Ethiopia: West Arsi Acute Watery Diarrhoea Follow-Up Assessment Report

ETHIOPIA: WEST ARSI ACUTE WATERY DIARRHOEA FOLLOW-UP ASSESSMENT REPORT

Assessment Team Members

Dr. Tesfaye Bekele Federal Ministry of Health Dr. Alemu Kabede Oromia Regional Health Bureau Dr. Jamel Adem Oromia Government President’s Office Eng. Daniel Gelan UNICEF Mr. David Tsetse UNICEF Ms Mary Chilvnda UN-OCHA Dr. Amanu Gisso WHO Dr. Tesfaye Ayalew UNICEF

Assessment Period: August 04-08, 2006

1. Executive Summary West Arsi is located in the Eastern part of Oromiya Region and it has an estimated total population of 1,815, 274. Administratively, the zone is divided into 11 Woredas and 312 Kebeles. AWD outbreak was first reported in the zone on the 22nd June and ever since there has been an increase in the number of cases and number of Woredas and kabeles affected. WHO and other agencies carried out assessment at the onset of the outbreak and efforts have been made by the Zonal health Office to contain the spread but has not been effective. A total of 7705 cases were reported in 135 affected Kebels in West Arsi Zone and total death stood at 46 when this assessment began. In SNNPR 20 cases and 2 deaths in Sidama Zone were reported at the same time. Due to the seriousness and urgency of the situation, UNICEF, WHO, OCHA and Oromia Regional Administration decided to undertake an urgent re-assessment of the AWD situation in the affected Zone.

The specific objectives of the mission are to: • re-assess the current extent of the outbreak of AWD and areas which are at risk of infection in the near future. • identify the current resources available to the Zonal Government teams, in terms of human personnel, logistical support, expertise in environmental health, financial and material resources. • identify the gaps and propose immediate actions for the Government, UN and other emergency partners where appropriate, to ensure an effective response to halt the further spread of the AWD.

The Assessment team composed of Oromia President office, Federal MOH Office, UN-OCHA, WHO, UNICEF and Zonal Health Office. A briefing on the existing situation and guidance for the selection of Woredas, communities and CTC for the assessment was given by the Zonal Health Office. A total of seven CTCs and neighboring communities were visited in Arsi Nagele, Shashamene, and Dodola Woredas reflecting areas with increasing, declining and new cases.

The following are the key findings from the assessment: At the onset of the outbreak 2 Kebeles in Wes Arsi Zone were affected. Presently 172 of 312 Kebeles in the affected woredas are affected representing 55% of the total Kebeles in the affected woredas of West Arsi Zone. Presently, 37 CTCs have been established, a total of 88474 cases treated and 89 deaths reported. There is a general increase in cases in West Arsi Zone and it has been reported that the problem have crossed over to Bensa, and Aroresa Woredas in Sidama Zone, and Borososore woreda of Walita Zone with 78 cases and 2 deaths in 7 kabeles reported and Bore Woreda of Guiji Zone

As far as cases management in the CTC is concerned, the oriented and assigned health workers are fully engaged and entertaining patients coming with diarrhea and screening is done so as to differentiate AWD from other diarrhea diseases. Having done this, patients with AWD are again taken and evaluated for the degree of dehydration. Patients with no and some sign of dehydration are given ORS to drink at the CTC and observed for sometime and sent home with antibiotic, ORS and advised to come back if situation get worse. In the case of severely dehydrated patients, they are admitted and managed in most places according to the treatment protocol with IV fluids and PO antibiotics. In some

CTCs, patients admitted for IV rehydration were seen without IV line. This has shown maltreating of the patients.

Poor hygiene and sanitation condition in Woredas is a major source of contamination and spread of the AWD. However, hygiene and sanitation has not been given the necessary attention in the communities and CTCs. Even though Zonal and Woreda Health Offices have structures and systems (group leaders, the use of megaphones, questionnaire) in place to disseminate hygiene and sanitation messages, little has been done to ensure activities are actually implemented in CTCs and communities and people are putting into practice. There is no data in the form of hygiene and sanitation indicators such as the number of campaigns organized, the number of households visited, the number of latrines constructed and used, number of focus groups discussion held and number of IEC materials distributed. Contamination from contact with affected people is the second major source of the outbreak based on the information collected from affected people and CTC staff interviewed. Looking at the trend and spread of the AWD, areas with safe and unsafe water have reported cases suggesting water only is not a major source of the outbreak. This is evident in Danshe area where EMWAT kit was installed to give safe water to community and cases are still being reported even though there has been general decline of cases.

Staff at the CTCs are working day and night since the onset of the AWD and the rotation roster is very rigid without protective apron. There are some medical, shelter and sanitary supplies at the CTCs but there is still the need for additional supplies since number of cases are not reducing but rather increasing in the affected areas. The Zonal Health Office has received some funds from UNICEF and the Regional Health Bureau to cover the operational cost of the AWD activities in the affected Woredas. The problem, however, the funds are not disbursed on time to the Woredas for quick implementation of activities.

There is AWD response and preparedness team composed up of all concerned sectors and meetings are held daily to evaluate activities and interventions for the following day are planned. Due to the spatial distribution of the Woredas two command centers have been established -one in Shashamene town and the other in Dodola town. All the affected Woredas have established Woreda level AWD response teams to deal with the outbreak. There is limited coordination between government and NGO and also between government institutions at Zonal and Woreda level in addressing the AWD. All information regarding cases treated and admitted is sent to the Woreda Health Office for compilation and there is no information kept at the treatment centers for reference purposes.

For strategy, households of affected Kebele are given water makers and PUR if their source of water is River while water guard is given to household using wells and piped water. Two EMWAT Kits are installed to treat turbid river water for drinking only. This has been effective in reducing the case load but does not seem to be the only solutions to contain the outbreak. With regards to hygiene and sanitation, the strategy of constructing latrines, promoting hand washing with soap or ash and boiling of water, conducting house-to-house visits, public campaigns, carrying out hygiene education at CTCs have used but little progress has been achieved in terms of number of activities undertaken and the impact of the activities in changing people behavior. The gaps identified by the assessment group and recommendations are presented below.

