SEA/EHA/A1
Gujarat Earthquake Relief Mission Third Report of WHO Activities following the Earthquake (1 August 2001 - 31 January 2002)
WORLD HEALTH ORGANIZATION Gandhinagar, Gujarat (India) World Health Organization May 2002 Gujarat Earthquake Relief Mission
Contents
Page
Backdrop 1
Health Sector Coordination 4
Operation Health, Kachchh 15
Malaria Outbreak in Kachchh District- a Case Study 15
District Disease Surveillance Task Force 18
Public Health Laboratory at Bhuj 19
Strengthening of Water Quality Surveillance for Kachchh District 24
Water Quality 25
Capacity Building through Training and Awareness Programmes 27
Water and Sanitation Sector Review Workshop, 29 Ahmedabad, 13 October 2001
Inter-State Meeting on “Gujarat Earthquake: Health Sector 31 Perspectives”, Ahmedabad, 6-9 November 2001
Expansion of WHO Activities in other Earthquake-affected 39 Districts of Gujarat
Report of WHO Activities, 1 August 2001 - 31 January 2002 Gujarat Earthquake Relief Mission
Backdrop
The devastating earthquake that hit the Kachchh district of Gujarat on 26 January 2001 affected 37.8 million people. Housing, schools, roads, communication systems and power lines were all completely destroyed which resulted in a loss of livelihoods as well as lives. The Government of Gujarat and the national and international community responded quickly to this disaster with emergency relief services. The emergency phase lasted until mid-March 2001. Since then, the rehabilitation phase began, keeping in mind the long-term goal of sustainable development. The United Nations Disaster Management Team (UNDMT) in India prepared a comprehensive report on the UN System response. WHO was designated as the focal agency for the health sector response and a cooperating agency for water, sanitation, food and nutrition. From the beginning, WHO was instrumental in acting as a link between the Government and NGOs, and coordinating activities to minimize overlap and maximize available resources. WHO played a vital role in protecting and promoting the health of the people through improving the quality of water supply and establishing a disease surveillance system.
The first quarterly report from 26 January - 30 April 2001, and the second report covering the period 26 January - 31 July 2001 were brought out earlier. This is the third report in the series for the period 1 August 2001 - 31 January 2002.
Report of WHO Activities, 1 August 2001 - 31 January 2002 1 Gujarat Earthquake Relief Mission
The main areas of activity of WHO in the last six months were:
(1) To support the re-establishment and rehabilitation of health services in the earthquake-affected areas with special attention to primary health care;
(2) To provide technical advice to the Government, UN agencies, bilateral agencies and NGOs on priority public health issues in the aftermath of an earthquake;
(3) To collaborate in the health sector coordination;
(4) To support the Government in establishing disease surveillance in the earthquake-affected areas, including an early warning system and capacity building for rapid response to epidemics;
Report of WHO Activities, 1 August 2001 - 31 January 2002 2 Gujarat Earthquake Relief Mission
(5) To provide technical support for emergency repairs of water distribution system, water treatment and temporary distribution, sanitation and solid waste disposal, food safety, vector and zoonoses control; and
(6) To expand all WHO activities in other earthquake-affected districts.
WHO Team in Bhuj (October 2001)
Designation Number
Team Leader 1
Disease Surveillance Coordinator 1
Water and Sanitation Specialist 1
Surveillance Officers (NUNVs) 6
Administrative Assistant 1
Logistics Assistant 1
Information Technology Assistant 1
Data Entry Operator 1
Drivers 7
• Technical advice and coordination in the health response to the emergency situation, disease surveillance, water and sanitation to the Government of Gujarat and other UN agencies.
• Working closely with international and local NGOs to support their activities and assist with coordination within the health sector.
Report of WHO Activities, 1 August 2001 - 31 January 2002 3 Gujarat Earthquake Relief Mission
Health Sector Coordination
WHO was requested by the United Nations Disaster Assessment and Coordination (UNDAC) Team to support public health and health sector coordination in Gujarat through restoration of public health services as soon as possible following the earthquake, and to maintain its presence in the state to help ensure that public health care was given adequate attention in the period of time after immediate relief and before complete restoration of the health services. WHO is the lead agency to support health sector coordination and cooperation amongst international agencies.
• Good coordination between WHO, Government, UN agencies, national and international NGOs. • Thirteen meetings of Health Sector Coordination Group held during the period of six months. • Sub-sector group meetings held regularly every fortnight. • Weekly coordination meetings at Taluka level in four most affected talukas, viz. Anjar, Bhachau, Bhuj and Rapar.
The first health sector coordination meeting was held on 5 February 2001 in the field headquarters of the International Federation of the Red Cross and Red Crescent Societies Field Hospital at Lallan College. Till 30 April 2001, ten health sector coordination meetings had been held, while during the period of six months from 1 May to 31 October 2001, a total of 13 meetings took place.
During the second and third quarters, as the need for intensive coordination decreased, the meetings were taking place fortnightly instead of weekly. The district government health officials regularly attended the meetings. Attendance at the meetings decreased towards the end of the third quarter as many agencies finished their work and left the area.
Report of WHO Activities, 1 August 2001 - 31 January 2002 4 Gujarat Earthquake Relief Mission
Meeting Days in Bhuj
Month Number Dates
May 2 10, 24 June 2 7, 21 July 2 5, 19 August 3 2, 16, 30 September 2 13, 27 October 2 11, 25 November 1 29 December 1 20
WHO is responsible for the health sector meeting minutes and the e-mail system was used effectively to communicate them to government officials in the state headquarters, all the agencies attending the meetings and even to those organizations whose representatives were unable to attend the meetings.
During the third quarter, with the initiative of the Collector and District Development Officer of Kachchh, an executive committee was established. The responsibility of NGO coordination was assigned to UNDP, while the responsibility of health sector coordination continued to remain with WHO.
