9 Turkana, Kenya Flooding and Cholera Outbreak
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! Turkana" Kenya Flooding and Cholera Outbreak The normally arid Turkana region is located in the far northwest corner of Kenya, bordering Uganda to the west, Sudan and Ethiopia to the North, and Lake Turkana to the east (Figure 25). The region has been affected by drought, insecurity, poor or no harvests, high malnutrition rates, water scarcity, and high food prices and is the site of an ongoing WFP intervention. Figure 25: Kenya map (from www.travelnotes.com) !#$ Emergency description Two days of heavy rains on January 2nd-3rd caused flash floods in Turkana East as the River Kerio overtopped her banks and flooded the valley for the first time since 1967 (Standard, 2010). A Kenya Red Cross Society (KRCS) assessment documented 4,294 displaced households (21,470 people) and five deaths in four highly affected sub-locations – Kangitit, Lokwii, Lotubae, and Elelea (KRCS, 2010a) (Figure 26). Five bridges, 20 pit latrines, the Morelum Irrigation Scheme, two schools, two health facilities, and 6,500 shelters were destroyed. In addition, 4,298 shoats (young sheep and goats), 184 cattle, 60 donkeys, and 193 camels washed away in the floods. The floods receded within 3 days. The storm also cut off the Kapenguria-Lodwar Road, which is a lifeline for Southern Sudan. Relief supplies destined for refugee camps in Kakuma, Kenya and Southern Sudan were delayed as transport was disrupted. Figure 26: A flooded village in East Turkana (courtesy of KRCS) In addition to the flooding, the larger northwestern region of Kenya has been the site of an ongoing cholera epidemic. Data obtained at the Lokori Health Center in the Turkana East Region documented a declining, but significant, number of cholera cases seen at the health center (Figure 27). Cholera case reporting was limited by the poor infrastructure in the region. Figure 27: Cholera cases reported at the Lokori Health Center Page 115 of 178 !"# Situational analysis and methods KRCS is currently operating an ongoing nationwide flood response project (KRCS, 2010b). The goals of this project are to: 1) undertake search and rescue operations in flood-affected areas; 2) provide non-food items (NFIs) to affected populations; 3) contribute to a reduction in excess morbidity and mortality by providing health services; 4) provide sustained access to safe WASH promotion to affected populations; and, 5) provide logistical support in the field for transport and stocking of non-food relief. As part of this larger flood response operation, the KRCS WASH team conducted two weeks of emergency response activities in Turkana East in January 2010. KRCS used staff and logistical resources from an existing sexual health project in the region to complete the response. HWTS options were included in the relief kits because while KRCS initially intended to disinfect all wells in the four highly affected sub-locations, they were unable to do so because of a lack of equipment and sufficient time. PuR and Aquatabs warehoused with KRCS in Kenya were distributed in an attempt to ensure safe water access for all families (whether or not they were using a disinfected well) in the NFI kit. The kit included two blankets, one tarp, one bednet, one kitchen set, two soaps, 2 20-L collapsible jerry cans, 100 Aquatabs (dosed for 20 Liters each) and 20 PuR sachets. All families in all four communities should have been reached with a kit (Figure 28). In total, KRCS reported that 66,700 PuR sachets and 225,800 Aquatabs were distributed in the four highly affected sub-locations (KRCS, 2010b). If the distribution numbers are accurate and if 20 PuR sachets and 100 Aquatabs were distributed per family, that would have provided 3,335 and 2,258 families with the products, or 77.7% and 52.6% of the affected population respectively. Figure 28: A recipient with PuR and Aquatabs (Turkana, Kenya) NFI kit distribution began January 8th, was completed by January 17th, and was accompanied by a 2-hour group training on hygiene, WASH practices, and water treatment. No materials to use PuR (10-Liter bucket, stirring rod, or cloth) were distributed. Half-day WASH training sessions with children in schools were also conducted. In addition, over 43 pit latrines were sited and excavated and 20 volunteers were trained in participatory hygiene and sanitation transformation in emergency response. World Vision and Oxfam are coordinating the WASH response through the recovery phase, including the development and repair of water systems, and MSF is coordinating the ongoing health response. World Vision has been operating in the region for 15 years, working with the WFP on malnutrition and irrigation programs. World Vision in Turkana East had stocks of Aquatabs and PuR for distribution in community health clinics. The District Public Health Officer (DPHO) in Turkana East also received supplies from UNICEF, including 192,000 Aquatabs, 14 Page 116 of 178 45 kg barrels of HTH, 484 jerrycans, 1,880 mosquito bednets, PuR sachets, hydrogen sulfide microbiological testing supplies, and DPD test kits. DPHO supplies had not yet been distributed at the time of the survey. The major water source in Turkana East is the River Kerio, and water is obtained from the river directly and from boreholes, shallow wells, and community piping schemes that World Vision has installed and manages. Users pay a monthly fee to access these supplies. !"