RED CROSS SOCIETY Emergency Response to Hepatitis E outbreak in Northern Uganda March to August 2008

BACKGROUND Districts of northern Uganda especially those in Acholi sub‐region are at high risk of epidemic outbreaks. At the height of the over 20 year LRA insurgency in the area; about 90% of the populations of Gulu, Kitgum and Amuru districts were displaced into IDP camps. Out of this, an estimated 59% are still living in the camps. Congestion, overcrowding, inadequate healthcare services, poor water and sanitation facilities and low literacy levels in the camps predispose the IDP population to high morbidity and mortality rates. The ability of the district health teams to timely detect and respond to epidemic outbreaks are limited due to lack of community alert system in most districts, lack of human, financial and material resources needed to effectively prepare for and respond to epidemics and lack of laboratory facilities capable of confirming the epidemic diseases.

Kitgum, one of the districts of Acholi sub‐region in Northern Uganda, started reporting suspected cases of Hepatitis E in the 3rd week of November 2007 when a cluster of 6 cases were notified in Madi Opei HC IV of Lamwo HSD. An outbreak investigation conducted by the District Rapid Response Team (RRT) revealed that the index case was a 40 year old pregnant woman who presented to the health facility on 25 October 2007 with symptoms fitting the case definition of Hepatitis. Laboratory confirmation of Hepatitis E was made in mid December 2007 after samples sent to UVRI – Entebbe were referred to CDC Atlanta for testing. Since then, the epidemic outbreak spread from an initial one sub‐county to 11 sub‐counties and from one district to almost three or four neighboring districts in northern Uganda and West Nile region. By 25th August 2008, a cumulative total of 7,598 cases were registered in Kitgum, Gulu, Pader, & Amuru districts with 119 deaths. Most of the deaths reported are of pregnant women in their trimester, with 60% fatality rate. Earlier on, a total of 23 cases (3 cases confirmed) were reported in a refugee camp in Odravu sub‐county in district from February 9, 2008, but there haven’t been any new cases from there since April 2008.

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South Sudan

Map 1: Sub‐counties affected by Hepatitis E in Kitgum, Gulu, Pader, & Yumbe Districts as of July 4, 2008

Extremely poor living conditions in the IDPs camps due to overcrowding, poverty, low literacy levels, inadequate access to safe water and sanitation facilities are among the key risk factors which have sustained the transmission of the disease for such a long period of time. The poor personal and household hygiene; notably poor hand washing practices, use of wide mouth water storage vessels, communal hand washing, drinking water from streams, open defecations and lack of community ownership of community‐based epidemic response activities further compounds the problem. These risk factors predispose these communities to cholera, and polio as these diseases are transmitted in the same way and outbreaks due to these diseases are ongoing in the country (cholera) and in neighboring DRC.

With financial support of CHF 157,310 raised from the Federation’s DREF application, the Uganda Red Cross Society through joint operation by the Disaster management and Health & Care departments, is playing a crucial role in controlling the epidemic in the affected districts through the local Kitgum branch in collaboration with local and international partners like the line Ministry of Health, World Health Organization, Unicef, AMREF, IRC etc. The following activities under 3 specific objectives were undertaken with commendable achievements that greatly contributed to the reduction of the spread of the disease in the target IDP communities in Agoro sub‐county in that the District Task Force allocated to the URCS as lead agency. Water, Sanitation and Hygiene promotion activities being undertaken include, provision of sanitation facilities through construction of household latrines in the Agoro main IDP camps; provision of hand washing facilities in the constructed latrines; distribution of soap for hand washing; hygiene education using various channels but largely reliant on the community based volunteers & VHTs using the Participatory Hygiene and Sanitation Transformation (PHAST) tools. Enforcement of Public Health Act, regulations and By‐laws on hygiene passed by the district council is also being done by the local authorities.

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Water, Sanitation and hygiene promotion Goal The overall objective of the intervention was to reduce the spread of Hepatitis E virus through heightened health education, hygiene promotion and sanitation facilities that mitigates the impact of the disease.

