i
SOMALI FEDERAL REPUBLIC
MINISTRY OF HEALTH AND HUMAN SERVICE
DRAFT AWD/CHOLERA PREPAREDENESS AND RESPONSE PLAN 2017-2022
“Our vision is to have a healthy and productive population contributing to
the development of the nation”.
Table of Contents
Abbreviations and Acronyms .......................................................................................... iv
Forward ...........................................................................................................................v
Executive Summary......................................................................................................... vi
1.0 Introduction ............................................................................................................. 1
1.1 Historical background of AWD/Cholera planning ................................................... 1
1.2 Target Audience..................................................................................................... 1
1.3 How to use this document ..................................................................................... 2
2. 0 Objectives of preparedness and response plan ........................................................ 2
3.0 Background ............................................................................................................... 4
3.1 Current risk of AWD/Cholera ................................................................................. 5
4.0 Gap analysis and basic needs for AWD/Cholera response ......................................... 6
4.1 Coordination of response activities ....................................................................... 6
4.2 Surveillance, laboratory and epidemiology ............................................................ 6
4.3 Case management ................................................................................................. 6
4.4 Water Sanitation and Hygiene ............................................................................... 7
4.5 Logistics and supplies ............................................................................................ 7
4.6 Social mobilization and communication ................................................................ 7
4.8 Rapid response and Rumor verification ................................................................. 8
5.0 Planning assumptions ............................................................................................... 8
6.0 Coordination of AWD/Cholera outbreak ................................................................... 9
6.1 Organisation of response of AWD/Cholera in Somalia ......................................... 10
6.2 Roles and responsibilities during the AWD/Cholera response ............................. 10
7.0 Preparedness activities.......................................................................................... 11
7.1 Risk and capacity assessment ............................................................................. 11
7.2 Prepositioning of supplies ................................................................................... 11
7.3 Human resources
7.4 Development of key messages ............................................................................ 12
7.5 Simulation exercises ............................................................................................ 12
8.0 Surveillance activities and outbreak detection ........................................................ 13
8.1 Sentinel Surveillance .......................................................................................... 13
8.2 Electronic Disease early Warning System (eDEWs) .............................................. 13
8.3 Cholera Case definition ....................................................................................... 13
8.4 Alert verification ................................................................................................ 14
8.5 Rapid field assessment ....................................................................................... 14
8.6 Advanced preparedness measures ...................................................................... 16
9.0 Laboratory testing and microbiological confirmation ............................................ 16
9.1 Collection and transport of stool specimens ...................................................... 17
9.2 Rapid diagnostic testing ....................................................................................... 18
10.0 Response activities ................................................................................................ 19
10.1 Emergency Team Activation .............................................................................. 19
10.2 Outbreak declaration ........................................................................................ 21
10.3 Establishment of AWD/Cholera treatment centers for case management ........ 21
10.4 Clinical management of cases ............................................................................ 22
10.5 Establishment of Oral rehydration points (ORP) ................................................ 23
10.6 Considerations for Oral Cholera vaccine (OCV) . ................................................ 23
10.7 Water, sanitation and hygiene (WASH) Coordination ...................................... 24
10.8 Funerals and Handling of Corpses ...................................................................... 24
10.9 Public communications ..................................................................................... 25
11.0 De-activation of Emergency Team and completion of outbreak response ........... 25
12.0 Evaluation of response activities ........................................................................... 26
13.0 Appendices........................................................................................................... 27
13.1. Appendix 1. AWD/Cholera Response and Activation Cascade. ......................... 27
13.2 Appendix 2: Drugs, supplies and materials to require initiating a response ....... 29
13.3 Appendix 3: Talking points and Key Messages for AWD/Cholera ....................... 30
13.4 Appendix 4: Technical sub committees Roles and Responsibilities .................... 31
13.5 Appendix 5: National AWD/Cholera Treatment Guidelines ............................... 33
13. 6 Appendix 6: Guidelines for establishing Cholera treatment centres ................ 38
13.7 Appendix 7: Detailed WASH Activities ............................................................... 41