Meetings at Planet Bollywood, International Federation of Red Cross and Red Crescent Societies (IFRC), Bhuj
Health Sector Meetings on Thursday Time Psychosocial support 9.00 A.M. Reproductive and child health 11.00 A.M. Rehabilitation and prosthesis 2.00 P.M. Health promotion 4.00 P.M. General health sector 6.00 P.M.
Report of WHO Activities, 1 August 2001 - 31 January 2002 5 Gujarat Earthquake Relief Mission
The health sub-sector groups of psychosocial support, reproductive and child health, rehabilitation and prosthesis and health promotion have maintained their schedule of regular fortnightly meetings throughout the six months.
The sub-groups of hospitals and infrastructure restoration were dissolved. The nutrition group was separated and the responsibility for coordination was taken by WFP.
Organizations attending the meetings:
Abhiyan Action Aid American Red Cross FICCI - CARE CESVI (World Aid from Italy) Catholic Relief Services (CRS) Government of Gujarat (GoG) Handicap International Health Services, Bhuj Hospital for Mental Health, Bhuj International Federation of Red Cross and Red Crescent Societies (IFRC) Kutch Vikas Trust (KVT) Life Line Express Merlin Oxfam, India Oxfam, UK Save the Children Fund (SCF), UK Self-Employed Women's Association (SEWA) UNDP UNICEF, Gujarat Voluntary Health Association of India (VHAI) WHO, Bhuj
Report of WHO Activities, 1 August 2001 - 31 January 2002 6 Report ofWHO Gujarat EarthquakeReliefMission Title of Sub-group L e ad Agency M eetings Key Issues
Psychosocial American Red 13 1. Training of teachers and health volunteers. Support Cross (ARC) 2. Innovative activities like painting and essay writing. Activities, 1August2001 3. Diagnostic and counselling camps with the involvement of psychiatrists from the Civil Hospital. 4. Psychosocial Support workers' directory prepared by the lead agency. 5. Extension of activities to other districts. Reproductive and UNFPA / 11 1. Ten mobile vans provided by UNFPA. The activities Child Health Integrated include preventive, promotive, and curative health services. -31January2002 2. Training of traditional birth attendants (TBAs) by various Population & agencies. Focus on increasing institutional deliveries. Development 3. Adolescent girls' fair: an innovative tool. (IPD) 4. Planning for Pulse Polio 2001-2002. 5. Growth Monitoring Campaign linked with measles, immunization and vit.A supplementation. Restoration of UNICEF 3 This group was dissolved in July 2001. Revived again in Health November 2001. Weekly meetings held to assess the Infrastructure progress construction. Prosthetic and Handicap 13 1. Stress on community-based rehabilitation. Orthotic International 2. Attempt to collect trauma-related data from different Rehabilitation agencies, though the quality of data was not good. 3. The compiled data handed over to government authorities for further validation. 4. SAFARI camps to provide care to the needy people. 5. Training activities. Health Promotion Oxfam 13 1. Colourful posters and handouts developed in local language carrying health messages about malaria and personal hygiene. 2. Use of electronic media, religious platforms, street plays. 3. Presence at public fairs. 4. Training activities. 5. Demonstrations, e.g. chlorination. 7 Report ofWHO Gujarat EarthquakeReliefMission
Activities, 1August2001 Gujarat State
ADMEDABAD BANAS KANTHA AMRELI
-31January2002 ANAND BANAS KANTHA BHARUCH PATAN KACHCHH MAHESANA BHAVNAGAR SABAR KANTHA DOHAD JAMNAGAR JUNAGADH PANCH MAHAL KACHCHH KHEDA SURENDRA NAGAR ADMEDABAD KHEDA DOHAD MAHESANA NARMADA NAVSARI ANAND PANCH MAHAL JAMNAGAR RAJKOT VADODARA PATAN PORBANDAR RAJKOT BHARUCH NARMADA SABAR KANTHA PORBANDAR SURAT BHAVNAGAR SURENDRA NAGAR AMRELI THE DANGS JUNAGADH SURAT VADODARA VALSAD
NAVSARI THE DANGS N VALSAD W E 100 0 100 200 S 8 Gujarat Earthquake Relief Mission
Communicable Disease Surveillance and Response
Highlights
• Sustained active involvement of private sector due to regular meetings, transparency in data and consistent feedback. • Weekly epidemiological summary with data analysis and use of Geographical Information System (GIS), also available on the WHO website. • Training of medical officers and paramedical staff for disease surveillance and diseases of public health importance. (Provided technical inputs on biochemical warfare, also). • Epidemic preparedness and adequate response ensured at the district and sub-district level. • Coordinated response to malaria outbreak - mobilization of medicine, fogging and spraying machines, and manpower (Operation Health, Kachchh). • Regular situation review meetings with the health department officials and district administrators. • Development of a platform for crucial review during malaria outbreak through field coordination meetings by WHO. • Provision of equipments and necessary support to establish the Public Health Laboratory at Bhuj.
Report of WHO Activities, 1 August 2001 - 31 January 2002 9 Gujarat Earthquake Relief Mission
Immediately after the earthquake, experienced surveillance medical officers already working under the National Polio Surveillance Programme of WHO (NPSP) in the state and neighbouring areas were mobilized to the worst earthquake-affected district of Kachchh. With technical guidance and direction from the NPSP coordinator of the West Zone, these surveillance officers established an immediate disease surveillance system. Mobile medical teams (approximately 450) mobilized from all over the state were the main reporting units. Very soon PHCs/ CHCs and hospitals became functional in tents and also started reporting.
