We identified important differences in the characteristics and the spectrum of disease among ill returned travelers from post-earthquake Haiti. In addition, we found that a significant proportion of disease among these travelers was caused by conditions that did not vary significantly across the two periods examined. This finding was especially true for diseases that caused the most severe illness—specifically, dengue and P. falciparum malaria.
Our finding that more than 75% of post-earthquake patients were IAWs, up from nearly 40% pre-earthquake, is not surprising. In Haiti, nongovernmental organizations (NGOs) have long delivered a substantial proportion of the healthcare. According to World Health Organization estimates, approximately 250 NGOs were operating in the health sector in Haiti just before the earthquake.8
Shortly after January 12, 2010, the Haitian government reported that more than 400 registered, and an unknown number of unregistered health sector NGOs were delivering services.2,20
Although GeoSentinel does not differentiate the various specific activities within the international assistance purpose of travel category (aid work/mission work/research/volunteer), a substantial proportion of these IAWs likely contributed directly to the relief and recovery effort.
We cannot fully explain the observed decrease in the proportion of ill travelers from Canada. A study looking at the quality and accuracy of information received by international travelers from North America found that Canadians received more accurate pre-travel preparation than travelers from the United States, although response rates were low, especially from United States clinics.21
It is possible that Canadian travelers to Haiti were better prepared for their trips and acquired fewer travel-related diseases than travelers from the United States. We cannot, however, postulate a reason why the quality of preparation would have varied in a way that would have led to differentially less travel-related disease among Canadians post-earthquake. Other potential explanations for the observation are that there may have been proportionately fewer travelers from Canada post-earthquake or that a greater proportion of ill Canadian travelers presented to non-GeoSentinel clinics for evaluation during the post-earthquake period.
There are at least three possible explanations for the increase in the proportion of patients who received pre-travel medical advice after the earthquake. First, a greater proportion of NGOs working in Haiti post-earthquake might have required their workers and volunteers to be medically prepared. Second, in the weeks and months after the earthquake, Haiti received a great amount of media attention, attention that was later fueled by a cholera outbreak first reported in October of 201022
and flooding caused by Tropical Storm Tomas in early November of 2010.23
This attention could have inspired caution among travelers to Haiti and prompted them to seek medical advice in preparation for their trip. Third, a heightened awareness on the part of GeoSentinel physicians of the events that occurred in Haiti could have led them to more carefully identify and document an ill patient's pre-travel medical preparation after January 12, 2010. Nevertheless, it is concerning that greater than one-quarter of ill post-earthquake travelers in our study went to Haiti without the benefit of having received pre-travel medical advice. Although at least a portion of these persons were among those people who deployed rapidly, with little or no time for medical preparation, these data serve as a reminder of the importance of efforts to increase the number of persons receiving a pre-travel medical evaluation, an effort that could help reduce travel-related morbidity among future travelers to Haiti and other disaster locations.
Dengue and P. falciparum
malaria were important contributors of morbidity and severe disease both before and after the earthquake. Together, patients with these two conditions accounted for 15% of the total diagnoses and 61% of the severe disease requiring hospitalization. Most patients with P. falciparum
malaria had no documented pre-travel counseling and were, therefore, unlikely to be taking malaria prophylaxis. Because malaria in Haiti is chloroquine-sensitive, any of the currently recommended malaria chemoprophylactic agents would have been appropriate, if taken correctly.24
These data correspond with a recent report of malaria in Haiti in which all cases of malaria among aid workers occurred in persons who had not taken malaria prophylaxis, and no cases were identified among 52 aid workers who took 346 person-weeks of chloroquine prophylaxis.16
The importance of providing all travelers to Haiti with accurate information on methods for mosquito bite avoidance and P. falciparum
malaria prophylaxis cannot be overemphasized. Mosquito bite avoidance counseling should be provided and is particularly relevant to the prevention of dengue virus infection, because there is no vaccine or chemoprophylaxis regimen. However, preventing dengue might not always be given the focus needed during pre-travel counseling. In a recent investigation of an outbreak of dengue among a group of missionaries returned from Haiti, 88% indicated that they had received pre-travel medical advice during a healthcare appointment; however, fewer than one-third knew about potential dengue virus exposure in Haiti, and only one-quarter used mosquito bite avoidance measures.17