13.8 Appendix 8 AWD/Cholera case based investigation form .................................. 43
13.9 Appendix 9. Regional risk and capacity assessment form for cholera ................ 45
13.10 Appendix 10 National AWD/Cholera operational plan for Somalia 2017-2022 53
Abbreviations and Acronyms AWD Acute Watery Diarrhoea
C4D Communication for Development
CFR Case fatality Rate
CSR Communicable Disease Surveillance and Response
CTC/U Cholera Treatment Centre/Unit
CTLS Community Total Lead Sanitation
DMO District Medical Officer
DSMC District Social Mobilisation coordinator
eDEWs Electronic Disease Early Warning System
EWARN Early Disease Warning and Response Network
FMoH Federal Ministry Of Health
IDDK Integrated diarrhoea Disease Kit
IDPs Internally Displaced persons
IEC Information Education Communication
IGAD Inter Government Agency for Development
IPC Infection Control and Prevention
NPHRL National Public Health Reference Laboratory
OCV Oral cholera Vaccine
ORP Oral Treatment Point
ORS Oral Rehydration Salt
PCR Polymerase Chain Reaction
RDK Rapid Diagnostics Kit
RMO Regional medical Officer
RRT Rapid Response Team
RSMC Regional Social Mobilisation Coordinator
RSO Regional Surveillance Officer
SBBC Social Behaviour Change Communication
UNHCR United Nations high Commission for Refugees
UNICEF United Nations Children Education fund
WASH Water Sanitation and Hygiene
WHO World Health Organisation
Forward Somalia is one of the countries in the EMRO region characterised by a complex humanitarian crisis. The crisis has been orchestrated by protracted civil conflict, drought and faminein most parts of the country. Of the over one million people living in IDPS, survey reports show that over 70% of them have limited access to water and sanitation and poor hygienic behaviour. The repeated contamination of water sources due to floods and total breakdown of health services has contributed to repeated cholera outbreaks especially in the regions of Banadir,Lower Juba,Hiraan and Middle Shabelle. The recurrence of AWD/Cholera outbreaks, other conditions and; events such as climate change and natural disasters has resulted into the need to develop AWD/Cholerapreparedness plan to streamline response activities by different agencies. These preparedness and response guidelines have been drafted based on lessons learnt during the subsequent response activities in the context of Somalia consolidating work plans for FMOH emergency unit, WASH and Surveillance activities. The guidelines aim at addressing how to coordinate response efforts to avoid duplication and provide timely information for public health action by all stake holders. These guidelines should be adapted to reflect national priorities, set policies and standards. The guidelines are intended for use as:
A general reference for AWD/Cholera preparedness and response activities at all
levels
A set of definitions for threshold levels that trigger some action for responding to
AWD/Cholera outbreaks
A stand-alone reference for level-specific and coordination guidelines
A resource for developing training, supervision and evaluation of response activities
A guide for improving early detection, preparedness for AWD/Cholera and case
management.
The guidelines are intended to be used by Health workers at all levels; IHR National Focal
Points; Regional medical teams, international agencies, civil society organisations and the
general public.
Thank you all
Dr. Abdullahi Hashi Ali
Director General, MOH, Somali, Federal Republic
Executive Summary The AWD/Cholera preparedness and response plan for Somalia 2017-2022 highlights the areas of focus for the prevention and control of cholera in Somalia. The plan is based on previous achievements and lessons learnt during the previous control efforts in the recent AWD/cholera outbreaks in the federal republic of Somalia. The plan incorporates key activities and strategies as stipulated in the Somalia National strategic plan 2011-2016 and the Water, Sanitation and Hygiene (WASH) cluster Acute Watery Diarrhea (AWD) preparedness and response plan of 2012. The goal of the AWD/Cholera preparedness plan is to ensure that a coordinated, effective and functional preparedness and response mechanism is in place at each level of the health system with the capacity to address AWD/Cholera outbreaks Cholera control strategies have stagnated over the years in Somalia due to a number of factors. The country has been characterized by a complex emergency situation leading to total breakdown of health services. Over 50% of the population have no access to safe water and Sanitation with over 1,1 million people living in IDP camps. Most of the parts of the country particularly in the riverine regions of Shabelle and Juba Rivers are prone to flooding almost twice in a year leading to contamination of water sources. The unlimited movement of the people across borders with Kenya and Ethiopia were cholera has also been endemic makes control efforts challenging.Despite various stake holders supporting the provision of Water and Sanitation and community engagement for adoption of hygienic practices using available channels of communications, the improvement of indicators in these sectors have been slow. Over the next five years the plan will focus on the following:
Strengthening coordination, Line of Communication of field level outbreak reporting
system, improving preparedness activities, Case management, Water and Sanitation,
community sensitization and introduction of proposed Oral cholera vaccine in hot
spot areas.
The plan will also focus on improving logistics and supplies disposition in different
regional hubs.
The plan also focuses on ministry and regional administrative units to take lead in the
planning and implementation of key activities with support from development
partners. Strategies such as integration of AWD/cholera prevention and control
activities with existing programs for Polio immunization, Communicable disease
surveillance and community for development will be used to achieve the established
targets.
The plan intends to identify cholera hot spots and develop targeted interventions in
all these areas focusing on the use of new technologies, research, consolidating
achievement in WASH, Surveillance and community mobilization.
Other proven strategies including introduction of Oral Cholera vaccine will be
considered as a complementary preventive strategies for cholera epidemics.
The plan also focuses on establishing the Emergency Operations center (EOC) at the
federal ministry of health and regional/states units’centers to coordinate the
implementation of response activities.