Specific objective 1:

To build the capacity volunteers in Kitgum Branch to support MoH efforts aimed at improving effective response to the Hepatitis E virus outbreak

Activity 1.1: Re‐activate the 100 CBFA volunteers for further training in general HEV information, PHASTER Methodologies and social mobilization skills

One hundred and four (104) community based volunteers that integrated the Village Health Teams (VHTs) were mobilized, trained, equipped and have continued to undertake social mobilization, door to door hygiene promotion campaigns and provision of safe water chain for the population un Agoro sub‐county. Besides, 51 local council one (LC1) leaders that were oriented are being supported to work together with the volunteers in conducting social mobilization, home visits, inspection of the latrines and hand washing facilities’ utilization, as well as promoting adherence to the set by‐laws against drinking of local brew (kwete), use of water from Okura river stream, latrine construction etc. The consistent work of these volunteers been contributed to the steady reduction in the trend of hepatitis E in Agoro sub‐county.

Figure 1: volunteers getting participate in PHAST training in Agoro sub‐county equipping them to undertake household hygiene through the same method hence reduce Hepatitis E disease spread in the community

Social mobilization strategies being employed include mobilization of community to encourage them to dig their own latrines (where slabs are provided by partners), regular camp clean up exercises that

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takes place once in a week; community dialogues/interpersonal communications through public meetings/rallies and volunteers/VHTs, focus group discussions, drama, & news media. Also, radio talk shows and jingles are being sponsored by other members of the task force (OXFAM, WHO) to promote public awareness about the disease and control measures also uplifting the hygiene situation in the target IDP camps.

Besides, the volunteers have been involved in active case search of the suspected Hepatitis E members in the camps being guided by the community case definitions developed, and then referring them to health facilities for verification of diagnosis. This has assisted the task force in surveillance that has been strengthened and active reported cases at the health facilities have increased tremendously leading to the increased cases recorded in the epi. database. The communities have also improved their health seeking behaviors.

Activity 1.2: Provide logistical and technical support to Kitgum Red Cross Branch for effective response.

A land cruiser vehicle was deployed in Kitgum to facilitate community mobilization and monitoring activities in Agoro sub‐county where URCS is the lead agency. In order to improve the URCS’ technical capacity on the ground, a volunteer with technical background on water and sanitation was deployed in Kitgum Branch for a period of one and half a month supporting the Branch Field Coordination with training of community volunteers, supervising their hygiene promotion, home visits and water chlorination activities, coordinating the sub‐county task force activities and supervising the latrines construction in collaboration with the sub‐county health assistant, sub‐county chief, camp commandants and other local leaders. After the expiry of this short contract of the volunteer, the operation started to make use of the local technical capacities by ffacilitating the sub‐county Health Assistant with daily incentives and fuel for the motor cycle to help in supervising and monitoring the VHTS’ as they carry out hygiene awareness/education in return sites

A digital camera was procured and sent to Kitgum branch to facilitate documentation of the intervention activities and promote evidence‐based reporting of the situation on the ground. This boosted the branch’s capacity and quality of reports and will therefore promote local capacity building.

In order to promote real‐time reporting of field activities and timely submission of the disease’ epidemiological updates, a GPS communication equipment was procured with fully paid 12 months subscription from MTN Uganda and delivered to Kitgum branch for the BFC to access the internet and submit timely reports and updates by electronic mails.

Activity 1.1: Construction of 100 stances of latrines in Madi Opei IDP camp to improve on latrine coverage and stop the open defecation

Out of the 100 stances of household latrines planned to be constructed in the IDP camp, an actual number of 264 stances (137 household latrine blocks) were constructed with a similar number of hand washing facilities that have been installed and already in use by the communities in Agoro main IDP 4

camp. The achievement beyond the target by over 100% was due to the fact that the needs on the grounds changed requiring us to construct many stances and so, a more economical and adoptable technology of household, as opposed to communal latrines were constructed. This was as well done in order to promote household ownership and improve on maintenance as opposed to communal ownerships. This has contributed to a remarkable increase in latrine coverage in the sub‐county and what remain are the soft‐ware issues that promote effective usage and maintenance of the facilities.

Due to poor soil texture, some of the latrines collapsed and were re‐worked on by the contractors under the supervision of the sub‐county Health Assistant, and the Ministry of Health environmental health division. The best way to avert this problem was to construct drainable latrines that could withstand any pressure on the loose soil, depending on the availability of resources and the urgency of the facilities.

