Second Session Report of The

Health Services Committee 10th July, 2018

REPUBLIC OF KENYA

COUNTY ASSEMBLY OF KWALE

SECOND ASSEMBLY – SECOND SESSION

REPORT

OF THE

COMMITTEE ON HEALTH SERVICES

The Question by

Hon Hanifa Badi

Aware that Health is a function of the County Government as devolved in the Constitution of Kenya, further aware there has been reported and confirmed cases of cholera in Kwale County and in the neighbouring County of Mombasa, Concerned there are also reported death cases and hospitalization of 15 MCAs from Migori County among others instances; What is the Kwale County Government’s preparedness status in handling the Cholera outbreak and other related water borne diseases in the County?

10 TH JULY, 2018

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Health Services Committee 10th July, 2018

Table of Contents LIST OF ACRONYMS AND ABBREVIATIONS ...... 3 PREFACE ...... 4 ACKNOWLEDGEMENTS ...... 4 BACKGROUND ...... 4 COMMITTEE MEMBERSHIP ...... 5 OBJECTIVES ...... 7 METHODOLOGY ...... 7 COMMITTEE REPORT ...... 7 COMMITTEE OBSERVATIONS ...... 15 COMMITTEE RECOMMENDATIONS ...... 15

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Health Services Committee 10th July, 2018

LIST OF ACRONYMS AND ABBREVIATIONS

1. CEC – County Executive Committee 2. HON – Honourable

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PREFACE Mr. Speaker sir, the Committee on Health Services is one of the sectorial committees under the second schedule of the standing order mandated to investigate, inquire into and report all matters related to county health services including, in particular county health facilities and pharmacies, ambulance services, promotion of primary health care, licensing and control of undertakings that sell food to the public, veterinary services (excluding regulation of the profession), cemeteries, funeral parlours and crematoria and refuse removal, refuse dumps and solid waste disposal, water and sanitation services.

ACKNOWLEDGEMENTS Mr. Speaker Sir, I want to sincerely thank the members of Committee on Health Services for their commitment and dedication throughout the exercise. The Office of the Clerk and the Speaker for their support and adequate facilitation not forgetting the Honorable Members for their valuable input.

BACKGROUND Cholera is an infection of the small intestine by some strains of the bacterium Vibrio cholerae . Symptoms may range from none, to mild, to severe. The classic symptom is large amounts of watery diarrhoea that lasts a few days. Vomiting and muscle cramps may also occur. Diarrhoea can be so severe that it leads within hours to severe dehydration and electrolyte imbalance. This may result in sunken eyes, cold skin, decreased skin elasticity, and wrinkling of the hands and feet. Dehydration can cause the skin to turn bluish. Symptoms start two hours to five days after exposure.

Cholera is caused by a number of types of Vibrio cholerae , with some types producing more severe disease than others. It is spread mostly by unsafe water and unsafe food that has been contaminated with human faeces containing the bacteria. Undercooked seafood is a common source. Humans are the only animal affected. Risk factors for the disease include poor sanitation, not enough clean drinking water, and poverty. There are concerns that rising sea levels will increase rates of disease. Cholera can be diagnosed by a stool test. A rapid dipstick test is available but is not as accurate.

Prevention methods against cholera include improved sanitation and access to clean water. Cholera vaccines that are given by mouth provide reasonable protection for about six months. They have the added benefit of protecting against another type of diarrhoea caused

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Health Services Committee 10th July, 2018 by E. coli . The primary treatment is oral rehydration therapy; the replacement of fluids with slightly sweet and salty solutions. Rice-based solutions are preferred while Zinc supplementation is useful in children. In severe cases, intravenous fluids, such as Ringer's lactate, may be required, and antibiotics may be beneficial. Testing to see which antibiotic the cholera is susceptible to can help guide the choice.

Mr Speaker sir, This is a report of the investigation of this committee after deliberations on the cholera cases subsequent to a question asked on the floor of the house, by Honourable Hanifa Badi on 6th December, 2017

That

COMMITTEE MEMBERSHIP Mr. Speaker sir, the Committee on Health Services of the County Assembly of Kwale as currently constituted, comprises of the following members:

1. Hon. Mwinyi Khalfan Mwassera Chairperson 2. Hon. Hanifa Badi Mwajirani V/Chairperson 3. Hon. Chirema Josephat Kombo Member 4. Hon. Suleiman Nzala Member 5. Hon. Juma Masudi Ngando Member 6. Hon. Patrick Mangale Member 7. Hon. Mwanauba Mwaphatsa Member 8. Hon. Yusuf Mubwana Member 9. Hon. Alfred Ruwa Bavu Member

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Health Services Committee 10th July, 2018

Pursuant to Standing Order 191(5) (a, g) the questions were then given to the Committee on Health Services to inquire into the matters raised and to report to the house. Mr. Speaker sir, the committee on Health Services has compiled a report on the questions by Hon Hanifa. Mr. Speaker Sir, on behalf of the Committee on Health Services, I now have the honour and pleasure of presenting the Report of the Committee on the question asked by Hon Hanifa Badi.