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1.0 Introduction
1.1 Historical background of AWD/Cholera planning
The development of the AWD/cholera preparedness and response plan follows the repeated outbreaks of cholera in Somalia and the need to harmonise the response and preparedness activities for cholera control and prevention. The WHO regional team in EMRO spearheaded the development of this plan by providing technical support for the development of the plan with the aim of strengthening national response capacity for cholera in Somalia. The consultant with the technical team of the WHO Country office in Somalia conducted a series of in-depth interviews with different partners participating in response activities in Somalia. Some of the international organisations consulted included OCH, UNICEF and UNHCR both in Nairobi and Mogadishu. The peace keeping mission medical team of AMISON was also consulted based on their extensive knowledge of the health situation in the field of their deployment. Local NGOs operating in different regions in the country were also consulted and these included ZamZam foundation, JF program, Trocaire, New ways, SWSSO and WADRI. Field visits were conducted in Banadir and Kismayu hospitals to get an in depth understanding of the implementation of case management and other activities. A series of meetings were held with the director general and the emergency team of the Federal Ministry of Health. A draft plan was then developed based on the findings on these interviews and reviews of field reports from different partners for the various response activities that had been conducted. This draft incorporated the different work plan of the WASH and health clusters and the coordination activities of the Emergency team of the federal ministry of health. A two day national consultative meeting for all regional emergency teams, civil society organisations and international Organisations was held in Mogadishu and the draft was adopted as a working document. The draft was then handed over to the federal ministry of health for finalisation of the work plan, budget and alignment in the development plan for the Somali republic.
1.2 Target Audience
This plan has been developed with the goal of strengthening the coordination mechanism for the cholera response activities in the Somali Republic. The documented in intended to guide the implementation of key preparedness and response activities for the AWD/Cholera outbreaks in Somalia. This document contains the contextual background of the risk factors of cholera in Somalia, Risk assessment findings, hot sport areas for cholera, Key coordination structures at all
levels of the response chain, Standard operating procedures for case management, Surveillance, Water and Sanitation and Hygiene, Laboratory activities, logistics and supplies and a 5 year strategic plan. This document will be used by the Federal Ministry officials, Organisations supporting cholera response activities in Somalia, health workers at all levels and the communities to implement cholera control and prevention activities in Somalia
1.3 How to use this document This document has been developed and modelled to the existing nation policy documents for the Somali republic. It incorporates all previous work plan for Water and Sanitation and response activities as was implemented by the national and regional emergency teams The document is structures to provide a historical perspective of AWD/Cholera outbreaks in Somalia with key emphasis of identifying strengths and gaps in the previous campaigns. The gaps identified have been structured to develop strategic objectives. Avenues for integration of key activities have also been explored Coordination structures for response at different levels of administration have been specified with a clear coordination mechanism for implementation of response, preparedness and evaluation of these activities under different themes. A proposed work plan based on activities, indicators and expected outputs has been developed under each strategic objectives and a responsible entity assigned to steer the implementation of these activities. For planning purposed, key assumptions have been made to cater for population growth, attack rates and severity of cases to support the planning of response activities. These percentages should be adapted to regional specific situations. The Annex provided an in-depth review of SOPs for case management, coordination, Water, Sanitation and hygiene, Social mobilisation, Surveillance and laboratory activities have been incorporated are reference materials for implementation of different activities. It has also been assumed that all the activities will be implemented at different administrative levels and coordination by regional emergency teams. Partners and organisations are expected to support the national and regional teams in the implementation of these activities to avoid duplication.
2. 0 Objectives of preparedness and response plan In response to the increased risk of AWD/Cholera and other diarrheal diseases, the federal ministry of health, in partnership with WHO, UNICEF and Key partners, has
compiled this AWD/Cholera Preparedness and Response Plan. While this document often specifically addresses AWD/Cholera, the principles can be applied to most diarrheal outbreaks. The objectives of the preparedness and response plan are to:
To strengthen the coordination of epidemic preparedness and response for
AWD/Cholera at all levels
To enhance surveillance and laboratory capacities at all levels in order to
reduce the spread of outbreak.
