ARTICLE - CHOLERA SITREP #22

HAITI: CHOLERA SITUATION REPORT #22
(ReliefWeb) - Source: United Nations Office for the Coordination of Humanitarian Affairs (OCHA)

Full_Report (pdf* format - 149.1 Kbytes)

I. HIGHLIGHTS/KEY PRIORITIES

- The Ministry of Health (MSPP) has reported 1,751 deaths and 34,248 hospitalised cases. The overall case mortality rate which includes deaths outside hospitals is 2.3 per cent.

- Standardization of chlorination levels, management of dead bodies and disposal of excreta remain key issues.

- Security restrictions around elections have impaired cholera response in some areas, although they have now largely been lifted and the situation is returning to normal.

- New customs clearance procedures for non-registered organizations involved in the cholera response have been published on the logistics cluster website.

II. SITUATION OVERVIEW

The MSPP, UN and humanitarian community continue to respond to cholera across Haiti with efforts for prevention and treatment. The MSPP reported that the cumulative number of hospital visits in lieu of cholera was 77,208 and that 1,751 deaths have been reported. Over half of the caseload, 34,248 of patients, were been hospitalized for cholera treatment. Presently 1,224 patients remain at hospital. The inhospital case fatality rate for the whole country is 3.6 per cent whereas the in-hospital case fatality rate for Port-au-Prince is 4.5 percent. The overall case mortality rate which includes deaths outside hospitals is 2.3 percent.

III. HUMANITARIAN NEEDS AND RESPONSE
Health

The health cluster continues to ramp-up the response to cholera. Health cluster partners continue to support the MSPP cholera response strategy with the establishment of additional cholera treatment centre/cholera treatment unit (CTC/CTUs), reinforcement of existing medical structures and support for oral rehydration centres for first-line response. The International Organization for Migration (IOM) has completed an assessment of 80 health facilities identified by PAHO/WHO and the MSPP for scaling up cholera treatment. Of these sites, 38 were deemed suitable for the establishment of CTUs or Oral Rehydration Posts (ORPs). Partners interested in supporting these facilities should contact the Health Cluster. IOM has adopted a threefold response approach to the cholera outbreak addressing cholera in camps, along the Dominican Border, and at the epicentres of the outbreak, namely St. Marc and Gonaives. At present Médecines sans Frontiers (MSF) have approximately half of all CTC/CTU beds while the Cuban Brigade manage about 30 percent of beds.

Responding to an increase of cases in the Northwest department, the International Medical Corps (IMC) team met with the MSPP coordinator in Port-de-Paix, along with CARE, ACF, MSF-France, the French Red Cross and PAHO/WHO to determine needs. Cluster partners report the need for cholera intervention in St. Louis de Nord, Baie de Henne, Anse-a-Foleur and Tortue Island. IMC plans to establish CTCs in these locations in the coming weeks. IOM Health, together with the logistics cluster, is coordinating the distribution of 1,200 Personal Protection Equipment (PPE) kits and 2,000 units of Ringers Lactate and other medical supplies in the Northwest. In Port-de-Paix, a two day inter-agency mission was conducted with humanitarian partners to carry out a rapid assessment of the situation, to identify gaps and improve the response. Local health authorities requested funding to train community mobilization and hygiene promotion staff. There were also requests for soap, filters, aquatabs, PUR, and hygiene kits.

The situation in Fort Liberté and the Northeast department overall is manageable at present. Case management continues to improve, although slowly, as data indicates that most patients are reaching medical facilities and more patients are using oral rehydration salts earlier. PAHO/WHO logistics team helped to create the layout and set up four tents in Fort Liberté to organize patient flow, in coordination with Merlin. Each of these tents will be used for a specific purpose: a clean area for nurses/supplies, triage, observation and an extra ward for hospitalized patients. Construction of latrines and other semi-permanent structures should start soon. Two other tents have been taken to Ouanaminthe hospital to support cholera response. In the North and Northwest, the Northeast department the focus remains on prevention of cases rather than case management. Local health authorities have identified and trained health teams in communities. In Grande Anse, MDM France is asking for intervention of other health and WASH partners to provide a complete coverage of the department.