Gaps and challenges 1. There seems to be limited coordination in the Woreda. There is no link between the Woreda health Office and Woreda Water Office regarding the AWD. As a result there was no planning on resources needs for response. 2. Identified gaps were not addressed which is observed from the second commanding unit. 3. Environmental experts from the regional health bureau was not observed supporting in the containment of the spread of the disease. 4. Isolation, hygiene and sanitation at the CTC are not applied properly or to the requirement. 5. Overcrowding of patients in some CTCs and/or space inadequacy is observed as the one the problem. 6. There are shortage of basic supplies for CTCs like mattress, bed pan, vomiting vowel, kerosene lump, torch, and hygiene and sanitation materials. 7. Health workers are not protecting themselves or are not using gowns and/or apron. 8. Training on case management and CTC management to health workers was not given from the woredas under the second commanding unit. 9. Hygiene messages given are not monitored by Woreda health office or any body else.. 10. No IEC material for the current problem is seen at all levels starting from zonal health department to the community level. 11. The response by the community to sanitation and hygiene campaign is very low. This is evident in the improper use of latrines and the reluctance of people to observe basic personal hygiene protocols such as washing of hands after defecating and before eating and boiling of River water before consumption in most affected kebelesIn other words, the majority are not practicing according to hygiene and sanitation. 12. Documentation and reporting is observed far behind the requirement like line listing. Other activities recorded are not compiled and reported. 13. Medical supplies are alright up to the date of assessment but some items are finished while we were in the assessment business and others will not serve more than a week which means no stock for medical supplies. 14. The health workers capacity is overstretched and if the cases are still continuing to occur and more CTCs are opened, there will be critical shortage of health workers. 15. Shortage of operational cost like for the DSA of health workers and non health working in the field related to this AWD epidemic. 16. Water purification materials used at house hold level are not distributed in a way that can influence the transmission.

this situation. This has to be supported by establishing CTCs in an area where there is adequate space to apply the proper activities and by availing the necessary materials for patient care and hygiene and sanitation materials. 4. Health workers at CTCs have to be encouraged and/or supervised to make them exemplary for the personal hygiene and sanitation at the CTCs. 5. Before the opening of a new CTC, the Woreda should make sure that CTC staffs are trained prior to opening and the equipment and supplies needed are available. The zone should continue to assist with coordination with activities especially using the daily evaluation meeting which has been a use forum for taking quick action to manage cases and also contributed to averting a wider spread of the AWD outbreak. 6. The Regional Health Bureau should develop IEC materials in local languages and make available the IEC materials in all health facilities, CTCs and as well in the communities. The Regional Health Bureau should also work with neighboring zones and Woredas on organization of orientation course for health workers, avail existing treatment protocols in all health facilities and carry out health education as soon as possible especially in neighboring Woredas. There should be a mechanism in place to monitor the hygiene and sanitation messages and practices in the community and to reach the affected families in the woredas where the cases are not many to monitor the mechanism of disposing their infectious wastes. The region has to use the mass media to have a wider overage of hygiene and sanitation messages in the region including the neighboring regions towards to the prevention of AWD till the problems ceases. 7. Proper recording has to be in place at the CTCs and the zone and woredas have to get support in the data management and reporting in a way that would help for monitoring of different aspects of the epidemic and for subsequent actions. 8. Drugs and medical supplies have to be stocked enough at least for two months taking in to consideration the magnitude and the spread of the disease up to now to prevent the rupture which will be a disaster in the intervention process. 9. The regional health bureau should work ahead to supply health workers to the affected Woredas on demand. 10. There should be proper guidance and microplan to distribute household level water purification chemicals to the prioritized Kebeles for higher coverage and adequate time to interrupt the disease spread through water. There should be also enough supplies for water purification. Water Bureau should ensure that communities with piped water have adequate chlorine and residual chlorine is regularly monitored. It is important that chemical and bacteriological analysis of all Rivers used by affected communities should be carried out to ascertain the type and level of contamination. 11. The current operational cost obtained from Regional health Bureau and UNICEF will not be enough to support the AWD response programme longer than expected looking at the current magnitude of spread. Therefore, financial support from donors is urgently needed.

2. Introduction Since the outbreak of Acute Watery Diarrhea (AWD) in West Arsi Zone on the 22nd June 2006, West Arsi Zonal authorities and Regional Bureau of Health established Case Treatment Centres, health staff and other resources mobilized and community mobilization campaigns started. Additional support has also been offered by UNICEF, WHO, MoWR, MoH, Merlin, PSI, MSF-CH, ESHE, CCF and resources provided through the RHB from other Zones. However, even with these efforts, after an initial indication that the cases were decreasing, the infection area is now believed to have spread to a total of nine Woredas in West Arsi Zone and to Harbe Gona and Bolososore Woredas in SNNPR. It has also now crossed over Regional Boundaries into SNNPR and to Guji zone. Due to the seriousness and urgency of the situation, UNICEF, WHO, OCHA and Oromia Regional Administration decided to undertake an urgent re-assessment of the AWD situation in the affected Zone.

3. Background

3.1 Geographical and administration West Arsi is a newly established zone in Oromia region and is located in the Eastern part of Oromiya Region with East Shewa Zone on the East and Arsi Zone and Bale Zone on the West and SNNPR in the South. It is one of the largest zones and it has an estimated total population of 1,815, 274, of which about 89 % resides in rural areas (Source: Zonal Health Office). The table below presents population figures for the different Woredas in West Arsi Zone. Table: 3.1. Population of woredas for West Arsi Zone.

Number Woreda Population 1 Shashamene 360401 2 Siraro (Siraro &Shala) 240934 3 Arsi Nagele 236595 4 Kofele 167175 5 Kore 109234 6 Dodola 179019 7 Adaba 142598 8 Asasa 170869 9 Kokosa 128712 10 Nensebo 79737 Total 1,815,274

Administratively, the zone is divided into 11 Woredas and 312 Kebeles. The rural population is dominantly Muslim with a significant number of populations engaged in agriculture. The West Arsi Zone is prone to epidemic and communicable diseases are rampant in this area because of deteriorated environmental situation, scarce and poor quality of water and existing low health service coverage. Personal hygiene and sanitation practices are poor; water is scarce and poor quality. The water supply coverage of the region is very low which is about 13.6 %. Particularly the rural population of the region has limited access to improved water supply service. This is worse even for sanitation coverage, which is only 7.6 % and the number of latrines constructed in the rural areas is very low while the majority of the people are not aware of personal hygiene and environmental sanitation.

Poor hygiene and sanitation contributed a lot for the illnesses, since the communities are practicing mal-disposal of excreta, unhygienic handling of food substances and utensils and poor domestic waste disposal including animal wastes and are risking the living environment.

3.2 Existing situation Arsi Nagele is the first Woreda to report the outbreak of AWD in Shashamene Zone in Oromia Region. Before the onset of this assessment, five CTC (Chafa Guta, Alelu, Jalo Dida, Fagi Goba and Obenso Jalo) were closed in Shashamene Woreda and other two were closed from Siraro woreda. The total number of AWD cases reported reached 5547 in Shashamene, Arsi Nagele 1506, Siraro 366, Kofele 70, Kore 46, Dodola 78, Adaba 29, Kokosa 19 and Assasa 44 giving a total of 7705 cases in West Arsi Zone on the beginning of the assessment. At the same time community death stood at 11 and facility death was recorded to be 35 adding up to 46 deaths in total. The total number of affected Kabeles was about 135.

Before the start of this re-assessment, it was also reported that there were 20 cases and 2 deaths in Sidama Zone in SNNPR.

