Range Sheep

¶ I wrote this about four years ago now, and had forgotten about it until recently. I was asked at the time how a biosurveillance organization/entity could improve information collection and increase the relevance of reporting for the consumer base. In analyzing the various biosurveillance programs in operation at the time, I realized a key element missing (or in some cases, not adequately developed) was a concerted effort at targeting (both internal and external). I think it is still pertinent today, not only in the biosurveillance arena, but in many operational realms globally. Therefore, I thought I would put it out there.

Technology Enabled Targeting and Analysis

¶ What is targeting?  The term has been used across multiple disciplines (e.g. military, marketing, environmental conservation, sales, etc.) to define various approaches to identify, locate, and gain access to information, locations, or persons of value to a particular discipline.  In these instances, the targeting methodology utilized is generally highly specialized toward the particular industry, customer base, or mission, and is outwardly focused and product-oriented.  A representative exemplar of this targeting approach is illustrated through the following definition: ‘the process of selecting targets and matching the appropriate response or message to them, taking into account the operational requirements, capabilities, and resources of the customer’.  While this has become the traditional conceptualization of ‘targeting’, we opted to develop and operationalize a more holistic methodology to targeting for use by biosurveillance organizations, which encompasses both externally- and internally-focused analyses of organizational process, decision modeling, requirements generation, source identification, data assessment, and taxonomy development.

¶ The key to effective targeting is to know one’s own processes, capabilities, resources, and weaknesses while simultaneously analyzing and understanding these same qualities in the organizations that will be using the information (customers); this is a time-consuming and difficult task, however, it significantly increases the relevance and timeliness of reporting.  In general, most individuals have an intuitive understanding of their specific job function and how their tasks fit into the organization’s overall mission, however, very few have truly conducted a holistic analysis of the organization, or even their division within the particular entity.  At the core of our holistic approach is the belief that every organization is like a living organism; knowing individual properties or processes of the organism is not sufficient, one must understand how they interact with one another to ensure optimal functioning of the whole.

Source: vethno

¶ The concept of Technology Enabled Targeting and Analysis (TETA) is not a new one, although, in recent years the trend has been shifting from the use of technology to enable the analyst to seeking out technology to replace human analytic functions.  In our approach, we posit that the human element is critical to development of a robust, effective, and near real-time biosurveillance monitoring capability and that technology should be selected which enhances the core functionality of the human analysts while simultaneously automating functions that are generally time consuming when conducted manually (e.g. data processing and input).  The core function of a biosurveillance professional is analysis of reporting, therefore, if one spends the majority of time searching for relevant sources and reports and subsequently processing raw data, there remains little time for true analysis of developing events.  In the TETA approach, we seek to alter the time constraints on the analysts through incorporation of technology that assists with these manually intensive tasks, thereby providing the analyst more opportunity to conduct his analysis and other critical functions; overall, the investment in this type of technology saves both time and money and allows the analytical requirements to be conducted by fewer, highly talented individuals.  So, one may ask why this is considered a relevant aspect of targeting?  In the holistic targeting approach, we regard both human and technological factors as key components in a process-oriented analysis.  It should again be noted that every aspect of holistic targeting is applied to internal processes of the biosurveillance entity, its external interactions, and the associated internal processes of customer organizations.

Holistic Targeting

¶ As mentioned previously, in the biosurveillance context, holistic targeting is the analysis of all aspects of an organization’s internal operations coupled with similar, external analyses of customer-specific operational requirements, internal processes, decision-making, and independent data sources.  This integration of internal and external processes ensures the customer receives pertinent and timely reporting of biological events.  Ideally, this holistic method should be applied to the biosurveillance operation initially, then once its operations are optimized, should then be applied independently to its various customers.

¶ In general, targeting lies at the core of the biosurveillance reporting cycle, both driving initial collection as well as providing a mechanism for continued refinement of reporting, source acquisition and validation, and identification of gaps in reporting.  Further, it is a continually evolving process that provides critical infrastructure to the reporting cycle, yet is flexible enough to enable customer feedback and regular refinement of operations.  Therefore, as presented in the figure below, targeting provides direct input to collection efforts and dissemination of reporting, while simultaneously optimizing biosurveillance operations through refinement of collection methodology, analysis, and acquisition of customer feedback.

¶ The initial focus of the holistic targeting methodology is detailing the organization’s internal operational processes and decision-making structure.  This is captured through identifying individuals’ responsibilities within the organization and how they integrate into the organizational structure and operational capabilities of the unit.  Thereafter, successive iterations of this analysis at the section, division, and organizational level will fully identify how each element within the corporate ‘organism’ operates and interacts.  From this initial template, various scenarios can be constructed and presented to each entity within the organization to capture decision-making processes under varying conditions, internal stop-gaps and trigger points in reporting and response, and identification of individuals, units, or data sources that are critical to mission function of the organization.  As with all detailed targeting efforts, this step is time intensive and, in many cases, may take several iterations to truly capture the processes and decision model used by the organization.  There is a tendency for individuals to initially present what they see as the ideal situation instead of how the organization truly operates.  Therefore, it must be made clear up-front that the entire targeting approach is not a judgmental critique of the organization; instead, it is merely used to model how the organization operates in order to understand how to best integrate reporting, data sets, etc.  However, it is not uncommon (and from our perspective encouraged) for organizations to use this initial template to refine their operations.

¶ In addition to process and decision modeling, the next critical targeting focus is on specific topics of interest in biosurveillance and corresponding development of relevant taxonomies composed of indications and warnings (I&Ws) of biological events, based on social disruption, animal, human, and crop disease models.  Historic case studies relevant to human, animal, and crop disease must be identified and analyzed in-depth to determine corresponding indications and warnings.  This is a structured and time consuming endeavor, which is critical to continued targeting efforts, development of initial reporting requirements, and a key to successful biosurveillance monitoring.  Further, continued evaluation of indications and warnings from historic case studies allows ongoing refinement of reporting tailored to customer requirements.  This procedure is somewhat flexible however, and can be accomplished either in a fully manual method or enable through the use of technology.  Additionally, depending on operational requirements, manpower, and funding situation, taxonomy development can be done in a stepwise or measured manner in the short-, medium-, and long-term.  The biosurveillance organization uses customer reporting requirements and priorities to stage the development of the taxonomies; however, due to the evolving targeting process, case studies that focus on lower priority requirements should already be identified so that they can be investigated as resources become available.

