ARTICLE - CHOLERA SITREP #23

CHOLERA SITUATION REPORT #23
(ReliefWeb) - Source: United Nations Office for the Coordination of Humanitarian Affairs (OCHA)

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I. HIGHLIGHTS/KEY PRIORITIES

· The Ministry of Health (MSPP) has reported 1,882 deaths and 84,391 hospitalised cases. The case mortality rate nationwide is now 2.2 percent.

· 56 CTCs and 105 CTUs are now operational across the county with further scaling up required.

· Although Water Sanitation and Hygiene (WASH) clusters are now functioning in seven departments, there remains a systemic lack of actors.

· The United Nations Secretary General made an urgent appeal today for funds to respond to the cholera outbreak in Haiti. During a General Assembly debate on Haiti today, he stressed that the UN appeal for 174 million dollars made last month has only been 20 percent funded and urged the donors to contribute more.

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** the detailed full report follows below **

This report was issued by OCHA Haiti. The next report will be issued on or around 7 December.

II. SITUATION OVERVIEW

As of 30 November 30, the Ministry of health has reported 84,391 hospitalization cases and 1,882 deaths due to the cholera epidemic. The Government of Haiti, through the MSPP, in coordination with the humanitarian community continues to be concerned about the spread of the cholera in the entire country, while the resources to face the crisis remain insufficient. To date, the United Nations appeal for US 174 million dollars is only 20 percent funded. The cholera epidemic has become such a concern that the UN secretary General, during a debate on Haiti at the General assembly today reminded the international community of the need to do more in order to prevent this crisis from becoming endemic in a country already facing the challenge of recovering from the 12 January 2010 earthquake.

However, funding is just one of the major gaps; there is also an urgent need for more actors to be involved in sensitization activities as well as in cholera treatment, particularly in the remote rural areas. President Préval has been consistently stressing that NOGs and humanitarian partners need to focus their activities in the rural areas and not to concentrate their activities in the Port-au-Prince metropolitan area, which has more medical facilities compared to other departments. Meanwhile the impact of the disease on food security, especially in vulnerable areas is a greater source of concern. The agriculture cluster stresses that it is extremely important that the disease transmission mitigation measures specifically target farm communities and farm workers.

Sensitisation work, particularly around the role of CTCs and stigmatisation of cholera victims and survivors needs to be increased. Local authorities in Grand Anse reported yesterday that 12 people were lynched after being accused of spreading cholera through witchcraft, and partners report continued stigmatisation not just of cholera survivors but also those involved in treating the disease or managing bodies. All working on CTCs/CTUs continue to report that concerns by local communities that these facilities will actually bring cholera to the area are an operational impediment to establishing and running CTCs and CTUs. This issue needs to be systemically addressed.

III. HUMANITARIAN NEEDS AND RESPONSE

Health
The Ministry of Health reported that the cumulative number of hospital visits and deaths due to cholera, as of November 30, was 84,391 and 1,882 respectively. The in-hospital case fatality rate is 3.4 percent nationwide, slightly higher than the overall case fatality rate of 2.2 percent (due to hospitals treating the most severecases). This data relates only to known cases, however, and WHO/PAHO estimates that the actual numbers could be up to twice those registered. The Ministry of Health daily reports available at: http://www.mspp.gouv.ht/site/downloads.

As the number of cases and deaths continues to increase, the Ministry of Health (MSPP) and PAHO/WHO recommend the installation of a prevention and hygiene promotion system associated with each Cholera Treatment Center (CTC). President Preval has called for a rapid deployment of CTCs and the unblocking of bottlenecks such as permits for land, human resources and transportation.

