Northeast Nigeria Response BORNO State Health Sector Bulletin

BORNO STATE GOVERNMENT

Newly arrived IDPs in Rann town, Kala Balge LGA (Photo: WHO)

Northeast Nigeria Response BORNO State Health Sector Bulletin #23 1st to 15th April 2017 6.9 MILLION 5.9 MILLION 1,428,947* PEOPLE IN NEED OF TARGET BY THE HEALTH 1,976,644 IDPS IN HEALTH CARE IN; SECTOR; ADAMAWA, POLIO VACCINATED CHILDREN ADAMAWA, BORNO AND BORNO AND YOBE BORNO STATE YOBE STATES STATES HIGHLIGHTS HEALTH SECTOR

 According to round XV of the Displacement Tracking Matrix (DTM) assessment report as of 31 March 2017, the estimated 21 HEALTH SECTOR PARTNERS number of IDPs in Adamawa, Borno and Yobe is 1,832,743 HEALTH FACILITIES** (326,010 households), representing a decrease of 77,223 288 (4%) from the figure of 1,899,830 in the last round. The key FUNCTIONING** (OF TOTAL 749 ASSESSED HEALTH FACILITIES) reasons for population movement continue to be to return to their place of origin and to search for livelihood 262 FULLY DESTROYED 215 opportunities. Some more people were also displaced due to PARTIALLY DAMAGED continuing military action and in some instances, due to IDP CAMPS CUMULATIVE CONSULTATIONS communal clashes. Borno continued to host the majority of IDPs (1,428,947), followed by Adamawa (146,605) and Yobe 213,282 MEDICAL CONSULTATIONS*** (116,619). EARLY WARNING & ALERT RESPONSE  The SMoH Rapid Response Team (RRT) mechanism has been 149 EWARS SENTINEL SITES 87 REPORTING SENTINEL SITES re-activated under the umbrella of the Health Sector Coordination, and with the support of WHO, UNICEF and 20 TOTAL ALERTS RAISED**** partners to respond to the looming threat of Cerebro-spinal Meningitis (CSM) epidemic which has already affected at least VACCINATION five states in Nigeria. A series of trainings for clinicians, nurses and laboratory scientists of secondary health-care 1,976,644 POLIO facilities is taken place in Maiduguri and Biu LGAs. IPV & OPV*****

 Rainy season is on the way for which partners need to be SECTOR FUNDING, HRP 2017 prepared in terms of prepositioning of medicines stock and supplies. Cross border collaboration between partners 93.8M US$ – HRP 2017 REQUIREMENTS working on Nigeria and Cameroon sides is the utmost priority 6.3 MILLION USD FUNDED (6.7%) during the rainy season. Inter country or cross border 2016 UNMET REQUIREMENTS collaboration will be needed for 3 locations at Nigaria- 11.8 MILLION USD FUNDED (22%) Cameroon border i.e. Rann, Ngala and Banki while at Niger 53.1 MILLION USD REQUESTED border Damasak/Mobbar is high priority area.

* Total number of IDPs in Borno State by IOM DTM XV April 2017. ** MoH/WHO HeRAMS December 2016. 1 *** Cumulative number of medical consultations at the IDP camps from 2017 Epidemiological Week 1- 13. **** The number of alerts change from week to week. *****Number of Polio vaccinated children in the Outbreak and Response campaign (IPV Inactivated Polio Vaccine & OPV Oral Polio Vaccine) as April 2017 Situation update:

The risk of outbreaks of meningitis, cholera and malaria is high which will further increase with the start of the rainy season in May. Preparedness plans are already in place and efforts are ongoing for mitigation and control of the outbreaks. Prepositioning of medicines stock and supplies is the utmost priority before start of the rainy season in order to control further deterioration of the health situation. During rainy season cross border collaboration will be needed for three locations at Nigerian-Cameroon border i.e. Rann, Ngala and Banki while at border with Niger the priority area is Damasak in Mobbar LGA.