¶ A clear picture of internal and external capabilities of the biosurveillance organization will soon emerge from the process/decision modeling and taxonomy creation.  This initial effort will ensure that subsequent steps in the targeting process are built on a solid foundation, where the organization fully understands its own methodology and requirements, as well as that of its initial customer base.  It should be highlighted once again how the targeting process is a dynamic and ever-evolving situation that provides continual feedback and refinement to a biosurveillance organization and its customers.  With these factors in mind, the organization can next develop a collection strategy and begin to identify potential sources of information.  This is again a fluid process where sources of biosurveillance information will be identified, evaluated, used for a time, and eventually dropped; sources have a lifecycle, whether they are media-based, technology-centric, sensors, imagery, human, etc.

¶ What drives source generation and why is this an ever-changing management challenge?  At the basest level, customer reporting requirements and the capabilities of the biosurveillance organization drive source generation; as these factors change over time, source types, locations, and reporting will correspondingly shift.  The biosurveillance entity should constantly strive to identify better sources of information with different collection capabilities; this broad-spectrum approach assists the organization with corroboration of reporting.  In other words, if there are local media reports from eastern Africa of Rift Valley Fever and corresponding reports of influenza-like illness and meningitis in humans, use of reporting from on-the-ground human sources and imagery showing flooding in the area will assist with corroborating the initial media report as well as provide a more robust picture of the ongoing event.  Such redundant mechanisms will also provide the organization an ability to obtain reporting across a broader range of locations and situations; if there is a gap in reporting from one type of source in a region, other monitoring methods can be used to at least obtain some measure of coverage in the region.

¶ Primary challenges in collection/source management are identification of reporting across several different regions and continually evaluating sources to identify gaps in that reporting.  Source bias can also come into effect and significantly alter reporting quality, which is why we advocate TETA; technology cannot identify, monitor, and correct for such bias, but humans, enabled by technology, are quite effective.  For instance, media sources will, in many cases, have a trend or bias in reporting depending on funding source, political agenda, etc., which must be identified, monitored, and compared to other sources by an analyst over time.  Building a solid and reliable reporting base takes time and effort, however, if good, methodical targeting of sources is conducted base upon reporting requirements, the time invested in this approach will provide a much more robust reporting capability and broader reporting coverage.

¶ The holistic targeting approach can be thought of as a circular feedback loop where initial targeting efforts drive collection, analysis, and dissemination, all of which feed back into the targeting process to continually refine the biosurveillance organization’s internal and external operational processes.  Technology can enhance this process by providing the analysts various time-saving, information processing, and visualization tools that not only add to the robustness of analysis and reporting, but also provide for an enhanced capability to identify reporting gaps, trends in reporting, and cross-indexing of sourcing to specific indications and warnings.  With suitable enabling technology, a developing biological event can now be more robustly analyzed across socio-economic, spatial, and temporal factors in near real-time.  A useful analogy can be made between TETA and geospatial visualization technology and spatial statistics; an analyst may not be able to identify clusters or clustering of disease from raw data, however, with geospatial software tools, such identification becomes quickly and readily available.  Therefore, the taxonomies developed for animal, human, and crop disease, coupled with customer requirements, drive source identification and collection management.  In turn, the information obtained from the various sources drives overall analysis, refinement of collection and requirements, with the overall goal of increased timeliness, validity, and specificity of reporting.

¶ Holistic targeting provides a robust infrastructure and methodological approach to development of a near real-time, reliable biosurveillance capability.  The previous description of TETA is meant provide a general overview of the methodology and is not meant to provide a detailed process-map of the technique.  Each organization is going to be different in its approach depending on a multitude of factors associated with its individual capabilities, customer base, requirements, etc.  However, a concerted and holistic targeting approach benefits any organization, be it a biosurveillance entity, local Department of Public Health, Agriculture, Emergency Response, or even a separate commercial entity.  In the biosurveillance community, holistic targeting is critical to mission success and ensures broad applicability of the reporting to a variety of users.

Source: vethno

¶ After the Haitian earthquake, I published several posts regarding agricultural surveillance, as well as surveillance of human disease using open source technology. Later, I was contacted by a consortium to submit some additional information for a proposal to obtain funding to continue to build out disease and infrastructure surveillance mechanisms in the country. I didn’t hear anything more from them, so I thought it would be interesting to publish a portion of my submission. It’s quite general, as I did not want to provide additional details at the time. Additionally, some of it is information already provided on this site. In any event, I ran across this the other day and I thought it might be interesting to put out there.

Agricultural Surveillance in Haiti:

¶ With over two thirds of the Haitian population engaged or reliant upon agriculture, support to this sector is critical for both the near-term and long-term health of the country and it’s people. Interventions and support must take a truly ‘One Health’ approach, where human, animal, crop and environmental health are all included in a holistic strategy for recovery. Critical needs exist in human disease surveillance, particularly in the Internally Displaced Persons (IDP) camps, but this need is also present in rural areas, largely untouched by international response mechanisms.

¶ Over 500,000 people fled the urban centers for rural regions following the earthquake, and even though some might have returned in the interim, many still remain in rural areas, thereby creating a variety of additional burdens on an already overtaxed system. Smallholder farms are the mainstay for much of the Haitian population, acting to not only feed individual families, but also to drive a portion of the economy that is important to the overall health of the nation. As early as 2009, farmers’ groups were engaged in protests at the national level, lobbying the government to focus on developing the country’s neglected agricultural sector in an effort to avert famine and decrease Haiti’s dependence on foreign food imports. Prior to the earthquake, Haiti imported 80% of its food, and now, some rural areas have experienced a population growth due to urban migrants that has doubled pre-quake numbers. This silent population growth has created a situation, not currently being addressed by the international community that could quickly lead to additional food insecurity, disease, and further degradation of the Haitian economy.

