national TB electronic surveillance system to determine outcomes for all patients receiving anti-TB treatment in the affected areas. We used logistic regression analysis to determine factors associated with treatment success.

RESULTS

Of the 66 health facilities in the three affected departments, we assessed 31, accounting for 536 (45.7%) of 1,174 TB patients registered in care when Hurricane Matthew made landfall in Haiti. Three (9.7%) health facilities sustained moderate to severe damage, whereas 18 (58.1%) were closed for <1 week, and five (16.1%) for ≥1 week. Four weeks after the hurricane, 398 (73.1%) of the 536 patients in the assessed facilities were located. Treatment success in the affected departments one year after the hurricane was 81.4%. Receiving care outside the municipality of residence (adjusted odds ratio [aOR]: 0.46, 95% confidence interval [CI]: 0.27-0.80) and HIV positivity (aOR: 0.31, 95% CI: 0.19-0.51) or unknown HIV status (aOR: 0.49, 95% CI: 0.33-0.74) were associated with significantly lower rates of treatment success.

CONCLUSIONS

Despite major challenges, a high percentage of patients receiving anti-TB treatment before the hurricane were located and successfully treated in southwest Haiti. The lessons learned and results presented here may help inform policies and guidelines in similar settings for effective TB control after a natural disaster.

Diagnosis of Tuberculosis Using Gastric Aspirates in Pediatric Patients in Haiti

BACKGROUND

We aimed to determine whether the Xpert MTB/RIF (Xpert) assay is a useful adjunct to culture for the rapid diagnosis of tuberculosis (TB) using gastric lavage aspirates (GLAs) in children aged < 5 years.

METHODS

We reviewed the yield from diagnostic modalities in children suspected of having TB followed at an infectious disease research and treatment center in Port-au-Prince, Haiti, from 2011 to 2016.

RESULTS

In 187 children clinically diagnosed with TB, a microbiologic diagnosis could be established in 40 (21%). Cultures, Xpert, and smears were positive in 30 (19%), 28 (17%), and 3 (1.6%) children, respectively. Ten cases that would not have been diagnosed by culture alone were found by the use of the Xpert assay. Collecting 2 GLA samples optimized microbiologic yield.

CONCLUSIONS

In GLAs, Xpert increased the yield of microbiologically documented cases by 33%. Additionally, the rapidity of diagnosis potentially makes Xpert a valuable adjunct in initiating treatment for TB in children. Smear microscopy has low sensitivity in GLA and did not add to the documented cases. Our findings also highlight the low rate of microbiologic confirmation of clinically diagnosed TB.

High Burden of Non-communicable Diseases among a Young Slum Population in Haiti

The objective of this study was to characterize the demographics and population health of four slum communities in Port-au-Prince, Haiti, including population density and the burden of communicable and non-communicable diseases. Four urban slums were surveyed using a population-representative design between July and October 2016. A multistage cluster area random sampling process was used to identify households and individuals for the survey. Household surveys included rosters of residents, household characteristics, adult and child deaths in the past year, child health, and healthcare access and utilization. Individual surveys of two randomly sampled adults from each household included sociodemographic data, maternal health, and adult health. Additionally, blood pressure, height, weight, and psychological distress were measured by study staff. Data were weighted for complex survey design and non-response. A total of 525 households and 894 individuals completed the survey (96% household and 90% individual response rate, respectively). The estimated population density was 58,000 persons/km². Across slums, 55% of all residents were female, and 38% were adolescents and youth 10-24 years. Among adults, 58% were female with median age 29 years (22-38). The most common adult illnesses were severe psychological distress (24%), hypertension (20%), history of physical injury/trauma (10%), asthma (7%), history of cholera (4%), and history of tuberculosis (3%). Ten percent of adults had obesity (BMI > 30 kg/m²), and 7% currently smoked. The most common under-5 diseases during the last 3 months were respiratory and gastrointestinal illnesses (50% and 28%, respectively). One-third of households reported needing medical care for a child in the past year but not being able to access it, largely due to financial constraints. Unique features of these slums are a population structure dominated by adolescents and youth, a high proportion of females, and a high burden of non-communicable diseases including hypertension and psychological distress. Screening, diagnostic, and disease management interventions are urgently needed to protect and promote improved population health outcomes in these slum communities.

