CHOLERA OUTBREAK RAPID ASSESSMENT IN

31ST -1ST APRIL 2010

Assessment Team

1. Dr Daniel Langat – DDSR/ MOPHS 2. Dr James Teprey – WHO 3. Mr Charles Njuguna – WHO Kenya 4. Mr Raphael Mwanyamawi – PDSC Coast 5. Mr G. M. Mwadime – Prov. Logistician, Coast 6. Jimmy Nyandaro – WHO Driver

Introduction

Coast province has been affected by cholera outbreak since 15th February 2010. A total of 552 cases and 14 deaths CFR 2.5% has so far been reported from 4 districts, namely , Msambweni, Kilindini and .

The team visited the Coast Provincial Director of Public health and sanitation on 31st March 2010 and briefed a section of the PHMT on the purpose of the Mission. Three districts; Msambweni, Mombasa and Kilidini were visited on 31st March and 1st April.

The team was briefed on the status of the outbreak by the District Health Management Teams of the respective districts .

Magnitude of the Problem in the districts visited

District Cases Deaths CFR Msambweni 430 11 ( 7 in Health Facilities and 4 in the 2.6% community Mombasa 40 0 0% Kilindini 34 3 (1 in Health Facility and 2 in the 8.8% community Total 504 14 2.8% N/B Kwale district was not visited, there was no active transmission at the time of our mission however the cumulative totals for Kwale district were 48 cases with no deaths.

1 Prepared by DDSR/MOPHS and WHO Assessment Team April 2010 Key Findings

Identified Risk Factors

1. Contaminated water sources • Msambweni - Local community are using water from stagnant water pans and shallow wells • Mombasa – Shallow wells • Kilindini – Shallow wells (927), Collapse water sewer system seeping underground and resurfacing as a “spring” 2. Poor sanitation standards • Msambweni - Low latrine coverage (32%), limited use of the available toilets. Open defecation is very common • Mombasa - Latrine coverage is 85% but lower in the informal settlements, defecations into the ocean is a common practice among the locals. • Kilindini – Latrine coverage is 52% but lower in the informal settlements, use of flying toilets as a way of human waste disposal and defecations into the ocean is a common practice among the locals. 3. Poor personal hygiene practices • Using the same water in a trough for hard washing by the entire family especially in Msambweni

Intervention Measure

• Case Management of suspected cases in CTCs. Msambweni had 7 CTCs, Kilindini had 2 CTCs and Mombasa had 2 CTCs. • Chlorination of water sources especially the shallow wells. Porous pots were mainly being used in Mombasa and Kilindini. • Awareness creation to the community through public barazas with the support of provincial administration. • Active surveillance. Case search and contact tracing. • Provision of safe clean water by coast water services board especially in Msambweni and Kilidini. • Closure of unhygienic food premises.

Strengths and Opportunities

• The districts have been trained in IDSR strategy (Oct 2009). The training strengthened their case detection and Management • The districts have Rapid Response Teams (RRTs) in place • Involvement of stakeholders in outbreak response activities

2 Prepared by DDSR/MOPHS and WHO Assessment Team April 2010 o Msambweni - MSF Belgium, Kenya Red Cross, Coast Water services board, Provincial Administration, CDF and Kenya Wildlife services and World Vision o Mombasa and Kilidini - Municipal council of Mombasa, Coast Water services board, Kenya Red Cross and World Vision • Active community involvement in outbreak response through CHWs • Presences and use of Cholera treatment guidelines in CTCs.