¶ These effects will carry on in the long-term, as crop and livestock production take time to reconstitute. Livestock are already nutritionally stressed at the end of the dry season, when forage is at its lowest quality and availability. With the arrival of the wet season, these stressed animals are more susceptible to parasites, infectious disease, and decreased reproductive capacity; thereby creating long-term implications to the overall production cycle. The sudden increases in human population act to form additional burdens on the system, since production capacity prior to the earthquake barely met individual family nutritional and monetary needs.

Source: vethno

Internal Migration and Impact on Rural Households:

The following is a map that combines information on agricultural regions in Haiti (via USAID Famine Early Warning System Network) to show food insecurity areas, as well as population displacement densities following the earthquake (via the UNOffice for the Coordination of Humanitarian Affairs). The size of the circles represents the relative proportions of total population migration. Notice the correlation of population movements with traditional agricultural areas. For instance, immediately following the earthquake, an estimated 62,500 Haitians relocated to the Artibonite Valley, a region that has historically received long-term foreign agriculture assistance. Due to the large population migration, it’s previous history as a site for agricultural studies and support, and it’s proximity to Port-au-Prince, this region might be one region to begin obtaining agricultural baseline information and assess the requirements of the farmers and livestock populations.

Livestock in Haiti:

¶ Haiti is comprised mostly of small, individual family farms that grow both crops and livestock for personal consumption. Excess livestock are sold to slaughter to generate additional income. Horses and donkeys are used for transportation and as draft/pack animals to carry goods.

¶ Unlike the danger of emerging human diseases directly resulting from disrupted infrastructure and living conditions following the earthquake in Haiti, the concern regarding livestock disease presents a different challenge. Haitian livestock production consists mainly of small-holder farms that grow crops and livestock primarily for their own consumption. Excess livestock are sold at market or used as a ‘bank account’ of sorts for payment and trade. Therefore, a major hurdle is obtaining baseline information about the type of livestock, the number of animals, their condition, and various production challenges faced by rural families in the different geographical regions in Haiti. Prior to the earthquake, livestock were already stressed by forage/feed limitations, parasite loads, vitamin and mineral deficiencies or excess, and lack of farmer education regarding production methods. Additionally, livestock feed sources are usually at their lowest point around February due to the dry season and crop harvests, thereby making the timing of the earthquake even more of a strain on an already stressed system. The potential destruction of animal shelters and neglect of normal production practices following the earthquake could present additional challenges and further decrease livestock growth, reproduction, and milk production. March and April begin the primary breeding season for goats and cattle in Haiti, therefore, additional stressors could cause detrimental effects upon this cycle’s kid and calf crop.

¶ Producer perspective might also not match with the true nature of disease risk in the livestock population. A previous study of livestock diseases and production methods describes how livestock owners were less likely to recognize production-related diseases as true problems; instead, catastrophic diseases like anthrax (‘Malcharbon’) were cited by Haitian farmers as the ‘most seen’ and ‘most serious’ of cattle diseases, even though the actual incidence is quite low. Parasitism (internal and external), feed deficiencies, and vitamin/mineral imbalances were observed to be the most serious production-related conditions; these were probably not as recognizable to producers, since they were chronically present for many years.

¶ Other disease concerns for the Haitian population include those affecting working animals and a variety of zoonotic diseases. Poor health of horses and donkeys translates directly to decreased productivity and livelihoods of their Haitian owners as they are relied upon to transport people, goods, water, etc. Zoonotic organisms like rabies, leptospirosis, tuberculosis, brucellosis, campylobacteriosis, escherichia coli, salmonella, and staphylococcus also pose significant risk to both animal and human populations – especially if milk is not pasteurized.

Environmental Implications:

¶ There is a wide-range of agricultural interventions that can be introduced to communities to improve livelihoods and increase incomes in rural Haiti. However, without concurrent environmental assessment and support, soil will continue to be of low quality for crop development and poor forage quality will keep livestock in a state of nutritional deficiency – affecting growth, disease prevalence and reproduction. Therefore, as an integral segment of any agricultural training and surveillance, environmental conditions in the specific location must also be considered and addressed. Cutting of trees for fuel and burning of vegetation have also led to derangements of macro and trace mineral content of the soil, thereby creating second and third order disruptions in the agricultural ecosystem whereby plants have deficiencies (or have high levels) of certain nutrients, which also affect the livestock that use the plant material for nutrition. An example of this is the high levels of phosphorus in the soil in certain regions, which is taken up by vegetation. This creates a derangement of mineral intake in livestock, contributing to a myriad of metabolic and reproductive problems. Environmental conditions set the stage for crop and animal health, which creates either opportunity or challenges for human public health, market conditions, and livelihood. Therefore, we consider environmental conditions to be instrumental in any long-term development in Haiti. While support to this arm might not be seen for some time, immediate interventions in crop and livestock production and health can be implemented in the interim, with consideration for long-term environmental support.

Source: vethno

Monitoring and Support:

¶ In parallel to the requirement to monitor for disease in the human population, measures must be put into place to collect information on the condition and disease burden in Haitian crops and livestock. Unlike it’s human counterpart however, agricultural surveillance must include broader components that incorporate production system indicators, market conditions, and environmental issues. Further, within this more holistic approach, there must be direct benefit to the local producer and individual household above and beyond the mere collection of information. Therefore, incorporated into this surveillance strategy are components that focus on training, business and production management, market value chains, continued access to information/outreach.

