AS IF a cholera epidemic were not enough, Haitian health authorities are investigating the sudden deaths of more than a dozen people after a voodoo ceremony and a deadly spate of paralysis in recovering cholera patients.

Ariel Henry, chief of staff of the Haitian health ministry, said epidemiologists were sent to the town of Fonds Baptiste, about 30km from Port-au-Prince, to investigate the large number of sudden deaths there.

"the victims were said to have died suddenly after being seized with strong migraines, vomiting and struck blind," Dr Henry said, recounting reports from witnesses.

A nurse contacted by telephone said 16 people had died since the start of the week in the town.

Dr Henry put the number of deaths at about a dozen, while Daniel Epstein, a spokesman with the Pan American Health Organisation, said the exact number had not been determined yet.

"we are investigating two groups of deaths … that occurred after a voodoo ceremony," Dr Epstein said, adding that they appeared to be from poisoning.

They may have consumed a homemade alcohol, or eaten fruit from the ackee tree, which contains a toxic compound that can be fatal if the fruit is not harvested and prepared correctly, he said.

Another doctor, who asked not to be identified, suggested the cause of death was probably ethanol poisoning."the first data gathered show that they had drunk homemade brew," he said.

In a separate medical mystery, the Pan American Health Organisation said Haitian and international health authorities were looking into four cases of paralysis in recovering cholera patients in the town of Port-de-Paix.

Three of the four patients died, and one is slowly recovering in a hospital in Port-au-Prince, it said.

"These patients, hospitalised for severe cholera, presented an ascending bilateral flaccid paralysis of acute onset 24 to 72 hours after the end of the cholera treatment," the agency said.

The cases were first reported on January 10 in Haiti’s Nord-Ouest Department.

"all of the cases were seen at the same cholera treatment centre and returned 2-4 days later with neurological symptoms, at which point they were hospitalised," the agency said.

"Experts including toxicologists are investigating possible contamination at a hospital or at home from medication, food, or another source as the cause of death in these cases," it said.

"Although considered highly unlikely, polio has not been completely ruled out, pending laboratory results of samples," it said.

The experts do not believe it is polio because the disease rarely causes death.

MR. TONER: Thank you and good afternoon. And thanks once again for joining us. As many of you know, this is the third of three briefings that we’ve set up in advance of Wednesday’s one-year anniversary of the tragic earthquake that struck Haiti. This particular briefing will look at strategies and logistics for saving lives, including treatment and prevention of cholera, HIV/AIDS, as well as other health concerns that the U.S. and its partners are addressing on the ground in Haiti.

We’re very fortunate to be joined today by Donald Steinbeg, who is the USAID Deputy Administrator, as well as Ambassador Eric Goosby, who is the U.S. Global AIDS Coordinator here at State; Dr. Thomas Frieden, who is the Director of the Centers for Disease Control; and finally, in Port-au-Prince, Carleene Dei, who is the USAID’s Mission Director in Haiti.

Since time is relatively tight, I’ll hand it over to Donald Steinberg to lead us off and we’ll let our speakers talk briefly about the issue and then hand it over to you journalists for Q-and-A. Don, do you want to go ahead?

MR. STEINBERG: Sure. I just wanted to provide sort of a broad overview, which is to say that at the time of the earthquake a year ago, we were involved in strengthening of health systems and working with the Ministry of Health, a variety of other agencies within Haiti, as well as civil society to address the concerns. And then with the earthquake, the dynamics shifted dramatically, obviously, to programs to assist the victims of the disaster.

In addition to the humanitarian relief efforts, however, we have been engaged over the course of the past year in trying to build health systems, in trying to provide assistance to individuals within internally displaced persons sites, and also to extend health systems throughout the rest of the country. that process was actually going fairly well and we were seeing some improvement in access to health services, to extension of services around the country, as well as the strengthening of the Ministry of Health system, when the cholera outbreak occurred.

As you’re aware, we have been responding to that situation. We have already provided some $40 million worth of assistance, primarily through the Office of U.S. Foreign Disaster assistance, but also through our regular aid mission and the Office of Transition Initiatives. We do have a situation now where they’ve – we have identified some 157,000 cholera cases. about half of those have involved hospitalization. We have seen about 3,500 deaths.