To improve case management and infection control protocols at health
facility level and AWD/Cholera treatment centers
To ensure adequate prepositioning of AWD/Cholera buffer stock, other
medical supplies and equipment in all regions
To Implement oral AWD/Cholera vaccine campaigns in high risk and
vulnerable populations
To strengthen WASH preparedness for rapid response during an outbreak
To contribute to reducing the risk of AWD/Cholera through appropriate HP
activities & acceleration of the widespread adoption of safe hygiene
practices
To mobilize and empower communities, policy makers, opinion leaders for
AWD/Cholera prevention and control
3.0 Background This plan builds on the lessons learnt in the previous AWD/Cholera response activities. It is intended to guide preparedness and response activities for timely, comprehensive, and coordinated national;-led, nationally supported response actions to priority epidemic diseases in accordance with the surveillance guidelines for Somalia. This plan focuses on preparedness and response activities before, during, and after AWD/Cholera threshold has been reached. It serves as a complement to the Surveillance guidelines for Somalia; which outlines surveillance, triggers, alert notification, alert verification, and field investigation procedures. Somalia is one of the AWD/Cholera endemic countries in the region. Response efforts to AWD/Cholera outbreak are led at both national and State/regional levels with support from international agencies. This plan captures lessons learned from those response efforts and outlines key preparedness and response activities that are necessary for mounting timely and effective response to future outbreaks. The plan outlines national roles and responsibilities in both preparedness and response activities and in return to routine activities. The content will provide an operational framework, with terms of reference (TORs) and standard operational procedures (SOPs) in the annexes. Somalia is located in the horn of Africa bordering Djibouti to the North, Ethiopia in the West ,Kenya to the South and the Indian ocean to the East. After the collapse of central Government of Somalia in 1991, the country was divided into three zones of Somali land, punt land and South central. These zones are further subdivided into 11 regions and over 100 districts.The health of Somalia is still in a critical situation with one of the worst health indicators in the world. With an estimated total population of 13.1 Million in 2016of whom 1.1 million live in IDPS, only 50.2% are women, only 42% and 46% of children below five years receive DPT and measles vaccination. The under-five mortality is 137 per 1000 live births, maternal mortality ratio stands at 732 per 100,000 live births. Only 24% of the population has access to proper sanitation with majority practicing open defecation. Only 32% of the population have access to safe drinking water.
3.1 Current risk of AWD/Cholera
Over the past five years,several AWD/Cholera outbreaks have been reportedin Somalia as shown in the figure 1. The protracted civil war has led to total breakdown of health services in the country. Repeated flooding in the riverine regions of Jubalnad,Shabelle,Hiraan and Banadir regions has led to contamination of the existing water sources. The increasing number of people displaced by the protracted war has led to limited access to safe water and sanitation especially in the Banadir region. Over the past five years, Cholera outbreaks have repeatedly occurred in regions of Banadir, Hiraan,Kismayu,Lower and middle shabelle (see map) mainly because of repeated flooding and overcrowding in most of the refugee settlements. Uncontrolled movement of people across Kenya and Ethiopia, countries which have also had repeated cholera outbreaks makes control efforts a challenge. As of August 30th 2016, a total of 13,453 suspected cholera cases including 496 deaths (CFR 3.7%) have been reported in 25 districts in Southern and central zones of Somalia. Of these cases 6378(47.5%) are women while 7791(57.9%) are children below 5 years. Of the 100 stool samples collected since January 2016, 45(45%) of them turned positive for Vibrio cholera Serotype “inaba” and “Ogawa”.
4.0 Gap analysis and basic needs for AWD/Cholera response
4.1 Coordination of response activities
The coordination of AWD/Cholera outbreaks is a key component in ensuring that all implementing partners are working closely together so as to avoid duplication and promote better utilization of resources. Cholera response activities are undertaken by the Emergency team in the Federal Ministry of health and this structure is replicated at state/regional level. Thisunit is supervised by the Department of Medical Service,supported bystate MOH, RMO, CSRs and partners. Because Cholera is now a regional phenomenon, an inter- ministerial committee for IGAD has been established to develop a regional strategy for cholera response. The Inter ministerial committee for Water and sanitation has also been established and is composed of different ministries and meets regularly. A national water policy for Somalia has been developed and distributed to all regions. However, different implementing partners work independent of the Ministry and regional teams. There is limited information sharing among partners in addition to lack of contingency fund for cholera presentations and control.