• Direct Assessment: Due to the nature of Haitian agriculture, obtaining baseline assessments in 2-3 locations is essential to correctly targeting critical training and surveillance components.
  • Production methods
  • Disease conditions
  • Animal and crop environmental carrying capacity
  • Food safety and consumer practices
  • Household conditions
  • Market value chains
  • Soil and forage considerations
  • Veterinary, animal health worker, and extension agent regional capacity
  • Governmental/NGO/Community organization presence and program focus

• Training: Focused on the individual producer and community-based animal health workers, leveraging existing farmer community groups
  • Production methods
  • Physical signs of disease and treatment options
    • visual aids to include pictures, video, and flow charts
    • production practices and treatment options
    • directly tied into surveillance system
  • Business practices, marketing, and integrated production management
  • Environmental impact and long-term sustainable production
  • Mobile and web-based surveillance reporting, information requests and production tracking

• Surveillance: Continued development of mobile and web-based capabilities already operational in the country, coupled with underlying disease and production-related indicators
  • SMS/MMS infrastructure
  • Standardized mobile and web-based forms for conducting assessments and surveillance
  • Capability to incorporate non-standardized (‘crowdsourced’) reporting
  • Use of an underlying taxonomy for physical signs of disease, production indicators, and market/household conditions
  • Ability to request addition information or provide feedback to the user base via both automated, taxonomy-based queries and situation-specific, human network interactions
  • Provide information compatible with local and international programs (e.g. community organizations, FEWSNET, LEGS, FAO, etc.)

• Facilitation and Information:
  • Maintain a central repository of information gathered from the system, accessible by cooperating entities and engaged population
  • Develop multi-format, informational resources for user-level training, agricultural production information, public health, and environmental methodology
  • Provide an open forum for entities engaged in agricultural, public health, and environmental programs, to facilitate coordination and sharing of information related to ongoing successes and challenges

I apologize for the long absence, but I’ve been concentrating on my veterinary curriculum and taking my board exam. Now that my board exam is done, I will start contributing again very soon. I will also be on a veterinary public health externship to Chile in January.

Source: Slopjop

¶ The aftermath effects of the earthquake continue in Haiti, even if other events seem to have supplanted the topic in the news.  The conditions in the Internally Displaced Person (IDP) camps continue to deteriorate and disease has now become a primary concern (and point of intervention) for the various members of the response networks.  There is an abundance of life-threatening diarrheal disease and a significant shortage of oral rehydration medications.  In particular, this places infants and children at increased risk.

¶ Additionally, the ‘silent population’ of Haiti (as I like to call them) are those individuals who previously fled the destruction of the urban centers to stay with family in more rural regions.  A previous post, “Dearth of Haitian Agricultural Baseline Information“, I wrote about this population and included a map of the areas which received the most migrants.  Recent reports from Haiti highlight the serious and continued degradation of the public health infrastructure, which appears to be straining, if not overwhelming, international medical responders.  If this is the case in areas with access to medical facilities, what is the disease burden and current status of the ‘silent population’ – those who migrated to rural areas?  Is there a potential for them to have carried infectious disease with them, after their short stay in post-quake urban areas?

¶ How can we assess, monitor and provide services to this, now inflated, rural population?  How do we identify the effects such a population growth has had on an already infrastructure-strained rural population?  What are the public health risks associated with degraded (or non-existent) food security measures, animal disease and zoonotic pathogens?  At what point are societal limitations, such as aversion to eating meat from a diseased animal, overcome by malnutrition and disease?  What are the risks to special groups, such as children and pregnant women, with such things as milk consumption and zoonotic disease exposure?  As discussed in the post, “A Framework for One Health Monitoring in Haiti“, the situation in the urban centers requires a timely and holistic approach to disease monitoring for development of targeted interventions.  With regard to the ‘Silent Population’, do we continue to ignore this gap (group) or institute a system that can not only assess the situation, but also provide information and direct assistance to more remote regions?

¶ A colleague, Jim Wilson MD, (Biosurveillance blog, twitter: @iceaxe5) is currently in Haiti conducting assessments of the international public health infrastructure, risk conditions for disease outbreaks, and in a ‘One Health’ mindset, has interviewed veterinary professionals about public health issues.  Below is an excerpt of an email Jim sent regarding conditions he has monitored in Haiti.  I have only posted his correspondence regarding veterinary public health topics – my response follows his comments.

¶ Jim’s Write-ups:

***Update for 11 March 2010***

My turn to be ill. Spent some quality time on a cot yesterday morning…

I met with Max Millien, the country’s Chief Veterinarian, to get his thoughts on the disease risk situation in an effort to calibrate our assessments.  In Haiti, there are an estimated 800k pigs, 700-800k cattle, and >2M goats- more than any other Caribbean country.  Thirty years ago Haiti exported meat, including rabbit meat, via the Haiti-America Meat Company.  But an American bought carpets at the market made with livestock hair and contracted inhalation anthrax- this brought the whole exportation market to a halt.

Max disagreed somewhat with [previous veterinarian], saying the anthrax vaccination levels, a yearly process in Haiti, now stand at much less than 40%.  Because of the recent focus on Teschovirus, they are behind on vaccination for classical swine fever.  Theft of livestock is a major problem in Haiti, particularly with livestock that migrate from Haiti to DR, where Dominicans will confiscate the animals- implication being any livestock disease in Haiti is likely to be found in DR as well.  Tagging was initiated for pigs because of the classical swine fever concern; tagging for cattle is about to begin.

Rabies is the top concern in regards to zoonotic disease in post-earthquake Haiti.  There were 29 fatalities recorded in the Americas in 2006, of which 11 were in Haiti.  Rabies is an underreported disease in Haiti.  In collaboration with other groups like ARCH, an overall vaccination coverage of >75% has been achieved in Port-au-Prince.  Dog tagging and tracking remain challenges. Mongoose and bats are the main reservoirs.

Gastrointestinal anthrax is the next concern.  Human and animal anthrax is underreported in Haiti, and it is believed the more serious cases go undetected in the rural areas because the animal or human dies before reaching care.  Attempted sale of anthrax-infected meat does occur occasionally at baseline. When asked if intestinal anthrax is a concern if the food security situation destabilizes, Max indicated yes.  The risk to Port-au-Prince is low because most meat is imported, and consumer demand is relatively low.  Poultry is in higher demand.  If access to food gets to the point of that seen in the mid-90s embargo, there will be cause for concern with a primary emphasis on rural followed by the urban areas. If gastrointestinal anthrax appears in Haiti, Max believes there will be diagnostic confusion because there is no laboratory diagnostic capability and physicians will not be pre-sensitized to look for it.