The Cerebro-spinal Meningitis (CSM) outbreak currently affects 25 Local Government Areas (LGAs) across six states i.e. Zamfara, Sokoto, Katsina, Kebbi, Niger, and Yobe. Fika LGA in Yobe State have reported NmA while no NmC has been reported in Yobe. According to situation report of NCDC/FMoH as at April 13, 2017, a total of 5,695 suspected cases have been reported; 221 (4%) are laboratory confirmed; 611 deaths (10.9%) have been recorded. As Nigeria is located in the Meningitis belt, cases of Meningitis are reported every year. Although Serotype A was identified mainly in previous years, the predominant serotype that has been identified this year is serotype C. The CSM season is usually taking place from March to June. A number of 41 suspected CSM cases were reported so far through the Early Warning and Reporting System since September 2016. The last case reported was in week 13 from Askira Uba and tested positive with RDT as CSM nonA/nonC serotype (pending on culture and serotyping results). Also, clusters of CSM have been reported lately from Yobe State, the latest including 25 cases characterized by serotype A reported in Fika LGA in south Yobe. WHO, UNICEf, NCDC and Health sector partners are supporting the state MoH on preparedness activities to mitigate and control risk of CSM outbreak.

For cholera preparedness and coordination, a task force has been established under SMoH supported by WHO and UNICEF. The cholera preparedness plan has been prepared for NE Nigeria which is regularly updated in consultation with SMoH and partners. The State MoH with the support from health sector, WHO and UINCEF, produced a dashboard to monitor planned activities from comprehensive cholera response work-plan. WHO supported the State MoH on training of cholera case management. SMoH and WHO jointly conducted a training of Rapid Response Team for Acute Gastro Enteritis and cholera surveillance, investigation and water, sanitation and hygiene. WHO logistic team is working on the prepositioning of cholera kits in areas that are at risk of cholera outbreak and with a difficult road access during the rainy season. For management of initial cholera cases two state hospitals (Fatima Ali Sharif hospital and Muleh hospital) have been identified in Maiduguri, Borno state.

Public Health Risks and Needs

 6.9 million people are in need of humanitarian health services including more than 1.7 million internally displaced people living in more than 100 IDP camps across Adamawa, Borno and Yobe states.  Cholera and meningitis, Viral Haemorrhagic Fever (VHF) such as Lassa fever, outbreaks are an increasing threat; full preparedness and response plans are ongoing.  Active surveillance for Polio and Acute Flaccid Paralysis remain extremely active.  Measles outbreaks continues to be a challenging to be contained.  The need for food assistance is likely to increase even further in the coming weeks.  Qualified health human resources, essential medicines and the destruction of medical facilities continues to hamper the delivery of lifesavings health interventions

Surveillance and communicable disease control

. Polio: No new cases of polio have been reported. A nationwide immunization plus days against polio took place between 25th -29th March, 2017 in 25 LGAs out 27 in Borno state.  The epidemiological data collected from 33 IDPs camps across Borno state shows cases of 2,750 for malaria, 2,628 for respiratory tract infection, 1,050 for diarrhea and 43 cases of measles during week 13. . Early Warning Alert and Response System (EWARS): In Epidemiological Week 13 - 2017, a total of 87 out of the 149 reporting sites (including 20 IDP camps) in 13 LGAs submitted their weekly reports. Completeness of reporting was 58% and timeliness was 74% (target 80% respectively). Twenty indicator- based alerts were received and 90% were verified.