4.2 Surveillance, laboratory and epidemiology
The electronic disease early warning system(eDEWs) is used to receive real time information from all regions about cases of Acute Watery Diarrhea (AWD). This enables the national task force and regional emergency response teams to verify and confirm any rumors before response can be initiated. This is complemented by the sentinel based system that is used to collect weekly reports. The completeness and timeliness of reporting is close to 90% and information is shared through the weekly bulletin. Stool samples collected from the health facilities are tested at the National Public HealthReference laboratory (NPHRL) in Mogadishu and quality controls done in Kemri Lab in Nairobi. However the eDEWs has not been running for the last 2 years, rumor verification is limited and sample collection for confirmation of cases has not been implemented as per protocols. Avenues for the use of alternative technology for reporting health events in a challenge in especially lower and middle Juba since these are perceived as a security threat in most of these areas. Regional surveillance officers are deployed across the region and supported by WHO, however their incentives have not been paid for the last 6 months making it difficult for them to send data on a weekly basis. Community alerts and rumors are received from media houses. Even when no rumor ledger exists, the rumor verification is done by the surveillance teams and RMOs
4.3 Case management
Cases of Cholera are managed according to WHO protocols in isolation facilities. Health workers are trained in case management, infection control and prevention
(IPC). However,the country has not established the required AWD/Cholera treatment centers in high risk areas to manage cases. The health workers who were trained have not been given refresher courses. Standard operating procedures (SoPs) for case management and IPC have not been distributed to all treatmentcenters.Training of health workers in management of AWD was last done in 2014 for selected health facilities. At least one health worker was trained per health facility. Even when Oral Cholera vaccine (OCV) has been found to be effective against AWD/Cholera outbreaks in hot spot areas in addition to other preventive interventions, it has not been found feasible in the context of Somalia
4.4 Water Sanitation and Hygiene
A review of the UNICEF WASH report for 2015 shows that 55% of the population have access to improved water source within in a walking distance form home while 77 % have adequate knowledge of water treatment. Only 21% of the population treat water for drinking with 55% of them storing water as recommended. Different organizations are supporting communities with aqua tabs for domestic water treatment and distribution of hygienic kits. UNICEF has deployed C4D officers in all regions and districts to sensitize communities in hygienic behaviour and provide key messages about AWD using community radios. Some villages have been declared open defecation free and these have been turned into model villages for sanitation. Even when food hygiene is important is reducing infection rates; there is no mechanism to educate food vendors and handlers in affected communities on food hygiene. This is worsened by the feeding behaviour of the Somalis who practice communal feeding especially during festivals and Ramadan.
4.5 Logistics and supplies
Hubs for the storing of stock piles for WASH activities have been established in nine (9) regions. This are supplemented by Diarrhea disease kits (DDK) supplied by different partners. These hubs are managed by different NGOs and are used for storing only hygienic kits. There is need for timely quantification and ordering of all supplies including IDDK on time and transporting them to points of use. There are still challenges in ensuring that supplies are delivered on time to affected areas due to poor transport and insecurity in some of the affected areas.
4.6 Social mobilization and communication
Engaging communities during outbreaks is important to provide them with adequate information about AWD/Cholera control and also empower communities make choices about adapting hygienic behaviors. AWD/Cholera affected communities are provided with key messages about modes of transmission and behavior change communication using available media. This is done using the
Community for Development (C4D) who have been trained at regional and district level. With cholera hot spots already mapped and key messages already developed and translated in local languages, finding sustainable media of transmission in these communities is a challenge. Lots of false messages are received in the country and this complicates response efforts. Information Education and communication (IEC) materials have not been distributed to affected communities, and the country lacks a communication strategy that can be used in the event of an outbreak. There is no specialized personnel in the federal ministry of health with skills in social mobilization and risk communication.
4.8 Rapid response and Rumor verification
Rumors about health events happening in the community are received through local communities’ phone call, local media, NGOs, Local authorities. The regional rapid response team is constituted by the Regional Medical officer, regional surveillance officers, comprising of surveillance officers, clinician and laboratory personnel are put on action for investigation, Verification and Response and are deployed as soon as feasible
5.0 Planning assumptions In order to guide the planning process, certain assumptions had to be made in order to estimatepotential evolution of the outbreak.Assuming that 50% of the population (13,000,000)1 in Somalia is at risk of AWD/Cholera and 1% attack rate Estimated number of cases over 1 year = 13,000,000 * 50% * 1% = 65,000
It is known that in most AWD/Cholera outbreaks, about 20% of symptomatic cases of AWD/Choleradevelop severe form of the disease which requires vigorous rehydration; therefore, one mayestimate about 13,000 cases among the estimated total of 65,000 cases would require admissionfor intensive treatment. Considering the prevalence of risk factors for AWD/Cholera transmission including lack of safe watersupply, poor sanitation conditions and the rainy season among many others, the estimation of anattack rate of 1% may be considered as an underestimation; As the consequence of a AWD/Cholera epidemic is a function of not only the outbreak itself but alsoof the effectiveness of the control measures put in place, the estimated figure may be lower orhigher than the estimated figure. In order to facilitate the initiation of response and mobilization of adequate personnel, drugs andmaterial resources, a consensus has been reached to 1http://worldpopulationreview.com/countries/somalia-population/
standardize the holding capacity of a CTC, andalso, the required personnel, kits and finances to operate a treatment centre and implementcommunity (household) activities aimed at limiting transmission AWD/Cholera. Accordingly, the holding capacity of AWD/Cholera treatment centre for the purpose of this plan hasbeen agreed to be 100. The human resource, material and logistical requirements have beenestimated based on this operational figure, and is further detailed in the annexes. For the estimated case load of 65,000, 650 kits (each kit adequate to treat 100 cases) should bestock piled. In each province, six kits will be prepositioned to allow rapid mobilization whenrequired; the rest will be kept as a national stock; For each CTC to be established, AWD/Cholera kit (for 100) people will be provided to initiate theresponse; additional materials shall be made available as per the request of the responsible CTCcoordinated; All humanitarian organizations involved in AWD/Cholera response are expected to contribute to theemergency Stock and subscribe to this operational plan to the best degree possible.