Figure 2: part of the 137 latrine blocks built in Agoro main IDP camp under final inspection & handover to the community for use hence stop the open defecation.

Activity 1.2: Procure and distribute water purification tablets at household levels.

Initially, ten thousand (10,000) aquatabs were procured and used by volunteers for chlorination at points of collection to provide safe water to the IDP communities. Chlorination is continuing in 21 water points (boreholes) in Agoro Sub County including some return sites where 2 volunteers are deployed daily at each of the water points from 6:00am to 6:00pm. Later on, an additional three hundred fifty nine thousand (359,000) pieces of water purifying tablets from the balance of stock meant for the Uganda floods operation were delivered to Kitgum to promote consistent supply of safe water. By the time of reporting, a cumulative total of 1,740,000 litres of water were already chlorinated. This has helped to reduce the spread of new HEV infections amongst the beneficiary communities.

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Figure 3: some of the trained volunteers conduct water chlorination at boreholes in return sites in Agoro sub‐county

Provision of clean water storage containers and soap to promote safe water chain and personal hygiene had not being done by end of August due to the lack of the facilities, but there is hope of receiving adequate supply of 12,078 pieces of 20‐litre capacity jerry cans and 6,039 bars of laundry soap from ICRC following the previous request submitted and subsequent assurance received. These water, sanitation and hygiene Non‐food items will be distributed to the target 9,039 households in Agoro sub‐county so as to help in cutting the HEV transmission chain as it is known that there is a very high level of water contamination at household levels due to the poor water storage and utilization practice from the wide‐mouthed clay pots.

Objective 2: To increase community awareness surrounding Hepatitis E virus prevention and control in the target IDP camps.

Activity 2.1: Carry out social mobilization activities at community gatherings and door‐to‐door sensitization in partnership with the village health teams and community leadership

Apart from the community health education, & door to door health promotion activities bring undertaken, the volunteers are as well engaged in the mobilization of the communities for general clean‐up activities of the water sources and the camp surroundings which is a recommendation from the local leaders to be done twice a week (Wednesdays and Saturdays).

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Figure 4: orientation of community leaders on Hepatitis E & Figure 5: volunteers conduct community awareness empowering them in social mobilization skills session in Potika parish – Agoro sub‐county

Despite the concerted social mobilization efforts by the volunteers, VHTs, & local leaders with the aim of promoting behavioral change to reduce the spread of the disease, the numbers of cases in all the affected sub‐counties in the district are contrarily increasing ‐ confirming the need to revisit the ongoing social mobilization strategies.

Figure 6: orientation of volunteers on home visits checklist at Agoro IDP camp

Activity 1.2: Develop, produce, translate and distribute posters, brochures and T‐shirts in Luo language for community education and awareness creation Procured and distributed assorted IEC materials with Hepatitis E messages (20,000 Posters, 35,000 Brochures and 450 T‐shirts) in Agoro, Potika A and B, Oboko parishes in Agoro sub‐county through the

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volunteers, VHTs and local leaders while other copies were donated to the MOH film van and the DHE to distribute in the other 19 sub counties affected by the disease. Besides, more than 1,000 copies of the posters and brochures were given to WFP to distribute to the public as they are undertaking food ration distribution in the other affected and non‐affected IDP camps.

Figure 7: Copy of the only leaflet produced by the URCS and distributed to promote public awareness about Hepatitis E virus

To promote public awareness about the little known epidemic at the national and international level, the URCS communications department has been engaging the print and electronic media to publicize URCS epidemic response activities in the newspapers and radio broadcasts, as well as posting updates on the URCS websites.

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Figure 8: A Newspaper cutting from the Daily Monitor recognizing the URCS’ contribution towards the Hepatitis E outbreak prevention

These have promoted the URCS’ corporate image as well as acting as an accountability to the donors of resources that were collected and utilized in the operation. Objective 3:

Improve the cooperation of the URCS with MoH, UNICEF, WHO and other key stakeholders on current and upcoming Hepatitis E response programmes As the lead Organization in Agoro sub‐county, the URCS has constantly been monitoring the Hepatitis E situation, through the local branch in Kitgum and the strong presence of community‐based volunteers in the affected sub‐counties.