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Malaria: Between Epi Weeks 34-2016 to Week 13-2017, a total of 188,406 suspected cases and 111,941 confirmed cases of malaria were reported. In Epidemiological Week 13, 3101 cases of confirmed malaria were reported with three malaria deaths, one at Federal Training Center Camp Deloris Camp Clinic A and two at Chibok General Hospital. 8000

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Number of cases - below 5 Number of cases above 5 Weekly trend of malaria cases reported through EWARS in Borno State from Week 34-2016 to Week 13-2017

. Acute Watery Diarrhoea (AWD): the number of AWD seems to re-increase in the past 3 weeks with 1371 cases reported in week 13. No death due to AWD was reported in week 13

Weekly trend of AWD cases reported through EWARS in Borno State from Week 34-2016 to Week 13-2017

. Measles: Between Epi Weeks 34-2016 and Week 13-2017, a total of 2,817 suspected cases of measles were reported from EWARS reporting sites in 13 LGAs. In Epi Week 13, 79 suspected cases were reported. They included 11 cases each from Dalaram PHC, and Gunda CHC, 6 cases each from Farm Centre Camp Clinic, Maimusari PHC, Yimirdalang PHC, 4 cases from Madinatu Camp Clinic, 3 cases each from Balbaya Model Health Centre, CBN Quarters Camp Clinic, Federal Training Center Camp Dalori Air Force Camp Clinic, Federal Training Center Camp Dalori Camp Clinic A and Jaradali Clinic.

Weekly trend of Measles cases reported through EWARS in Borno State from Week 34-2016 to Week 13-2017 3

 Maternal death: In Epidemiological Week 13, two maternal deaths was reported  Neonatal death: In Epidemiological Week 13, there were no neonatal deaths reported  Severe Acute Malnutrition (SAM): In Epidemiological Week 13, 938 cases of Severe Acute Malnutrition cases were reported with one death.

Weekly trend of Severe Acute Malnutrition cases reported through EWARS in Borno State from Week 34-2016 to Week 13-2017

Health Sector Coordination

Inter sectoral follow up mission to Rann: Registration of new arrivals from Cameroon, Dikwa, Ngala, Bama and some from surrounding villages of Kala Balge LGA is ongoing in Rann. Average 50 families per day are arriving in camps and host community. 5000 people (912 families) have arrived since 21st March. The camp population reported on 4th April was 50,162 persons. The population is living in the host community in Rann town and three IDPs camps sites namely: General Hospital, Boarding Primary School and Siddegery. Average family size is six. In meeting with community the key needs prioritized were Food, WASH, Shelter, Health, Education and NFIs. More than 8,000 shelters are needed for new arrivals and for some families already living in camp.

Key health service providers are:

1. ICRC – PHC clinic with RH services for ANC and PNC 2. MSF-Swiss (operating from Cameroon 10days/month) 3. SPHCDA health facility supported by UNICEF with monthly stipend for staff and health-nutrition supplies. 4. WHO – Hard to reach Teams, CORPS volunteers, Polio immunization teams ICRC is running a health facility on 24/7 basis with 20 staff including doctors, nurses, midwives and support staff. RH services are available with 8 matrices (no beds). Safe deliveries are conducted in the labour room which is in the tent. Midwives are also conducting safe deliveries at homes. Enough stock of medicines available in the health clinics. From the consultation register the main diseases are malaria, diarrhoea and respiratory infections. Only one measles case was reported in last two months. According to medical staff of the health facility no risk of measles at the moment. No meningitis cases reported. Referral services are weak as ambulance services are not available. The patients are normally taken through civilian transportation to Maiduguri with security support from military. Some patients are taken to secondary level health facility to the neighbouring Cameroon. RDT kits are available at ICRC clinic. No information available on the mortality ratio.

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OXFAM and ICRC are supporting water supply through water bores but not enough as long ques of women and children were seen at the water points. Hygiene is a big issue especially open defecation due to lack of enough number of latrines. Weak hygiene promotion and awareness among the community for both environmental and personal hygiene was noted in the community. No stabilization centre for severe acute malnutrition children.

Five cases of snake bites reported in the camp, anti-snake venoms required at field level. Polio campaign was conducted last month. Children of new arrivals are vaccinated for polio at registration/entry point before coming to camps.