3.3 Objective of mission The specific objectives of the mission are to: • re-assess the current extent of the outbreak of AWD and areas which are at risk of infection in the near future. • identify the current resources available to the Zonal Government teams, in terms of human personnel, logistical support, expertise in environmental health, financial and material resources. • identify the gaps and propose immediate actions for the Government, UN and other emergency partners where appropriate, to ensure an effective response to halt the further spread of the AWD.

3.4 Methodology Before the assessment started, Assessment team composed of Oromiya Presidency, Federal MOH Office, UN-OCHA, WHO, UNICEF and Zonal Health Office met at Shashamene clinic to discuss the TOR of the mission. The team agreed to visit community, offices and CTCs together in order to have same understanding of the AWD situation in the Zone.

General briefing on the AWD situation was presented to the team during the daily evening evaluation meeting of the Zonal AWD response committee. The team got the opportunity to present the mission of the re-assessment to the members of the daily evaluation meeting.

Detailed briefing on the AWD situation and the selection of affected Woreda reflecting high cases and declining cases, with constant case or increasing trend and woreda start to report new cases was agreed based on the suggestion of the zonal health office. The three Woredas selected were Arsi Nagele- high cases and increasing trend, Dodola-new cases and Shashamene- high cases. With respect to the selection of CTCs to be visited, the head of health of the respective Woredas were consulted. In Arsi Nagele Woreda, Danshe and Gambleto CTC and community were selected for the assessment. The second command office of the Zonal AWD response based in Dodola was consulted and Eddo and Dodola CTC and community were selected also for the assessment.

Visits were undertaken to the selected CTC and communities. Approach to the management of AWD cases and water, hygiene and sanitation situation in the CTC was observed. Staff at the CTC interviewed to check their knowledge on AWD treatment protocols, the resources needed and their challenges that need to be addressed to improve the current case management strategy. Community members were interviewed to understand their level of awareness of AWD and the preventive measures that needs to be undertaken. 7

Meetings were held with the AWD response team of the three Woredas officials to discuss current case management of the disease, the current trend of spread, water, hygiene and sanitation activities implemented to prevent the spread and resource. Data and information regarding the number of cases reported in the whole Zone, the resources available, gaps and were collected from the Zonal and Woreda Health offices and reviewed.

Where there was a need based on the poor situation of the CTC, action was taken immediately to improve the situation or recommendation presented at the daily evening evaluation meeting for the necessary action to be taken. Quick actions that were undertaken as a result of the teams recommendations include: the relocation and weatherization of the CTC at Gambelto in Arsi Nagele Woreda, reorganization and expansion of the CTC in Shashamene and expansion of CTC at Gigeesa in Shashamene Woreda

4. The Magnitude, spread and the trend of the disease. Acute Watery Diarrhea (AWD) was reported retrospectively from Arsi Negele woreda on the 22nd of June 2006 on the patient who was treated at Shashemene hospital. On the subsequent days increased number of similar cases were reported from Shashemene and Arsi Negele woredas which later on spread to nine woredas of the zone and affecting 172 kebeles up to the 7th of August. In Shashemene woreda alone, the first 15 kebeles were affected within the first 13 days of the epidemic. The disease spread to these nine woredas and 172 kebeles within 39 days. The first reporting date for each Woredas are indicated below that shows the rate of spread of the disease to the nine woredas of the zone.

Table 4.1. The date of the first case report by Woreda and the rate of spread of the disease to affected woredas.

Woredas First date of case report for each woreda 1st 2nd 3rd 4th 5th 6th 7th 8th 9th affected affected affected affected affected affected affected affected affected Arsi Negele 22/06/06 Shashemene 23/06/06 Siraro 05/07/06 Kofele 16/07/06 Dodola 18/07/06 Adaba 20/07/06 Gedebe Asasa 21/07/06 Kokosa 23/07/06 Kore 30/07/06

How the first case/cases contracted the disease is not known or the route of the transmission is not established for index cases. However, river waters were attributed as the source of infection for the Danshe kebele of Arsi Negele and for kebeles around Chefa guta treatment center of Shashemene woreda where many cases were reported initially. EMWATKITs put in place in this two areas. Disease transmission around Chefa guta area stopped in about a month time. In Danshe area, the transmission has continued for more than 45 days in spite of supplying safe water from EMWATKIT. Cases are seen from kebeles/villages which have safe water too but the spread is observed not fast. The cases reported from one kebele in Kofele, Dodola, Adaba, Gedeb assasa and kokosa are not many. In other words, the reported cases are scattered to many kebeles. There is also report of cases from one family

8 while no cases in the village or at least cases in the village reported after a while. We don’t see common source type of epidemic especially in the woredas affected later on. There are reports of cases who developed the disease after definite contact with cases or the family of cases like in funeral ceremony or just from visiting well known affected kebeles. Others who come from non affected villages or kebeles to the relative in the affected kebeles contracted and manifested the disease even before they return back to home. The team has seen such a case at Danshe treatment center. There are cases also contracted the disease due to their contact to the CTC either to care the sick or for other reasons.

From this scanty information, the route of transmission seems in most areas from personal contact due to lack of personal hygiene and basic environmental sanitation in addition to water source.

The disease is still further spreading out of the zone and reported from SNNPR and Guji and East Shoa zone of the Oromia region.

Nine woredas out of the 11 woredas affected in the zone. A total of 172 kebeles are affected which has reported 8474 cases in the last 47 days of the epidemic. The number of affected kebeles, cases reported and deaths against the affected woredas of West Arsi zone since the beginning of the epidemic upto the 7th of August are presented in the table below.

Table 4.2. Number of kebeles affected, cases reported, the attack rate and proportion of cases by woreda.

Woreda Total Affec % of Total Cases % cases Proportion of Deaths kebeles ted affected populati reported reported cases by woreda Facility Commu kebel kebeles on (attack based nity es rate) death Shashemene 45 45 100% 360401 6012 1.67% 71.0% 37 11 Arsi Negele 47 35 74.5% 236595 1717 0.73% 20.3% 6 22 Siraro 64 20 31.3% 240934 370 0.15% 4.4% 1 2 Dodola 27 7 25.9% 179019 107 0.06% 1.3% 1 1 Kofele 38 30 78.9% 167175 96 0.06% 1.1% 0 0 Asasa 26 7 26.9% 170869 70 0.04% 0.8% 4 0 Kore 21 19 90.5% 109234 46 0.04% 0.5% 0 0 Adaba 24 5 20.8% 142598 30 0.02% 0.4% 1 0 Kokosa 20 4 20.0% 128712 26 0.02% 0.3% 0 3 Total 312 172 57.4% 173553 8474 0.49% 100.0% 50 39 7

The coverage of the problem for the woredas has a difference. It ranges from affecting 100% of the kebeles in Shashemene woreda to 20% of the kebeles in Kokosa woreda. The attack rate has also differences among the woredas, like it is 1.67% for Shashemene which is followed by Arsi Negele with the attack rate of 0.73% and the lower is for Adaba and Kokosa woreda with the attack rate of 0.02%. Among the reported cases, more than 90% has come from Shashemene and Arsi Negele woredas. On top of the duration of epidemic in this woredas for such a big difference, the number of cases reported in the first days of the epidemic was quite big as compared to the rest of the woredas.