A surveillance format was agreed upon with the government in the local language, with the assistance of NPSP state surveillance officer located at the state HQ. It was a daily syndromic reporting system and aggregate data were analyzed at the sub-district and district levels. With the same sources and methods for data collection functional all over the district of Kachchh, a regular weekly epidemiological summary (disease surveillance report) was released/published in the health sector coordination meeting. This practice continued in the second and third quarter, which was very well appreciated by all including the senior government officials.
In the second quarter, a new multi-disease standard surveillance format was prepared in consultation with the government counterparts, with inputs from international NGOs. This was a mixed approach in many contexts. It was a disease-specific and a syndromic approach, combining both institutional and field surveillance. It collected aggregate secondary data and primary case-based data in certain identified diseases of public health importance. It involved the fixed and mobile medical institutions of both the state and central governments. It also collected data from short-listed private practitioners and all NGO/Trust hospitals of the district. In addition, international NGOs camped in the field for medical services were also included in the reporting network. This new weekly surveillance system was expanded to include all the state government institutions of the district, i.e. all ten talukas of district Kachchh.
Report of WHO Activities, 1 August 2001 - 31 January 2002 10 Gujarat Earthquake Relief Mission
WHO standard case definitions were accepted in consultation with the Government of Gujarat and treatment protocol advocated. The WHO surveillance unit conducted an exhaustive training programme of all medical officers of reporting units and private practitioners. The topics included were:
v Concepts, principles and methods of epidemiology; v Disease surveillance - reporting and analysis; v Outbreak investigation and epidemic preparedness; v Acute respiratory tract infections; v Diarrhoeal diseases; v Malaria; v Dengue fever; and v Biochemical warfare.
Senior district and state level government officials from the health department, experts from the Regional Family Welfare Centre of the Government of India, Ahmedabad, and independent renowned consultants participated as resource persons in this training programme. This WHO initiative was very well converted into a Continuous Medical Education programme by good coordination between WHO, government and international NGOs. Many NGOs made use of the WHO established training platform for various training programmes on health and nutrition, mental health, prosthesis and rehabilitation.
Report of WHO Activities, 1 August 2001 - 31 January 2002 11 Gujarat Earthquake Relief Mission
Training Category No. PHC medical officers 36 MOs - State dispensary 40 MOs - Mobile team 124 MOs - Community Health Centre 16 MOs - Civil / Referral hospitals 8 Sub-district public health professionals 22 Paramedics / ICDS workers 160 MLVs 245 Private practitioners 57
Presentation by WHO staff of Malaria case study Training course for Medical Officers of Rapar at Bhuj Taluka PHCs at Rapar in Kachchh district
These training programmes were very interactive, with group work and exercises. All the participants took very active interest in them. Through this, medical officers (government and private) were sensitized for epidemic preparedness and trained in reporting, investigation procedures and rapid response.
National United Nations Volunteer (NUNV) doctors with the government counterparts met and convinced the identified private practitioners for the regular reporting. They assisted in collection, compilation and analysis of these weekly reports. They continuously nurtured the system by providing the regular feedback, training and
Report of WHO Activities, 1 August 2001 - 31 January 2002 12 Gujarat Earthquake Relief Mission technical material, chlorine tablets, ORS, IV solutions, chloroquine and primaquine tablets, and chloroscopes. The state government or international NGOs working in the aftermath of the earthquake provided all these medical supply items and equipments with WHO coordination efforts.
In India, private practitioners of a district reported for the first time, throughout the last nine months, in the aftermath of the earthquake. National UNV doctors provided all necessary reporting formats and trained them in the various procedures. Regular technical meetings in the evening using the platform of Indian Medical Association were organized. WHO ensured the participation of senior government officials in this meeting to provide feedback to the private reporting units. The 'Action' component of the surveillance was given proper emphasis in these meetings. Private practitioners extended full support and cooperation to the health department and very much appreciated WHO's efforts to bring the two together. In addition to reporting of diseases of epidemic potential, private practitioners also assisted the government in immunization campaigns, cleanliness drives, health education and hygiene promotion. Their role in controlling the malaria epidemic was very important and appreciated by the government health department. They helped in radical treatment, drug resistance and G6PD deficiency studies, public acceptance of insecticide spraying and fogging, and malaria talks on TV and Radio. WHO ensured proper and timely feedback to all these private reporting units and ensured complete transparency in the data and reporting.
After regular reporting from all over the district, baseline data for certain common syndromes and diseases were worked out. Non-availability of the previous year's data and uncertain/unknown denominator made it very difficult, but in consultation with the state level health officials, the figures used in the last pulse polio immunization campaign (January 2001) were considered as authentic population figures.
Report of WHO Activities, 1 August 2001 - 31 January 2002 13 Gujarat Earthquake Relief Mission
Syndrome / Disease A* B**
Bloody diarrhoea 0.48 0.16
Watery diarrhoea 4.63 1.35
Gastroenteritis 0.13 0.05
ARI 13.33 4.43
URTI 11.03 3.61
LRTI 2.30 0.82
Fever 4.02 1.74
Malaria 0.21 0.11
* Weekly incidence rate per 1 000 children below five years of age in Kachchh District ** Weekly incidence rate per 1 000 persons (all age groups combined) in Kachchh District
An early warning system was established, based on weekly data comparison against this baseline data for the ARI, fever and diarrhoeal diseases. A regular system of weekly situation review meeting with the district officials was established. WHO surveillance officers provided detailed information where action was necessary to prevent/control the rising trend of a particular illness or syndrome.
Hepatitis E in Rapar, food poisoning in Mandvi and Bhuj, cholera in Gandhidham, outbreak of fever in Abdasa and Nakhatrana, and malaria in Rapar and Anjar, are few examples of the use of early warning system. In all cases, proper and timely information to the district authorities and prompt action significantly reduced further morbidity and mortality.