In Port au Prince the French Red Cross has installed 12 CTUs in addition to the 13 which are already operational. The plan is to install CTUs in 34 primary health centres in the metropolitan area of Port au Prince. Since the beginning of the epidemic, PROMESS, Haiti’s central warehouse for health supplies, distributed cholera supplies worth US $ 750,000. Current stocks include ORS sachets for the treatment of 87, 500 mild cases and IV fluids sufficient for 3,670 severe cases. Additional IV fluids to treat 53,700 cases are in the pipeline. PROMESS is now focusing on improving the strategy of pre-positioning stocks in strategic locations ahead of the demand. It plans to pre-position the equivalent of US$ 250,000 in supplies every week in the Ministry of Health’s 14 peripheral depots. This is enough to meet the needs of 50 CTCs of 50 beds each. As part of the improved strategy, PROMESS will continuously monitor the stocks, assist the government in the management of stocks, and ensure that the most affected areas are prioritized.

The Ministry of Public Health and the CDC are providing—alongside with technical assistance, surveillance, and supplies—a training program for Haitian health care workers. These trainings have been organized in three phases. A “Training-of-Trainers” session was held to create a team of 37 “master trainers,” identified by the Ministry of Health and drawn from across Haiti. The standard training modules are: the cholera outbreak; Pathophysiology of cholera; transmission mode; Clinical Presentation and Case Management; Assessment of hydration status; Treatment; Cholera prevention. During the second phase of the training, the trainers were sent to nine departments to deliver the training to department-level public health officials. At least 11 trainings were given. The final phase involves department-level health officials training community health workers (CHW) across the country. These CHW will go on to continue the training within their communities.

Additionally, laminated cards for community education were provided on each of these topics. CDC’s cholera training documents, including French and Creole versions, are available at: www.cdc.gov/haiticholera/training

In Cite de Soleil, where the Port au Prince outbreak is most serious, the Chapi center will open 24/7 hour services the first week of December, with an expanded capacity of 12 beds. MDM Canada supports Chapi during the day, and the French Red Cross take over during the night. Five new community oral rehydration posts (ORPs) will also open in Cite de Soleil on December 6th, with a further 12 ORPs planned for camps. An oral rehydratation point (ORP) has been installed in Dahomey camp, in Port-of-Prince. Two other ORPs will be shortly installed in Accra Nord and Accra Sud camps. One ORP is operational in the camp of Bonnefil.

MDM Canada has trained 150 persons, including its entire staff working in the four mobile clinics and in the Chapi health center in Cité Soleil. At the moment there are five community brigades, with 18 agents providing sensitization on cholera prevention, treatment and disinfection in five neighbourhoods. As of December 3,116 sensitization meetings and training of trainers in all 14 camps and three neighbourhoods were held, reaching 46,746 people and distributing 30,388 soap bars.

Gaps and Challenges
Despite new sites being identified for constructions of CTCs and CTUs in the West Department, problems with land allocation remain. The president will address this with administrative authorities at the COUN. MDM has reported being overstretched in Grand Anse and has requested additional partners to upscale activities.

Water, Sanitation and Hygiene (WASH)
In Port au Prince, chlorine residual testing in water supplies has indicated a large improvement in water quality in tanks and bladders, with DINEPA standards now being reached in 82% of cases. However, the minimum target residual is not achieved in 48% of home measurements, with particularly low results in Croix de Bouquets, Carrefour, Petionville and Port au Prince.

Chlorination of wells is ongoing in Artibonite under a project implemented by ACF, who are recruiting 10 new technicians as the project scales up, and nationwide as per the DINEPA national strategy to chlorinate town supplies across the country. Scaling up sustainable chlorination is necessary to reduce the need for aquatabs.

Scaling up of soap distribution, ORS and Aquatabs is ongoing, with targeted distributions to priority households (eg those without a water supply) where possible. In the North Ouest, for example, ACF will distribute to 15,000 houses, and in the North Oxfam GB have set up 50 ORS corners in Petit Anse with identification of further sites ongoing, and 30,500 households will receive soap and aquatabs under a blanket distribution also by Oxfam GB.

