WATER, HYGIENE AND SANITATION ACTIVITIES FOR CHOLERA PREVENTION IN COMMUNITIES LIVING ADJACENT TO LAKE KIVU OR RUSIZI RIVER. CYANGUGU PROVINCE, RWANDA Presented by Peter Maes WHO & UNICEF CHOLERA CONFERENCE, DAKAR 2008 Cholera in Rwanda

SINCE 1994: • Cholera became endemic in communities surrounding Lake Kivu • Outbreak mainly in Cyangugu but also Kibuye, Gisenyi and Ruhengeri

Annual numbers of cholera cases in Rwanda and Cyangugu province: 1996-2003

3.000 s e s a c

f 2.000 o

r e b m u

N 1.000

0 1996 1997 1998 1999 2000 2001 2002 2003 Rwanda Cyangugu

70 % of all cholera cases in Rwanda have occurred in Cyangugu province Cholera in Cyangugu (1)

EPIDEMIOLOGICAL CURVE

Monthly cholera cases in Cyangugu Province: 1998-2003

600 1998 1999 2000 2001 2002 2003 500 s e

s 400 a c

First Well f o

First HP-session r 300 e b m

u 200 N 15 months 15 months 100

0 r l r l r l r l r l r l y i y y i y y i y y i y y i y y i y l l l l l l e r r e r r e r r e r r e r r e r r u u u u u u b p a b p a b p a b p a b p a b p a J J J J J J o u o u o u o u o u o u A A A A A A t t t t t t n n n n n n c c c c c c a a a a a a O J O J O J O J O J O J

3150 1300 800 Expect yearly sporadic cholera cases with outbreaks every 2-3 years depending on herd immunity and environmental factors Cholera in Cyangugu (2)

TARGET IN TIME: METEREOLOGICAL FACTORS

Monthly cholera cases in Cyangugu Province: 1998-2003

600 250 1998 1999 2000 2001 2002 2003 500 200 s ) e

s 400 m a c

150 m

( f

l o l 300 r a f e n i b 100 a m 200 R u N 50 100

0 0 l r l r l r l r l r l r y i y y i y y i y y i y y i y y i y l l l l l l r r e r r e r r e r r e r r e r r e u u u u u u a p b a p b a p b a p b a p b a p b J J J J J J u o u o u o u o u o u o A A A A A A t t t t t t n n n n n n c c c c c c a a a a a a J O J O J O J O J O J O

New Cases Rainfall

March and June critical months for the flare up of —wet“ and —dry“ seasonal pattern Cholera in Cyangugu (3) TARGET IN SPACE: (i) IDENTIFY HEALTH CENTRE ZONES

Cellules: GROUPED Health Centre Zones: Most detailed Population in catchments administrative unit area of each of 24 Health centres Cholera in Cyangugu (3 cont.) TARGET IN SPACE: (ii) IDENTIFY TRANSMISSION —HOTSPOTS“

Muyange

Mukoma Nkombo Nkanka

AR > 0,3 % in 2 out of 3 outbreaks

Bugarama

• 5 Health Centre Zones (HCZ) comply => target population of 140.000 persons • In 5 HCZ of 140.000 people occurs 63 % of all cases in Cyangugu (610.000) • In 5 HCZ of 140.000 occurs 50 % of all cases in Rwanda (8.000.000) Risk factors (1) CHOLERA ATTACK RATE – PROXIMITY TO THE LAKE: • The relative risk for cholera in the health centre zones adjacent to the lake was 11, 48 and 1,4 times higher (in 1998, 2000, 2002) than in non-adjacent zones, highly significant at 95 % confidence level (p<0,001)

© Ian Berry/Magnum Photos Risk factors (2) … CHOLERA ATTACK RATE – COVERAGE WATER POINTS:

Coverage of w ater points by AR Cyangugu province 1998 3 ) % ( 2 e t a r

k c

a 1 t R² =0,423 t

A P value = 0,005 0 4 6 8 10 Ln coverage (persons/w ater point) 1998 Coverage of water points by AR Cyangugu province 2000 3

) R² =0,320 % ( 2 P value = 0,011 e t a r

k c

a 1 t t A

0 4 6 8 10 Ln coverage (persons/water point) 2000 Coverage of w ater points by AR Cyangugu province 2002 2 ) % (

e t a r

1 k

c R² =0,440 a t t P value = 0,002 A A t t a c k R a t e 1 9 9 8 C o v e r a g e 1 9 9 8 0 0 - 0 . 1 4 5 0 - 1 4 9 4 6 8 10 0 . 1 5 - 0 .2 9 1 5 0 - 2 9 9 Ln coverage (persons/w ater point) 0 . 3 - 0 . 4 9 3 0 0 - 4 9 9 2002 0 . 5 - 0 . 9 9 5 0 0 - 7 9 9 1 - 3 8 0 0 - 1 6 0 0 0 —Epidemiological“ —Antropological“ —Technical“ study