Acute diarrhea, as expected, was common.18
We identified no change in the proportion of these diagnoses after the earthquake, despite the massive destruction of Haiti's basic infrastructure. Travelers or their host agencies and organizations may have taken extra measures to avoid the transmission of diarrheal diseases or had widely available self-treatment medications because of their knowledge of the post-earthquake physical environment in Haiti, and these measures may have been effective. Despite the cholera outbreak that began in Haiti during the fall of 2010,22
no cases were reported by GeoSentinel network providers, although foreign national travelers to Haiti are known to have been infected.15
For victims of a natural disaster, an increased risk of psychopathology may persist for decades.25,26
Concomitantly, psychological issues among disaster first responders and aid workers are not uncommon and can include post-traumatic stress disorder, major depression, substance abuse, anxiety, sleep disturbances, and others.27–31
We identified an increase in the proportion of post-earthquake travelers who were diagnosed with psychological disorders and a significant increase in work-related stress. Nevertheless, we believe the magnitude of psychological disorders among our study population is likely an underestimate. Recognizing that most current GeoSentinel Global Surveillance Network sites do not formally screen returned travelers for psychopathology and that, if such conditions are suspected, these patients would likely be referred elsewhere for definitive diagnosis and treatment, at least some GeoSentinel patients with travel-related psychopathology may go undiagnosed or uncounted in the database. Greater awareness among health professionals of the potential for psychological issues among travelers to disaster areas could lead to better identification of those people who might benefit from specialized psychological health services and support. Finally, we recommend that persons heading to disaster areas be provided with information about the psychological challenges that they may face and effective strategies to reduce stress and build resilience. These travelers should be made aware of normal and abnormal responses to stress and know when and how to seek additional help.
Natural disasters, such as earthquakes, have been linked to increases in respiratory complaints and disease.32,33
Such observed increases can be caused by the direct effects on the lung from exposure to amplified levels of airway contaminants from fires and building collapse or indirectly because of exposure to pathogens in situations of overcrowding and a disrupted basic infrastructure and healthcare delivery system. We identified an increase in respiratory illnesses specifically attributable to an increase in URI diagnoses among a group of early earthquake responders that traveled and/or worked together in Haiti. However, we found no increase in other respiratory conditions that might have been expected had there been widespread exposure to airborne contaminants and no evidence of a broader outbreak of communicable respiratory disease, but the numbers were small. Clinicians should emphasize good hand and general hygiene practices among travelers to Haiti, especially those people likely to be in an environment where clean free-flowing water might be limited, to try to lessen the risk of transmitting and acquiring communicable diseases. In the acute disaster setting or situations where dust and other airway contaminants might be present, disaster responders should have access to and training in the use of proper fitting National Institute of Occupational Safety and Health-certified respirators (e.g., N-95).34,35
These data have several limitations. First, GeoSentinel data are not population-based and therefore, cannot be used to calculate disease rates or estimate risks among ill returned travelers from Haiti. Second, most GeoSentinel sites collect data on persons seeking specialty care for suspected travel-related conditions, and therefore, the data are not representative of all ill returned travelers from Haiti. Many returned travelers seek care in primary care settings and are not captured by the GeoSentinel network. Additionally, some very ill patients who seek treatment at emergency departments and some patients receiving inpatient care might also not be captured. Third, diseases with short incubations, such as dengue and acute infectious diarrheas, may be underrepresented in our study. Such conditions could cause symptoms in a large proportion of travelers while still in Haiti and may not have been captured by GeoSentinel. Fourth, our analysis was limited by the fact that relatively few ill travelers with exposure in Haiti were seen at GeoSentinel sites during the specified study period. With larger numbers of ill travelers, additional differences and patterns between the post- and pre-earthquake periods may have emerged.
The data presented in this report show that the characteristics of travelers to a nation afflicted by a natural disaster and the health risks that they may face can differ greatly from travelers to non-disaster zones. These results highlight the importance of travelers receiving destination- and disaster-specific pre-travel counseling; correspondingly, clinicians should provide destination- and disaster-specific post-travel evaluations and medical management of ill persons returning from such locations.