Victims of Haiti

Caring for Victims of the Earthquake in Haiti

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Because of changes in the legal status of Haitians in the United States following the January 2010 earthquake, more patients from Haiti are entering the US healthcare system. Some are adults whose legal status prevented them from previously seeking medical care; others are orphaned children who arrive without any prior immunizations. In either case, medical screening recommendations exist to help you keep these patients well.

On January 12, 2010, Haiti suffered an earthquake that caused unprecedented injury, death, and destruction. According to the latest estimates, more than 200,000 people have died with an additional 1.5 million people living under tarps, in tents, and in transitional shelters.

Even prior to the earthquake, Haiti’s economy was unable to support a robust public healthcare system. Almost half the population had no access to safe drinking water or medical care, 40% lacked adequate food leading to malnutrition and a high rate of low-birth weight babies, and more than 75% lived without adequate sanitation.[1] According to a 2006 report from the World Health Organization,[2] approximately 43% of all deaths in Haiti were related to infectious diseases, including HIV/AIDS, lower respiratory illnesses, meningitis, diarrheal illnesses, and tuberculosis (TB). In 2007, diarrheal illnesses alone were associated with 16% of mortality in children younger than 5 years.[3] The earthquake exacerbated these issues as the living conditions deteriorated and medical care became sparse.

On January 15th, the US Department of Homeland Security (DHS) announced that the estimated 100,000 to 200,000 Haitians “not legally in the United States” as of January 12 would be granted a form of asylum called Temporary Protected Status, which would allow them to work in the United States for the next 18 months. On January 18th, DHS announced a humanitarian parole policy allowing orphaned children from Haiti to enter the United States temporarily on an individual basis to ensure that they receive the care they need—as part of the US government’s ongoing support of international recovery efforts after the earthquake. And in the wake of the devastation caused by the earthquake, thousands of evacuees from Haiti are likely to try and join their families in the United States. (For ease of reading, these 3 groups will be referred to collectively as “refugees.”)

What to Expect

Unlike most refugees, those arriving from Haiti will probably have not undergone prior health screening. In addition, they will be arriving from an environment of devastation without the most basic sanitation, food, shelter, or obstetric care (Box 1). Many refugees have never undergone routine preventive screening or child development assessments. In particular, many refugee women have not received gynecologic examinationss, Pap smears, mammography, or training in breast self-examination.


The incidence of TB in Haiti is one of the highest in the Western hemisphere. Therefore, all refugees should be evaluated for TB after arrival. Malaria is also endemic to Haiti, so anyone presenting with a fever requires urgent evaluation, even if already receiving anti-malarial prophylaxis. In addition, Haiti has the highest prevalence of HIV in the northern hemisphere,[4] so all refugees should be tested for HIV, unless they decline.

Vaccine-preventable diseases are another important public health consideration for this population. Most children arriving here from Haiti have probably not received hepatitis B, haemophilus influenzae type B (Hib), varicella, pneumococcal conjugate (PCV), hepatitis A, rotavirus, and human papillomavirus vaccine as none of them are included on Haiti’s vaccine schedule. Individuals without written documentation of immunization should be considered unvaccinated. Children and adolescents should receive immunizations according to the recommended schedule in the United States for healthy children and adolescents. Please note that children may require up to 2 doses of MMR due to the lack of previous mumps immunization.

It is estimated that up to one-third of school-aged children in Haiti will test positive for intestinal parasites.[5] As children will likely arrive without having received prior treatment, empiric therapy with a single dose of albendazole (400 mg, 200 mg for children 12-23 months) should be sufficient to treat most intestinal parasites. Additionally guidance on this issue is available at the Centers for Disease Control and Prevention.

Regardless of country of origin or age, 45% of all refugees and 65% of all refugee children have significant dental disease. You should be prepared to emphasize personal hygiene, prevention of early childhood (ie baby bottle) caries, use of fluoridated water and toothpaste, and regular dental care. Because state- and federally funded insurance plans typically provide limited coverage of services for adults, education regarding personal oral hygiene practices is very important. Refugees of all ages should be referred for dental consultation as soon as possible to clinics that offer appropriate financial arrangements.

In the aftermath of disasters, many child and adult survivors will begin to feel acute reactions to stress that may appear immediately or days or even weeks later. However, because of the stigma in Haitian culture about mental illness, many patients are reluctant to discuss their fears and worries. Haitian patients may refer to stress and psychiatric symptoms in culturally specific ways, such as ‘saisissement” (rapid heartbeat and cool blood due to trauma), or as supernatural causes of symptoms, such as voudou or hexes.[6] Any discussion of mental health or stress reactions should be explained in a culturally sensitive, supportive, and nonstigmatizing manner. While grief is a normal response to the extensive losses that occurred during the earthquake, unrelenting grief—especially in children—may require referral to a mental health professional.

General Considerations

Components of the medical history should include the following:

  • History of trauma, both emotional and physical, including witnessed violence
  • Symptoms of communicable disease (ie, fever, cough, rash, diarrhea, vomiting, weight loss, failure to thrive)
  • Past medical and surgical history including any known chronic diseases
  • Specific history of TB and HIV should be solicited
  • Medication history
  • Immunization history if documented

Components of the full physical examination should include–

  • Vital signs and assessment of vision and gross hearing
  • Height, weight, head circumference (if age appropriate) and determination of growth percentiles
  • Obvious injuries that may have resulted from trauma
  • A full physical examination with particular attention to signs that may indicate underlying medical problems such as heart disease, asthma, chronic malaria (eg, tachycardia, heart murmurs, labored respirations, abdominal tenderness, lymphadenopathy) or undetected injury from trauma (eg, splenic rupture)
  • Assessment of nutritional status
  • Signs and symptoms of TB
    • Previous history of TB
    • Illness suggestive of TB (cough of >3 weeks duration, dyspnea, weight loss, fever, or hemoptysis
    • Prior treatment suggestive of TB treatment
    • Thorough pulmonary exam
    • Inspection and palpation of appropriate lymph nodes
    • Inspection for TB chest scars and prior chest surgery
  • Laboratory and other tests (Box 2)

It’s important to remember that the concept of primary care and prevention may be new to refugees from Haiti, where health services focus on treatment of acute conditions. As a result, newcomers may wait until they are in crisis, either physically or emotionally, before seeking care. Try and introduce the concept of preventive medicine, primary care clinicians, and your role as ‘gatekeeper.’ Reinforce prevention messages in the context of the importance of primary healthcare, such as immunizations and early and periodic screening for children and check-ups for adults.

Jill Shuman, MS, ELS
Published on June 22, 2010


References

  1. World Health Organization. Public Health Risk Assessment and Interventions: Earthquake: Haiti January 2010. Geneva, Switzerland, WHO.
  2. World Health Organization. Haiti: Mortality Country Fact Sheet 2006. Geneva, Switzerland, WHO.
  3. World Health Organization. Haiti Earthquake Health Response. 16 January 2010. Geneva, Switzerland, WHO.
  4. UNAIDS, World Health Organization. AIDS Epidemic Update 2009. Geneva, Switzerland, UNAIDS.
  5. Champetier de Ribes G, Fline M, Desormeaux AM, et al. Intestinal helminthiasis in school children in Haiti. Bull Soc Pathol Exot. 2005;98(2):127-132.
  6. Mental health advocacy for health professionals providing care for survivors of the 2010 Haitian earthquake. Centers for Disease Control and Prevention Web site. http://emergency.cdc.gov/disasters/earthquakes/mentalhealth_usdocs.asp. Updated March 2, 2010. Accessed June 3, 2010.