DEFINITION OF THE PROJECT To reduce the incidence of cholera in the target area by reducing the risk factors for primary and secondary cholera transmission TARGET AREA 4 –not 5- Health Centre Zones out of 24 in Cyangugu Province TARGET POPULATION 140.000 TIMEFRAME June 2002 – June 2006 (4 effective – 5 financial years) Means (1) HUMAN RESSOURCES (43 + outsourcing)

COORDO:#1

ADMIN/FIN:#1 PROJECT ASSISTANT:#1 Cook: #1 Guards:# 5 Reception: #1

HP # 2 Watsan: # 1 Log supply: # 1 Assistant: # 1 Driver: # 1 Macons, diggers: #27 Means (2): Finance: 1.100.000 EURO

300000

250000 68 Consultants and Field support 67 Transport - Freight - Storage 200000 66 Training and local support 65 Logisitic and Sanitation 150000 64 Medical and Nutrition

100000 63 Operation running costs 62 National staff 50000 61 Expatriates

0 2002 2003 2004 2005 2006 Activities (1) IMPROVE AVAILABILITY OF POTABLE WATER FOR POPULATION • Islands: Construction of 35 hand dug wells with Afridev handpumps (health centre and population) • Peninsular / mainland: Rehabilitation of 21 protected springs, 3 wells & rehabilitation gravity network

• Promote safe water consumption: counting of users and testing at all water points Activities (2) IMPROVE WATER COLLECTION, TRANSPORT AND STORAGE PRACTICES

• Distribution of 20.000 water containers

• Hygiene Promotion focus on cleanliness of water containers

• Promoted household water treatment especially in March and June

© Ian Berry/Magnum Photos Activities (3) IMPROVE HYGIENE BOTH BODY AND ENVIRONMENT

POPULATION • 417 promotion and mobilisation sessions organized for 20.000 people • transmission of 3 different radio spots for cholera prevention during 9 weeks broadcasted 609 times on Radio Communitaire de Cyangugu • Creation and transmission of 2 radio chat programmes of 30 minutes each on the prevention of cholera

SCHOOL and Health structure: • Training of 351 teachers in 26 primary and 1 secondary schools • Creation and distribution of Hygiene booklet and toolkits in schools • Cholera poem “Concours” organised in 26 schools • Training of health promoters and health Centre staff

Drink safe water - Wash your hands - Use a latrine Activities (4) FURTHER APPROPRIATION OF LATRINES BY THE COMMUNITIES

• Hygiene Promotion focus • Construction of 20 on cleanliness of latrines and blocks of 4 latrines each safe disposal of children’s in 10 schools stools

© Ian Berry/Magnum Photos Activities (5) HAVE A REAL COLLABORATION WITH THE STAKEHOLDERS IN THE DESIGN, IMPLEMENTATION AND MANAGEMENT OF THE PROJECT • Training of 56 water users groups with elected hygiene, technical and financial responsible per well and free of Umuganda • Formalised operational partnerships on all administrative levels:

• Kigali (MINITERE) • Cyangugu (Directors) • Districts (Mayors) • Cells Monitoring (1) EVALUATION USE OF SAFE WATER POINTS: • 8,3 [95 % CI: 7,9 – 8,6] litre water collected / person – day • Rain water collection for domestic purposes • Children are 63 % of water collectors => adapt size of jerry cans • Only 14 % collect water properly.

Well water collection and rainfall on Ishywa island 8 250 watercollection rainfall

200 6 ) ³ ) m m 150 (

m (

e l 4 l a m f u n l 100 i a o r V 2 50

0 0 111 122 13 42 35 46 75 Time (months)

© Ian Berry/Magnum Photos Monitoring (2)

WATER QUALITY SURVEY: 8 9!! ! 7 S u r o ! K am a g im b o ! 5 1 0 ! ! 4 ! 2 ! 1 N k o m b o M u v a Ish yw a R w e n tje B u n ye s h y a B u g a ru ra G as h ya B ig o g a

K ar o ro G as h en yi ! N k a n k a 13

! 11 G ih ay a

© Ian Berry/Magnum Photos G ih u n d w e

• 10 families around 10 wells • Verify faecal-oral contamination of the waterchain (well => cup) • Indicator: Number of Thermo-Tolerant Coliforms (TTC) per 100 ml of water Monitoring (2 cont.) POST DELIVERY CONTAMINATION SURVEY:

Water chain TTC-mean Risk with TTC > 10 per 100 ml (geometric) (%) Well 0 [95 % CI: 0 - 0] 0