Weakness and Threat

• Limited pharmaceutical and None Pharmaceutical supplies. • Inadequate fund to support staff allowances and logistic tics • Negative community cultural beliefs and practices. That Cholera is caused by evil spirits (Pepo Mbaya), it is a taboo to share a latrine with your daughter in law…. • Low acceptance of use of chlorine tablets and solutions in treatment of drinking water among the community members • Water turbidity in most of the sources makes it difficult for wide use of aqua tabs. Limited supplies of PUR • Lack of Cholera preparedness plans • Delayed Notification of initial suspected Cholera cases to the next level. o Msambweni - 1st case occurred in the community on 2th Feb, Seen on 27th Feb in the Health facility, Province notified on 2nd March, Lab confirmation on 10th March and National level notified on 18th March. o Delayed notification of the outbreak observed in Mombasa

Way Forward

(i) Immediate actions 1. Urgent supply of more pharmaceutical and none Pharmaceutical supplies to the affected districts. 2. Financial support to the districts to take care of fuel and payment of allowances for the field officers. 3. Strengthen laboratory capacity by supplying antisera for V. cholerae confirmation 4. Provision of PUR in Msambweni and aquatabs in Kilidini and Mombasa. (ii) Medium and Long term actions 5. MOP up IDSR training in coast province. 6. Strengthen support supervision at Provincial and district level. 7. Strengthen multisectoral coordination through cholera preparedness and response training for various stakeholders. 8. Improve latrine coverage. Coast province to develop a strategy 9. Sustained Community dialogue to address negative cultural beliefs and practices.

3 Prepared by DDSR/MOPHS and WHO Assessment Team April 2010 10. Health Promotion in the most affected communities. Promote home base management of diarrhoea by use of ORS

. Conclusion

• There is still active transmission of the outbreak in the three districts visited especially in Msambweni and Kilidini. • The risk factors are still present in all the district • While all the affected districts had problems with accessibility of safe water, interventions need to take a specific approach based on unique challenges existing in the three districts. A blanket approach should be avoided.

Annex 1: Cholera Epicurve for Msambweni district

Cholera Epidemic Curve for Msambweni district 2010 45 40 35 30 25 20 15

No cases of 10 5 0 1.3.2010 2.3.2010 3.3.2010 4.3.2010 5.3.2010 6.3.2010 7.3.2010 8.3.2010 9.3.2010 25.2.2010 26.2.2010 27.2.2010 28.2.2010 10.3.2010 11.3.2010 12.3.2010 13.3.2010 14.3.2010 15.3.2010 16.3.2010 17.3.2010 18.3.2010 19.3.2010 20.3.2010 21.3.2010 22.3.2010 23.3.2010 24.3.2010 25.3.2010 26.3.2010 27.3.2010 28.3.2010 29.3.2010 30.3.2010 Dates

4 Prepared by DDSR/MOPHS and WHO Assessment Team April 2010 Annex 2: Cholera Epicurve for Kilidini district

Epicurve of Cholera outbreak in Kilindini District, Feb/March, 2010 7

6

5 cases 4 of

3 Number

2

1

0

10 10 10 10 0 0 0 10 10 10 10 0 10 0 0 0 0 0 0 0 0 010 010 010 010 010 0 /2 /2 /2 /2010 /2/2 /2/2 /2/2 /2/2 /2/201 /2/201 /2/201 2/2/2 4/3/2 6/3/2 8/3/2 0/3/201 /3/2 /3/2 /3/2 1/4 16 18 20 22 24 26 28 1 12/3/201014/3/201016/3/201018/3/201020/3 22/3 24/3 26 28 30 Date of onset of illness

Annex 3: Cholera Epicurve for Mombasa district

Cholera EPICURVE for Mombasa District

16

14

12

10

8

No cases of 6

4

2

0 14th Feb 2010 21st Feb 2010 28th Feb 2010 7th March 2010 14th March 2010 21st March 2010 28th March 2010 Week ending

5 Prepared by DDSR/MOPHS and WHO Assessment Team April 2010 Annex 4: Photo

Vitsangalaweni stagnant water pan in Msambweni district is the only source of water to the local community. A population of 26,000 within a radius of > 10Km depends on this source. A total of 285 cases with 3 deaths have been reported in the local dispensary.

Annex 5: Photo

The assessment team in a meeting with Mombasa District Health Management Team

6 Prepared by DDSR/MOPHS and WHO Assessment Team April 2010 Annex 6: Photo

The assessment team inspects a septic tank with open manholes serving Port Reitz Hospital. It is reported that the neighbouring community sometimes draw water from the septic pit

7 Prepared by DDSR/MOPHS and WHO Assessment Team April 2010