At the same time, what we have seen is a massive expansion of the cholera treatment facilities in Haiti. As you’re aware, this has been virgin territory for cholera, and so the challenge has been very great. But we have now set up health facilities throughout the country, using in large part the PEPFAR facilities on the ground. We’ve been providing a variety of health commodities – water purification tablets, chlorine for health systems, Ringer’s lactate, which is an IV solution that’s used. And we believe that we’re in a situation where, in terms of commodities and services, we’re at least a bit ahead of the curve, although that changes on a day-to-day basis.

I think the overall point that I wanted to make, however, is that we are still in the wake of the earthquake response that occurred a year ago and that we are continuing to try to strengthen existing health services. We have active programs in water and sanitation. And we’re going to continue those efforts going off into the future.

AMBASSADOR GOOSBY: Okay. This is Ambassador Eric Goosby. Thanks, Don. I – since 2004, the United States has been a strong supporter of Haiti’s fight against HIV/AIDS through the President’s Emergency Plan for AIDS Relief, or PEPFAR. In a country with a weak health infrastructure even before the earthquake, really, the PEPFAR investments have not only supported prevention of HIV treatment and care, but they’ve helped build a critical health infrastructure to provide what is much needed medical services.

Following the earthquake, through PEPFAR and our partner organizations such as USAID and CDC, we were able to leverage this health infrastructure to marshal a rapid and robust response. PEPFAR’s immediate mobilization of its sites and making them available for the broader earthquake response was critical to that. A hundred and forty-nine prevention, treatment, and care sites provided earthquake response in the initial weeks, as well as the ongoing HIV/AIDS services being continued.

PEPFAR’s networks of facilities, healthcare workers, community health workers, supply chains, have engaged in a wide variety of response activities. Regional hospitals in the most affected areas provided disaster-related medical care, including surgeries for trauma and other urgent conditions. Other PEPFAR sites made food, water, and shelter available to earthquake victims in displaced populations. Our sites became really the centers for mapping of the tents for shelter in terms of where in relationship to the known PEPFAR sites were the tents and shelters located.

It’s important to note that from day one, our priority was focused on really looking at issues and foundations of sustainability. We knew we had to do this with the Haitian Government, especially post-earthquake. And then there was a shared responsibility to deal with the emergency response and the rebuilding with the convergence of all these external outside-of-country resources.

In the coming year, the U.S. Government will continue to support its longstanding AIDS programs while simultaneously supporting the Haitian Ministry of Health’s efforts to build its primary healthcare system. We’re pleased to report that by may, 2010, the number of patients on AIDS treatment at sites supported by PEPFAR was back up to close to 95 percent of its pre-earthquake levels.

We’ve also been working with the Haitian Government and other international partners to establish a plan to rebuild Haiti’s public healthcare system. As one component of our support, we will partner with the governments of Haiti and France to reconstruct the university hospital in the center of Port-au-Prince, which will provide medical, nursing, pharmacy, and other allied health professional training.

As part of the Global Health Initiative, the United States is also adding services to the PEPFAR platform to provide care for people with disabilities, continued support for child protection and comprehensive health services, including maternal child health and family planning services.

But in light of all this, there’s clearly no doubt that there is still much work to be done. The devastation is still being felt virtually in every community in Haiti. Americans really should be proud of their country’s involvement in trying to add and enhance the help that’s afforded, but the effort is far from over. I think this anniversary, one year post-earthquake, should serve as a reminder that progress can be made and we can achieve real good and clean outcomes that we really, from day one, again, have an eye to really strengthening the larger healthcare delivery system.

So I’ll turn it over to Tom Frieden from Center for Disease Control.

DR. FRIEDEN: Thanks very much, Don and Eric. I wanted to just give a little bit of a perspective from a public health standpoint, because on the one hand, a year later, given the rubble and displaced people and cholera epidemic, it can seem that little or no progress has been made. And in fact, there are enormous obstacles, but there has been real progress in preventing, tracking, and responding to public health threats. Preventing through immunization initiatives, through water and sanitation, through education; tracking through a laboratory in Haiti that’s now much more functional than it ever was; a monitoring system that’s able to track diseases and conditions better and in closer to real time than has ever been available before in Haiti; and to respond through treatment centers for cholera, HIV, and TB; and in all of this, also strengthening Haiti’s ability to do this on their own.