SNNPR First affected is Arabagona Woreda in Sidama Zone which is adjecant to Kokosa Woreda in West Arsi Zone. The date of onset of the outbreak in Arabagona woreda is 21/07/06 and spread to Bensa, and Aroresa Woredas in Sidama Zone and Bore Woreda of Guji Zone of Oromia Region. Beside to Sidama Zone, the AWD was reported from Borososore of Walita Zone. The total cases reported from SNNPR 9 are 78 with 2 death in 7 kebeles. Because the outbreak is not controlled in West Arsi, Sidama and Woliyta Zones, there is a great fear that the diseases can spread to neighboring zones and Woredas of the region.

Figure 4.1. AWD case load by woreda, West Arsi zone.

AWD cases by woreda

6000

5000

4000 orted p

3000 Series1

Num re cases of 2000 ber

1000

0 A/N Shash.T Siraro Kofele Kore Dodola Adaba Kokosa Gedeb asasa Name woreda

The trend of the disease occurrence was increasing since the starting date up to the 13th of July and starting to fall down from 14th of July up to around 21st of July and then after continued more or less the same. The trend of Shashemene woreda is more or less similar to the zonal trend or in other ways the pattern of the trend at zonal level seems influenced by the data or case load of Shashemene woreda. Arsi Negele and kofele woreda is showing constant increase of cases since it started in the respective woredas. Siraro woreda is showing the reduction of cases while the rest of woredas have low number of cases and the trend is fluctuating. All woredas affected still harboring cases even though case reduction is observed in Siraro woredas and five treatment centers are closed from Shashemene and two from Siraro because of absence of cases in the vicinity kebeles for five or more days. The trends for the zone and each woreda has been presented below for comparison based on the 10 daily data. The detail cases on daily bases by woreda and by treatment sites for Shashemene woreda are presented in appendix I and II.

Figure 4.2. Trends of AWD cases in West Arsi Zone and the different Woredas.

West Arsi Zone AWD trend 450 400 350 300 250 Zonal.T 200

of case reportedNumber 150 100 50

0 6 6 6 0 06 0 06 06 06 06 06 06 06 7/ 7/ 7/ 06/ 06/ 06/ 06/ 200 2006 2006 07/ 07/ 07/ 2006 7/ 7/ 7/ 8/ 22/ 24/ 26/06/06 28/ 30/ 2/7/2006 4/ 6/ 8/7/2006 0/ 2/7/2006 14/07/06 16/ 18/0 20/07/06 22/ 24/0 26/07/06 28/ 30/0 1/8/2006 3/ 5/8/2006 7/8/2006 1 1 Date of report

Shashemene Woreda AWD trend

350

300

250

200 Shash.T 150

Number of cases reportedNumber 100

0 6 6 0 06 0 06 06 06 06 /06 06 7/ 06/ 06/ 06/ 06/ 2006 2006 2006 07/ 07/ 07/ 2006 7/ 7/ 7/ 6/07/06 /8/2006 8/ 8/2006 22/ 24/ 26/06/06 28/ 30/ 2/7/2006 4/ 6/ 8/7/2006 0/ 2/7/2006 14/07/06 16/ 18/0 20/07/06 22/ 24/07 2 28/ 30/07/06 1 3/ 5/8/2006 7/ 1 1 Date of report

Arsi Negele Woreda AWD trend

120

100

60 A/N

40 of cases reportedNumber

0 11

6 6 6 6 6 6 6 6 6 6 6 0 0 06 06 06 0 0 0 06 0 0 0 06 06 0 0 06 06 / / / 0 0 0 00 / / 0 0 0 6/ 6/ 2 7/ 7/ 7/ 0 0 06 /06 /06 /2 /2 /2 0 0 /07 /07 /07/06 0 /2 /2 /2 2/ 4/ 6/ /7 /7 /7 8/ 0/ 0/ /8 /8 8 2 2 2 28 30 2/7/2006 4/7/20 6 8 0 14/07/06 16/07/ 1 2 22 24 26 28/07/06 3 1 3 5/ 7/8/2006 1 12/7/ Date of report

Siraro woreda AWD trend

50 45 40 35 30 25 Siraro

20 of cases Number 15 10

06 06 06 2006 8/07/06 /8/2006 22/06/06 24/06/06 26/06/06 28/06/06 30/06/ 2/7/ 4/7/2006 6/7/2006 8/7/2006 2/7/2006 14/07/06 16/07/ 1 20/07/06 22/07/06 24/07/06 26/07/06 28/07/06 30/07/06 1/8/20 3 5/8/2006 7/8/2006 10/7/20061 Date of report

Kore woreda AWD trend

14 12

8 Kore

6 cases reportedNumber

0 6 6 6 6 6 6 6 6 6 6 6 6 6 0 0 0 0 06 06 0 0 /0 0 0 0 0 /0 /0 /0 /0 006 0 006 6/ 6 6/ 7 7 7 7/ 7 2 2 0 /0 /06/06 0 /2 /2 /2 /2 /0 /07/06 /0 /0 0 /0 /2 2/ 4 6 0/ /7/200 /7 /7 /7 7 4 6 0 2 6/ 8 /8 /8/200 2 2 2 28/06/06 3 2 4/7/2006 6 8 2/ 1 1 18/07/06 2 2 24/07/06 2 2 30/07/06 1/8/ 3 5 7/8/ 10 1 Date of report

Dodola woreda AWD trend

8 Dodola

Number ofcases Number 6

0 6 6 6 6 6 6 6 6 6 6 6 6 6 06 0 0 0 06 06 06 0 /0 / 0 0 /0 / /0 / /0 0 0 6 2006 2006 7 7 7 7 2006 /06/0 0 /06/0 /2 / / 0 /07/0 0 0 /07/0 /0 /07/0 / /2 2/06/06 6/ 8/06 /7 /7/2006 /7 4/ 6/07 0/ 2/ 8/07/06 /8 /8/2006 /8 2 24 2 2 30 2 4 6/7/2 8 1 1 18 2 2 24 26 2 30 1 3 5/8/2 7 10/7/20 12/7 Date of report

Adaba woreda AWD trend

3 Adaba

2 of cases reportedNumber

0 6 6 6 06 06 06 06 06 06 06/ 06/ 2006 2006 2006 07/ 07/ 07/ 07/ 2006 2006 7/ 7/ 8/ 8/ 22/06/06 24/06/0 26/ 28/ 30/06/06 2/7/2006 4/7/ 6/ 8/7/2006 14/ 16/ 18/07/06 20/07/06 22/ 24/ 26/07/06 28/07/06 30/07/0 1/ 3/ 5/8/2006 7/8/200 10/7/200612/ Date of report