#"$ Spatial analysis Due to the remoteness of the region, maps of this area were extremely limited. Upon arrival, we met with the District Chief, who approved the study and arranged for us to meet with the sub-chiefs of the four highly affected sub- locations. Each sub-chief provided hand-sketched maps of the villages in their sub-location, along with the most recent unofficial census data collected last year of population per village. In addition, information about migration patterns of the population in the post-emergency situation was provided. With this information, we were able to develop a dual-stage PPS sampling methodology by sub-location and village. Within each village, we asked the enumerators to walk the length and breadth of the village and sample a random selection of houses for survey. A more rigorous method of household selection was not feasible within the context of the temporary and transitory housing type seen in this environment (Figure 29). Figure 29: Representative households (Turkana, Kenya) GPS points in each village of the four sub-locations were collected by the field researcher and the KRCS driver and mapped in Google Earth. As can be seen, the sub-locations of Kangitit, Lokwii, Lotubae, and Elelea are located along the road that begins in Lokori and follows the river to the north and the Sudan border (Figure 30). Page 117 of 178 A total of 39 villages in the four sub-locations were surveyed. As can be seen the sub-locations were near the river bed. The first sub-location (light blue) is Kangitit, the second (light green) is Lotubae, the third (pink) is Lokwii, and the fourth (blue) is Elelea. Kangitit is nearest the larger city of Lokori (to the south), Elelea the furthest away. Figure 30: Map of communities surveyed (Turkana, Kenya) !"#"# Methods used in investigation !"#"#"$ Household survey A randomly selected sample (as described in Section 4.4.3) of 409 households targeted with HWTS distribution was surveyed using a questionnaire developed by the field researcher. The survey was translated by a native Turkana speaker and printed in the regional city of Eldoret, Kenya on January 22nd, 2010. Five enumerators were trained in Lokori, Turkana on January 24th and 25th, 2010. The enumerators back-translated the survey and hand-wrote edits onto the data sheets. The survey was administrated between January 25th and February 4th, 2010, a minimum of eight days and a maximum of 27 days after distribution. Page 118 of 178 The survey consisted of 34 questions on respondent and household characteristics, effect of the emergency, assets, diarrhea prevalence, and water knowledge and source before and after the emergency. This was followed by 13-15 questions on each HWTS option received and six product summary questions. The survey concluded with up to six questions about, water quality testing of, and collection of, current treated and untreated stored household drinking water. A maximum of 81 questions (all products received) and a minimum 35 questions (no products received) were asked, and the survey and associated water quality testing and sample collection took about 20-30 minutes per household. !"#"#"# Water quality testing The enumerators tested FCR using Hach (Loveland, CO, USA) ColorWheel test kits during the survey at any household reporting household water treatment and collected samples of treated water (if available) and untreated water from each surveyed household in sterile WhirlPak! bags. The bags were stored on cold packs collected each morning. The field researcher completed membrane filtration microbiological testing each afternoon/evening. The only deviations from Standard Methods included: 1) samples were incubated at ambient temperature as by keeping the doors and windows closed at all times the field researcher’s room remained between 35-39°C (there was no electricity available); 2) due to the heat of the environment samples were cool, but not cold, when removed from the coolers for analysis; and, 3) on one sampling day the holding time of eight hours was exceeded (to 12 hours) because the field researcher had heat exhaustion in the afternoon after taking pictures at a funeral for a family. A dedicated turbidity tester was hired to test samples within 24 hours of collection the morning after they were collected. !"$ Qualitative interview results Formal qualitative interviews were not conducted in this setting, as KRCS staff who responded in East Turkana were responding to more recent emergencies and unavailable for formal recorded conversations during the time the field researcher was in Kenya.