At the national level, the taskforce sitting at WHO where the URCS is a member is sub‐divided into 5 sub‐committees namely coordination, case management, epidemiology and laboratory, water and sanitation, social mobilization and logistics. At the district level, the taskforce has 4 sub‐committees namely coordination, surveillance/ case management, water and sanitation and social mobilization.

As the lead agency, the URCS replicated and established a multi‐sectoral sub‐county taskforce in Agoro to ensure effective coordination of the response efforts. Gulu and Pader districts have also established Hepatitis E task forces to coordinate the epidemic response in the districts.

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Figure 9: a sub‐county coordination meeting taking Figure 10: members of the district & national task place at Agoro sub‐county headquarter force hold a community dialogue in a return site during a joint field monitoring visit facilitated by the URCS.

National Society Capacity Development Objective 3:

To strengthen URCS’ visibility and image in the community

Activity 3.1: Procure and provide volunteers with gumboots, raincoats, megaphones and caps

110 pairs of gumboots and 304 T‐shirts were procured and distributed to the trained volunteers including local council & other community leaders in Agoro, and Potika IDP camps. In order to facilitate effective health education and social mobilization in public gatherings like market places, churches, schools, army detaches etc six (6) megaphones were procured and sent to Kitgum and were effectively being used by the volunteers and local leaders to boost this activity.

Figure 11: the trained volunteers are equipped with T‐shirts, gumboots, and IEC materials ready for the task

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Monitoring and evaluation of the interventions Regular monitoring of the situation and the progress with the implementation of the planned action in a timely and effective manner has been undertaken by the URCS programme staff at the headquarters, regional centre and the central Governing Board (Health & Care sub‐committee) in addition to the operational joint field missions of the National Task Force (wash partners) and the District Task Force.

The epidemic response will therefore be evaluated jointly by the national and district task forces at the end of the emergency. The evaluation will review the timeliness and effectiveness of the response. An evaluation team will be established and it will use several methods including review of reports, field visits, focus group discussion, and interviews with key informants within the WASH cluster, the districts, MoH, UN agencies, OPM, and NGOs. Lessons learnt and best practices will be documented and used to inform decisions in preparedness and response to future Hepatitis E outbreaks, and will also be transmitted directly to the URCS local branches.

Coordination and Networking.

• There has been very close and good networking with other stakeholders namely Ministry of health and WHO –these have trained our volunteers in both prevention and psychosocial support which the volunteers are using for social mobilization .In addition there has been good networking with and WFP and MSF in the response operations. • There has been sharing of updates on response progress through meetings at both Field and National levels through the established task forces. The National Task Force meetings have been coordination by WHO and MOH at while the Field levels meetings have been coordinated by the District Health Offices and chaired by the Resident District Commissioner (RDCs). Coordination meetings are continuously conducted until the affected districts are declared free of Hepatitis E epidemic. Summary of Achievements

• Establishment of multi‐sectoral taskforces at Agoro sub‐county and representation at the National and District Task Forces to ensure effective coordination of the response efforts • Case management is being done at health facilities level although there are major constraints with availability of district health workers. The available staff at the treatment centres, mainly supported by partners, have been trained on hepatitis E case management and treatment guidelines printed and widely distributed with support from WHO & MoH • Active surveillance has been strengthened and active case search is being conducted in Agoro main camp and return sites by URCS volunteers & VHTs who refer the suspected cases to health facilities for verification of diagnosis. • Water, Sanitation and Hygiene promotion activities being undertaken include chlorination of water at point of collection, provision of sanitation facilities through construction of 137 household latrine blocks (274 stances) in the Agoro main IDP camp; provision of hand washing facilities at the constructed household latrines; hygiene education using various channels but largely reliant on the volunteers and VHTs using the Participatory Hygiene and Sanitation Transformation (PHAST) tools. Enforcement of Public Health Act, regulations and By‐laws on hygiene passed by the district council is also being done by the local authorities as the URCS volunteers only help to promote its 11

awareness amongst the IDP communities • Social mobilization strategies that have been employed include mobilization of community to encourage them to dig their own latrines where slabs are provided, regular camp clean up exercises; community dialogues/interpersonal communications through public meetings & rallies with the volunteers, VHTs and opinion leaders, focus group discussions, drama, news media and radio talk shows and jingles (sponsored by Oxfam GB & Unicef). • There has been strengthened network and collaboration with other humanitarian players in the response mainly with, Federation, the ICRC, WH0, UNICEF, Ministry of Health, MSF, IRC, AMREF, and Oxfam GB whom have provided technical support and joint planning and coordination of the response activities that has enabled Uganda Red Cross Society to effectively respond to the outbreak in the affected communities.