Kokosa woreda AWD trend

8 7

5 Kokosa 4 3 Number of cases reportedNumber 2

0 6 6 6 6 6 6 06 0 0 0 06 06 06 06 06 06 06 06 0 0 0 06 0 0 0 0 0 / / 6/ 6/ 7/ 7/ 7/ 0 0 0 /06/06 /2 /2 /2 /2 /07/06 /07 07 0 0 0 /2006 /2 2/ /7 /7 /7 /7 /7/2 0/ 2/ 4/ 6/ 8 /8 2 24/ 26/06/ 28/06/ 30 2/7/2006 4 6 8 0 14 16/07/06 18 2 2 2 2 28/07/ 30/07/06 1/8/2006 3/8/2006 5/ 7 1 12 Date of report

Kofele woreda AWD trend

10 d

Kofele

6 Nuber ofNuber reporte cases 4

0 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 / / 0 0 0 0 00 / / / / 0 0 6 6 2 2 2 2 7 7 7 7 2 2 /0 /0 /06/0 / / / /07/ /0 /0 /0 /07/ /0 2 6 0 /7/ /7 /7 /7/2 /7 4 6 0 2 6 8 /8/ /8/ 2 24/06/ 2 28/06/0 3 2 4 6/7/20 8 0 2 1 1 18/07/ 2 2 24/07/0 2 2 30/07/ 1/8/200 3 5/8/200 7 1 1 Date of reported

Gedeb asasa woreda AWD trend

16 14 12

10 Gedeb asasa 8

6 of reported cases Number 4 2 0 /06 006 006 6 2 2 22/06/06 24/06/06 26/06/06 28/06/06 30/0 2/7/2006 4/7/2006 6/7/2006 8/7/2006 0/7/ 2/7/ 14/07/06 16/07/06 18/07/06 20/07/06 22/07/06 24/07/06 26/07/06 28/07/06 30/07/06 1/8/2006 3/8/2006 5/8/2006 7/8/2006 1 1 Date of report 5. Cases Management With case management, curative services are considered to control AWD in the Zone. For this reason, the Zone made orientation to the health workers in the health facilities as well as for those who came from the nursing college. This was followed by the assignment of health staff of different categories i.e. clinicians and public health with the allocation of drugs, treatment protocols, guidelines, reporting formats and other necessary materials to the isolated established CTCs. At CTCs, patients who come with chief complaints of diarrhea and vomiting are screened whether it is AWD or other diarrhea diseases. After screening, patients are evaluated with different degree of dehydration i.e. no, some and severe. Patients with no and some degree of dehydration are treated with ORS and PO antibiotics. Patients who are severely dehydrated and in shock are admitted to the CTC and treated with IV fluids (in most places with Ringer Lactate) and which is followed with PO antibiotic and ORS. In most places, tetracycline, doxicycline and ampecillin syrup are used for treatment. Other antibiotic like Ciprofloxacin is not being used in some CTCs as observed by the assessment team. For example in Danshe the health workers interviewed did not properly respond to when and how to use Ciprofloxacin. This could be so because they might have not acquired enough knowledge in the management of AWD with severe dehydration. Moreover, patients who deserved IV line are kept and made to drink ORS.

All CTCs are housed in tents supplied by the woredas or from the communities. The tents were in satisfactory condition however it was observed by the team in two CTCs of Shashemane woreda to be overcrowded with patients and caregivers, and in one, patients were admitted in the open air. The CTC in Shashemane town was strongly recommended for relocation to an isolated place however the Zonal administration preferred it to remain in situ and proposed instead closing the entrance and re-opening another one closer to the CTC tent. Additional tents for admitting patients and an eating place for caregivers was erected. In one CTC of Arsi Negele patients who most were children, were admitted in a tent surrounded by water which exposed them to the elements. In most of the areas visited patients were observed sleeping on the floor on plastics sheets with no mattresses.

Majority of the CTCs are erected within health facility compounds and were found to have inadequate space especially for implementing effectively isolation measures such as fencing, entrance and exit doors and chlorinated water facilities at the latrine and the main health facility entrances. The inadequate space in these CTCs resulted to latrines and medical waste pits constructed in close proximity to the tents. There were shortages in bed pans, mattresses, vomiting bowls and other CTC supplies reported by staff and observed by the team in most CTCs visited.

Generally the health staffs were observed to be knowledgeable on the treatment of AWD in almost all CTCs visited except the CTC in Dodola town. Case management was observed to be quite good such as criteria of admission of severely dehydrated cases, and Doxicycline, Tetracycline and Ampicillin syrup antibiotics use for adults and children cases respectively. In most CTCs it was identified that Ciprofloxacin antibiotic was also stocked for use and it was not clear why this antibiotic was accessible for AWD treatment. The staffs were able to identify resource needs required in the facilities. In Dodola CTC however, case management was found below acceptable standards and raised concerns as to the level of technical capacity of the staff working in that CTC. CTCs opened and giving services are totally 44, out of which seven are closed since no cases are reported from the vicinity four to five days. The rest 37 CTCs were functional at the time of assessment. The distribution of CTCs by woreda is depicted in the table below.

Table 5.1. Number of CTCs for each woreda since the beginning of the epidemic.

Number Woreda Number of Total cases CTC 1. Shashamene 10 5819 2. Arsi Nagele 7 1648 3. Kofele 5 83 4. Kore 4 49 5. Siraro 3 369 6. Dodola 9 103 7. Adaba 2 30 8. Asasa 3 58 9. Kokosa 1 24 Total 44 8183

6. Water, Hygiene and Sanitation CTCs Hygiene and sanitation situation at treatment centers is still a challenge. A lot needs to be done to prevent contamination. At all the CTC visited, there are no clear entrance and exit form the centres and movement of patients are not regulated. Handwashing facilities and latrines do exist in the CTC. With the respect to hand washing facilities, they are either place far from latrines or not near the entrance and exit points. Most of the staff at the CTC visited are not using the protective clothing while handling patients and footbaths are virtually none existing at the centre and CTC with footbaths are not properly used. Even though hygiene education given to patients in the areas of pre and post treatment, there is no follow-up by health extension workers or any bodyelse on patients to see whether the hygiene messages are put into practice. Overall, hygiene and sanitation situation at the CTCs is very poor and is likely to be the a major source of contamination. The picture shows hands washing facility with soap installed at the entrance and exist of a CTC.

