The cholera epidemic has now killed nearly 7,000 people and sickened almost half a million.

The social media study, part of a special Haiti-themed issue of the American Journal of Tropical Medicine and Hygiene, is characterized in a news release as “the first to demonstrate the use of data from “informal” media sources in monitoring an outbreak of a neglected tropical disease in a resource-limited setting,” and it demonstrates that “these sources can yield reliable decision-making data during deadly disease outbreaks almost in real-time, often far earlier than traditional surveillance methods that include surveys of hospitals and health clinics…”

The release quotes Rumi Chunara, Ph.D, of the Informatics Program at Children’s Hospital Boston, Research Fellow at Harvard Medical School, and the lead author of the study:

“When we analyzed news and Twitter feeds from the early days of the epidemic in 2010, we found they could be mined for valuable information on the cholera outbreak that was available up to two weeks ahead of surveillance reports issued by the government health ministry. The techniques we employed eventually could be used around the world as an affordable and efficient way to quickly detect the onset of an epidemic and then intervene with such things as vaccines and antibiotics…”

The data-collection in Haiti relied in part on a tool called “HealthMap” — which, by the way we at CommonHealth use to track outbreaks in Massachusetts — developed by Children’s Hospital to offer “real-time surveillance of emerging public health threats.”

Again, from the release:

Chunara and her colleagues used HealthMap to automatically capture any coverage or mentions of cholera from a variety of information sources—including news media, blogs, and discussion groups—that occurred in the first 100 days of the outbreak, from October 20, 2010 to January 28, 2011. The search included information sources from eight languages. In addition, the investigators probed Twitter posts from the same time period for any mentions of cholera.

Overall, the researchers amassed 4697 distinct reports via HealthMap and 188,819 Tweets. They found that in general, they could make an assessment of disease activity using these “informal” sources, including a calculation of the outbreak “reproductive number” which indicates how an outbreak is progressing. At times, the estimate from “informal” sources very closely matched estimates made using case reports released by official sources, but the advantage, they said, is that the data derived from the informal sources is available almost instantly.

Other related articles include:

–A report by Dr. Louise Ivers, of the Boston-based aid group Partners in Health, that identifies what researchers believe to be the “first” case of cholera in Haiti in 2010, a 28-year-old man from the town of Mirebalais with “a history of severe, untreated psychiatric illness.” Here’s Don McNeil’s coverage in The New York Times.

–A commentary by Dr. Paul Farmer, a co-founder of Partners in Health, on cholera, health equity and the future of tropical medicine.

Yesterday, Dr. Paul Farmer, co-founder of the group that has been working in Haiti for 25 years, spoke to reporters about the need to greatly intensify efforts to stop the epidemic, and mount a more comprehensive response, including vaccinating about 100,000 Haitians with a cholera vaccine that is “safe, proven, effective.”

(The cholera vaccine, never before used in Haiti, will be rolled out beginning in January, PIH says.)

Here’s a bit of what Farmer said on the call (transcribed by PIH) which you can listen to here.

On the Need for a More Integrated Approach:

“What we’re calling for, a year into the epidemic, is a prompt integration of these prevention and care and treatment measures, including: chlorinated water at the household or village level, hand washing and hygiene measures, building up systems that haven’t previously had them, improved case-finding, treating with oral rehydration salts and finally integration of oral cholera vaccine.”

On Stopping the Water Insecurity:

“Some years ago, PIH and many sister organizations began talking about the right to water. We did so because those of us who are clinicians, we can sit in our clinics and work in our hospitals and wait for people to come in sick with complications of water-borne diseases, or we can work with public authorities and appropriate NGO partners and others to build real water security in Haiti. We’ve been sounding that drum for some years now.”

On AID Agencies Are Leaving Haiti:

“There’s been this steady erosion of support, people coming in and leaving, it’s been ADD of humanitarian work, it’s just so short term. But we’re not there for the short term, our partners are Haitian, we work with the Ministry of Health, our organization is really fundamentally a Haitian organization. And we, unable to retreat to some other activity or some other place in the world, are now probably putting in a half million dollars a month into cholera.”