Challenges /Gaps

• There is still low latrine coverage in the affected sub‐counties, especially in the return sites coupled with poor operation and maintenances of the latrine stances provided in Agoro main IDP camp. • There is a string belief in Agoro sub‐county and other parts in Kitgum district that the epidemic is from evil spirits and not water borne, coupled with a strong belief in drinking water from Okura & Aringa streams and use of these water sources for making local brew (kwete). All these local beliefs promote the spread of the disease, rendering interventions fruitless. • The current dynamics of population movement between camps, return sites and home villages is impeding the effectiveness of WatSan implementation that is aimed at reducing the spread of Hepatitis E virus • There is total reluctance and resistance by the community to adapt behavior change and poor participation of community leaders • The decreased food ration to the IDP communities by WFP is giving priority to livelihood interventions as opposed to construction of latrines • The multipurpose use of VHTs makes them not dedicated enough in Hepatitis E tasks and responsibilities. Some VHTs are being used for different interventions like indoor residual spray ongoing in the Kitgum district and so calling for rationalization of the use of VHTs. • Changes in Volunteer allowance from 5000/= per day to 5,000/= per week has reduced their participation and some have left joining the indoor residual spraying against mosquitoes there by reducing number. • As a preparedness strategy, it is foresighted that given the current rainy season, it was most likely for cholera to break out soon in Kitgum and that will make matters worse if it adds on the existing Hepatitis E conditions. • Since the Hepatitis E response Appeal was launched in July 2008 after the DREF funds were exhausted up amidst increasing trend of the epidemic, the amount of money so far received has been meager and inconsistent that cannot manage the response for the planned period of 6 months to completely contain the out beak .There is therefore need for more aggressive resource mobilization strategy from both the Local and international partners to fill up the Budgetary gaps.

Recommendations /suggestions • Given the emergency nature of this operation, participating agencies should be encouraged to use funds at hand to start and sustain implementation pending the time the donors fulfill their 12

pledges. This will ensure timely and consistent intervention that promotes effective strategy of disrupting the spread of the disease with minimal attack and fertility rates • Follow ups should be made to the partners where the appeal was submitted to raise more funds to sustain the activities like water chlorination and hygiene promotion that is already started and launch new strategies like procurement and distribution of latrine digging kits to IDP communities to promote provision of sanitation facilities in the return sites, hence decongesting the crowded main IDP camps until these areas are declared Hepatitis‐free. • Schools should be focus of control activities because of the poor sanitary conditions usually common in schools and the high population is a good avenue for community sensitizations.

Conclusion The contribution of the Uganda Red Cross Society towards scaling down of the spread of Hepatitis E Virus amongst the IDP communities in the country is evident Agoro sub‐county through efforts made in the sole procurement and distribution of Hepatitis E related IEC materials (posters & leaflets), community sensitization, hygiene promotion, home visits and consistent chlorination of water. However there is need for both financial and logistical support to intensify reponse activities until end of October 2008 to completely disrupt the transmission of Hepatitis E in the affected districts. On a general recommendation, if we are to completely stop the spread of the disease, then the WASH cluster members, all humanitarian partners undertaking interventions in the IDP camps in Kitgum and other affected districts including the Ministry of Health should treat the HEP – E within an emergency framework. Besides, the Ministry of Health should review all the man‐power and other resources that it has on the ground to make sure they are adequate to address the problem of lack of medical staff in the rural health facilities, especially those that are undertaking case management of hepatitis E.

Contacts For further information about this operation please contact:

1. Mr. Michael Nataka, Acting Secretary General, Uganda Red Cross Society (URCS); email: [email protected], [email protected]; telephone: +256-0414-258701/2, +256-031-2606625/6/7 2. Dr. Baguma Bildard, Ag. Deputy Secretary General, Uganda Red Cross Society (URCS); email: [email protected]; telephone: +256-0414-258701/2, +256-031-2606625/6/7

Website: www.redcrossug.org

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