Once the disease surveillance system became fully established, its integration with the polio Acute Flaccid Paralysis (AFP) surveillance, TB control programme, and malaria control programme was worked out in consultation with the concerned officials. Each and every case of AFP got reported immediately and the concerned SMO/NPSP was informed of it.
Report of WHO Activities, 1 August 2001 - 31 January 2002 14 Gujarat Earthquake Relief Mission
With the guidance of ISM/WHO/SEARO, an efficient Geographical Information System (GIS) was established. Every week, WHO and GoG jointly released geographical maps in relation to disease distribution (ARI, diarrhoea, and malaria) as a component of weekly epidemiological summary, which became very well known to all including the district administrators. For medical officers and others, it became an important tool for decision and action.
With the help of WHO/HQ, Health Mapper, customized software was also introduced. An exposure-cum-orientation programme was conducted at Bhuj (district HQ) and Gandhinagar (state HQ) for the officials of concerned departments.
Operation Health, Kachchh
This was a Government of Gujarat initiative. It mainly looked after the epidemic preparedness and diseases of public health importance. Practically, it was a mirror image of WHO's disease surveillance mechanism, but with more field staff to implement various surveillance activities. Under this initiative, the Government of Gujarat deputed a public health expert, Taluka liaison officers and Epidemiologist-cum- Sanitary Supervisor in all four worst affected Talukas and approximately 400 malaria link volunteers. The operation facilitated smooth transition of WHO surveillance system (in the emergency) to the government-owned surveillance mechanism. WHO surveillance officers worked in close cooperation with the government officers for outbreak investigation, reporting, and analysis.
Malaria Outbreak in Kachchh District - a Case Study
In mid-July 2001, the disease surveillance system started giving early warning signals for the impending outbreak of malaria. The analysis also correlated the cyclical epidemiological pattern of the malaria outbreaks in the district, particularly in relation to the rainfall. The district and state officials were alerted and the whole system was charged to tackle the problem well in time. Operation Health, Kachchh officials were
Report of WHO Activities, 1 August 2001 - 31 January 2002 15 Gujarat Earthquake Relief Mission immediately identified as the focal points at the district and sub-district HQ. WHO conducted a rapid training programme of all medical officers and private practitioners regarding epidemiology of malaria, epidemic preparedness, parasitology and biological control, standard treatment including radical treatment, drug resistance (in certain areas of the district) and Early Diagnosis and Prompt Treatment (EDPT).
The weekly surveillance system continued to pinpoint efficiently the problem areas. Government medical officers reported confirmed malaria cases on daily basis over telephone. The weekly reports became a very crucial tool to monitor the epidemic situation. Weekly Taluka field coordination meetings became the platform for malaria situation review. Health field staff, integrated child development service (ICDS) workers and malaria link volunteers (MLVs) working under the Operation Health, Kachchh did effective field surveillance and ensured radical treatment (RT) to all positive patients.
National UNV doctors (WHO surveillance officers) collected positive blood smears/slides from the private practitioners. Trained laboratory technicians of the district malaria control programme verified and cross checked these slides. Field workers provided radical treatment to all positive patients.
The problem started actually due to migrant labourers coming from malaria endemic districts of the state, for the reconstruction work in the earthquake-affected areas. Their screening and fever radical treatment (FRT) and mass radical treatment (MRT) programmes were implemented, with the help of construction contractors and district administrators.
WHO played a very vital role in coordinating the response to this malaria outbreak. Private practitioners were provided with chloroquine and primaquine tablets and were requested to follow National Malaria Eradication Programme (NMEP) treatment guidelines, to ensure complete treatment and avoid drug resistance. The District Malaria Programme of the Government of Gujarat asked for WHO assistance to
Report of WHO Activities, 1 August 2001 - 31 January 2002 16 Gujarat Earthquake Relief Mission compensate for the shortage of insecticide spraying and fogging machines. WHO, understanding the urgency, itself procured and provided five portable thermal fogging machines immediately. WHO convinced IFRC and Oxfam for the same, and they provided many spraying and fogging machines.
National UNV doctors functioned as the backbone of the outbreak investigation and rapid response teams.
During August 2001, an outbreak of fever was investigated in Kurbai village. Serum samples were collected for dengue virus, which ultimately tested positive. But due to timely and proper control measures, a simultaneous outbreak of dengue fever could be prevented.
To tackle the malaria situation during the months of September-October 2001, extra personnel from other parts of the state were called in. Special teams attached to the respective PHCs (under direct supervision and direction of PHC medical officer) looked after each positive case, particularly amongst the camps of migrant labourers.
At the request of the Health Secretary, WHO also coordinated a health education campaign regarding control of malaria. Regular data input and analysis continuously evaluated this campaign. All international agencies including Oxfam, Merlin, CARE, IFRC, and other partners in the field contributed for this programme with the technical guidance provided by WHO and necessary support by the Government of Gujarat.
Weekly Incidence of Malaria in Kachchh
Post-Disaster Week
Report of WHO Activities, 1 August 2001 - 31 January 2002 17 Gujarat Earthquake Relief Mission
The malaria control programme had several gaps in the form of shortage of manpower, insecticides and fogging machines. WHO surveillance officers addressed these problems very well in respective Taluka coordination meetings. In Rapar, even intersectoral coordination mechanism was developed for malaria control. Every week, the disease surveillance unit provided detailed linelist of slide positive (P. falciparum and P. vivax) cases to urban malaria control personnel and followed-up to ensure that radical treatment is given to all. WHO, in consultation with the National Anti-Malaria Programme, also advocated prophylactic treatment of malaria for the pregnant women in the district.
With the overall well coordinated response generated by the efficient surveillance system, malaria incidence showed a downward trend. The number of new cases decreased rapidly by November 2001.