On 23 November 2010, a team from PAHO/WHO was deployed to a dispensary in Perodin (Artibonite), to verify a reported increase in 21 November. Perodin and Medor communal sections cover around 15,000 and 16,000 habitants respectively, living three hours from the nearest hospital in Petite Riviere, which has been severely affected by cholera. Facilities were set up in each village by Interaide, personnel were trained and supplies distributed. A nurse and a statistician from the UCS SDG (Saint Marc, Desdunes and Grande Saline) have been designed to assist the PAHO/WHO team (Epidemiologist and WASH Specialist) in order to collect and gather data of number of deaths at community level and provide training in best practices on body management.

In Léogane, there is only one CTC with 168 beds and one oral rehydration post in nearby Gressier. Though two ambulances are available, the distance between the oral rehydration post and the CTC is too far to transport patients. The health cluster reports partners struggle to obtain ORS for oral rehydration posts and the WASH kit that health agents would bring for sensitization. More support in Léogane is required.

The MSPP approved the installation of a Red Cross CTC with 80-beds at Camp La Mertan in Carrefour, Portau-Prince. The CTC will be operated with the support of the Canadian, the Japanese and the Spanish Red Cross. The International Federation of the Red Cross (IFRC) is supporting Red Cross National Societies and Bureau of Delmas, Medecins du Monde Canada/France, Save the Children, Merlin and other health partners in their efforts in the field. Some 45,000 ORS sachets, 1,000 litres of ringer lactate, soap and tents, chlorine and aquatabs were given for distribution to CTU and mobile clinics. The IFRC, supported by the British, Canadian and Spanish Red Cross, has provided six trucks for the Haitian Red Cross ambulance service for the cholera patients. This activity will be further strengthened. The German Red Cross report that their CTC in Arcahaie (West) is still operational. IMC will set up a 30-bed CTC around Archaie as well.

MSF and the MSPP have requested IMC to manage CTCs at several areas in the South department, including in Les Cayes. Local health authorities report a significant increase of cases across the department. IMC is reportedly involved in discussions on land availability for a CTC nearby Les Cayes.

Gaps & Constraints
The health cluster notes that safe management of excreta is essential to limit the spread of diarrheal diseases. In particular at CTC/CTU, excreta should be disinfected by on-site chlorination which greatly reduces the risk of infection before transport to the final discharge. The excreta of the camps present a higher risk of transmission than those of CTCs/CTUs (provided disinfection measures are applied properly), due to the high percentage of asymptomatic infected persons. Application of disinfection measures in the CTCs/CTUs and the regularity of the discharge facilities should be assessed and monitored. For human waste transport, specific trucks must be dedicated solely to the emptying of CTCs/CTUs. The garbage trucks are allowed to dump in designated areas arranged by the authorities. A specific landfill site, Truitier, has been allocated in Port-au-Prince where this sort of waste can be disposed.

Water, Sanitation and Hygiene (WASH)
The WASH cluster team has completed a mapping exercise of WASH actors nationwide. In the capital 4.55 millions Aquatabs have been distributed so far by UNICEF through various partners. IOM has completed a distribution of soap and Aquatabs to 1,316 Households in two camps in Cite Soleil, and 1,500 households in Petionville and 7,000 households in 20 Camps of Croix-de-Bouquets. Meanwhile Chlorine Residual (sis-klor) testing is ongoing through training of departmental CAMEP and SESAM (Societé des Eaux de Saint Marc) staff as well as through NGOs working in the field. Through its water, environment and sanitation authority (CASEB), the Brazilian government has sent a five member team of sanitation engineers to undertake studies on the implementation of a condominium system, pumping stations and treatment plant for sewage in St Marc and a study on the possibility of collection, processing and disposing of excreta toilets in Port-au-Prince. Meanwhile, Oxfam community mobilisers are working with camp food vendors in the communes of Corail, Port-au-Prince, Croix-des-Bouquets and Carrefour in Port-au-Prince. Oxfam has 200 trained Community mobilisers carrying out door to door hygiene campaigns in Carrefour Feuille. Specific focus is on chlorination, ORS preparation and handling of soiled/contaminated articles. Target population is 64,000 people. CDC will be carrying out a KAP study – similar to the one done in Artibonite –in Port au Prince. Training of enumerators began today. CRS is also planning a KAP survey in Port-au-Prince and is coordinating with CDC to avoid duplication.