Recommendations:  Rainy season is on the way partners need to be prepared in terms of prepositioning of medicines stock and supplies to control the deterioration of the health situation. Cross border collaboration between partners working on Nigeria and Cameroon sides is the utmost priority during the rainy season. Inter country or cross border collaboration will be needed for 3 locations at Cameroon side i.e. Rann, Ngala and Banki while at Niger side Damasak/Mobbar is high priority area.  Malaria cases are increasing which means more LLINs, RDTs and anti-malarial drugs will be needed in coming weeks.  Diarrhoea cases will increase in coming rainy season which means Diarrheal Disease Kits-DDKs will be needed in large numbers. The priority areas for prepositioning of diarrhoea/cholera kits are Rann, Ngala, Gamburu, Banki and Damasak as the access to these areas is very challenging during rainy season.  Nutrition support need to be enhanced along with food distribution to keep the malnutrition cases under control from further deterioration. For malnourished children plumpy nuts and other nutrition supplement are needed.  WASH Sector support is urgently needed specially for health and hygiene awareness and community mobilization for mitigating risk of outbreaks. Number of latrines are not enough need immediate support for additional latrines as population is increasing.  For referral service ambulance is urgently needed to take patients for specialized care to secondary level facilities.  The federal MoH mobile health team need to be on ground to fill critical gaps in the health services delivery. The FMoH team have enough human resource capacity to cater the needs of affected population.  More health partners are need to be on ground to improve the health situation as population is increasing every day. The current population is around 50,000 with the new arrivals which means additional 1-2 health clinics will be needed to cater the additional case load. MSF-Swiss health clinic is also 10 days per month which create a gap in health service delivery during the 20 days /month. Findings of the inter sectoral follow up mission to Ngala: There are two clinics next to each other in the camp and one clinic in Gambaru town. There is no clinic in Ngala town, so the clinics in the camp cover the population from there. The LGA Desk Officer identified no gaps regarding health services in the camp although cold storage of medical supplies is a challenge. The first clinic is the government clinic supported by UNICEF in collaboration with FHI360 and ICRC, with two doctors, six nurses and four midwives. The second clinic in the camp is managed by MSF-CH. The Government and MSF clinic have a good collaboration for avoiding duplication. MSF clinic focuses on children from 0 to 5 years old while the government clinic focuses on adults and some paediatrics cases. Both can practice minor surgeries. MSF clinic conducts ANC, PNC, consultations of primary health care, Maternity, OTP and has a stabilization center for malnourished children. MSF receives its medical stock from Cameroon. The Government clinic conducts ANC, PNC, consultations of primary health care, Maternity and OTP. As of the date of the assessment, there were 150 patients in the Government clinic and 180 children being treated for malnutrition. The clinics are far from some areas of the camp in the northern side. UNICEF mentioned that it would be useful to have a health post in these areas as it would support around 30,000 people.

The Government clinic in Gambaru town is supported by UNICEF. There is in-patient support (30 beds), two doctors and nurses. There are vaccination programmes in place reported by UNICEF and MSF. There are vaccination programmes in Gambaru also covering the returnees from Cameroon. Sometimes there are distributions and vaccination campaigns at the same time and IDPs prefer to go to the distributions. The most common health issues are malaria and malnutrition. There are also cases of gastroenteritis, diarrhea, mumps, skin diseases and respiratory tract infections. Some cases are referred to Fotokol and Mada in Cameroon or

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Maiduguri in Nigeria. It seems that there is no ambulance service to Cameroon and no rape service support nor HIV support.