As Ambassador Goosby just noted, PEPFAR has been enormously important in ensuring that Haitians with HIV continue to receive antiviral drug treatment, and for health in general. Close to 95 percent of people who were on antiviral treatment before the earthquake were rapidly resumed in care. And in terms of prevention of maternal-to-child transmission, the coverage has continued to increase. Between Fiscal 2009 and Fiscal 2010, a larger number of women were tested and a larger number of women were found to be HIV-positive and treated. And therefore, an increasing number of infants were born free of HIV, who would certainly have been infected had these programs not been in place. The number of women being counseled and tested continues to increase and, in fact, is now at a higher level than the pre-earthquake baseline.

In terms of tuberculosis care, which is an ongoing and serious problem in Haiti, most of the surviving patients from the pre-earthquake TB registries were rapidly put back on treatment. So there has been real progress. Challenges remain and progress is fragile. Political stability, international assistance, and having the workforce that’s needed within Haiti are all critically important.

Opportunities and hope for the future, I think, are also very strong. We have a ministry of health that’s increasingly able to provide guidance and oversight to programs, we have a laboratory that’s able to document conditions and respond to them, we have efforts that will address longstanding health problems such as filariasis and malaria and rabies, maternal mortality programs that have been longstanding challenges in Haiti, and for which we now have a real possibility of making significant progress in the months and years to come.

So the challenges are enormous but the progress is real and the potential for future progress is, I think, very strong. And now, I’ll turn it over to the USAID Haiti.

MS. DEI: yes, I want to join in with the other three and reiterate that our health program pre-earthquake, in response to the earthquake, in response to the cholera epidemic, has been something that we can be incredibly proud of. As you heard, we’ve been working at health for a while and our most recent projects were – resulted in services accessible to 50 percent of the population. We support services to 50 percent of the population.

This is the infrastructure that permitted us to mount a very, very successful response to the health issues that were posed by the earthquake. This is the system, the base that permitted us to respond to the cholera epidemic in a manner which, frankly, if we had not had surveillance systems, if we had not had partners on the ground, the results would have been much more devastating than they actually were.

And going forward, our intent is to build on this base and make it stronger. We’re using a whole-of-government approach, meaning that CDC and USAID and any other U.S. Government service that provides healthcare, we work in a uniform manner, in a unified manner. what we want to do is to go beyond the 50 percent and broaden the access of the individual living, whether in a town or in a rural area, to services by setting up a ladder of availability starting in the home, moving on to the local health provider, moving up to reference hospitals and then to hospitals. In other words, everybody should know where to go to get help.

And I also want to reiterate that the Ministry of Health has been a superb partner. Imagine a ministry which has lost its offices, lost some of its key personnel, yet pulling itself together, sitting down, working with us to address the – both the earthquake and the cholera epidemic, and to have a very, very clear plan for where it wants to go in terms of basic service delivery.

The only thing that has not been mentioned so far is our program that will – dealing with disabilities. As you know, the earthquake resulted in a lot of people with injuries, with amputations, and they need and require long-term care. And one of the things we’re doing is supporting services that will ensure that this is available, because this is something that was not there in pre-earthquake Haiti.

I would like to give everyone a chance to ask questions, so I’m going to limit my remarks to that. thank you.

MR. TONER: thank you very much, Carleene. just a reminder before we open it up to questions, this is all, of course, on the record. And with that, Erin, we’ll go ahead and turn it over to questions, and just ask that you give your name and media affiliation.

OPERATOR: great, thank you. We will now begin the question-and-answer session. if you would like to ask a question, please press *1 and you will be prompted to record your name. to withdraw your request, please press *2. one moment, please. one moment for our first question.

Our first question comes from Bret Stephens from The Wall Street Journal. Sir, your line is now open.

QUESTION: hi, thank you for taking the time to do this. I’m wondering if there’s any kind of dollar figure that you can attach to the efforts by USAID on the health front to how much has just been spent or allocated and also disbursed for efforts in the last year.