Pump 2 [2 – 3] 17

Jerry can 5 [4 -7] 34

Cup 6 [4 - 8] 43

Domestic stock 9 [5 - 16] 43

• Water quality compromised by progressive post delivery contamination • Values for TTC/100 ml are lower than those reported in literature • Risk for secondary transmission of V. cholerea during outbreak • Promoted household water treatment especially in March and June Lessons Learned JULY 2007 EVALUATION General • Project did not cover Bugarama HCZ • Poor medical data collection (incomplete as of 2004) Improve availability of potable water for population • Wells still in good condition – no clear numbering done Improve water collection, transport and storage practices • Jerry cans still in use Improve hygiene both body and environment • Include food handling/preparation in promotion messages • Less emphasis on utilisation of latrines (78% households have a latrine ) • Important turn-over of teachers low coverage with small sessions • Use mass communication approach sooner – more frequent Further appropriation of latrines by the communities • Design issues, location issues Collaboration with the stakeholders • Pump maintenance/repair Operational Conclusions

Monthly cholera cases in Cyangugu Province: 1998-2007

600 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 500 s e

s 400 First Well First SOURCE a

c First HP-session First HP-session

f

o ISLAND PENINSULAR 300 r e b m

u 200 N

100

0 l r l r l r l r l r l r l r l r l r l i y y i y y i y y i y y i y y i y y i y y i y y i y y i y l l l l l l l l l r r e r r e r r e r r e r r e r r e r r e r r e r r e r r u u u u u u u u u p a b p a b p a b p a b p a b p a b p a b p a b p a b p a J J J J J J J J J u o u o u o u o u o u o u o u o u o u A A A A A A A A A A t t t t t t t t t n n n n n n n n n n c c c c c c c c c a a a a a a a a a a J O J O J O J O J O J O J O J O J O J

• So far no cholera outbreaks recorded when prevention project implemented • Outbreaks recorded in neighbouring zones – e.g. Bukavu 2004/5 – E.g. Bukavu 2006/7 (3508 cases, mortality 0,54 %) • Targeted strategy enables operational implication in similar context’s • Ongoing evaluation to duplicate targeted strategy in RDC Acknowledgements ALPHABETICAL ORDER

• Roger Teck (Epidemio)

• Liz Walker, Peter Maes, Zoe Young (Project support)

• Ana Berga, Raissa Azzalini (Project Coord)

• Appelès Kwizera Kapitula, Eugénie Mukabaziga, Florence Uwineza, Norbert Habiyaremye, Souleiman Nizeyimana, Zacharia Ntakirutimana (Senior National Staff) • Humanitarian Non-Governmental Organisation 5 Operational Centres + 19 Partner Sections + 6 Branch Offices • Providing medical assistance without discrimination to populations in need • Present in 61different countries • Supported by 2022 international & 24,959 national staff • Budget of 600 million euro in 2007 80 % from a private donor base • Awarded the Nobel Peace Price in 1999 Hanika ! ! M!u!yange ! Gatare ! ! !! Nyamasheke !! ! ! # ! ! Kibogora # ## !!M!!uko!ma ## ## !! ! Ruheru Nkom#bo# # !!! !! # ## ! !!! # ## !!! #### ! !!! !!! Rangiro Yove # ! ! ! # !!!!! Nkanka ! # ! # Gisakura Bushenge Gihundwe Kamonyi

Rusizi Mwezi

Mibilizi Nkungu Nyabitimbo Bweyeye Mashesha

Mushaka

Bugarama Control of Diseases Related to WHS transmission Reservoir Host

Reduce Interrupt Reservoir Transmission

Prevent Disease Treat Disease in population in person WHS Activities Reduce Reservoir - Interrupt Transmission • Water Supply • Excreta Disposal • Waste Water Management • Waste Management • Vector Control

"Infrastructural aspects" "Human related aspects" Structures Culture, Attitudes, etc.

+ Cholera Reservoir and Transmission

PRIMARY AND SECONDARY TRANSMISSION CYCLE OF CHOLERA

ENVIRONMENTAL RESERVOIR

PRIMARY WATER AND FOOD-BORNE TRANSMISSION

ORAL HUMAN FAECES

SECONDARY FAECAL ORAL TRANSMISSION

Discharge in FAECES HUMAN ORAL environment X 105 - 108 INFECTIVE DOSE

ADAPTED FROM SACK, ET. AL.,2004. CHOLERA. THE LANCET

“Primary” transmission mainly through water or food borne routes. Once people infected, and depending on prevailing conditions of crowding, behavioural practices, water supply, hygiene and sanitation, V.cholerae enters “secondary” transmission cycle that gradually becomes the most important pattern.