Jim’s Previous Update:

A field veterinarian who works closely with the Chief Veterinarian of Haiti and has been working Haiti for 26 years in both small and large animal medicine provided information on animal disease in Haiti.  Veterinary laboratories in Haiti are able to perform serologies for avian influenza and classical swine fever but no other viral diseases. They are also able to perform fecals and salmonella diagnostics.  According to the veterinarian, rabies and anthrax are the top disease concerns considering the current post-earthquake conditions and the intersection with human health.

Rabies

The veterinarian indicated that as a result of USDA- and NGO-funded vaccination, as well as other agricultural infrastructure initiatives in Haiti, more than 75% of cats and dogs in Port-au-Prince have been vaccinated for rabies.   He indicated there is still a high prevalence of rabies in Les Cayes. In addition, there are mongooses in Haiti that are an important reservoir for rabies virus in the wild.

Anthrax

The veterinarian discussed the potential risk of anthrax infection in humans and noted that in the past, outbreaks in livestock typically affect cattle, goats, or sheep and can be as large as 200 animals involved in an outbreak with no concurrent human infection. When anthrax is present in the human population, the bulk of recognized human infections are cutaneous, with a seasonal peak in May – June.   Given these observations, the veterinarian surmised that there could be some indigenous human immunity in Haiti.  However, he believes there may be a bias in recognized human clinical forms of anthrax in Haiti, because undeclared gastrointestinal, pulmonary, and meningitic cases may not survive long enough to reach a healthcare provider in rural areas.  Similarly, he believed livestock probably die too quickly to be processed in the field and brought to market, so to see diseased meat in the markets is uncommon.

Farmers occasionally try to sell anthrax-infected meat at markets; however, the local population avoids diseased meat and well understands the risks. That said, there is little food quality control and enforcement in Haiti.  The veterinarian considers gastroenteric anthrax of low potential risk in Port-au-Prince, but of increasing risk in the rural areas.  He lived in Haiti during the embargo of the mid 1990s and believes the current food security situation is nowhere near as bad as it was then.

Current national anthrax vaccination coverage in Haitian livestock was estimated to be no more than 40%; cattle, goats, and sheep are vaccinated but not pigs.

Known anthrax hot spots include Dessalines / Artibonite Valley, Anse Rouge, Limbe, and in the mountains around Les Cayes – there was a suspicious goat die-off there in the recent past.  They have rarely observed pigs to be infected; porcine infection is thought to be largely subclinical.

Other Entities of Interest

An abortion storm was recently reported among goats in a rural area outside of Leogane – the veterinarian suspects leptospirosis as the cause.  He is concerned about the human health risks due to the increasing problem of rat infestation. He has no laboratory capability to test for leptospirosis in animals, which he suspects is under-diagnosed as with human cases.  He has not heard of large outbreaks of leptospirosis in Haiti.

Low pathogenic / subclinical influenza A (H1N2) is also present in Haiti, first detected in Dominican Republic.

The veterinarian raised the recent concern regarding Teschovirus, which appeared abruptly and unexpectedly in Saint Marc last year. The origin of the virus is unknown, given the low volume of pig importation to Haiti.  As with Newcastle’s disease and classical swine fever, Teschovirus does not produce clinically significant illness in humans.

In our conversation last night, you also mentioned the myriad of livestock that are present in the camp as well as in the city.  Could this population face the same challenges when faced with maintaining their animals and being in close proximity under the current conditions?

Our assessment of the current animal health situation is they are getting containment of the rabies concern, and anthrax will not be a significant concern until the food security situation gets to the point where starvation is observed on a broader basis.

¶ My response:

Great update and thanks for including some of the vet public health aspect.  The abortion storm in goats has me a little concerned due to the number of zoonotic pathogens causing abortion in small ruminants – especially an abortion storm.  Without being able to necropsy the animals or have additional information as to during what term the abortions occurred, some other zoonotic diseases of concern (other than lepto) come to mind.

• Campylobacter fetus (and C. jejuni) – can cause abortion storms and is transmissible to humans via secretions (e.g. consumption of unpasteurized milk).

• Chlamydophila abortus (formerly Chlamydia psittaci) – also causes abortion storms and has caused infection in humans – there are case reports of pregnant women becoming infected and subsequently aborting

• Toxoplasma gondii - depending on the number of cats in the area, might be a concern for human transmission – also causes abortion storms

• Q Fever – can be transmitted via contact (and inhalation) – also causes abortions

As you can see, there are human public health risks associated with small ruminant abortions, from consumption of milk, to direct contact with fetal/gestational materials.  This is in addition to other standard risks with ruminants (in particular with a lack of sanitation) such as Cryptosporidium.  While there might be host immunity with the human population, due to the stressors of recent events, this could potential pose a risk.

One of my concerns on the veterinary public health side regarding disease surveillance, is the population of people who migrated from urban centers back to more rural areas to stay with family.  Did they bring disease with them if they were in the urban centers for some time prior to leaving?  With the added number of mouths to feed, will the local inhibition to eat contaminated meat and/or feed unpasteurized goat milk to children be degraded?  In a sense, without some sort of surveillance capability and an ability to target different populations for monitoring and intervention, will this be a ‘silent population’ of disease?

Source: Diegosaurius Rex

¶ For updated media reports on the Chile earthquake and it’s aftermath, see Newsography.

¶ On 22 May, 1960, the largest ever recorded earthquake (9.5) struck Chile between Conception and Valdivia.  At 03:34 local time (06:34 GMT) today another extremely strong earthquake measuring 8.8 on the Richter scale also struck near Maule, Chile (near Conception).  At the time of this writing, there are 122 deaths confirmed, as well as reports of extensive damage to some of the buildings/infrastructure.

¶ While this is a massive earthquake, much of the Chilean infrastructure has been built to withstand earthquakes.  Therefore, the massive destruction seen with the recent Haiti earthquake is unlikely – that quake was 7.0 on the Richter scale, approximately a 500 times less powerful but causing an estimated 200,000 deaths.  Regardless of the infrastructure hardening, however, there is likely to be large disruptions in services, as well as health- and welfare-related impacts…time will tell.