Thank you

Signed ………………………………………………

Hon. Mwinyi Khalfan Mwassera, MCA

Chairperson Committee on Health Services

Date …………………2018

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Health Services Committee 10th July, 2018

OBJECTIVES

i. To determine if there is a cholera outbreak in Kwale County ii. To determine if the Kwale County Government is prepared in handling the Cholera outbreak and other related water borne diseases in the County

METHODOLOGY

The committee collected the information through:

i. Engaging with the CEC Water Services

COMMITTEE REPORT This report provides: 1. Submissions by the CEC Water 2. The committee observations 3. The committee recommendations

The population affected by suspected cholera infection cases were detected from Kinango (3), Matuga (3) and Msambweni (2) Sub Counties. The point source of the infection was suspected from the faecal contaminated drinking water sources and importation from Mombasa County which is carrying the heavy burden of the outbreak since January 2017.

Kwale County has experienced sporadic cholera cases between 19th November and 7th December 2017. Eight (8) cases were admitted and discharged alive at Portreiz, Kinango, Kwale and Msambweni Hospital (still in the ward). Vibrio cholera was isolated from 7 cases. All the 4 clusters are not epidemiologically linked.

Cholera Epidemiology Trend

The first 2 cases were confirmed on 20th November 2017 admitted at Portreiz Hospital. They were managed and discharged on 22nd November stable. Other 2 cases were admitted at Kinango Hospital on 22nd and 24th November 2017 from Mgamani (Vigurungani) and Miatsani (Kizibe) villages in Kinango and Matuga sub counties respectively. Patients were all discharged home stable on 4th December 2017. On 3rd December, 2 cases from Denyenye were admitted at Kwale Hospital and discharged home in stable condition on 7th December. By date 13th December, 2017, Msambweni Hospital had two patients still admitted in the

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Health Services Committee 10th July, 2018

Amenity ward. The patients are continuing with the treatment protocol and barrier nursing care in the ward. Both patients' general condition is fair. These two cases were from Nyumba Sita Village. One case, Mr Bakari Swalehe Mwambewe 60 years of age from Nyumba Sita Vingujini in Msambweni Sub County had been admitted as a cholera case but later patient presented with dyspnoea (difficult breathing), distended abdomen and restlessness. On examination and investigation, hepatomegaly and PTB were diagnosed. Laboratory tests indicated impending renal failure as the keratin levels were high. This led to the transfer of the patient to the renal unit (Msambweni CHR) for specialized healthcare. Dialysis was done successfully (1200 mls of dialysis fluid was extracted). The patient's condition deteriorated, resuscitation done with no positive results. Mzee Bakari S. Mwambewe died on 13/12/2017 at 5:42 p.m.; the family was supported with an Ambulance to transport the body home (Nyumba Sita) for burial. The hospital bill was waived in consideration of the cholera outbreak situation.

Cases by week of onset

Week Cases CFR

1 (19th Nov - 25th Nov) 4 0

2 (26th Nov - 2nd Dec) 0 0

3 (3rd Dec - 9th Dec) 4 0

4 (10th - 16th Dec) 0 0

Cholera Laboratory Investigation

Sno. Residence Specimen Results Outcome Comments taken

1 Dziphani Rectal swab Positive Alive Discharged

2 Dziphani Rectal swab Positive Alive Discharged

3 Mgamani Rectal swab E.coli Alive Discharged

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4 Miatsani Rectal swab Positive Alive Discharged

5 Denyenye Rectal swab Positive Alive Discharged

6 Denyenye Rectal swab Positive Alive Discharged

7 Nyumba Sita Rectal swab Positive Alive Admitted

8 Nyumba Sita Rectal swab Positive Alive Admitted

Areas affected and number of cases

County Sub County Ward Cases

Kwale Kinango Kinango 2

Puma 1

Matuga Mkongani 1

Ng'ombeni 2

Msambweni Ramisi 2

Total 8

Surveillance and contact tracing

Active case search for contacts with the cases were traced and dosed to control further spread of the disease as below:

Dziphani. 145

Miatsani. 34

Mgamani. 29

Denyenye. 27

Nyumba Sita. 24

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Other interventions

1. Water sampling and chlorination

Samples collected from public water sources 10 House hold water treatment 562

2. Awareness on cholera alert

Village barazas were conducted in all affected sites and key health messages given.