District Disease Surveillance Task Force
In view of sustainability of the surveillance mechanism, a task force needs to be established to ensure efficient and sensitive data collection process, epidemic preparedness and timely response. The Chief District Health Officer (CDHO), Chief District Medical Officer (CDMO) and other senior district health officials, renowned private practitioners, representatives of Indian Medical Association (IMA) and Indian Academy of Paediatrics (IAP) would constitute this task force. District Development Officer and Collector would also play a vital role in this task force. The surveillance officer of WHO would provide the technical expertise. The necessary steps are being taken in this direction.
WHO has now established its Kachchh District Disease Surveillance Unit (DSU) in the campus of the District Development Officer's Office. It serves as a common platform for senior government officials for technical guidance, updates and liaison. One can say that practically all health sector activities in response to the earthquake are centred in this WHO office.
Report of WHO Activities, 1 August 2001 - 31 January 2002 18 Gujarat Earthquake Relief Mission
Public Health Laboratory at Bhuj
To support the disease surveillance system established in the aftermath of the earthquake in Kachchh district, WHO established a very well equipped public health laboratory in a pre-fabricated structure at Bhuj. WHO provided the structure, equipments, reagents and other supplies and technical guidance. The Government of Gujarat agreed to provide the manpower to look after day-to-day functioning of the laboratory. Due to this initiative of WHO, confirmatory diagnosis of diseases of public health importance would become possible at Bhuj. The medical college laboratories and the private sector laboratories were also involved in the surveillance activities.
WHO-Gujarat's Water and Sanitation (WATSAN) division and Disease Surveillance division worked in close cooperation with the water and health department of the state government, which resulted in very effective coordination between these two linked departments.
Epidemiological data has also been used for evaluating interventions in health education and hygiene promotion, sustainable water quality control. For example, the Disease Surveillance Unit staff have conducted regular checking of free residual chlorine in drinking water in the field, maintained records and provided feedback to the concerned authorities.
A very effective liaison and coordination resulted in - No Epidemics even after such a devastating earthquake. This was very well appreciated by the health and water department which requested WHO to expand/replicate the Kachchh district model in other earthquake-affected districts.
GIS (Geographic Information System) developed by WHO was a very effective decision-making tool.
Report of WHO Activities, 1 August 2001 - 31 January 2002 19 Report ofWHO Gujarat EarthquakeReliefMission
Weekly Epidemiological Summary, Kachchh District, Gujarat Activities, 1August2001 Post Disaster Week No: 38 Period: October 15 to October 21, 2001 Confirmed P. Falciparum Cases Taluka: Rapar -31January2002
N
< 2 case
3 - 5 case
> 5 case The boundaries shown on his map do not imply official endorsement or acceptance by WHO World Health Organization (WHO) Source: Disease Surveillance Unit, WHO Bhuj 20 Report ofWHO Gujarat EarthquakeReliefMission
Weekly Epidemiological Summary, Kachchh District, Gujarat Activities, 1August2001 Post Disaster Week No: 43 Period: November 21 to November 25, 2001 Confirmed Malaria Cases -31January2002
Rann of Kachchh
N
W E
< 2 case S
3 - 5 case 70 0 70 140 Miles
> 5 case The boundaries shown on his map do not imply official endorsement or acceptance by WHO World Health Organization (WHO) Source: Disease Surveillance Unit, WHO Bhuj 21 Gujarat Earthquake Relief Mission
Technical Support for Water and Sanitation Services
Highlights
• Continued WHO support to the Government and local authorities in improving water and environmental sanitation services to achieve sustainable level.
• Expansion of activities to seven more earthquake-affected districts.
• Appointment of one more national UNV (WATSAN Engineer).
• Emphasis on monitoring of quality of water supply.
• Monitoring of rural chlorination on daily basis and regular review.
• Awareness and health promotion drive through public fairs and religious platforms.
• Supply of chlorine solution to 200 villages and four towns.
• Upgrading water-testing facilities for earthquake-affected districts other than Kachchh.
• Training activities in water quality and sanitation facilities in coordination with government departments and local NGOs.
• Strengthening water quality surveillance for the Kachchh District.
• MOU with German Federal Agency for Technical Relief (THW) for chlorination of rural water supply.
Report of WHO Activities, 1 August 2001 - 31 January 2002 22 Gujarat Earthquake Relief Mission
The water supply and sanitation facilities were very badly damaged due to the earthquake. Considering the promotion of health as the main objective, WHO continued to extend support to the Government and local authorities in improving water and environmental services to the sustainable level. The water and sanitation experts worked closely with the Gujarat Water Supply and Sewerage Board (GWSSB). Coordination at district and taluka levels is well established. In addition to the sanitary engineer provided to undertake an assessment of the damage to the water supply and sanitation systems in the affected area, two more public health engineers joined the team as UN volunteers to strengthen the field activities.
Since December 2001, WHO has expanded its water and sanitation activities to seven more districts in addition to Kachchh. The WHO office for state activities has been shifted to Gandhinagar, the state capital, to have close linkage and coordination with government machinery. During the course of time, two more national UNVs have been recruited to cope with the increased work. One UNV each looks after Kachchh- Saurashtra and central-north Gujarat region.
WHO's main support included the following:
v Strengthening of water quality surveillance for Kachchh district; v Monitoring of water quality through testing chlorination; v Upgrading water-testing facilities for earthquake-affected districts other than Kachchh; v Capacity building through training and awareness programmes; v Coordination with Government, NGOs and other actors in the sector; v Technical advice and counselling; and v Health promotion through various activities.
Report of WHO Activities, 1 August 2001 - 31 January 2002 23 Gujarat Earthquake Relief Mission
Strengthening of Water Quality Surveillance for Kachchh District
The State Government through the Gujarat Water Supply and Sewerage Board (GWSSB) has been making commendable efforts to supply water to the affected villages. UNICEF has been supplementing their efforts by providing hardware support. However, water quality surveillance and monitoring was one area which was adequately attended by WHO.