Training of community mobilisers in hygiene promotion and WASH messaging is also ongoing as part of the effort to scale up community level public information work. MSPP have trained two-thirds of the CAZEC “agents communataires” in Centre department in hygiene promotion and Mercy Corps, World Vision, Oxfam GB, Concern and other partners are providing training in several departments, targeting existing actors in this area (such as health ministry workers) as well as recruiting and establishing dedicated teams. Further scaling up of this work is however necessary.

WASH activites at CTCs and CTUs is an urgent priority, as is dealing with sludge (liquid excreta). In Port-au-Prince, mobilization by UNOPs of the DINEPA-UNICEF desludging truck fleet is ongoing, and desludging of CTCs will begin on December 15th.

A second draft of the WASH 3W and agency gap map is now available from the WASH cluster. WASH clusters have now been established in Bas Artibonite, Haut Artibonite, Est Centre, Ouest Centre, Leogane/Gressier and Petit Goave/Grand Goave – contact the WASH cluster for more details.

Gaps and constraints
Although WASH clusters are now functioning in seven departments, there remains a systemic lack of WASH actors. Particular areas of concern include Croix de Bouquets, Centre (Thommasique and Massaide), Nord Ouest and Nord. Gaps in all areas are reported in the latter two departments.

Communications work also requires scaling up, and the messages need revising to address emerging issues such as misuse of chlorine products, misunderstandings around safety of food produce from Artibonite and stigmatization of cholera victims and their families. This is being taken up by CDAC and the communications teams, who are awaiting input from the WASH cluster.

Desludging of toilets in IDP camps also remains a challenge. Many toilets are full and thus no longer operational, and full toilets are a potential source of contamination, but desludging in some camps has been hampered by the amount of garbage in the toilet pits. DINEPA policy is clear that agencies constructing toilets are responsible for their maintenance.

There is also a gap in information regarding WASH needs in health facilities. A WASH assessment of CTCs/CTUs in Nord Ouest will take place this weekend, but more detailed information is also required in all departments to guide response.

Camp Coordination/Camp Management (CCCM)
CCCM partners continue to require consistent supply of WASH materials, including soap, water purification tablets, latrines, to address the humanitarian needs in camps. CMOs have 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 campaigns, which included distribution of soap and water purification tablets; 18 percent of the activities were focused on the disinfection of latrines in 95 camps; and 24 percent were linked to the installation of Oral Rehydration Posts (ORP).

The establishment of the ORPs is being coordinated with local authorities and other organizations working in IDP camps. CMO teams have installed the physical facilities for the establishment of 124 ORPs, mostly in camps located in the communes of Croix des Bouquets, Delmas and Port au Prince. Three ORPs are already functional, with 250 planned. IOM has been preparing the ground for the installation of ORPs by going ahead of time to prioritized camps to explain the function and importance of ORPs and rehydration to fight cholera.

This week, teams visited 12 in Cite Soleil, and nine in Delmas. ORPs will also serve focal points for activities on cholera prevention and sensitization campaigns.

Handicap International continues to work to guarantee the access of persons with disabilities hosted in IDP camps and settlements to the on-going activities undertaken by humanitarian actors.

Thirty (30) community mobilizers have been re-trained by IOM on Hygiene Promotion specifically to respond to the cholera outbreak. IOM's daily national radio program "Chimen Lakay" focused on cholera treatment and prevention during the whole week, except for one day (World AIDS Day). IOM continues to produce and distribute its journal "Chimen Lakay" with information and graphics on cholera prevention and treatment within the affected areas.

Gaps and constraints
Despite the Cluster’s response, IDPs are in need of more WASH related items; including water purification tablets, as well as latrines and sensitization campaigns throughout camps in the earthquake affected areas.

CCCM partners also require additional medical and WASH assistance teams, communications assistance, communications materials and medical items.