On the Increased Production of Cholera Vaccine:

“This entire debate should sound familiar… [because there were] the same discussions around HIV. The failure of imagination regarding price and this fetishized cost — that it had to cost $10,000 per patient per year [for HIV], which was absurd at the time, because it’s not as if these drugs or the vaccines were made out of platinum… they could easily be manufactured, and the same plunge in prices with the increased demand, we expect to see that with cholera vaccine, and that of course will help us to have a global vaccine stock pile”

Today, the renowned infectious disease doctor and passionate promoter of decent health care for the poor as well as the affluent, Paul Farmer and his colleagues at the nonprofit Partners In Health write in The Lancet that it’s time to get more aggressive in thinking about how to tackle Haiti’s escalating cholera outbreak.

In a nutshell, their five “complementary interventions to slow cholera,” are:

1. Identify and treat everyone with symptoms.
In a news conference today Farmer said there must be “active case finding,” using community health workers to help. “We can’t just wait for people to show up.”

2. Treat the sick with antibiotics and make the oral cholera vaccine available. (The logistics of getting the vaccine to those who need it is explored on NPR today.) “Rehydration without antibiotics is not a good idea,” Farmer said. “We’re arguing for anitbiotics for all comers.”

Farmer said there is resistance from the public health community on this aggressive approach to treatment. “We are seeing resistance,” Farmer said. “I’m not going to be arch about it, the resistance is not coming from patients and their families, it never does. There’s great doubt around logistics and cost. In a battlefield situation, what do you do first?”

Still, he says, there is vaccine available: “Based on our discussions with experts, there are potentially 2 million doses of the cholera vaccine available. In the face of a regional, long-standing epidemic, it does not seem too much to ask to start ramping up that effort to make available significantly more doses of vaccines. I would have expected more engagement on some of these tough logistic questions – how do we have the vaccine, how do we distribute it, make it more available, etc.”

3. Remedy Haiti’s problem with “water security” (i.e. — not having enough clean water) and improve sanitation

4. Make sure all efforts to deal with specific diseases (HIV/AIDS, cholera) include a focus on strengthening the country’s overall health care system, particularly primary care

5. Raise the bar on health care goals in Haiti. “No cholera epidemic is local for long,” they write. “The goals of responding to cholera in Haiti should look the same as the goals of responding to cholera in the Dominican Republic or Florida, to name two settings already touched by what is widely termed the Haitian epidemic.”

Farmer noted: “You don’t make one standard for poor countries, a different one for middle income countries and another one for affluent countries.”

“Although cholera had not been documented in Haiti for many decades,” Farmer and his colleagues write in the Lancet, “it has long been the most feared waterborne disease. Health-care providers working in informal settlements and refugee camps, both especially vulnerable to waterborne diseases, know that cholera’s profuse secretory diarrhoea can shrivel a healthy adult in less than 6 h. Case-fatality rates of untreated severe cholera can reach 50%, while most agree that aggressive case management can drop this figure to under 1%.”

You can listen to the entire news conference here.

Earlier today, Partners In Health’s Chief of Mission in Haiti Dr. Louise Ivers spoke to reporters on the status of the ongoing outbreak and PIH’s response. She said that the situation has taken a dramatic turn for the worse, with clear signs that the outbreak has spread to the crowded slums and settlement camps in Port-au-Prince. According to the latest report from the Haitian Ministry of Public Health and Population, a total of 12,303 people have been hospitalized and 796 have died since the outbreak began.

The number of new cholera cases and the death toll have both risen sharply in recent days. Roughly 1,000 new cases have been reported each day this week. The disease has been confirmed among nearly 200 people in Port-au-Prince, and there is great concern that the disease will spread rapidly among more than a million people who have been living in overcrowded settlement camps with limited access to clean water and sanitation since the January earthquake. More than 700 people have died and more than 11,000 have fallen ill since the epidemic first began in October.

PIH has seen dozens of cases in Parc Jean-Marie Vincent, the largest of the four settlement camps where we work in Port-au-Prince. Our teams are carrying out intensive education and prevention campaigns with camp residents and have set up a separate Cholera Treatment Unit (CTU) to provide care for patients. Outside the capital, PIH is rapidly strengthening cholera treatment capacity at all of our sites, as the number of new cases is increasing in the Artibonite and Central Plateau.

Other highlights of recent updates from PIH staff in Haiti include:

• In Port-au-Prince, we are seeing a steady stream of cases with classic clinical symptoms of cholera. Of the first 32 patients seen at the CTU in Parc Jean-Marie Vincent, many had come from outside the camp. PIH is directing medical operations at the CTU. The British Red Cross is taking responsibility for water and sanitation.

• In the Central Plateau, a Cholera Treatment Center has been established in Mirebalais and is being operated jointly by the Haitian Ministry of Public Health and Population (MSPP), Partners In Health, and a Cuban medical team, with support from Medishare and J/P HRO (Jenkins Penn Haitian Relief Organization.)