The team observed that people taking care of AWD patients did not have enough hygiene and sanitation knowledge. Also, precaution that should be taken when handling AWD patients was not being practiced. These are reflected in the poor way they disposed off excreta, urine and vomitus at the CTCs. Staff in all the CTCs visited reported that patients were given education messages focusing on sanitation and hygiene practices at CTC level and upon discharge. However, not clear whether they should conduct follow up visits to discharged patients in their communities or if there was strong link and follow up by community health agents. Based on patient history gathered by CTC staff, some patients were reported to be infected by contacts of same house household members who were previously admitted and people bringing patients to CTCs got attack whilst caring for the patients.

The Zonal health office trained and deployed non-health professionals in presentation skills in the prevention of AWD as well as up-grading public nurse students in all affected Woredas. However, during visit to the CTCs and communities the team did no see visible hygiene education materials displayed. Water used in CTCs for preparing ORS solution is not disinfected. This was observed in Dodola Town CTC and Eddo. This is due to lack of awareness among the health professionals.

Community Sanitation is still a problem in the communities as household latrines are not being constructed. The team felt that expecting large scale household latrine construction is unlikely in the short time-frame., so focus should be on improving the dissemination of hygiene messages to communities for them to improve personal hygiene and drink safe water. The level of hygiene awareness in the communities visited is relatively good since all the people interviewed knew about AWD, the cause and ways to prevent the spread. Hygiene messages are presented at through home visits, at public places such as churches, mosques and market places.

Non-health and health professionals are reported to be deployed to Kabeles to conduct house-to-house visits and also use megaphone to educate people in common places such as markets, churches and mosques. In addition to this, there is a’ Garee’ (group leader) responsible to disseminate hygiene messages and at the same time to follow up to see whether the household have constructed and used latrines and also put into in practice hygiene messages they have been exposed too. In Arsi Nagele Woreda in particular, leaflets with hygiene and sanitation messages have been developed and are reported to be distributed. The assessment did not get any quantitative data reflecting the effect implementation of these strategies. However, there is still lot to be done. For example, open defecation is practiced and the few latrines are poorly constructed and not used properly. The key problem in the communities is sanitation and practice of personal hygiene.

The Zonal Health Office reported hygiene and sanitation promotion started immediately after the onset of the outbreak. When new cases are reported, case management goes hand-in-hand with hygiene and sanitation promotion activities. Notwithstanding the hygiene and sanitation promotion activities undertaken in the affected kabeles, there has been a general increase in cases in the zone since the outbreak was reported

The source of contamination and spread of the disease is personal contact with people who have been to AWD affected areas or CTC and the poor sanitation level in the communities. EMWAT Kits is installed at Chafa Guta and Danshe to treat turbid river water for drinking. Based interviewed held with communities using the EMWAT kit, it was confirmed that water from the river is still used for other household activities such washing of utensils and food. Also it was noticed that the household use the same containers to collect water from EMWAT kit and the River. These are possible sources of contamination that needs serious attention. The installation of these kits has contributed to the decline in AWD cases. However, as noted earlier in the report, cases are still being reported. This reaffirms the lack of sanitation and hygiene and personal contact with affected people as the possible main cause of the spread of the AWD.

The present distribution of water purification agents such as Water guard, PUR and water Maker is tiered to the supply available and the reported AWD cases in the various kabeles. Households of affected Kabele are given water makers and PUR if their source of water is River while water guard is given to household using wells and piped water. The Team noted that distribution of these water purification agents are not done taking into account the number (percentage) of households that will be reached for a specific time in order to achieve a break in the spread of the AWD.

In Sidama Zone, mass education programme is given in market areas, religious institutions, trade centres such as butchery and restaurants. House-to house educations have been conducted by HEW, community leaders, health promoters and health workers. Awareness creation through the education of transmission and prevention are communicated to the public through local radio (Sidama Radio). HEW conducted assessment and report their finding to their immediate supervisors. Addition to all these, they are also distributing Water Guard to most affected communities starting from 28/07/06. Community health promoters and the health extension workers have been given ORS sachets to distribute to households in the communities.

7 Resources The assessment team observed that staff are working without protective apron and gown. In terms of capacity, some limitations were also observed especially in the area of case management in second command zone based in Dodola. Staff reported that they have been working day and night since the onset of the AWD and the rotation roster is very rigid. This has resulted in staff being exhausted and have negatively impacted the proper management of the centres. Sanitarians were not observed in the CTCs visited and hygiene and sanitation promotion is done by public health nurse professional.

With regards to supplies at the CTCs, even though there are some medical supplies currently available at zonal level for about two to three weeks, there is still the need for additional supplies. This is because of the number of cases are not reducing and rather increasing in the affected areas. Other supplies such bed pans, mattresses, vomiting pans, disinfectant chemicals were reported by the CTC staff and Woreda officials and also observed by the assessment team to inadequate. The list of medical supplied needed is presented in the appendix 3.

The rub hall used as shelter for the CTCs were observed by the team to be crowded with patients and some patients are forced to be admitted and left in the open space with out shelter and bed. This was particularly a problem in Shashamene Health Centre and Jegesa Korke CTC. On the other hand CTCs which are able to accommodate patients in the rub halls lack sleeping beds.

The zone has got some fund from UNICEF and from the Regional Health Bureau to cover the operational cost of the Woredas. This financial assistance is not disbursed on time to the Woredas for quick implementation of activities. For this reason, 48 health professional deployed from Bale Nursing School working in the CTC reported delay in receiving their allowances.

All the CTCs visited do not have enough hygiene and sanitation items such as bed pans, basins for washing, etc.

There are 276 health persons in the Zone Woreda. These professional are not enough to deal the AWD outbreak. To support service delivery, the Zonal administration has deployed 100 students from Shashamene Nursing School at the beginning of the epidemic who are now replaced by 48 students from Bale Nursing School to the affected Kebeles. The table below presents the health professional in West Aris Zone by Woreda Table 7.1. The distribution of health workers by woreda, West Arsi zone. Number Woreda Number of health person 1 Kofele 23 2 Arsi Nagele 48 3 Shashamene 52 4 Asasa 21 5 Adaba 33 6 Siraro 44 7 Dodola 33 8 Kore 13 9 Kokosa 14 10 Nensebo NA Total 276

NA= Data note available

8. Coordination West Arsi Zonal Administration has formed a AWD response and preparedness team composed up of all concerned sectors. For coordination purposes the zone has been divided into two commanding areas. The first commanding area comprises of Shashemane, Kore, Kofele, Arsi- Negele, Shala and Siraro woredas where the coordination teams are based in Shashemane and led by the zonal administrator in close collaboration with the Zonal health department. The commanding area is observed to have very good attention being the zonal capital or in proximity of the capital. It benefits constant supervision from the Oromia Health bureaus and other related departments including the

18 federal Ministry of health. Coordination meetings are held daily whereby committees from woredas present the days findings including data. Gaps are identified and plans put in place to address on the following day. The meetings are also attended by UN and NGO staff deployed to the area. Data is centrally consolidated and analyzed at zonal level and shared during meetings. From the UN, UNICEF and WHO are providing technical and material support. Currently UNICEF is supporting the Zone to establish a system for materials and medical supplies and other resource gaps for the next three months.