Nutrition
The nutrition cluster continues to focus on mitigating the impact of the cholera epidemics among children under 5, pregnant and/or lactating women, and other vulnerable groups. Sixteen nutrition cluster partners including, Médecins du Monde (MdM), Action Contre la Faim, Haiti Participitative among others, have mapped their activities in the cholera response. UNICEF and WHO developed for the cluster several cholera response specific documents including a detailed list of key nutrition activities to be supported at CTC/CTU, a decisional flowchart for Infant and Young Child Feeding in CTC/CTU context and a poster on the screening of severe acute malnutrition and rehydration guidelines have been developed. They are now under review by the MSPP to better reflect the needs of severely malnourished children with cholera in CTCs and CTUs and will be made available when finalised.

Gaps & Constraints
The cluster reports that only 16 out of 51 nutrition partners have communicated their coverage in response to the cholera outbreak, which limits gaps analysis. A lack of NGOs intervention is reported in certain areas, including Nippes, South and South-East departments. Lack of staff is also a major constraint for nutrition cluster’s partners. In addition the list of CTC/CTU is still changing making planning of support activities more difficult for the cluster.

Agriculture
The cholera affected communities are primarily rural farming ones, depending on this season’s rice cultivation for their food security and livelihoods and the impact of cholera on food security is a serious concern as the outbreak will impact farmers in a number of different ways. It is extremely important that disease transmission mitigation measures specifically target farm communities and even more to the point, farm workers.

FAO sent a Cholera Expert to assess the state of cholera in rural farming communities. The results of the tests showed that the immediate risks of the river, irrigation canals etc are considered to be minimal.

However, early reports reveal that farmers are afraid of cultivating their fields during this rice harvesting season due to the fact that cholera originally has been primarily transmitted through the river and irrigation canals. As a result, this season’s rice harvest will most likely be lost and farming families in Artibonite will not have access to revenue and food during the coming months, prolonging the upcoming “hunger season”. It is vital to support these already vulnerable farmers and ensure that they will be able to plant during the next harvest. There are also reports of consumers being unwilling to purchase produce from Artibonite, which will further impact agricultural commerce in the area. More in depth assessments are being prepared with CNSA.

Rapid assessments have noted the monitoring and sensitization campaigns have not reached the out-of-theway rural areas. An FAO assessment team recently noted that many of the deaths in rural areas are not recorded by the authorities and many cases probably result from farming families not having access to the right information. Furthermore, sensitization campaigns are not apparently designed for areas with little infrastructure such as lack of latrines and lack of regular access to potable water. CDAC recently revealed that the radio stations used for transmission of sensitization messages don’t reach some areas in the north and that more sensitization needs to be done in person through hands on training and outreach.

In addition to the impact of cholera, Hurricane Tomas severely hit the agriculture sector, damaging crops and resulting in loss of livestock in key areas for agriculture. Rapid assessments conducted by the CNSA and MARNDR with FAO support estimate that 78 700 hectares (Ha) of crops have been destroyed including mainly roots and tubers, peas, maize and banana crops.

The same assessment documents heavy livestock losses, specifically 1,025 heads of cattle, 11,249 goats, 20,640 chickens and 3,274 pigs. The most damaged areas are the departments where agricultures remains the dominant economic activity, including Grande Anse with 25 468 Ha destroyed, the South with 13,298 Ha destroyed, the South–East with 9,614Ha destroyed, and Nippes with 7,688 and the particularly vulnerable North-West department with 6,863Ha destroyed. In most of the country the agricultural sector has been severely affected. The fisheries sector was also badly affected losing 400 boats from an already small fleet along with 15,156 fish traps and 788 nets. At least 50,000 farming families have been affected; stressing that in some cases recovering the losses can take decades. For example, a coconut or mango tree takes seven years to begin producing.

The agricultural cluster has launched a communication campaign to fight against cholera fear and bring farmers back to their fields and to support other cluster's communication to remote (uncovered) rural areas.

The cluster plans on developing programming to combat the imminent food insecurity through provision of inputs and labour intensive Tomas damage rehabilitation projects.