Recommendations:

 There is a need to upgrade existing peripheral health facilities managed by the Ministry of Health as well as increase number of dedicated human resources within health centers, improve their supervision and provide training for staff. Revitalization of community volunteers, upgrade messages and training in community screening of malnutrition is also needed.  In general, partners are also encouraged to ensure immunization activities according to the national protocol for children 0-11 months and for women of childbearing age, establish minimum service Package for Reproductive Health (family planning, birth attended by medical personnel etc.) and maintain flexibility towards mobile clinic activities to ensure care for remote locations.  Additionally, there is a need for an ambulance service to Fotokol. Humanitarian should also urgently address rape and HIV cases and agree on a calendar for their activities to address all the people and not having them to choose between activities.

Health Sector Action

WHO in collaboration with the SMOH has trained 41 health care providers (Doctors, Nurses, CHEWs-Community Health Extension workers, cleaners, security etc.) that would be responsible to manage the isolation centre for VHF (Lassa fever) constructed at the General Hospital Molai. 148 Community resource persons were trained on integrated community case management and on preventive CIMCI-Community Integrated Management of Childhood Illness. Commodities were provided to them for commencement of activities immediately. With this, the emergency team has trained 500 CORPS providing ICCM- Integrated Community Case Management and CIMCI in 25 LGAs of the state.

The physical internal re-arrangement of the 6 warehouses of the CMS continues and will improve visibility as well as the quality of storage. Field data regarding drug consumption have been collected and are being analysed to adjust at best the drug distribution plan. A tented isolation ward has been setup up in Muleh Hospital with a capacity of 32 beds. While its design has been primarily designed to ensured safety of patient and staff in case of VHF, it can also be used for any other highly contagious diseases. With the forthcoming rainy season coming, 9 strategic places have been identified as hot spots for prepositioning of cholera/IDDKs kits based on certain criteria such as accessibility, past epidemiological data, or presence of IDPs camps.

PUI is supporting Yarwa Primary Health Care Centre since 13th March. The total number of OPD consultation for the last two weeks is 1,671. The epidemiological trends, the events illustrate a surge in number of malaria during week 14 about four times of the previous week and this could be due to hot weather forcing people to sleep outside and exposed to mosquito bites. The most common causes of morbidity recorded in the PHCC were URTI and diarrheal diseases over the reporting period.

A total of 757 mothers attended ANC during two weeks, while the overall SRH consultation stands at 777 in two weeks. Four family planning and 12 post-natal care clients were seen during this period. The rate of family planning utilization is very low in this area and health awareness focusing on family planning was given by PHC staff to women who came for ANC/PNC. More efforts are needed on awareness raising in the communities.13 patients were referred to different hospitals in two weeks and majority of the referrals were to government hospitals and two were to MSF facilities. In case of emergency where patients should go immediately to hospital, PUI provides transportations but in non-emergency ambulant cases referral cards are provided. Health

6 awareness is given at waiting areas in Sexual and Reproductive Health unit (SRH)and at general waiting area. Family planning, hygiene, importance of ANC and nutrition were among the topics covered during the reporting period

The SRH unit which was under construction was finalized and Antenatal Care (ANC) activities has commenced. This has solved the problem of space for screening ANC patients and giving health education. The room for ANC is also operational

IRC: Through the integrated mobile clinics in Rehabilitation/renovation of health facility completed in Yarwa PHC (Photo: PUI) MMC, Jere, Konduga and Monguno (Borno State), the IRC reached 3,042 patients (45% children under 5) this month. Sensitization and awareness raising activities, with a particular focus on hygiene, ANC, breastfeeding and meningitis, reached 6,683 people (81% women). The IRC provides RH services at its facility in Bakassi IDP camp and at two Comprehensive Women Centres in Monguno and in Konduga. Furthermore, 4 PHC facilities in MMC-Jere are supported by IRC. The IRC will support the SPHCDA in primary health care services at 20 Housing Estate camp in Gwoza, anticipating a handover from UNICEF in the coming week. In Adamawa State, the IRC supports 20 PHC facilities in Mubi North, Mubi South, Maiha and Michika. Awareness raising sessions in the communities reached 1,448 people. Special sessions were held at schools for 332 adolescent girls and dignity kits were distributed to them. From Mubi, IRC will expand its support to Askira Uba in the coming weeks.