¶ There are many Tsunami warnings across the pacific and western coast of South and North America, reaching to Alaska.  While it is traditionally hard to estimate the size and strength of resulting Tsunamis, there is great concern for the potential consequences of a large Tsunami striking places like Hawaii, Samoa, Japan, etc.

Source: USGS

¶ There are reports of people using Twitter to contact friends and loved ones, and to send updates to various news sources.  However, much of the communications infrastructure near the epicenter appears to be disrupted.  You can follow the Chilean Red Cross on Twitter (@CruzRojainforma).  Google Translate can be used to translate the tweets here.  Trendsmap can be accessed here.

¶ Apparently, people are already beginning to use Twitter again in an attempt to contact family members as well.  The Ushahidi-Chile Media Monitoring Group has set up a Google Doc to collect media reports of the Chilean earthquake, which can be found here.

¶ Below is a map of the potential tsunami impact areas and magnitudes.

¶ On a related note, Colorado State University College of Veterinary Medicine and Biomedical Sciences has multiple faculty from Chile.  I am due to travel to the Valdivia region next January for veterinary public health purposes; therefore, I have a special interest in the people of this region.  I want to send out my hope that all of the families and friends of my colleagues are in good condition following this catastrophe.

Open Atrium for Pan American Health Organization – Rethinking Customized Development

Black Box - a device, system or object which can (and sometimes can only) be viewed solely in terms of its input, output and transfer characteristics without any knowledge of its internal workings (wikipedia).

¶ In my experience, having been an ‘end-user’ in government agencies (Federal as well as State and Local), private companies, and non-profit organizations, the aforementioned approaches lead to a ‘black box’ syndrome, where the contracting entity is then tied for the life of the product to the contractor originally hired to develop it.  Good for the contracted developer, but bad for retaining flexibility, scalability and cost-effectiveness.

¶ Enter Development Seed and their Drupal-based content management system, Open Atrium.  Last week, Development Seed released a customized version of Open Atrium for thePan American Health Organization‘s (PAHO) Emergency Operations Center.  This customized system incorporates a requirements-driven, PAHO-specific functionality on top of the baseline Open Atrium Foundation.  I’ve used Open Atrium for my own work and have had the opportunity to test out other Development Seed products, such as Managing News.  

Source: Development Seed

The data collection forms are used to assess damages to and the availability of services in health institutions in affected regions, report water quality, shelter availability, and health conditions on the ground, and give an overall situation report.  This feature is meant to be used in a distributed way, whereby a country’s Emergency Operations Center team installs a custom distribution of Open Atrium on a local office web server. The feature is then used to organize the local team’s data collection and make it easy to get the data out of the system and sent to the central regional Emergency Operations Center or to headquarters.

¶ From my perspective, the PAHO build represents an ever-increasing trend in technology development – one I think is long overdue.  Open source packages like Drupal are become more robust, with worldwide developer support and ever-increasing capabilities.  This allows for use of modular and easily customizable tools for a variety of functionalities.  No longer does an organization have to pay huge sums for an off the shelf product that doesn’t meet their specific requirements, or pay even more to have a system built from the ground up.  As the PAHO example shows, companies like Development Seed can build very customized products, based on Open Source systems, that meet the exact needs of an organization for a fraction of the price.  They can focus on the underlying methodology of the organization and build functionality to match.  Now, smaller organizations (to include a start-up or non-profit) can afford to get exactly what they need.  It is truly the blending of both product and platform – Open Atrium is the product foundation, while customization turns it’s capabilities into a true platform.

¶ It is now three weeks following the devastating earthquake in Haiti, with more than 150,000 estimated deaths, that number again in injuries, and 1.5 million Haitians displaced.  As we move forward past the initial response, public health and infrastructure disruption continue to grow as primary concerns (when I use the term ‘public health’ I generally mean the overall interaction of human, animal and crop health).  Housing conditions, post-trauma injuries, mental health, and infectious disease all rank high as human public health threats, while the agricultural infrastructure faces challenges associated with mass population migration, food security, infectious disease, and production-related dysfunction.  The condition of Haiti’s public health infrastructure was degraded before the earthquake, which will exacerbate the health and infrastructure challenges to come.

¶ There is an urgent need for increased and continuing public health monitoring throughout the country.  What mechanism will be used to track disease and public health infrastructure in the coming days and months?  How will international organizations, the Haitian government and relief agencies track and respond to the inevitable public health emergencies that are likely to crop up as we move forward in rebuilding Haitian infrastructure?  Non-traditional methodologies and technologies can play a significant role in monitoring and responding to such important infrastructure risks, it’s just a matter of deciding the best way forward since the tools are available.  Continuing to break through bureaucratic and organizational barriers is the key. 

¶ Urban centers such as Port-au-Prince, Jacmel, and Leogane have been the primary locations for public health response and intervention to date.  However, upwards of 500,000 Haitians have already relocated to more rural areas of the country following the earthquake.  This influx of population in rural areas risks straining infrastructure in those locations, to include increasing both human health risks and strain to agricultural systems.  As described in the previous post, Ag in the Aftermath: Dearth of Haitian Agricultural Baseline Information, due to the nature of the rural Haitian agriculture industry, there was a significant lack of socio-economic and animal demographic information prior to the earthquake.  Now, the population dynamics and societal infrastructure has been even more disrupted, thereby further confounding baseline information for human and animal populations throughout the country.  Population movements and societal disruption can have profound effects on disease transmission, food security, and infrastructure strain – the ability to monitor these populations and infrastructure components will become ever more important as relief efforts move from response to recovery.

¶ So, how would one go about collecting demographic data on human/animal populations, identifying disease outbreaks and other public health concerns, while also providing useful information back to the local Haitian population?  As this press release points out, the CDC plans to collect reporting from approximately 50 sentinel surveillance sites.  This system represents the ‘gold standard’ for haiti disease surveillance and public health response; however, due to the nature of the reporting mechanism and requirements for validation, it can tend to be somewhat slow.  Additionally, it tends to be associated with one-way communication (collection) and dependent upon local Haitian use of the sentinel sites’ services.