• In the Artibonite Valley, an increasing number of cases is being reported from communities in the Upper Artibonite, outside the area around St.-Marc where the outbreak began in October. PIH operates the hospital in St.-Marc and two other facilities in the Lower Artibonite in partnership with the MSPP.

Running a hospital: I'm sorry, Doctor Famous is busy Beth Israel Deaconess Medical Center CEO Paul Levy writes: “What happens when a referring doctor insists that "Doctor Famous" see his or her patient, even when other physicians on the staff can do the job just as well? In Lean terms, waste is introduced into the system. As diagnosed below: The minute an additional seemingly unnecessary step is added to the flow it adds a huge delay.” (Running A Hospital)

Cholera Is Found in Port-au-Prince, Haiti – NYTimes.com “Medical officials say they believe that there are at least 73 cases here in the capital and, based on outbreaks in other countries, they fear that cholera may become a way of life that could afflict as many as 270,000 people over the next several years.” (The New York Times)

Rick Perry Calls On Mitt Romney To 'Repudiate' His Health Care Plan (VIDEO) “PERRY: I think it's a problem to go — if he were to stand up and say "You know what, this was a program that didn't work, and I wish I hadn't tried it" — I think that would help him substantially. But the fact is: they are so similar that it is going to be a major anchor unless he stands up and repudiates that approach.” (Huffington Post)

At PIH’s medical facilities, she said, there has been, on average, a steady population of 400 patients a day requiring hospitalization. But, she added, “the number (of patients) has been about the same for the past few days. “There hasn’t been a dramatic increase or decrease,” she said, and the organization is “seeing slightly less severe cases; more people are going to hospital for services when they are more ambulatory.”

She said PIH is working with community health workers, the Haitian Ministry of Health and Doctors Without Borders to conduct a widespread community education and mobilization effort to get the message out about hand-washing and using clean water and toilet facilities. The groups are also distributing water purification packets and oral rehydration salts. But with “no plan to truck in clean water,” there is still the potential for the epidemic to worsen, she said.

She said the Ministry of Health has a three-part plan to deal with sick patients. It will:

– Set up a post where people have have quick, easy access to oral hydration solution
–Establish a center for intravenous hydration
–Send patients with more severe diarrea and dehydration symptoms to treatment centers

When asked what the chances are that the epidemic could hit Port-au-Prince and spiral out of control, Dr. Ivers said it is still possible that the epidemic could be contained. “I don’t think it’s inevitable there will be a more widespread outbreak in the capital,” she said. “But I think it is inevitable there will be more cases.”

Still, with so many transient families living in the densely packed camps, with limited access to soap, clean water and proper toilets, at this point, public health officials tell NPR, they are preparing for the worst.

CommonHealth will post an update following the conference call this afternoon.

PIH reports: “As of Sunday more than 3,000 cases and over 250 deaths had been reported. Hôpital Saint Nicolas in St. Marc, which PIH operates in partnership with the Haitian Ministry of Health hospitalized 300 patients on Sunday. Every day hospital patient management improves. PIH and its partners have rushed clinical reinforcements and supplies to the region and have mounted a massive community education and mobilization campaign. Community health workers are fanning out throughout the area to distribute oral rehydration salts and soap and to warn people of the need to drink only clean or purified water and wash their hands frequently—the two keys to preventing further spread of the disease.”

Haiti hasn’t had a documented case of cholera since the 1960s but the chaotic conditions following January’s earthquake have left the tragically fragile country even more vulnerable. The Boston-based aid group, Partners In Health, with its long history helping to build up Haiti’s medical infrastructure, is now trying to grapple with the latest outbreak. PIH’s Chief Medical Officer, Joia Mukherjee, explains what’s going on:

An outbreak of cholera has been documented in the area surrounding the lower Artibonite region of Haiti by the staff of PIH’s sister organization Zanmi Lasante (ZL,) working with the Haitian Ministry of Health and other partners. As of Friday morning October 22, 2010; there have been more than 2000 cases of acute watery diarrhea and 160 deaths reported at the facilities in St. Marc, Petite Riviere d’Artibonite, Mirebalais, Lascahobas, and Verretes; the death rate since Tuesday night, October 19, 2010, has been approximately 10 percent.

NPR reports that officials are worried that the outbreak might spread to the tens of thousands of people living in unsanitary conditions in camps around the capital.