Gaps & Constraints
Focus on cholera has slowed the response from donors to Tomas destruction. Inter and intra cluster coordination has become difficult due to security restrictions imposed as a result of security restrictions. Initial assessments were also hampered due to excessive travel restrictions to affected areas. Agriculture cluster partners’ rapid assessments have found that cholera sensitization campaigns are not reaching remote areas and are not designed to target rural low-income communities.

Early recovery
The Livelihoods Working Group, within the framework of the Early recovery cluster, and in coordination with the Agriculture cluster, is supporting the initiative from the National Commission for Food Security (CNSA in French) to conduct a survey to measure the impact of cholera in livelihoods in Port-au-Prince and rural areas.

Technical assistance as well as financial and in kind support is being provided to national authorities to conduct the assessment, analyze the data, process the information and make recommendations. NGOs and UN agencies participating in the Early Recovery cluster are contributing to the exercise.

Gaps and Constraints
The financial gap for the impact assessment has been reduced down to US5, 000 dollars.

Education
UNICEF and the education cluster partners are working closely with the District Education Office (BDS) to coordinate the interventions on cholera prevention in schools. Plan International has produced a document with key messages on its cholera prevention activity, and has drafted a short training module on emergency hygiene promotion and cholera prevention, which will be used for a 2-day training of trainers. The Cluster will share this document with partners for feedback and comments. The Adventist Development and Relief Agency (ADRA) has distributed 19 boxes of soap, 440,000 aquatabs, 10 buckets and posters provided by UNICEF in 5 schools in Carrefour, reaching 4,581 students. The module for drama activity for children on hygiene promotion has been produced, and is shared with the Cluster members.

In the metropolitan area of Port-au-Prince, activities are taking place in 50 kindergartens and orphanages, for the security of 2,000 children and 500 staff, including training of the management, hygiene promotion activities for children, and distribution of hygiene kits, such as bars of soap, and chlorine tablets.

As part of ongoing earthquake response work, IOM has finalized the data collection and entry of the survey on approximately 5,200 children’s school enrolment situation in 43 IDP camps – full findings will be disseminated shortly. Islamic Relief completed the rehabilitation of 2 schools in Tabarre and 1 school in Delmas that were damaged by the earthquake. A total of 2,230 students and 41 teachers are now learning in school buildings, moving from temporary learning spaces.

Information was shared by other partners: Inter-America Development Bank has obtained the approval of the USD 26 million fund for the Ministry of Education (MENFP)’s Operational Plan, adding to the already provided USD 24 million to MENFP. USAID has informed that they have thus far constructed more than 320 classrooms for 76 schools in the earthquake affected zones, distributed more than 120 tents in 49 schools, trained teachers, and supplied teaching and learning kits to 32,100 students and 642 teachers to accommodate a double shift of students into each classroom, etc. They will continue to work on teacher training, semi-permanent school construction and school supplies.

Gaps & Constraints
Due to insecurity concerning the presidential election, the closure of schools continues to disrupt children’s education until the coming week. The limited coverage in geographical areas in many part of the country, such as the North, North-west, remains a critical issue.

The Cluster coordination is seeking more funds to fill the gap in the current cholera prevention efforts and is approaching other partners, such as Inter-America Development Bank (IDB), whose support on cholera is currently focusing on health and WASH sectors, and USAID, and will maintain the contact in order to cover more schools.

Logistics
In order to map the logistics capacity at national level, the logistics cluster created and circulated an Inventory matrix requesting all partners to complete the document. Feedback is currently being consolidated by the cluster and will be shared shortly.

Since Tuesday, 30 November, the logistics cluster provided road transport services to Action Contre la Faim (ACF) delivering 3.3 metric tons of plumpy nuts, power washer and chlorine, from Port-au-Prince to Gonaives; as well as 225 boxes of Cholera kits (2 metric tons) for Handicap International/Atlas Logistique from Port-au-Prince to Gonaives. United Nations Humanitarian Air Service (UNHAS) airlifted Ringer’s lactate, medicines and logistics material (9mt), on behalf of MdM-France from Port-au-Prince to Jeremie. In addition, two assessment teams from J/P Haitian Relief Organization were flown to Cornillon and Thomassique to identify areas impacted by the Cholera and resources need to be addressed in these areas. Following the request that the Logistics Cluster submitted to the EJOC in the aftermath of Hurricane Tomas, MINUSTAH has conducted the assessment of the quay of the private port in Gonaives that was damaged by the hurricane.