PARTICIPANT: Carleene, you want to try that?

MS. DEI: It’s – yes. In terms of our response to the earthquake, the figure that we use is well over a billion dollars, and that combines with what the Department of Defense spent, what we spent. But in health specifically, we have spent about 115 million, that’s for nutrition health and for non-cholera, plus an additional 40 million for cholera.

QUESTION: I’m sorry. How much for cholera?

MS. DEI: about 40 million to date. This is by OFDA/USAID, but it’s also – we should point out that CDC has also spent 17 million – sorry – 14.6 million – I’m speaking on their behalf – (inaudible) health-related activities.

QUESTION: So that’s 14 – one-four or four-o? I’m just – I can’t quite hear you.

MS. DEI: one four.

QUESTION: okay. All right. So the answer, just to clarify, OFDA of USAID (inaudible).

MS. DEI: All right. This is USAID. 40 million for USAID and 14 million for CDC, plus they have requested and received additional money. This year, through, altogether, for just our ongoing health programs, we have spent $51 million.

QUESTION: thank you.

OPERATOR: Again, if you would like to ask a question, please press *1. one moment please. Our next question comes from Michael Smith from MedPage Today.

QUESTION: Oh, great. thank you. This question is for Dr. Frieden. I was – I took it from what you said that most of the patients and some 95 percent – most of the HIV/AIDS patients were – got back on treatment. But I think you also implied that as a result of sort of an increased medical intervention or increased medical care that more people have been identified with HIV and AIDS, and in particular women. I wonder if you can elaborate on that.

DR. FRIEDEN: Yeah, I wanted to just highlight that despite the enormous challenges, there continues to be progress. And as an example of that, the number of women – tested, pregnant women tested for HIV and the number found positive and therefore started on treatment has continued to increase. So in Fiscal 2009, it was around 132,000. it increased to nearly 156,000 by Fiscal 2010. And the number of women therefore given antivirals to prevent spread of HIV to their infant increased from 1,100 in 2009 up to 1,900 in 2010. So this is having an increasing impact on preventing the spread of HIV to – from mothers to children. it was just as one example that despite all of the real challenges, there continues to be important progress.

QUESTION: It’s just a – the presumably women tested and found to be HIV-positive were given the standard signal dose of Nevirapine, or how – what was the treatment regimen? Do you know?

DR. FRIEDEN: As a general rule within PEPFAR, it depends on both the stage of illness and the country policies. Ambassador Goosby, did you want to say anything further about this with respect to Haiti?

AMBASSADOR GOOSBY: Yeah, it – as Dr. Frieden is saying, we’re in a situation where if you have the benefit of having the woman in a relationship pre – in the prenatal period, you are able to start a combination that includes two drugs at a minimum. For those that have 350 T cells or less, we really strongly urge that that woman be put on three drugs and a full antiretroviral compliment and continue through her delivery and through her breastfeeding period. For those below 350, that should be continued forever; for those with high T cells, that a dialogue be engaged with her to decide if she should continue them or if she should go off of therapy.

For those that just show up at the delivery, you often only have an opportunity to give them the one single dose of Nevirapine for mother and child, which is suboptimal but much better than not giving any antiretroviral. And then that individual is followed and her children that she’s had already delivered so older children are also brought in for testing, as well as partners. that is the Haitian preference, that they be on three drugs, and then their standard is to have women on two drugs if they’re not going to continue on all three.

QUESTION: thank you very much.

OPERATOR: Our next question comes from John Donnelly, freelance writer. your line is open.

QUESTION: hi, thank you for having this call. I have two questions. one is about GHI, and I’m wondering what the impact the earthquake had on the rollout of GHI. it sounds like it may have accelerated the process a bit after the emergency response in the first several months, but I’d like some details, then, if you have some.

The second one is more information from Ambassador Goosby on just this 95 percent figure, which seems amazingly high. could you give some more detail about how you got to that figure, because I would assume that there were a number of sites that were damaged or destroyed from the earthquake? And I would also assume that that figure would include people shifting from one site to another, and I would also assume that there would be a number of patients who died, as well as perhaps some providers who died in the earthquake. So I’m just – if you could give a more fuller picture, I’d appreciate it. Thanks.