Outside of Port-au-Prince, the British development DFID announced a grant of 1.9 million pounds sterling to Oxfam for work in the North department and a 1 million pounds sterling grant to Plan for the Northeast department. CARE and Action contre la faim (ACF) have now reached a total of 46 wells in the bucket chlorination project in Gonaives (Artibonite), which commenced on the 11 November. 46 chlorination technicians have been trained, 690 liters of chlorinated solution have been delivered and 2,235 people have been sensitized at the wells. In order to ease the process of renewing and following up on the stocks of chlorinated solution, teams are planning to train technicians in preparation of mother solution. DINEPA/SNEP is actively working on Chlorination of the St Michel water system; this will provide the health centre and possibly hospital with a chlorinated supply. It should be operational in the next few days. Chlorination of Ville de Mirebalais and Ville de Hinche is now underway and analyzed daily. The introduction of daily network chlorination to all functioning water points in Centre Department should be made within two weeks. The list of the functioning water points will be provided to partners as soon as possible.

DINEPA has launched a campaign to identify localities without secure access to water in the Artibonite Valley. This study extends from Gonaives in Artibonite to the villages of Saut d'Eau, Boucan Carre, Mirebalais and Las Cahobas in the Centre. Partners are invited to contact DINEPA to share all information regarding localities without access that they consider priorities. Interaide has trained two leaders (Partners in Health/Zanmi Lasante health officers) on the preparation of chlorine from chlorine powder. These health officers will distribution chlorine solution to 14 leaders of the area Boucan Carre and 17 leaders of the Petite Montagne area, who will in turn distribute to households (30mL of 5% clorox for each household). They are also seeking health workers and others to track distributions in each zone. They plan another distribution in two weeks. Meanwhile, 12,278 children, women and men were sensitized by Plan-Haiti through their training and mobilization strategy in schools, communities and camps in Southeast, West, Northeast Departments.

Gaps & Constraints
Chlorine residual measurements remain low at the household level especially in Carrefour and Tabarre in Port-au-Prince. Lack of maintenance of tanks and bladders prohibits appropriate chlorine residual levels in public water distribution points. Commencement of the UNOPS managed CTC/CTU de-sludging fleet has been delayed and is expected to commence on 10 December. There is also an absence of a clear overview of the actual situation in Port au Prince: (lack of information, inadequate distribution of hygiene promotion products) and where hygiene promotion activities should be focused. Moreover, there is an inadequate epidemiological data underlining a need for the hygiene sub-cluster to work closely with WHO/PAHO for a
solution to this problem. WASH cluster in the Centre department is looking into the mass chlorination of drinking water through chlorination points in areas not on a town network.

There is need for systematic monitoring of distributions and use of distributed products – both in Port-au-Prince and in the provinces – to ensure accessibility for all, especially for the vulnerable. Demonstrations in Gonaives have resulted in all international organizations having restricted movement during the election weekend through Monday, thus limiting WASH response. The eastern half of the Centre department has no known WASH actors; 6 communes are affected and already several cholera deaths have been confirmed. Key gaps have also identified in the Northwest department and additional actors required. The cluster reports a need for JEDCO or other companies outside Gonaives for the removal of cholera waste in CTUs in St Michel and other communes. Management of dead bodies continues to be an issue throughout all affected departments. In the Centre department, transport of cholera patients is reported as an issue.

Camp Coordination/Camp Management (CCCM)
CCCM cluster continues to focus on hygiene promotion, distribution of water purification tablets, installation of latrines and sensitization campaigns throughout camps in the earthquake affected areas. CCCM partners continue to distribute prevention messages approved by the MSPP to IDPs while Camp Management Operations (CMO) teams have implemented 529 cholera risk reduction activities in IDP camps and surrounding communities. CCCM partners require consistent supply of WASH materials (e.g. soap, water, purification tablets, latrines, etc.) in order to address the humanitarian needs in camps. CMOs implemented 529 cholera risk reduction activities in IDP camps and their surrounding communities throughout the earthquake affected communes. Out of these activities, 58 percent were sensitization and included distribution of WASH supplies (e.g. soap and water purification tablets); 18 per cent were focused on the disinfection of latrines in 95 camps; and 24 per cent were linked to the installation of Oral Rehydration Posts (ORP) which are essential first-line response, taking pressure off hospitals and CTCs. CMO teams have installed the physical facilities for 113 ORP of a 250 planned, mostly in the communes of Croix-des-Bouquets and Port-au-Prince. The ORPs focal points are trained by IOM and WASH facilities, coordinated with local authorities, coupled with cholera prevention and sensitization activities are carried out for the community.