Considering the health significance attached to the quality of water, it was felt essential to provide support to the District Water Laboratory of GWSSB at Bhuj. A project worth US$ 93 000 has been taken up for providing following support to strengthen the water quality surveillance and monitoring activities in the Kachchh district:
a. Manpower to carry out surveillance and water testing;
b. Mobile water testing laboratories mounted on utility vehicles;
c. Field-testing kits;
d. Chemicals, glassware and miscellaneous items;
e. Training of staff; and
f. Strengthening and furnishing of laboratory building.
Under the project, checking of drinking water samples from all villages on regular basis by scientific staff, who will be provided vehicles to move in the field is envisaged. The findings of the visit and analysis will be reported to the concerned authorities for remedial action. The project is also expected to improve data bank and information dissemination.
Report of WHO Activities, 1 August 2001 - 31 January 2002 24 Gujarat Earthquake Relief Mission
Water Quality
The quality of drinking water is essential to the health of communities. Hence, WHO has accorded priority attention to the monitoring of water quality in the earthquake- affected Kachchh district. Chloroscopes were distributed to the government and local agencies during the first quarter.
Chlorination is considered to be the most essential operation in water treatment to prevent any morbidity related to drinking water, more so, in an earthquake-affected area. WHO, therefore, established a network for monitoring of chlorination in the four worst affected Talukas (sub-districts) of the district, through the support of the health department, Gujarat Water Supply and Sewerage Board (GWSSB) and German Federal Agency for Technical Relief (THW).
THW provided about 50 chlorination plants for villages, which were being managed through the Gram Panchayats. WHO entered into an agreement with THW to monitor the working of the plants. THW has withdrawn from the field since September 2001, and WHO is looking after the performance and providing technical guidance in trouble- shooting. As a result, chlorination in rural areas has appreciably improved and is regularly reviewed in the weekly health coordination meetings. This has helped to a great extent in preventing any water-borne disease so far.
WHO had provided 1 250 chloroscopes to field staff for measurement of residual chlorine and also imparted necessary demonstrations and training. The health staff in the field is regularly checking the residual chlorine in villages and reporting the performance in weekly coordination meetings held at the Taluka level. On an average, more than 85% samples show presence of chlorine. The representative of GWSSB present in the meeting takes note of the shortfalls and reports compliances in the next meeting. WHO surveillance officers persuade follow-up action during the following week.
Report of WHO Activities, 1 August 2001 - 31 January 2002 25 Gujarat Earthquake Relief Mission
Good understanding and working relations prevail between the Water and Health Departments due to advocacy by WHO. The quality surveillance mechanism has been appreciated by the State Government and it has requested for its replication in other earthquake-affected districts. WHO has considered this request under its future expansion plan that has become operational since December 2001.
Severe effects of the earthquake were reported in Kachchh district where WHO has been paying maximum attention. However, other districts suffered moderate to heavy damages, which included water services also. The districts other than Kachchh affeced by the earthquake were mainly Rajkot, Jamnagar, Surendranagar, Ahmedabad, Banaskantha, Mahesana and Patan. The district laboratories for these districts are located at Rajkot, Gandhinagar and Palanpur. At the request of GWSSB, WHO also provided laboratory equipment for testing of water samples at these district laboratories. Chlorination practices on the lines of Kachchh district are planned to be taken up in other earthquake-affected districts also.
Demonstration of chlorine measurement in water supply by WHO staff
Online chlorine check by staff of district water laboratory at Bhuj
Report of WHO Activities, 1 August 2001 - 31 January 2002 26 Gujarat Earthquake Relief Mission
Capacity Building through Training and Awareness Programmes
It was essential to develop the manpower that would take up the new challenges posed by the situation. In these circumstances, WHO took up an extensive programme to provide training to the professional staff and create awareness among the user communities.
WHO took up training programmes for pump operators, linemen, water supply supervisors, health workers, PHC and sub-centre staff, village head and Panchayat members, conservancy staff of municipalities and representatives of NGOs. There are several Government agencies and NGOs working in the water and sanitation sector. Each agency has got its own mandate of work. To avoid duplication of work and to share the information, a sub-group on WATSAN activities was formed which meets regularly (initially weekly, then fortnightly and now monthly) to review and take follow-up action. WHO has been playing an active role in organizing such meetings and taking follow-up action. WHO also maintains regular contacts with other NGOs and UN agencies for concerted efforts.
Health message through religious platform at Anjar in Kachchh district
Report of WHO Activities, 1 August 2001 - 31 January 2002 27 Gujarat Earthquake Relief Mission
Review mission of Dr Dennis Warner, WHO Short-term Consultant, who visited Bhuj in the month of June 2001. In his extensive report, the work of WATSAN sector is appraised.
Chlorination Status in Kachchh District from August to December 2001
Source: WHO Water and Sanitation, Gujarat
Report of WHO Activities, 1 August 2001 - 31 January 2002 28 Gujarat Earthquake Relief Mission
Water and Sanitation Sector Review Workshop, Ahmedabad, 13 October 2001
As recommended by Dr Dennis Warner, WHO Short-term Consultant, in his review mission report of July 2001, a one-day workshop was organized at Ahmedabad on 13 October 2001. The objectives of the workshop were:
(1) To review the activities of the WATSAN sector in Kachchh, and (2) To invite suggestions for planning future activities.
The workshop was inaugurated by Hon'ble Mr Narottambhai Patel, Minister for Water Supply, Government of Gujarat, and was presided over by Mr SK Nanda, Secretary (Health), Government of Gujarat.
More than 50 participants from the Departments of Health and Water of the Government of Gujarat, NGOs and other UN Agencies participated in the workshop.