AMBASSADOR GOOSBY: sure. We monitor the number of patients that we put on antiretroviral therapy very closely, right down to the site level. We know who and how many are on full antiretroviral therapy as well as those for tuberculosis. it puts us in a situation where knowing the pre-earthquake and post-earthquake number was actually a real calculation, not a modeling exercise. So that’s a real number.

The second component is we were also very fortunate not to have out of the 149 sites any of the PEPFAR treatment sites destroyed in the initial earthquake, even though the ones in Port-au-Prince were affected. Indeed, one of our major sites had the death of a woman who was over the laboratory, a very senior person in the lab. But she died not in the site but at her home because she was off that day. The sites for PEPFAR were remarkably well – not damaged by earthquake and as a result were able to play a role in both the immediate emergency response but also in shifting our human resources from outside Port-au-Prince sites to or near Port-au-Prince sites as they were set up in the immediate post earthquake period as a triage center.

And indeed, some of our sites actually played kind of minor to – for orthopedic injuries, broken bones, compound fractures were triaged; head and neck injuries were triaged as well. But our people were able to play that initial triage evaluation and referral. I think that the human resource broadly in the Haitian broader department region also was undamaged in the specifics of both site and human resources. And as a result, in the cholera response, both USAID, CDC, and the Government ministry of Haiti were able to use our healthcare workers, nurse, nurse providers, as well as the physicians, to pre-train in the use of oral rehydration salts, early diagnosis and pickup of early symptoms of cholera, and general kind of fecal-oral hand washing sanitation concerns around water and fecal material that were able to be rolled out to broad geographic areas that allowed us to actually be in front of the wave of cholera as it moved into more than just the northern department, where it originally rose.

Those early training and having a cadre of healthcare professionals who knew about oral rehydration have always shown that that early training, that a cadre of available, capable people, minimizes morbidity and mortality figures. So we believe we’ve contributed to that. Time will tell as to how much we can quantify that, but we clearly took that – pulled that trigger early to anticipate, really, an informed and responsive healthcare provider cadre.

OPERATOR: Our next question is from Frances Robles of the Miami Herald. your line is now open.

QUESTION: Hi. good afternoon. My (inaudible) question was answered. I’m wondering whether there was – how smooth the transition was from – shifting from quake mode to cholera mode. And also, can you talk a little bit about the partnership with the Cuban doctors? And I’m sorry, and can you introduce yourself before you speak because I don’t know who’s voice is whose.

AMBASSADOR GOOSBY: This is Eric Goosby. I can – Dr. Dei would probably have the most current and immediate kind of reaction to some of those nuances. But from very early on in the earthquake response, and actually before the earthquake, the approach in USG was really to engage in a substantive discussion with the Ministry of Health leadership to really describe – to get them to develop a strategic plan that we fed off of to really look for every opportunity to expand the capacity of the Ministry of Health in their strategic planning, budget preparation, the definition of unmet need across all diseases, and in them informing and/or making allocation decisions with divergent resources such as PEPFAR, Global Fund, or other multilateral resources.

So that orientation was there before earthquake. Post-earthquake, I would only say that it, from my perspective, the willingness on part of the Haitian health leadership to partner was just that much more urgent, even though there was willingness before. And I believe that it positioned us to be maybe more clear in actually moving to discussions around shared responsibility and specifics of implementation – what Haitians do, what we do, what other bilateral or multilateral groups do.

MS. DEI: May I add to that just a little bit? what I’d like to say is that the earthquake puts us (inaudible) in a emergency mode which was immediately applicable to the cholera epidemic. You were talking about how that transition took place. yes, we were absolutely amazed when cholera popped up, but we were able to respond because we were already thinking along those lines, moving resources around and using systems that we already had in place – most spectacularly, I think, the communications systems, to help us respond to what had taken place.

QUESTION: And the Cubans?

OPERATOR: Our next question comes from Michael Smith of MedPage Today. your line is now open.