3. Food hygiene emphasis and medical screening in the market and shopping centres is on going

Mitigation plan

• Community mobilization • Risk assessment • Redistribution of supplies • House hold water treatment • Continued disease surveillance • Controlled food hygiene and sanitation • Capacity building health workers on Rapid Response (RRT) • Preparedness The objective of the preparedness and response The purpose is to reduce morbidity and mortality resulting from the Acute Watery Diarrhoea (AWD) among members of the community through timely preparedness for epidemic and early case detection. Coordination 1. Held a consultative meeting with County Health Management team (CHMT), Sub-County Health Management Team (SCHMT) and Hospital in-charges. 2. Established coordination task force both at the County and Sub County 3. Strengthened Rapid Response Teams (RRTs) have been formed both at the County, Sub County and facility levels

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4. Initiated micro plans for cholera control and prevention from Sub County and Ward level 5. Mobilized all health workers in the health facilities on high alert

Drugs

Protocol drugs that are required in the cholera treatment are available all through January 2018 The department has access to adequate quantities of essential supplies (ORS, IV fluids, giving sets, antibiotics, chlorine granules, Aqua lab and other none pharmaceutical commodities/supplies) Chlorine solution and Aqua tabs have been distributed to CHVs for community water treatment

Communication

Improved communication at all levels from level 4 to level 1 Continued community dialogue on cholera mostly in all four sub counties (Kinango, Lungalunga, Msambweni and Matuga) Mapped the cholera IEC materials/posters Engaged stakeholders (Community, Red Cross and Medicines' San Frontiers)

Cholera treatment centres (CTCs)

Infection prevention in cholera treatment centres mandated Standard operational procedures designed and disseminated to facilities Sited the CTCs in the Sub Counties

Food hygiene and sanitation

Intensified food hygiene and screening for medical examination in the market centres Ongoing household water treatment using the Community Health Volunteers (CHVs) Engaged stakeholders (Community, Red Cross, Plan International, MSF)

Resource Mobilization

Mobilizing resources for different cholera prevention and control activities

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Preparedness and Response Plan

No. Intervention Activities Standard Required

1. Preposition chlorine Preposition chlorine and hygiene kits and hygiene kits

Coordination Review of preparedness prevention measures, monitor response and facilitation action

2. Chlorine unsafe Test community Boreholes, protected water sources water sources shallow wells to identify high, medium or low risk of bacterial contamination

Map water sources

Chlorinate A positive free unprotected wells chlorine at all time of and unsafe sources the day

100% household Household water water treatment treatment with Aqua tabs for clear water and Pur for high turbidity

3. Behaviour change Hygiene promotion One CHV per village in household (500 people)

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Hygiene promotion should be at least 6 months

Assumption behind Prevention and response

Increasing sanitation coverage Countywide is a long term undertaking otherwise ensuring safe disposal of excreta should be key in cholera response.

The response will continue in high risk areas until the end of 7 weeks after the last confirmed case.

Following the outbreak, a total of 9 cases (7 - lab confirmed, 2 probable) were reported between 20th November and 12th December, 2017. All cases were in-patient at Kinango, Kwale and Msambweni hospitals. Wards affected included Kinango 2, Puma 1, Mkongani 1, Ng'ombeni 2 and Ramisi 3.

Thematic goal

To reduce cholera case fatality by less than 1% at all levels

Objective

To reduce morbidity and mortality resulting from Acute Watery Diarrhoea (AWD) among the members of Kwale County community through timely preparedness for epidemic.

Coordination

• Held a consultative meeting with CHMT, SCHMT and hospital in charges at County level • Established coordination task force both at the County and Sub County • Initiated micro plans for cholera control and prevention at ward level • All the H/Ws in the facilities were on high alert mode

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• Distributed chlorine granules, chlorine solutions and Aqua tabs to CHVs for household water treatment

Drugs

• There were adequate essential supplies (ORS, IV fluids, giving sets, antibiotics, chlorine and non-pharmaceuticals commodities)

Rapid Response

Contracting Site Total managed

Dziphani 145

Miatsani 34

Mgamani 29

Denyenye 38

Nyumba Sita 49

Community mobilization /awareness

Site Meeting/baraza conducted

Dziphani 3

Miatsani 1

Mgamani 1

Kizibe 1

Ng'ombeni 3

Nyumba Sita 2

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Household water chlorination

Over 4000 households were accessed

Water sampling

18 samples were drawn from community water sources (wells/open ponds and taps). All the sources were heavily contaminated with E.coli

Thematic gaps

• Cholera beds • Training of Rapid Response Teams (RRT) • Broaden Laboratory diagnostic capacity for cholera in high risk wards.

COMMITTEE OBSERVATIONS The committee observed that:

i. There were several cases of cholera confirmed. ii. The preparedness of the department of health is not up to par. iii. The public health officers are not performing their roles actively.

COMMITTEE RECOMMENDATIONS The Committee recommended that:

i. The CEC Health should come up with public health laws and policies at a county level to govern the public health officers. ii. The department should be more proactive and not reactive in dealing with outbreaks of communicable diseases.

Thank you

Signed ………………………………………………

Hon. Mwinyi Khalfan Mwassera, MCA

Chairperson Committee on Health Services Date …………………2018

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