6.0 Coordination of AWD/Cholera outbreak For effective outbreak response and preparedness,coordination of AWD/Cholera outbreak is important in the outbreak response and preparation for any future outbreaks. The coordination of AWD /Cholera activities in Somalia is done by the Emergency team in the federal Ministry of Health and Human Service. The team is composed of the coordinator, surveillance officer, Emergency Medical Officer, Risk Communication/Social Mobilization officer and operations manager. Other activities include
Establish a framework for AWD/Cholera preparedness for all actors will contribute.
Identify key partners with their skills and competencies as far as AWD/Cholera control is concerned
Provide official Communication to the concerned stakeholders about the final Verification of outbreaks and/or denial of false rumors.
Provide information against which resources can be mobilized from which agency and to what location/s.
Providing a monitoring and evaluation framework and documenting best practices during the response
Conduct periodic risk and capacity assessment to guide to the planning of response activities.
Following the WHO guideline, the team advice on When to open or close CTC, who can open, where to open and whether incompliance to the Criteria.
The emergency team works with supervision of the DirectorGeneral with support to the Minister of Health. The Minister briefs the Prime minister and the inter-ministerial committee on water, Sanitation and Hygiene.
6.1 Organisation of response of AWD/Cholera in Somalia
6.2 Roles and responsibilities during the AWD/Cholera response
Minister of health of the Federal Government is the only one who can declare any Communicable Disease outbreak in consultations with the prime minister. Deputy Minister, performs duties delegated by the minister Director General advises the ministers on the AWD/outbreak and response Emergency Team.Headed by the Coordinator, composed of the emergency coordinator, surveillance officer, Operations manager, Risk communication/C4D officer and medical emergencyofficer. The teamis responsible for
Support the building of capacity for health workers in cholera case management
Risk and capacity assessment
Coordination of national and regional response activities (Case management, Surveillance, outbreak investigation, verification and Laboratory, Water Sanitation and Hygiene, Social mobilization and risk communication, Logistics and supplies
Min
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Deputy Minister of health
Director general
Director Departnent of Medical Services
Emergency Team and Response
State/Regional Response team
District Response Team
Advocacy and resource mobilization
Information sharing through weekly bulletins
Support to regional teams to respond to the outbreak
Preparing AWD/Cholera Situation update on Weekly and monthly basis with the support of Surveillance team and WHO technical adviser
Regional response teams.Headed by the Regional medical officer.These are composed of regional medical officers, regional surveillance officers, Regional Social Mobilization Co-ordinator and key partners implementing Health and WASH partners, case management and logistics in the regions. They are responsible for
Outbreak investigation and rumor verification
Support quick implementation of community social mobilization and hygiene Promotion for AWD/Cholera Prevention.
Support case management and surveillance activities in the region
Report AWD/Cholera cases to the Emergency medical team
Mobilize communities to take up hygienic behavior
Liaison with the local authorities and mobilize resources needed for immediate response and for preventive measures
7.0 Preparedness activities Preparedness activities will be done with the mind of the rainy seasons and during the dry season when water is scarce inSomalia. Activities will be done for case management and infection control and Prevention, WASH, Risk communication and strengthening the distribution of logistics as informed by the finding of the risk assessment.
7.1 Risk and capacity assessment
This activity is done periodically by different partners as part of support to the federal ministry of health to determine the available resources,hot spots and high risk areas for AWD/Cholera transmission,key partners and their support levels,availability of supplies, training teams, WASH activities and community engagement strategies.
7.2 Prepositioning of supplies 2
Interagency Diarrhea Disease Kit (IDDK)(Appendix 2) will have to be procured and stationed at the regional centers for emergency supplies. One kit will be distributed to each of the AWD/Cholera Treatment center (CTC) while one will be kept at the regional hub.
2WASH cluster report current hubs in Somalia as of May 2016
7.3Human resources
Different health facilities and training institutions in different regions have varying
capacity to train and recruit health workers. As part of needs assessment by the
partners, the training needs of health workers will be highlighted and surge teams
deployed by the emergency team in the federal ministry of health supported by
different partners.A team of national trainers should be trained and supported to
carry out periodic training to health workers in the areas of
Case management i.e. assessment of patients, management of dehydration,
use of adjuvant treatment and management of co-morbidities especially Mal
nutrition
Infection control and prevention
Surveillance of AWD/Cholera case definitions, data collection, analysis and
reporting
Sample collection and use of RDTs
Water management, waste disposal, community hygienic measures
7.4 Development of key messages
Informing the public is an integral and important part of acute watery diarrhea/AWD/Cholera control strategies. The population must be informed of the epidemic and of the measures to be taken. The WASH cluster will support the Emergency Team at Federal Ministry of Health to take the lead in information, education and communication (IEC). Federal MOHhas developed standard Key AWD/Cholera Messages in Somali script with the Printing support provided by UNICEF andpre-tested and developed talking points for rollout during an emergency (Appendix 5). In order to allow rapid scale-up during an emergency the following tasks will be undertaken
Preposition of IEC materials in all high risk areas
Training of health workers and communities on the key messages
Line listing of all media houses and channels of communication For the purpose of communication,the key messages have been attached inTable 3.