QUESTION: Hi. I just wanted to follow up again on this number of people who are back on the ARVs. And the reason I’m – the question that arises is I’m looking now at Dr. Frieden’s article which will appear in the – online in The new England Journal. it says 94 percent of patients were back at – back getting their ARVs. on the other hand, it says 67 percent of patients in the TB registries were back and it’s just that as many as 30 percent may have died or moved away. And I’m wondering why, if – it strikes me that there is no particular reason why HIV-AIDS patients should be more likely to survive an earthquake than TB patients, and so I’m trying to get those numbers clear in my mind.

DR. FRIEDEN: Well, remember that you’re talking about a period of several months from January through may. And in that period of time, TB patients may have completed treatment, may have died, or may have moved. The ARV being a lifetime treatment has a more consistent follow-up and also, I think, kind of a more consistent approach throughout Haiti because it’s a more recent program implementation.

I think the big point with both is that despite the earthquake, there were strong systems in country through the Haitian Government and important NGO partners which were able to rapidly track down and return patients to treatment and then move on to try to get to the next level in terms of implementing effective programs.

QUESTION: All right, thank you.

OPERATOR: We have no further questions in queue.

MR. TONER: Okay, well, thanks to all of our participants, and thanks to the journalists for joining us on these calls. I very much appreciate everyone’s participation, and have a great afternoon. thank you.

since October 22, 2010, Doctors without Borders/Médecins Sans Frontières (MSF) has treated 62,000 people with cholera symptoms in Haiti. This week, MSF's 4,000 Haitian staff and 315 international employees treated close to 2,000 patients each day in the 47 centers and cholera treatment units it has established across the country.

MSF has treated more than 15,000 people in the capital with cholera symptoms since the epidemic began. The number of patients admitted into MSF facilities in Port-au-Prince has stabilized at a daily average of 385 patients this week. The situation is also stabilizing in the Artibonite department, which has thus far been hardest hit by the epidemic and where more than 23,000 people have been treated. This week, slightly more than 1,000 people were admitted into MSF facilities there.

however, the epidemic continues to spread in Haiti's northern cities and rural areas. during the past week, more than 4,000 patients were treated in the Department du Nord, as its known locally, and 1,100 patients were treated in the Department du Nord Ouest. despite the significant logistical challenges involved in reaching isolated parts of both departments, MSF teams are expanding the number of units, treatment centers, and rehydration points in both areas.

MSF is treating victims of post-election violence

MSF treated 96 victims of the violence that erupted in Port-au-Prince and several other cities between December 7 and 12. Of that number, 38 had gunshot wounds. four people died of their wounds. MSF has surgical supplies and medical teams at six facilities in Port-au-Prince and two in other regions of the country. The organization remains prepared to treat any additional wounded patients. despite the insecurity, MSF teams have managed to ensure continuity of medical care, including responding to the cholera epidemic and treating persons wounded in the violence.

meanwhile, the epidemic has increased sharply in the South. Of the 475 people treated in the South for cholera since the start of the outbreak, 439 presented in the past seven days. in Jacmel, in the Departement du Sud Est, approximately 100 patients are arriving at MSF's 50-bed cholera treatment unit every day. "our team had to handle an inflow of 260 in a single day," says Dr. Loreto Barcelo, MSF's coordinator in Jacmel. "there were people everywhere… Patients, their families… there were several hundred people at the treatment site. We had to put up to four patients in a single bed and try to save as many as possible while waiting for extra help to arrive. We now have an additional 20 nurses helping us and opened a new 100-bed treatment center, which is helping us manage the situation."

This week, new cholera treatment facilities were set up in Pignon, St Raphaël, Ranquitte (Nord), Gaspard (Nord Ouest), and Jérémie (Grande Anse). however, as the epidemic continues to spread, the response by local and international organizations remains inadequate.

Some have raised the possibility of launching a vaccination campaign. Under the circumstances, epidemiologist Kate Alberti wonders if this is appropriate. "The epidemic affects the entire country today, including the most remote areas. This isn't the time to carry out a vaccination campaign. The priority is to treat patients, provide access to chlorinated water and improve hygiene measures to prevent others from becoming ill." however, Alberti adds, "in the future, we will consider vaccination as a viable option to immunize the population and limit the appearance of a new epidemic."