Nutrition

WHO: During the reporting period a total of 6,701 children 6-59 months were screened by hard to reach team in 25 LGAs in Borno state. About 347 (5%) children were identified as Moderately Acute Malnourished (MAM) and 66 (1%) as Severely Acute Malnourished (SAM) according to MUAC measurement. The remaining children (94%) were normal according to the screening exercise. The hard to reach team has screened a total of 52,967 children from January 2017. Out of the total, 3,566 (7%) were identified as MAM and 717 (1%) as SAM. The acutely malnourished children were referred to the nearest CMAM sites for further care and treatment.

The Hard to reach team also conducted health and nutrition education sessions with mothers in their target areas. About 5,076 mothers were given information on the importance of exclusive breastfeeding and introduction of timely and appropriate complementary feeding in the reporting period. As of January 2017 more than 33,395 pregnant and lactating women have been sensitized on appropriate infant and young child feeding practices.

The Stabilization Centre (SC) at Umaru Shehu hospital in Maiduguri was visited during the reporting period. 14 SAM children with medical complications were admitted at the SC on the assessment day and were provided treatment by the SC staff. The SC is following the national protocols and met the sphere standard indicators.

Gaps in response

 Prevention of the further deterioration of the health system in the newly accessible LGAs in the remote areas of Borno state.  Control of ongoing polio and measles outbreaks; cholera and meningitis preparedness; malaria prevention and control measures, to reduce high morbidity levels.  Still critical gaps in the health services need to be filled through mobile teams and outreach services; regular nutrition screening in all the catchment areas, for the timely detection of children who have severe acute malnutrition (SAM), with complications; and community mobilization on key health issues and public health risks.

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 Need to revitalise health facilities damaged or destroyed during the conflict; Prevent further deterioration of the health system by filling critical gaps in the primary health care services, essential medicines and medical supplies to care for the affected population.  The shortage of skilled health care workers, especially doctors and midwives, and their reluctance to work in recently accessible areas, presents a challenge.  In the hard-to-reach or insecure wards, it is difficult to provide affected populations with quality primary and secondary health care services, and with essential medicines and medical supplies.

Resource mobilization

During 2016, the health sector received only 22% for northeast Nigeria. In 2017, the Health Sector funding requirements under the Nigeria HRP-2017 are US$ 93.8 million to provide essential health services to 5.9 million targeted people in three states of Adamawa, Borno and Yobe. The latest funding overview of the 2017 HRP reports shows that health sector is currently 6,313,683 USD (6.7%) funded of the required funding of USD 93,827,598 (FTS/OCHA, 16/04/2017). Health Sector Partners

- Federal Ministry of Health and Borno State Ministry of Health - UN Agencies: IOM, UNFPA, UNICEF, WHO, OCHA - National and International Partners: ALIMA, Action Against Hunger, MSF (France, Belgium, Holland, Spain and Switzerland), ICRC, Medicines du Monde, Premiere Urgence Internationale, International Rescue Committee, FHI-360, International Medical Corps, Catholic Caritas Foundation of Nigeria, Nigeria Centre for Disease Control, BOSEPA, WASH & Nutrition Sectors, Nigerian Armed Forces, Nigerian Air Force & others.

-Health sector updates and reports are now available at http://who.int/health-cluster/news-and-events/news/en

For more information, please contact:

Dr. Haruna Mshelia Dr. Abubakar Hassan Commissionner for Borno State Ministry of Health Permanent Secretary, BSMOH Email: [email protected] Email: [email protected] Mobile: +23408036140021 Mobile +2340805795680

Dr. Jorge Martinez Mr. Muhammad Shafiq Health Sector Coordinator-NE Nigeria Technical Officer- Health Sector Email: [email protected] Email: [email protected] Mobile +23408131736262 Mobile: +23407031781777

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