The second commanding unit comprises of Dodola, Gedeb - Asasa, Adaba, Kokossa and Nansebo woredas and coordinated by the woreda administration in collaboration with the woreda health office supported by a representative from the Oromia Health Bureau and zonal administration. It was reported that coordination meeting are held involving committees. However it was observed by the teams that there are coordination gaps. Problems identified do not have actions planned to address them. For example in Dodola it was noticed that the water concerns were not addressed and there was no focus to ensure that the wells are chlorinated. Only purification sachet distribution was the strategy put in place. There were shortages of CTC supplies and also funds for logistics were not disbursed as at the time of our visit.

All the affected Woredas with support from the Zonal AWD response team have established Woreda level AWD response teams. It was reported by the Woreda team there are four sub committees (logistic, surveillance and reporting, hygiene and sanitation, and administration & security) chaired by the Woreda Council. This committee hold daily meeting to evaluate activities and plan for the next day.

Even though CTCs are the main source of information for the outbreak and daily reports were compiled including number of cases, new admissions and deaths, there is no information kept at the centres for reference purposes. Admission registers are kept in each center however the team was not able to access any compiled data report at the facility level for verification. All information regarding cases treated and admitted are sent to the Woreda Health Office for compilation on daily basis. The only information available at the Centres are the number of cases treated, admitted, and died on the same day.

9. Gaps and challenges 1. There seems to be limited coordination in the Woreda. There is no link between the Woreda health Office and Woreda Water Office regarding the AWD. As a result there was no planning on resources needs for response. 2. Identified gaps were not addressed which is observed from the second commanding unit. 3. Environmental experts from the regional health bureau was not observed supporting in the containment of the spread of the disease. 4. Isolation, hygiene and sanitation at the CTC are not applied properly or to the requirement. 5. Overcrowding of patients in some CTCs and/or space inadequacy is observed as the one the problem. 6. There are shortage of basic supplies for CTCs like mattress, bed pan, vomiting vowel, kerosene lump, torch, and hygiene and sanitation materials. 7. Health workers are not protecting themselves or are not using gowns and/or apron. 8. Training on case management and CTC management to health workers was not given from the woredas under the second commanding unit. 9. Hygiene messages given are not monitored by Woreda health office or any body else..

10. No IEC material for the current problem is seen at all levels starting from zonal health department to the community level. 11. The response by the community to sanitation and hygiene campaign is very low. This is evident in the improper use of latrines and the reluctance of people to observe basic personal hygiene protocols such as washing of hands after defecating and before eating and boiling of River water before consumption in most affected kebelesIn other words, the majority are not practicing according to hygiene and sanitation. 12. Documentation and reporting is observed far behind the requirement like line listing. Other activities recorded are not compiled and reported. 13. Medical supplies are alright up to the date of assessment but some items are finished while we were in the assessment business and others will not serve more than a week which means no stock for medical supplies. 14. The health workers capacity is overstretched and if the cases are still continuing to occur and more CTCs are opened, there will be critical shortage of health workers. 15. Shortage of operational cost like for the DSA of health workers and non health working in the field related to this AWD epidemic. 16. Water purification materials used at house hold level are not distributed in a way that can influence the transmission.

10. Recommendations and actions 1. Government offices at Weroda level should develop strong coordination mechanisms with the support of the regional government to plan and implement activities that will prevent the transmission and also to manage AWD cases. 2. The zone and woredas should get expertise support in the area of hygiene and environmental sanitation. 3. Notwithstanding the training MSF conducted for staff at the CTC, there is still an urgent need for hygiene and sanitation training for staff especially in the areas of cleanliness, isolation of patients, ensure the proper handling of patients and follow up on patients. The ongoing training for CTC staff being carried out with the support of UNICEF and Merlin is expected to address this situation. This has to be supported by establishing CTCs in an area where there is adequate space to apply the proper activities and by availing the necessary materials for patient care and hygiene and sanitation materials. 4. Health workers at CTCs have to be encouraged and/or supervised to make them exemplary for the personal hygiene and sanitation at the CTCs. 5. Before the opening of a new CTC, the Woreda should make sure that CTC staffs are trained prior to opening and the equipment and supplies needed are available. The zone should continue to assist with coordination with activities especially using the daily evaluation meeting which has been a use forum for taking quick action to manage cases and also contributed to averting a wider spread of the AWD outbreak. 6. The Regional Health Bureau should develop IEC materials in local languages and make available the IEC materials in all health facilities, CTCs and as well in the communities. The Regional Health Bureau should also work with neighboring zones and Woredas on organization of orientation course for health workers, avail existing treatment protocols in all health facilities and carry out health education as soon as possible especially in neighboring Woredas. There should be a mechanism in place to monitor the hygiene and sanitation messages and practices in the community and to reach the affected families in the woredas where the cases are not many to monitor the mechanism of disposing their infectious wastes. The region has to

use the mass media to have a wider overage of hygiene and sanitation messages in the region including the neighboring regions towards to the prevention of AWD till the problems ceases. 7. Proper recording has to be in place at the CTCs and the zone and woredas have to get support in the data management and reporting in a way that would help for monitoring of different aspects of the epidemic and for subsequent actions. 8. Drugs and medical supplies have to be stocked enough at least for two months taking in to consideration the magnitude and the spread of the disease up to now to prevent the rupture which will be a disaster in the intervention process. 9. The regional health bureau should work ahead to supply health workers to the affected Woredas on demand. 10. There should be proper guidance and microplan to distribute household level water purification chemicals to the prioritized Kebeles for higher coverage and adequate time to interrupt the disease spread through water. There should be also enough supplies for water purification. Water Bureau should ensure that communities with piped water have adequate chlorine and residual chlorine is regularly monitored. It is important that chemical and bacteriological analysis of all Rivers used by affected communities should be carried out to ascertain the type and level of contamination. 11. The current operational cost obtained from Regional health Bureau and UNICEF will not be enough to support the AWD response programme longer than expected looking at the current magnitude of spread. Therefore, financial support from donors is urgently needed.