The Risk of Tuberculosis among Populations Living in Slum Settings: a Systematic Review and Meta-analysis

According to the WHO, half of the 10.4 million incident cases of TB in 2016 came from five countries where 20-50% of the urban population live in slums. Crowded living conditions and limited access to healthcare further contribute to the burden of TB in urban slums. This article aims to assess the odds of the burden of TB in urban slums through a systematic review and meta-analysis. Four electronic databases were searched for studies published between 1993 and 2017, with TB defined as at least one sputum smear-positive. The review followed the PRISMA protocol and information was extracted from articles for a full-text review to determine eligibility. Odds ratios were calculated for studies reporting sputum smear-positive TB cases in slum settings with national incidence as a comparison. Summary estimates were calculated using the random effects model (95% CI) and publication bias was assessed through funnel plot analysis. A quality assessment of included articles was also conducted. This meta-analysis was conducted across three categories: (1) across all 22 studies, (2) studies utilizing Active Case Finding, and (3) studies conducted in a high TB-HIV setting. The odds of sputum smear-positive TB were significantly higher across all three categories of analysis. Compared with national TB incidence rates, the combined odds ratio of smear-positive TB within slums was 2.96 (2.84, 3.09; p < 0.01). The combined odds ratio for smear-positive TB with active case finding across 15 studies was 2.85 (2.71, 2.99; p < 0.01). Among the 11 studies that reported incidence of smear-positive TB with prevalent TB-HIV coinfection in the community, the combined odds ratio for slum residents with the random effects model was 2.48 (2.34, 2.63; p < 0.01). Using Egger's funnel plot, publication bias was not detected within the three categories of analysis. The findings of this analysis indicate that the odds of developing TB are almost five times as great in urban slums. Reaching the most vulnerable and often overlooked groups in slums is crucial to achieving the SDGs and End TB Strategy by 2035.

Loss to follow-up among patients receiving anti-tuberculosis treatment, Haiti, 2011-2015

Setting: Tuberculosis (TB) treatment facilities in Haiti. Objective: To assess factors associated with loss to follow-up (LTFU) among patients receiving treatment for tuberculosis (TB) in Haiti. Design: We analyzed Haiti's national surveillance data for patients started on anti-tuberculosis treatment from 2011 to 2015 to determine factors associated with LTFU using multivariable logistic regression and describe LTFU in terms of subnational units to target future intervention strategies. We also conducted a survival analysis to estimate hazard ratios of factors associated with time to LTFU. Results: Of 81 490 TB cases reported, 7423 (9.1%) were LTFU during anti-tuberculosis treatment, increasing from 7.1% in 2011 to 10.3% in 2015. Six high-volume facilities had significantly higher rates of LTFU (14.3-31.9%) than the rest of the country, accounting for 18.8% of all TB cases reported, but 41.7% of all LTFU patients. Male sex, previous treatment history, and human immunodeficiency virus infection were associated with higher rates of LTFU. The median time to LTFU was 94 days. Conclusion: A small number of facilities accounted for disproportionately high rates of LTFU. These results identify characteristics of facilities and individuals leading to concentrated interventions to reduce LTFU and improve treatment success.