7.5Simulation exercises
As part of training, round-table simulations of outbreak responses will be conducted to assure timeliness of response. The simulation allows for assessment of strengths and weaknesses of each key player, as well as evaluation of important decision-making skills that are required in an emergency in the setting of a simulated outbreak.
8.0 Surveillance activities and outbreak detection
8.1 Sentinel Surveillance 3
The electronic disease early warning system is used to collect daily alerts form all health facilities on a daily basis. The surveillance focal person is responsible for analysis of the alerts and the Emergency Team is alerted whenthe alert or epidemic threshold is reached.Communicable disease surveillance (CSR) is the national routine health facility -based surveillance system. Health facilities report suspect and laboratory confirmed cases for a number of epidemic prone diseases, disease targeted for eradication or elimination, and other conditions of public health importance. The information is reported to the national surveillance office. Data is analyzed weekly by time and place to look for clustering. An alert is sent to National and regional response teams if the number of AWD cases is twice the number reported the previous week. The Regional medical officer verifies and responds to increases over baseline expected values.
8.2 Electronic Disease early Warning System (eDEWs)
The Early warning system that was established will used to collect information about alerts and rumors of AWD/Cholera and other deadly diseases in health facilities and in the community as well. The data is analyzed on a weekly basis by the national team. When any alert threshold is reached (see Table 4), the regional surveillance officers notified the national emergency team ; the alert will lead to verification of this information by the regional CSR team
Table 4: Case Definition and AWD Alert Thresholds Syndrome Case Definition Alert Thresholds
Acute Watery Diarrhea
• 3 or more loose stools in 24 hours, with or without dehydration
• 1 death from AWD in a patient 5 years of age or older • A cluster of 5 cases of AWD in 1 week in patients 5 years or older • A doubling or more of number of AWD cases within 1 to 2 days
8.3 Cholera Case definition4
For purposes of this plan, the following case definitions will be used where applicable A Cholera alert
3 Somalia ccommunicable disease and surveillance field manual 2013 4Adopted form technical guide for cholera case definition for WHO
the detection of a cluster of severe acute watery diarrhoea cases (personsaged of 5 years old or more) from the same area within one week OR two-fold increase of acute watery diarrhoea cases (persons aged of 5 years old or more) compared to the previous week in two consecutive weeks in the same geographical area OR one death from severe AWD in ≥ 5 years old OR one positive AWD/Cholera case by rapid diagnostic test (RDT), culture or PCR. For a AWD/Cholera suspected case “ any patient aged 2 years or more presenting with acute watery diarrhea” For a confirmed case “A suspected case for which Vibrio Cholerae O1 or O139 is confirmed by culture or PCR”
8.4 Alert verification 5
Alerts notices must be verified within 24 hours by the Regional team with support from WHO or as soon as technically feasible. Information collected should include for each suspected case (including deceased) checking whether case definitions were used appropriately and whether alert thresholds have actually been exceeded. If the alert is verified, and a case or cases of AWD/Cholera is suspected, an initial field investigation is expediently conducted. Refer to Appendix 1 for detailed activation cascade.