Child Protection
Security continues to be a major concern for some partners who report some isolated incidents in the regions, especially anti-MINUSTAH sentiments being directed categorically against them. Though too early to call a trend, something that needs to be monitored closely and possible address as it does impede NGO ability to respond effectively and efficiently. A child protection rapid assessment on CTCs is necessary to understand if medical staff is aware of child separation risks, have access to relevant information for referrals, and provide sufficient psycho-social support and to assess contagion hazards for children near centers. Increased reports about stigma, especially for children treated and then returning to communities, stress an importance to enhance sensitization campaigns to include this vital component going forward.

A key issue identified by the sub cluster through discussion with other clusters is the need to undertake joint efforts to establish protocols, to identify and refer separated children as well as to provide psychosocial support to children affected by the disease. Sensitization, hygiene promotion and preventing child separation continue to be the main focus of all child protection actors activities. World Vision child protection partners are conducting a rapid assessment on child protection that includes questions on cholera response. Distributions of materials and training sessions in cholera prevention and response are ongoing across CFS and schools
by a number of partners.

IBESR / UNICEF/ SAVE THE CHILDREN –toll-free call center is now operational from 8:00AM to 8:00PM to support a rapid identification and response to children separations (Centre d’appel d’urgence 2942-1000).

Gaps & Constraints:
There are not enough child protection specialized partners in rural and hard-to-reach areas especially in the North and North-West departments. Most partners are still based in earthquake affected areas. Distribution of supplies through CP partners continues unevenly given bottlenecks in supply distribution. Access to remote areas is particularly difficult given a constraint on capacity.

While the effects of the epidemics are protracted, vulnerability is not only associated to health but also –progressively- to protection. Thus there is a need to assess the impact of cholera on child protection.

Communications
Oxfam in coordination with PHARE started a major hygiene promotion campaign in Carrefour-Feuilles, training 200 community mobilizers on hygiene promotion. Fifty four partner organisations participated in these training. The 200 community mobilisers were then divided in 4 groups of 50 in order to cover the 300,000 people living there.

GOAL keeps reinforcing hygiene promotion messages via community mobilisers in 38 camps and through training of teachers in 4 schools in Port-au-Prince. The sessions on cholera prevention and treatment include preparation of Lakay ORS and use of aquatabs and ORS sachets. CARE continues its sensitization campaigns which have reached almost 230,000 people in the North West, Artibonite, Grand Anse and Nippes departments since. CARE is now planning to scale up sensitization activities in its camps in Carrefour. Tshirts and flyers are also being distributed in IDP camps in Carrefour.

This week the 20 minutes ENDK radio program produced by Internews and broadcast on 41 radios across the country focused on the response of DINEPA. The show looked into the IFRC’s assistance in 14 prisons in the country where 174 prisoners have cholera. The Internews research team carried out data analysis for the baseline survey coordinated by CDAC on the impact of the communication on cholera, and results will be made public shortly. MINUSTAH FM continues to broadcasting MSPP spots. MINUSTAH FM also invited a host from PAM to talk about their washing hands/hygiene promotion campaign and soap deliveries in schools.

Funding
The UN Secretary General Ban Ki-moon made an urgent appeal today for funds to respond to the cholera outbreak in Haiti and Cuba said it was sending another 300 doctors and nurses to support the humanitarian efforts to stop the spread of cholera in Haiti. During a General Assembly debate on Haiti, the Secretary General of the UN stressed that the UN appeal for 174 million dollars made last month has only been 20 percent funded by international donations and he urged the donors to urgently help meet the appeal in full.

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.

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