Drivers of Tuberculosis Transmission

Measuring tuberculosis transmission is exceedingly difficult, given the remarkable variability in the timing of clinical disease after Mycobacterium tuberculosis infection; incident disease can result from either a recent (ie, weeks to months) or a remote (ie, several years to decades) infection event. Although we cannot identify with certainty the timing and location of tuberculosis transmission for individuals, approaches for estimating the individual probability of recent transmission and for estimating the fraction of tuberculosis cases due to recent transmission in populations have been developed. Data used to estimate the probable burden of recent transmission include tuberculosis case notifications in young children and trends in tuberculin skin test and interferon γ-release assays. More recently, M. tuberculosis whole-genome sequencing has been used to estimate population levels of recent transmission, identify the distribution of specific strains within communities, and decipher chains of transmission among culture-positive tuberculosis cases. The factors that drive the transmission of tuberculosis in communities depend on the burden of prevalent tuberculosis; the ways in which individuals live, work, and interact (eg, congregate settings); and the capacity of healthcare and public health systems to identify and effectively treat individuals with infectious forms of tuberculosis. Here we provide an overview of these factors, describe tools for measurement of ongoing transmission, and highlight knowledge gaps that must be addressed.

Diagnostic yield of active case finding for tuberculosis and HIV at the household level in slums in Haiti

SETTING

Haiti has the highest burden of tuberculosis (TB) in the Americas, with an estimated prevalence of 254 per 100 000 population. The Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (Groupe Haïtien d'Etude du Sarcome de Kaposi et des Infections Opportunistes, GHESKIO) conducted active case finding (ACF) for TB at the household level in nine slums in Port-au-Prince.

OBJECTIVE

We report on the prevalence of undiagnosed TB detected through GHESKIO's ACF campaign.

DESIGN

From 1 August 2014 to 31 July 2015, we conducted a retrospective cohort analysis using GHESKIO's ACF campaign data. All individuals who reported chronic cough (cough 2 weeks) were tested for TB at GHESKIO, and those aged 10 years were included in the analyses.

RESULTS

Of 104 097 individuals screened in the community, 5598 (5%) reported chronic cough and satisfied the study inclusion criteria. A total of 1110 (20%) were diagnosed with active TB disease (prevalence of 1066/100 000). Of the 5472 (98%) patients tested for human immunodeficiency virus (HIV), 528 (10%) were HIV-positive; 143 (3%) patients were diagnosed with both diseases.

CONCLUSION

Household-level screening for cough with TB and HIV testing for symptomatic patients was a high-yield strategy, leading to the detection of a prevalence of undiagnosed disease exceeding national estimates by more than four-fold for TB, and by five-fold for HIV.

Trends in Tuberculosis Case Notification and Treatment Success, Haiti, 2010-2015

Since the 2010 earthquake, tuberculosis (TB) control has been a major priority for health sector response and recovery efforts in Haiti. The goal of this study was to analyze trends in TB case notification in Haiti from the aggregate data reported by the National TB Control Program to understand the effects of such efforts. A total of 95,745 TB patients were registered for treatment in Haiti between 2010 and 2015. Three regions, the West, Artibonite, and North departments accounted for 68% of the TB cases notified during the period. Patients in the 15–34 age groups represented 53% (50,560) of all cases. Case notification rates of all forms of TB increased from 142.7/100,000 in 2010 to 153.4 in 2015, peaking at 163.4 cases/100,000 in 2013. Case notification for smear-positive pulmonary TB increased from 85.5 cases/100,000 to 105.7 cases/100,000, whereas treatment success rates remained stable at 79–80% during the period. Active TB case finding efforts in high-risk communities and the introduction of new diagnostics have contributed to increasing TB case notification trends in Haiti from 2010 to 2015. Targeted interventions and novel strategies are being implemented to reach high-risk populations and underserved communities.

Sheltering Haitian Humanitarian Parolees in San Diego: A Local Health Department's Response to an International Crisis

From the Field is a semi-regular column that explores what it means to be a local health professional on the front lines of an emergency. National Association of County and City Health Officials (NACCHO) members share their stories of preparing for and responding to disasters, epidemics, and other major health issues. Through exploring the analysis of the challenges faced and the solutions developed, readers can learn how these public health champions keep their communities safe even in extreme situations. Readers may submit topics of interest to the column's editor, Meghan McGinty, PhD, MPH, MBA, at mmcginty@naccho.org .