ETHIOPIA: WEST ARSI ACUTE WATERY DIARRHOEA FOLLOW-UP ASSESSMENT REPORT Assessment Team Members Dr. Tesfaye Bekele Federal Ministry of Health Dr. Alemu Kabede Oromia Regional Health Bureau Dr. Jamel Adem Oromia Government President’s Office Eng. Daniel Gelan UNICEF Mr. David Tsetse UNICEF Ms Mary Chilvnda UN-OCHA Dr. Amanu Gisso WHO Dr. Tesfaye Ayalew UNICEF 1 Assessment Period: August 04-08, 2006 1. Executive Summary West Arsi is located in the Eastern part of Oromiya Region and it has an estimated total population of 1,815, 274. Administratively, the zone is divided into 11 Woredas and 312 Kebeles. AWD outbreak was first reported in the zone on the 22nd June and ever since there has been an increase in the number of cases and number of Woredas and kabeles affected. WHO and other agencies carried out assessment at the onset of the outbreak and efforts have been made by the Zonal health Office to contain the spread but has not been effective. A total of 7705 cases were reported in 135 affected Kebels in West Arsi Zone and total death stood at 46 when this assessment began. In SNNPR 20 cases and 2 deaths in Sidama Zone were reported at the same time. Due to the seriousness and urgency of the situation, UNICEF, WHO, OCHA and Oromia Regional Administration decided to undertake an urgent re-assessment of the AWD situation in the affected Zone. The specific objectives of the mission are to: • re-assess the current extent of the outbreak of AWD and areas which are at risk of infection in the near future. • identify the current resources available to the Zonal Government teams, in terms of human personnel, logistical support, expertise in environmental health, financial and material resources. • identify the gaps and propose immediate actions for the Government, UN and other emergency partners where appropriate, to ensure an effective response to halt the further spread of the AWD. The Assessment team composed of Oromia President office, Federal MOH Office, UN-OCHA, WHO, UNICEF and Zonal Health Office. A briefing on the existing situation and guidance for the selection of Woredas, communities and CTC for the assessment was given by the Zonal Health Office. A total of seven CTCs and neighboring communities were visited in Arsi Nagele, Shashamene, and Dodola Woredas reflecting areas with increasing, declining and new cases. The following are the key findings from the assessment: At the onset of the outbreak 2 Kebeles in Wes Arsi Zone were affected. Presently 172 of 312 Kebeles in the affected woredas are affected representing 55% of the total Kebeles in the affected woredas of West Arsi Zone. Presently, 37 CTCs have been established, a total of 88474 cases treated and 89 deaths reported. There is a general increase in cases in West Arsi Zone and it has been reported that the problem have crossed over to Bensa, and Aroresa Woredas in Sidama Zone, and Borososore woreda of Walita Zone with 78 cases and 2 deaths in 7 kabeles reported and Bore Woreda of Guiji Zone As far as cases management in the CTC is concerned, the oriented and assigned health workers are fully engaged and entertaining patients coming with diarrhea and screening is done so as to differentiate AWD from other diarrhea diseases. Having done this, patients with AWD are again taken and evaluated for the degree of dehydration. Patients with no and some sign of dehydration are given ORS to drink at the CTC and observed for sometime and sent home with antibiotic, ORS and advised to come back if situation get worse. In the case of severely dehydrated patients, they are admitted and managed in most places according to the treatment protocol with IV fluids and PO antibiotics. In some 2 CTCs, patients admitted for IV rehydration were seen without IV line. This has shown maltreating of the patients. Poor hygiene and sanitation condition in Woredas is a major source of contamination and spread of the AWD. However, hygiene and sanitation has not been given the necessary attention in the communities and CTCs. Even though Zonal and Woreda Health Offices have structures and systems (group leaders, the use of megaphones, questionnaire) in place to disseminate hygiene and sanitation messages, little has been done to ensure activities are actually implemented in CTCs and communities and people are putting into practice. There is no data in the form of hygiene and sanitation indicators such as the number of campaigns organized, the number of households visited, the number of latrines constructed and used, number of focus groups discussion held and number of IEC materials distributed. Contamination from contact with affected people is the second major source of the outbreak based on the information collected from affected people and CTC staff interviewed. Looking at the trend and spread of the AWD, areas with