Concern Worldwide reports carrying out activities including soap and water purification tablet distribution, conducting mini-surveys on the knowledge on what to do in case of emergency, and on water supply and treatment, and sanitation (installation and desludging of latrines). IEDA Relief has been conducting cholera response activities in the 14 IDP camps managed by the organization, including the distribution of hygiene kits and sensitization messages, the provision of continuous cholera-awareness training and distribution of messages approved by the MSPP. IOM distributed 26,650 flyers with cholera information (directly and through CCCM partners). IOM’s radio program Chimen Lakay did three national broadcasts of cholera-related radio programming and content.

Gaps & Constraints
The CCCM cluster reports that IDPs are in need of more WASH related items (e.g. water purification tablets), installation of latrines and sensitization campaigns throughout camps in the earthquake affected areas. CCCM partners also require additional medical and WASH assistance teams, communications assistance in terms of human resources, communications materials and medical items.

Food
Since the start of the cholera response, World Food Programme (WFP) has assisted approximately 3,400 people with over 93,000 meals-ready-to-eat (MRE) rations and 10.7 metric tonnes of dry rations. Food has been distributed to those suffering from cholera and those assisting cholera patients in hospitals and CTC/CTU. In the Northwest department, WFP met last week with departmental health authorities to discuss the increase of cholera cases. For the West department, Médecines du Monde (MDM)-Canada, Merlin, Partners in Health, AVSI, Gheskio and MSF have received 406 metric tonnes of food for patients, caretakers and staff for one month.

Education
Schools were closed on Friday and Monday due to the elections, with a very low turn-out on Tuesday as parents were reportedly monitoring the security situation. The education cluster held an open forum meeting on Tuesday, November 30, with the participation of three new cluster members: ProDev, American Red Cross, and Hero. USAID joined the forum in order to share information and to seek partnerships for cholera prevention in schools. A consolidation exercise of data collected in the field is taking place in order to identify gaps and challenges in the cholera response in schools. These issues will be addressed in the coming days. Given the importance of knowledge and practice in cholera prevention, the education cluster is working on the preparation of a KBP (Knowledge, Behavior, Practice) survey in schools in order to help partners to adjust the messages, the content of training, and the overall interventions relating to teachers and students.

While pursuing efforts on cholera prevention in schools, cluster partners are working together on a joint project in a relocation site and on integrating IDP children in neighbouring schools. WFP distributed over 6.5 million water purification tablets and 30 metric tonnes of soap have been distributed in schools since 21 November to support clean school kitchens. Ongoing training of teachers and parents in schools reinforces cholera prevention, detection and treatment messages.

Logistics
New customs clearance procedures for non-registered organizations involved in the cholera response have been published on the logistics cluster website:

http://www.logcluster.org/ops/hti10a/customs_clearance_procedures_for_non-registered_organisations/view

This custom clearance process will be managed by the Direction de la Protection Civile (DPC). The usual procedures remain in place for all registered organizations. Due to the presidential and legislative elections last weekend and the imposed movement restrictions, logistics cluster surface transport activities, using Handicap International/Atlas Logistique inter–agency fleet, are temporarily on hold nationwide resuming Thursday, 02 December. In order to follow up with cargo movement requests, WFP/Logistics Cluster contracted commercial transporters and moved medical items on behalf of WHO/PAHO to Gonaives, St Marc, Mirebalais and Hinche. In addition, UNHAS helicopter (not operating over the weekend, but flights resumed on Monday 29 November) airlifted medical items on behalf of WHO/PAHO to Hinche, Port-de-Paix, Gonaives, Leborgne and Port-de-Paix. The logistics cluster has liaised with the JOTC in relation to UNICEF request to have MINUSTAH assistance for the unloading of a 95 metric tonnes of cholera response cargo to arrive on Wednesday 01 December at the International Airport in Port-au-Prince.

Contact Information
Head of OCHA Haiti (a.i.) Catherine Huck
Email: huck@un.org

Head of Communications, Imogen Wall
Email: wall@un.org

Reports Team: Jessica DuPlessis, Abdourahmane Diallo
Email: ocha.haiti@gmail.com

United Nations Office for the Coordination of Humanitarian Affairs, (OCHA Haiti), Boulevard Toussaint Louverture et Clercine 18, Port-au-Prince, Haiti. For more information on the response in Haiti, please visit:

http://haiti.humanitarianresponse.info/

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