Appendix 1 West Arsi zone AWD Treatment sites and/or woredas Date Shashemene woreda outreach treatment sites A/N H.C Hos. C.G A.I B.F J.D A.D F.G O.J F.G Jigese Water Sh U.D.N Idola O.S.T Shash.T Siraro Kofele Kore Dodola Adaba Kokosa G/ Asasa Zonal.T 22/06/06 1 00000000000000 0 00000000 1 23/06/06 0 30000000000000 0 30000000 3 24/06/06 4 40000000000000 0 40000000 8 25/06/06 7 06000001000000 1 7000000014 26/06/06 2 125000000000000 0 17000000019 27/06/06 5 112000000000000 0 13000000018 28/06/06 3 04000000000000 0 40000000 7 29/06/06 0 85000000000000 0 13000000013 30/06/06 6 1119000000000000 0 30000000036 1/7/2006 7 314100000000000 1 18000000025 2/7/2006 14 1017700115000000 14 41000000055 3/7/2006 25 83310101014000000 26 67000000092 4/7/2006 23 292832201025000000 601170000000140 5/7/2006 28 202529200035000000 661112000000141 6/7/2006 17 32386833147290000001241945000000216 7/7/2006 47 3023402429233170000001361896000000242 8/7/2006 27 2825492630482070000001802338000000268 9/7/2006 38 362138261558393800000021427114000000323 10/7/2006 60 253152171826162117000001672235000000288 11/7/2006 53 29184232591315461518000024028747000000387 12/7/2006 20 39192014495931212519000023829615000000331 13/07/06 25 2923226253318224512000018323533000000293 14/07/06 59 22152322243410242014000017120811000000278 15/07/06 5 5213171594113161914000014420918000000232 16/07/06 25 28162810413622196000010815216400000197 17/07/06 41 2926202622320330000 7913415600000196 18/07/06 31 4928102010163131030000 8516226302000224 19/07/06 41 36122344731613160000 8613415000000190 20/07/06 40 32131411177102714000 7311815101200177 21/07/06 30 29184040520719300 44 9116202005146 22/07/06 60 4018714031006122200 6512318309000213 23/07/06 39 263410406619924140 7413422202520206 24/07/06 38 39378031322141410150 8115711304300216 25/07/06 41 56481102028061426170 8619015100584264 26/07/06 51 4146105137041527190 821696503001235 27/07/06 48 4042001021042636160 8616845012117246 28/07/06 58 2635203031042831180 901511301211218 29/07/06 55 401600018304212210 601164503102186 30/07/06 57 342200321600852394 7012643611100208 31/07/06 56 2422001310308527161588134 3 4 14 12 1 0 0 224 1/8/2006 67 3980020114009605211121595298100251 2/8/2006 97 1523006081048228258212047115170252 3/8/2006 92 12120020800041073566 902609500204 4/8/2006 63 2625004090046135418213305050314223 5/8/2006 6/8/2006 Total 1506 1102 885 566 231 340 435 292 470 190 184 209 356 150 141 3564 5551 366 70 40 78 29 22 44 7706

Appendix 2

West Arsi zone AWD Treatment sites and/or woredas Date s A/N Shash.T Siraro Kofele Kore Dodola Adaba Kokosa asa Gedeb Zonal.T Death.T 22/06/06 1 0 0000000 1 0 23/06/06 0 3 0000000 3 0 24/06/06 4 4 0000000 8 0 25/06/06 7 7 0000000 14 1 26/06/06 2 170000000 19 0 27/06/06 5 130000000 18 1 28/06/06 3 4 0000000 7 1 29/06/06 0 130000000 13 3 30/06/06 6 300000000 36 1 1/7/2006 7 180000000 25 5 2/7/2006 14410000000 55 0 3/7/2006 25670000000 92 0 4/7/2006 231170000000 140 1 5/7/2006 281112000000 141 0 6/7/2006 171945000000 216 3 7/7/2006 471896000000 242 2 8/7/2006 272338000000 268 0 9/7/2006 3827114000000323 3 10/7/2006 602235000000 288 1 11/7/2006 5328747000000387 0 12/7/2006 2029615000000331 1 13/07/06 2523533000000293 1 14/07/06 5920811000000278 1 15/07/06 520918000000232 1 16/07/06 2515216400000197 0 17/07/06 4113415600000196 0 18/07/06 3116226302000224 1 19/07/06 4113415000000190 1 20/07/06 4011815101200177 0 21/07/06 309116202005146 1 22/07/06 6012318309000213 1 23/07/06 3913422202520206 0 24/07/06 3815711304300216 5 25/07/06 4119015100584264 1 26/07/06 511696503001 235 0 27/07/06 4816845012117246 0 28/07/06 581511301211 218 3 29/07/06 551164503102 186 2 30/07/06 5712643611100208 1 31/07/06 56134341412100224 2 1/8/2006 671595298100 251 1 2/8/2006 9712047115170252 1 3/8/2006 92902609500 204 0 4/8/2006 6313305050314223 1 5/8/2006 6214836110136240 6/8/2006 80 141 0 7 0 15 0 0 10 253 3 7/8/2006 69172113540110275 Total 1717 5551 370 96 46 107 30 26 70 8013 50

Appendix 3 Medical supplies needed

Drugs and Medical supplies needed

S.N. Drugs required Unit Quantity Quantity needed Quantity on Hand Gap for three for 2 month on 3 august 2006 days 1 Ringer’s lactate solution Bag 100 60000 5362 of ,1litre with givining set 54638 5 Dextrose 40% 20ml and Bottle 10 6000 800 50ml 5200 12 Amoxicillin Bottle 5 3000 396 syrup,250mg/5ml,100ml 2604 19 Cannula 22G pc 10 6000 136 5864 20 Exam glove M,L Pair 10 6000 27 5973 4 Doxycyciline, 100mg capsule 50 30000 capsule 25800 4200 2 Nasogastric tubes, 2.7 mm Each 5 3000 0 OD. 1.5mm ID (8 French) , 38 cm long for children 3000 3 Nasal gastric tubes 5.3 Each 5 3000 0 mmOD,3.5 mm ID(16French),50 cm long for adults 3000 6 Dextrose 5% Bag 5 3000 261 2739 7 Paracetamole 500mg Tablet 20 12000 0 tablet 12000 8 Aspirine 300mg tablet Tablet 20 12000 0 12000 9 PPF 4MIU Tablet 3 1800 0 1800 10 Furosemide 20mg/ml,2ml Vial 5 3000 0 ampoule 3000 11 Diazepame 5mg/ml Bottle 5 3000 0 ampoule 3000 13 Amoxicilline 500mg Capsule 50 30000 13000 capsule 17000 14 Cotton wool 100g rolls 5 3000 31 2969 15 Abcess Box with 3 Set 1 600 0 instruments 600 16 adhesive tape 7.5cmx10M rolls 2 1200 320 880 17 cannula 16G pc 10 6000 0 6000 18 cannula 18G pc 10 6000 1000 5000 21 Ordinary blade pcs 10 6000 200 5800 22 PVP 10% 200ml Bottle 2 1200 0 1200 23 Register Pc 1 600 0 600 24 Scalp vein set Pc 10 6000 31 21G/Butterfly 5969 25 Sphygmomanometer Each 2 1200 4 1196 26 Sthethoscope Each 2 1200 4 1196 27 Syring with needle 50ml pcs 5 3000 5 2995 28 syringe with needle 10cc pcs 10 6000 0 6000 29 Syringe with needle 5cc pcs 10 6000 9600 0 30 Alcohol