safe and unsafe water have reported cases suggesting water only is not a major source of the outbreak. This is evident in Danshe area where EMWAT kit was installed to give safe water to community and cases are still being reported even though there has been general decline of cases. Staff at the CTCs are working day and night since the onset of the AWD and the rotation roster is very rigid without protective apron. There are some medical, shelter and sanitary supplies at the CTCs but there is still the need for additional supplies since number of cases are not reducing but rather increasing in the affected areas. The Zonal Health Office has received some funds from UNICEF and the Regional Health Bureau to cover the operational cost of the AWD activities in the affected Woredas. The problem, however, the funds are not disbursed on time to the Woredas for quick implementation of activities. There is AWD response and preparedness team composed up of all concerned sectors and meetings are held daily to evaluate activities and interventions for the following day are planned. Due to the spatial distribution of the Woredas two command centers have been established -one in Shashamene town and the other in Dodola town. All the affected Woredas have established Woreda level AWD response teams to deal with the outbreak. There is limited coordination between government and NGO and also between government institutions at Zonal and Woreda level in addressing the AWD. All information regarding cases treated and admitted is sent to the Woreda Health Office for compilation and there is no information kept at the treatment centers for reference purposes. For strategy, households of affected Kebele are given water makers and PUR if their source of water is River while water guard is given to household using wells and piped water. Two EMWAT Kits are installed to treat turbid river water for drinking only. This has been effective in reducing the case load but does not seem to be the only solutions to contain the outbreak. With regards to hygiene and sanitation, the strategy of constructing latrines, promoting hand washing with soap or ash and boiling of water, conducting house-to-house visits, public campaigns, carrying out hygiene education at CTCs have used but little progress has been achieved in terms of number of activities undertaken and the impact of the activities in changing people behavior. The gaps identified by the assessment group and recommendations are presented below. 3 Gaps and challenges 1. There seems to be limited coordination in the Woreda. There is no link between the Woreda health Office and Woreda Water Office regarding the AWD. As a result there was no planning on resources needs for response. 2. Identified gaps were not addressed which is observed from the second commanding unit. 3. Environmental experts from the regional health bureau was not observed supporting in the containment of the spread of the disease. 4. Isolation, hygiene and sanitation at the CTC are not applied properly or to the requirement. 5. Overcrowding of patients in some CTCs and/or space inadequacy is observed as the one the problem. 6. There are shortage of basic supplies for CTCs like mattress, bed pan, vomiting vowel, kerosene lump, torch, and hygiene and sanitation materials. 7. Health workers are not protecting themselves or are not using gowns and/or apron. 8. Training on case management and CTC management to health workers was not given from the woredas under the second commanding unit. 9. Hygiene messages given are not monitored by Woreda health office or any body else.. 10. No IEC material for the current problem is seen at all levels starting from zonal health department to the community level. 11. The response by the community to sanitation and hygiene campaign is very low. This is evident in the improper use of latrines and the reluctance of people to observe basic personal hygiene protocols such as washing of hands after defecating and before eating and boiling of River water before consumption in most affected kebelesIn other words, the majority are not practicing according to hygiene and sanitation. 12. Documentation and reporting is observed far behind the requirement like line listing. Other activities recorded are not compiled and reported. 13. Medical supplies are alright up to the date of assessment but some items are finished while we were in the assessment business and others will not serve more than a week which means no stock for medical supplies. 14. The health workers capacity is overstretched and if the cases are still continuing to occur and more CTCs are opened, there will be critical shortage of health workers. 15. Shortage of operational cost like for the DSA of health workers and non health working in the field related to this AWD epidemic.