The Hon'ble Minister, in his inaugural address, lauded the role of WHO. He appreciated the joint efforts of WHO, the Department of Health and the Gujarat Water Supply and Sewerage Board (GWSSB) due to which major outbreaks of water-borne diseases could be contained. The Hon'ble Minister stressed the need for monitoring the disposal of domestic wastewater, and protection of the sources of the public water delivery system. More attention needed to be paid to chlorination of water and the water quality monitoring network required strengthening. He further said that the WHO activities should be replicated and expanded to other earthquake-affected parts of the State.
Mr SK Nanda, Secretary (Health), Government of Gujarat, said that a disease surveillance model linked to the water quality surveillance should be developed and more technical inputs provided to control the malaria menace. The information, education and communication (IEC) activities should be strengthened to decrease water-borne morbidity and mortality. The constraints in the sanitary facilities should be
Report of WHO Activities, 1 August 2001 - 31 January 2002 29 Gujarat Earthquake Relief Mission removed through R&D activities, and adequate water supply and sanitation facilities ensured at all health infrastructures. He suggested that WHO should plan for long-term assistance to the State.
At the conclusion of the workshop, the following recommendations were made :-
A. Drinking Water Supply
(1) Priority must be accorded to monitoring of drinking water quality. (2) Community-based approach should be encouraged. (3) Capacity building exercise should be made an ongoing programme. (4) WATSAN activities should be expanded to other affected districts and coordination between health and water supply departments established as done in Kachchh. (5) Documentation of data and experience gained should be ensured. (6) Support should be provided to water quality monitoring in urban areas. (7) Programmes to provide sanitary protection to the water supply sources should be undertaken. (8) WATSAN committees should be motivated.
B. Environmental Sanitation
(1) Help must be extended to urban bodies in the treatment and disposal of wastewater. (2) Proper procedures for disposal of biomedical waste should be established. (3) Training manuals in Gujarati language should be developed. (4) Intersectoral coordination must be promoted. (5) Water and sanitation awareness programmes should be initiated.
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Inter-state Meeting on “Gujarat Earthquake: Health Sector Perspectives”, Ahmedabad, 6-9 November 2001
With technical and financial support from WHO, the Government of Gujarat organized an Inter-state Meeting on “Gujarat Earthquake: Health Sector Perspectives” at Ahmedabad, from 6-9 November 2001. The purpose of the meeting was to introspect some of the policy, managerial and operational issues related to emergency response and preparedness.
50 senior government officials from Delhi, Gujarat, Himachal Pradesh, Manipur, Punjab and Rajasthan participated in the meeting, besides the Indian Army officials. From Gujarat, the Health Commissioner, the Health Secretary and senior government officials took active part in most of the deliberations.
The meeting was inaugurated by Hon’ble Dr Vallabhbhai Kathiria, Minister of State for Heavy Industries and Public Enterprises, Government of India. Hon’ble Mr Ashok Bhatt, Minister of Health and Family Welfare, Government of Gujarat, along with Mr SK Nanda, Health Secretary and Mr Joy Cheenath, Health Commissioner, also attended the inaugural session. In addition, the Health Minister also participated in the deliberations of the meeting on a number of occasions.
Inaugural session of the Inter-State Meeting on "Gujarat Earthquake: Health Sector Perspectives" held in Ahmedabad, from 6-9 November 2001. The meeting was inaugurated by Hon'ble Dr Vallabhbhai Kathiria, Union Minister of State for Heavy Industries and Public Enterprises
Report of WHO Activities, 1 August 2001 - 31 January 2002 31 Gujarat Earthquake Relief Mission
Various NGOs which were actively engaged in the earthquake-affected areas took part in the deliberations of the meeting. Amongst the UN agencies, UNICEF and UNFPA, besides WHO, participated in the meeting.
The Government of Gujarat organized a two-hour session through the state-owned remote sensing satellite for close interaction with those districts level officials who could not attend the meeting due to ceiling on the number of participants which was enforced to make the meeting more effective. In this session, the WHO team consisted of Dr Abdul Sattar Yoosuf, Director, SDE/WHO/SEARO; Dr Tej Walia, WHO Public Health Administrator, WHO Representative's Office, New Delhi; Dr Luis Jorge Perez, EHA/WHO/SEARO; Dr Lin Aung, STP-EHA/WHO/SEARO, and Dr Bipin Verma, WHO Focal Point for EHA Activities in India. The Government of Gujarat team consisted of Dr Joy Cheenath, Health Commissioner, and Dr Paresh Dave, Assistant Director, Health Education Bureau. About 1,500 district level officials participated through the satellite.
At the conclusion of the meeting, the following observations and recommendations were made :-
S.No. Observations and Expectations Recommendations
1. Dedicated work and It is unanimously resolved that appreciation. appreciation should be expressed to all those who worked to save lives and minimize the losses to the community affected in the disaster- affected areas. This is more crucial for those who worked in the first 24 hours simply on their human instincts and in the absence of adequate resources.
Report of WHO Activities, 1 August 2001 - 31 January 2002 32 Gujarat Earthquake Relief Mission
S.No. Observations and Expectations Recommendations
2. Exemplary attempts to help Various stories and tales of their fellow brethren and battles for survival and outstanding courage seen in the local courage should be recorded and community. published by the Government.
3. Coordination had A permanent state level coordination significant positive impact committee, with various stakeholders on the outcome. as members, should be an integral part of the Disaster Management Authority. Similar units could be formed at the district, taluka and village levels. The approach should be to build a transparent and efficient system.
4. A permanent organization for The proposed plan by the disaster management is Government of India should established by PMO. States immediately be discussed and are to prepare State plans. adopted with appropriate modifications.