¶ Using a multi-tiered approach to these challenges provides the most cost-effective, timely, and overall comprehensive mechanism.  The CDC approach of high fidelity, validated and structured information on current disease, injuries, and treatments is one tier.  Couple this with less validated, but more mobile and dispersed collection mechanisms, which provide a broader reach, near real-time reporting, and inclusion of cultural components.  True, such less validated mechanisms might not provide a fully accurate picture of the specific disease situation, but it provides a tip-off to a potentially disruptive public health or agricultural event that might warrant more detailed follow-up.

¶ Let’s explore the integrated components included in such a system:

System Components:

• Tier 1: Validated, Structured

Established hospitals and treatment facilities, NGOs, and international organizations (e.g. Centers for Disease Control and Prevention‘s proposed surveillance mechanism) provide high fidelity, validated, and structured information on current disease, injuries, and treatments.  They are dependent on physical presence at sentinel sites, as well as collection and validation protocols that have the risk of being fairly slow, especially with increased workloads at the various sites.  The strength is that such a system provides detailed information that is generally validated by health care professionals, relief workers, etc.  In Haiti, initial presence of such sites focused on urban centers, leaving public health and agricultural infrastructure in rural areas without coverage.  Further, since many such mechanisms rely on professionals not native to the location, some loss of cultural context is expected.

• Tier 2: Unvalidated, Structured:

Using various lightweight technical means, demographic, public health, and agriculture reporting can be brought to the level of the local population in a distributed manner.  Systems such as EpiSurveyor, FrontlineSMS, Geochat, and Ushahidi, and Sahana have already been successfully implemented and validated in various public health and disaster response roles.  The integration methodology and application of such technology on the ground in Haiti is where the true value lies.

In Africa, mobile technology has been used successfully to report local market prices to agricultural producers, in order to provide them with near real-time pricing information used by the producers to determine the best market at which to sell their products.  A co-op of producers from a community hire mobile-enabled individuals, referred to locally as ‘market spies‘, to troll the various regional markets and return current prices to the co-op.  These market spies generally also come from the region in which they serve, thereby adding valuable local knowledge and cultural considerations to their reporting capacity.

The United Nations plans to hire up to 200,000 Haitians by March to assist with post-earthquake clean up and reconstruction efforts.  I would propose hiring Haitians from various locations throughout the country to report demographic, public health and agriculture information via mobile devices.  Basic training on the reporting format, physical signs, etc., would be provided to enhance easy processing and increase specificity of reporting.  Selection of literate individuals who potentially also have specific local/regional knowledge, specialized skill sets, etc., would also increase the fidelity of reporting.  As an example, EpiSurveyor allows a user to develop specific forms to conduct surveys from mobile devices.  As the surveys are conducted, it sends the results wirelessly back to the central server.  Individual public health and agricultural surveyors could have multiple, standardized forms on their mobile devices and report remotely from regions throughout Haiti.  The standardization of questionnaires would provide more validation to the reporting; however, this would not preclude the surveyors from sending free-form or minimally-formatted SMS messages back to the central aggregator.

• Tier 3: Unvalidated, Unstructured:

The least validated and most unstructured reporting tier would be collection of unstructured SMS reporting from the public at large.  The adoption of public reporting was exemplified by the response to the Ushahidi platform following the earthquake.  The Haitian public can use a SMS short code to send requests for emergency response assistance, food, and shelter, as well as to report searches for family members.  GeoChat, by InSTEDD, is also currently being used with a shortcode to coordinate efforts between citizens, NGOs, and various government agencies.  Providing the general population the ability to report disease conditions, agricultural requirements, etc., would provide an additional source of information, adding to the overall demographic and public health picture.  The limitation in current systems is enabling (and enacting) a conversation between the aid providers, government organizations, etc., and the Haitian people.  While much previous work has focused on receiving reports from the population, we now need to transition to more of a two-way information flow.  The question now becomes, are aid organizations and government entities willing and interested to engage in this sort of conversation with the Haitian citizenry?

¶ Adoption/Incentive: How would this system incentivize the local population to report information and cooperate with public health and infrastructure reconstruction efforts?  This is one of the biggest barriers to direct mobile reporting systems and is quite dependent upon the characteristics associated with the current situation, population and economic demographics, and cultural/societal practices.  In the case of Haiti, Tier 1 reporting is sustained through bureaucratic mandate of reporting requirements at sentinel sites and adopted/supported through buy-in by health and relief professionals staffing those locations.  Separately, Tier 2 collection incentivizes the surveyors to report by maintaining their employment and salary, providing basic levels of training, and through the selection process to hire individuals who are suitable and motivated.  Finally, Tier 3 reporting raises the most difficult challenges to system adoption and incentive to report.  As was observed with Ushadihi, emergency situations can quickly lead to adoption; however, on a non-emergency basis, the same motivation to use the Ushahidi platform will greatly decrease.  Therefore, providing information back to the user population, proper advertising of the system, and providing access to services quickly and easily could all be used as incentives – it’s just a matter of identifying the correct ones.  BarCamp-like community meetings could provide an interesting method to determining the key interests and needs of the potential user population, based on their own assessment, not those of an external source.

¶ Services and Information: Successful outcomes for all three surveillance tiers ultimately rely upon the provision of services and information to the Haitian population.  Whether these services and information are direct medical care, food distribution locations, shelter and employment programs, or market prices and livestock production assistance, depends upon the target population and local requirements for assistance.  There are many examples of mobile systems being used to both collect information and provide information back to populations.  An example of this is very well described by Grameen Foundation’s AppLab in Uganda:

Farmer’s Friend is an agricultural information service based on text messages. It was launched in June by MTN (Ugandas largest mobile network operator), Google and the Grameen Foundation’s “Application Laboratory”, or AppLab. The service accepts queries such as “rice aphids”,”tomato blight”or “how to plant bananas” and retrieves advice from a database. More complicated questions are forwarded to human experts. The query “pineapple disease” elicits the answer “Copper deficiency in pineapples leads to fruit rot. Cut affected fruit as soon as noticed and dispose of where they will not contaminate other fruits or burn.”