5. The disaster management A disaster management plan should plan is the immediate need immediately be prepared and, if and it should reflect ground already prepared, should be level realities and applicable modified with current information to local situations. and technology.
Report of WHO Activities, 1 August 2001 - 31 January 2002 33 Gujarat Earthquake Relief Mission
S.No. Observations and Expectations Recommendations
6. The first response was The rescue teams should be unplanned and rescue identified, effectively trained and operations in future require equipped with self-sufficient preparedness. facilities for uninterrupted action. The need for rapid transportation of such teams with effective communication systems should be guaranteed. This is necessary for quick transfer of critical cases to nearest care centres and deploying other mobile medical units.
7. The nodal institutes have to All nodal centres for health and be safeguarded so that the medical care and other emergency key facilities do not get and essential civil services should be damaged, crippling the relief assessed for their vulnerability to operations. disasters. The plans should be implemented by allocating appropriate funds to apply technology for the new constructions of such centres before clearance for the work is given.
8. Active participation of local A detailed directory of various doctors and social workers is agencies that can assist in disaster imperative. management should be prepared and made available to all concerned.
Report of WHO Activities, 1 August 2001 - 31 January 2002 34 Gujarat Earthquake Relief Mission
S.No. Observations and Expectations Recommendations
All these agencies should have coordination so that their participation at any given point of time and place is ensured.
9. Periodic drills for the rescue All activities aimed at immediate activities will be necessary. action in a disaster situation should be subjected to periodic (once in six months) drills or mock events. This will require a manual detailing the person, task, time-frame and responsibility for the entire operation. The manual can be part of (or a separate identity) a manual covering guidelines for relief and rehabilitation issues.
10. Training and awareness are A state Disaster Management important in disaster Institute running multi-faculty management. courses and providing refresher courses recognized by the University is necessary. Such an institute in a border state like Gujarat will help in combating any situation related to man-made disasters like war. The institute should have the capacity to take up operational research on disaster management.
Report of WHO Activities, 1 August 2001 - 31 January 2002 35 Gujarat Earthquake Relief Mission
S.No. Observations and Expectations Recommendations
Simple modules and health education material for the general public should be prepared in vernacular and lessons on disaster management should be incorporated in school textbooks and college education. Till the institute comes up, appropriate regional centres should be identified to carry out this function.
11. Disease surveillance and Disease surveillance by trained environment management workers has to be a regular activity have potential to prevent of the health sector. Better softwares epidemics after disasters. and analytical methods and WHO assistance in training equipment must be made available and monitoring is for this crucial activity. commendable. The issues of safe water and sanitary waste disposal should be tackled even in normal times. The surveillance in the rehabilitation stage should include recording, managing and follow-up of injured and handicapped. WHO assistance should extend to other districts for betterment of surveillance and reporting system.
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S.No. Observations and Expectations Recommendations
12. The role of the media in a A media cell within the health sector disaster is very crucial and is needed. Some senior academicians should be utilized in best and public health managers should possible manner. be trained for media interaction. A close liaison with media should be ensured by frequent regular interaction.
13. Psychosocial and nutritional Necessary planning for long-term rehabilitation to the affected intervention should be made by the population. core groups and reviewed periodically.
14. Physical rehabilitation. An organization should be set-up for all such cases that may require physical and social rehabilitation.
15. Training for material It is recommended that the management by using supply personnel at CMSO be trained in and management (SUMA). supply and management (SUMA).
16. Planning for reconstruction It is recommended that the and redevelopment of the experience be supported, health facilities is subjected strengthened and disseminated. to new initiatives which have This particularly applies to the been quite successful. empowerment of the health sector for taking up the construction projects.
Report of WHO Activities, 1 August 2001 - 31 January 2002 37 Gujarat Earthquake Relief Mission
S.No. Observations and Expectations Recommendations
17. Coordination experience in This experience needs to be the disaster management has documeted. The team of experienced been quite satisfactory. officers should be used effectively in future so that their skills are best utilized.
Report of WHO Activities, 1 August 2001 - 31 January 2002 38 Gujarat Earthquake Relief Mission
Expansion of WHO Activities in other Earthquake-affected Districts of Gujarat
The administrative and coordination unit of WHO has been shifted to Gandhinagar, the state HQ, and it will continue to function as the State liaison office, while the disease surveillance unit will remain in Bhuj with minimal staffing.
His Excellency the Governor of Gujarat inaugurated the first state level liaison office of WHO India country office, in the presence of WHO Representative to India, Hon'ble Health Minister of Gujarat, and senior government officials.
Three surveillance officers (National UNV doctors) now share offices and other resources with NPSP officers in the field (Rajkot, Mahesana and Gandhinagar), to build on the existing system and network of different surveillance activities. Currently, five national UNV doctors and two national UNV engineers (water and sanitation) work in the field for the integration of disease surveillance and coordinated water quality surveillance in eight needy districts of north-west Gujarat.
In addition to the existing funds of Gujarat Earthquake Relief Mission, new funding from the European Commission is assured for integrated disease surveillance activities in these districts (June 2002 - August 2003), based on lessons learned in Kachchh.
The new WHO office at the state HQ has started functioning as the state liaison office for WHO India country office. In addition to the integrated disease surveillance and regular liaison with the state authorities, many more activities are being considered.
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• Integrated disease surveillance in eight districts of Gujarat; • Coordinated approach with water quality, sanitation and environmental health; • Linkages with health sector disaster preparedness; • Developing guidelines for surveillance of noncommunicable diseases; • Developing a public health resource centre at the state HQ; • A disaster epidemiology training course for government officials; • Improvement of water and sanitation facilities in the health institutions; • NGO partnership for pilot, innovative projects in the fields of: o Indian systems of medicine; o Blood disorders; and o Prosthesis and rehabilitation.
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