¶ In the end, the overall time and financial investment to implement such a system would be fairly minimal in relation to the benefit of receiving demographic, public health, and infrastructure information from across Haiti.  Each tier acts in concert (and complement) to the others, augmenting reporting while mitigating the particular weaknesses of each individual component.  The technology is already available, motivated people have shown a willingness to donate time and expertise (as seen with CrisisCommons), and the need for such information is critical.  The primary challenges would be successful integration to ongoing efforts and successful adoption, by the Haitian population as well as the various government, international organizations, and NGO stakeholders currently operating in the country.

Source: NAF : 4D

¶ Unlike the danger of emerging human diseases directly resulting from disrupted infrastructure and living conditions following the earthquake in Haiti, the concern regarding livestock disease presents a different challenge.  Haitian livestock production consists mainly of small-holder farms that grow crops and livestock primarily for their own consumption.  Excess livestock are sold at market or used as a ‘bank account’ of sorts for payment and trade.  Therefore, a major hurdle is obtaining baseline information about the type of livestock, the number of animals, their condition, and various production challenges faced by rural families in the different geographical regions in Haiti.  Prior to the earthquake, livestock were already stressed by forage/feed limitations, parasite loads, vitamin and mineral deficiencies or excess, and lack of farmer education regarding production methods.  Additionally, livestock feed sources are usually at their lowest point around February due to the dry season and crop harvests, thereby making the timing of the earthquake even more of a strain on an already stressed system.  The potential destruction of animal shelters and neglect of normal production practices following the earthquake could present additional challenges and further decrease livestock growth, reproduction, and milk production.  March and April begin the primary breeding season for goats and cattle in Haiti, therefore, additional stressors could cause detrimental effects upon this cycle’s kid and calf crop.

¶ Producer perspective might also not match with the true nature of disease risk in the livestock population.  A previous study (1,2) of livestock diseases and production methods (from 1993 – old, I know, but it’s the only one I could find) describes how livestock owners were less likely to recognize production-related diseases as true problems; instead, catastrophic diseases like anthrax (‘Malcharbon’) were cited by Haitian farmers as the ‘most seen’ and ‘most serious’ of cattle diseases, even though the actual incidence is quite low.  Parasitism (internal and external), feed deficiencies, and vitamin/mineral imbalances were observed to be the most serious production-related conditions; these were probably not as recognizable to producers, since they were chronically present for many years.

¶ Other disease concerns for the Haitian population include those affecting working animals and a variety of zoonotic diseases.  Poor health of horses and donkeys translates directly to decreased productivity and livelihoods of their Haitian owners as they are relied upon to transport people, goods, water, etc.  Zoonotic organisms like rabies, leptospirosis, tuberculosis, brucellosis, campylobacteriosis, escherichia coli, salmonella, and staphylococcus also pose significant risk to both animal and human populations – especially if milk is not pasteurized.

¶ As mentioned in the previous post, Ag in the Aftermath: Dearth of Haitian Agricultural Baseline Information, the sudden migration of Haitians out of the urban centers and back into the rural areas poses a risk of overburdening an agricultural system which was already stressed.  The increased population numbers in rural areas also increases the risk of food-borne and/or zoonotic disease transmission among this new population, since already limited food safety and production practices were likely disrupted following the earthquake.

¶ So, what might be the current animal disease priorities for Haiti?  In some cases, it’s very species-specific; however, I’ve selected some of the most significant that come to mind that are also, in general, multi-species in origin.  The following is in no way a comprehensive list.

¶ I’ve struggle with the most intuitive way in which to classify them, but there remains overlap due to the nature of the system/diseases:

Production-related Diseases:

Source: DanieVDM

¶ It has been exceedingly difficult to find baseline agriculture information for Haiti.  In order to conduct proper planning, response and recovery operations, the organizations providing support must have a better idea of the agricultural demographics associated with the country.  From the sources available, Haiti is comprised mostly of small, individual family farms that grow both crops and livestock for personal consumption.  Excess livestock are sold to slaughter to generate additional income.  Horses and donkeys are used for transportation and as draft/pack animals to carry goods.  The agricultural infrastructure – basic production systems, forage availability, animal health care, and food safety practices – was degraded significantly prior to the earthquake.  Without a baseline from which to work, it will be extremely difficult to assess the needs of the agricultural system now, post-earthquake.  As response to the human population continues, agricultural baseline assessments should begin as soon as possible – consider agriculture support a means to enhance food security and public health, as we move forward.

¶ A breakdown of the estimated livestock in Haiti is on the Caribbean Animal Health Network (CaribVet) website and provided below:

¶ Population displacements out of the urban centers and into the countryside appear to be tapering off; however, an estimated 230,000 Haitians have moved back to more rural areas following the earthquake – most returned to live with family.  This also places an additional burden on the already strained agricultural production systems, where families might not have enough crops and livestock to feed additional mouths.  Adding to the burden is that fact that Haiti is in it’s dry season at the moment, and forage for goats, sheep and cattle reaches it’s lowest point in February.  With the social and infrastructure disruption caused by the earthquake, the seasonality of the situation (and already degraded quality of livestock) poses a risk for further under- or malnutrition for the country’s production animals.  In such situations, reproduction also suffers, and as the producers move into their breeding seasons later this year, livestock reproduction rates might plummet.  This will create additional strain to the system due to decreased replacement offspring.

¶ The following is a map that combines information on agricultural regions in Haiti (via USAID Famine Early Warning System Network), as well as population displacement densities following the earthquake (via the UN Office for the Coordination of Humanitarian Affairs).  The size of the circles represent the relative proportions of total population migration.  Notice the correlation of population movements with traditional agricultural areas.  For instance, an estimated 62,500 Haitians have relocated to the Artibonite Valley, a region that has historically received long-term foreign agriculture assistance.  Due to the large population migration, it’s previous history as a site for agricultural studies and support, and it’s proximity to Port-au-Prince, this region might be the most ideal to begin obtaining agricultural baseline information and assess the requirements of the farmers and livestock populations.  Without an agricultural assessment and collection of up-to-date information, it is hard to determine where to begin…

Source: FEWSNet; OCHA

**Next we will explore various specific animal disease and production risk factors for assessment and surveillance in Hait**