8.5 Rapid field assessment 6
An initial field assessment team led by the Regional Medical officer or regional surveillance officer and comprised of members of Regional rapid response team,clinician, health and WASH cluster representativesEnvironmental officer/ inspector, a member from Key NGO,security personnel will deploy as soon as feasible to determine whether the situation is suspect for an outbreak and whether there is potential for ongoing transmission.A sample risk assessment form is attached in Appendix 9 1. Line list of cases that should include the following information
a. Name, title, and contact details of person reporting the alert/rumor
b. Patient name, age, sex, location of residence
c. Date and location of symptom onset
5Outbreak surveillance and response in humanitarian emergencies WHO guidelines for EWARN implementation
Geneva, 2012 6Adopted from UNICEF cholera tool kit 2013
d. Date and location of consultation, if applicable
e. Treatment and outcome
f. Case definition and alert threshold used and symptoms/signs exhibited 2. Assessment of clustering of cases in time and place
3. Review of cases with clinicians
4. Interviewing cases and contacts
5. Conducting active case finding: visiting households to determine if other cases or deaths from diarrhea have occurred. This may not be applicable in Somalia due to the high levels of insecurity
6. Performing rapid tests on all suspected cases
7. Collecting rectal swabs or fresh stool samples in relevant media for culture confirmation 8. Establish active surveillance in the in the surrounding areas using health workers or community health volunteers Based on this initial assessment, the Regional surveillanceofficer will make a recommendation to the Regional medical officer who in turn informs the Emergency Team. If the situation is highly suspect to be an outbreak of AWD/Cholera, the Regional Medical officer will recommendfull immediate activation of the Emergency Team. The decision to activate the Emergency Team will be made by the central MoH in collaboration with WHO, and the Emergency team will be led by the Regional surveillance officer and RMO. While in the field, the Regional Surveillance officer and rapid response team should assure that patients are being treated appropriately using WHO case management protocols. The team should ensure the treating health facility has adequate personnel and supplies; needs should be communicated through the Emergency Team; and resources and surge staff mobilized The environmental inspector will direct the following: 1. An environmental WASH assessment in the affected households and surrounding households. Household water and all spring’s chlorination will be initiated.
2. Investigations with the team of potential suspect sources of contamination and transmission, and water safety assessments at all neighboring drinking water sources and point-of-use sites.
3. Quickly start chlorination of Water sources, distribution of household water purification tablets, ORS and Hygiene kit distribution to Vulnerable Communities/Families.
4. Activities to stop open defecation practice on affected communities, including upstreams, communities.
5. Mobilization of the communities about safe hygienic practices like hand washing, referring cases early, water treatment, dead body management as per protocol
8.6 Advanced preparedness measures
If AWD/Cholera outbreak is determined to be less likely but still a possibility, advanced preparedness should be taken and the regional Emergency team should be put on alert. The Advanced preparedness measures are summarized below. Refer to Appendix 13.4 for detailed tasks of different sub committees
Notifying all National task force partners
Establishing active surveillance in the neighboring communities surrounding the focal area of concern
Initiating community-based WASH interventions and community health promotion activities
Assuring readiness of public communications team
Pre-positioning IDDKs, tents and other elements of AWD/Cholera treatment unit as necessary near area of the cluster of suspected cases
As necessary, deploying the training team to train health workers on appropriate clinical management of cases, ORS administration, and running a AWD/Cholera Treatment unit
Awaiting culture results
9.0 Laboratory testing and microbiological confirmation When a case of AWD/Cholera is suspected in an area where there is no confirmed AWD/Cholera outbreak, the rapid response team will conduct rapid diagnostic testing (RDT) and collect stool specimens for culture. RDT will be conducted only on patients who fit the AWD/Cholera case definition, have not received antibiotics within the past 5 days, and have signs and symptoms that are highly suspicious for AWD/Cholera. RDT results will be read in the field. Stool specimens in the form or rectal swabs will be collected from the first suspected case. If there is more than one suspect case, specimens will be collected from 5-10 suspected cases. The stool specimens will be sent to the Public health laboratory in Mogadishu for culture, and the isolate forwarded to the reference laboratory toKemri in Nairobi for confirmation, serotyping and antimicrobial susceptibility testing. An outbreak of AWD/Cholera will be declared if culture confirms Vibrio AWD/CholeraeO1 or O139, although the AWD/Cholera Task Force will be fully activated in response to a cluster of diarrhea based on level of suspicion prior to receipt of culture results. Activities to be undertaken at the NPHRL as part of preparedness and response include
At all times there should be a focal person in reference laboratory who will be
responsible for developing SOPs, handling samples, carrying out all laboratory
investigations and submitting laboratory reports in a timely manner.
All samples received must be logged into a master register with all information
pertaining to the details of the patients any demographic data from the affected
area.
A specific SOP for handling Cholera samples including sample collection, culture,
biochemical analysis, serotyping and anti-microbial sensitivity testing should be
developed, reviewed and approved by the director of NPHRL. The same should
be trained on all staff handling laboratory tests and should be reviewed on
annual basis to adapt any developing technologies and approved laboratory
procedures.
The minimum identification and confirmation of V. choleraeO1 should be based on the serologic confirmation of the presence of O1 serotype antigens with suspect isolates. This should be in addition to the routine characteristic on Gram stain, culture characteristics and the various biochemical tests.
The laboratory should develop and adapt a strict turn-around times to process
suspected cholera samples and submit results to MOH Cholera preparedness
and response task force.
All laboratory isolates from suspected cholera cases should be labelled clearly,
stored with appropriate storage media and should be archived in an ultra-low
freezer for future referencing and analysis.
9.1 Collection and transport of stool specimens 7
Stool specimens should be collected via rectal swab as per MOH protocol as soon as possible and before administration of antibiotics from eligible patients. Gloves should be worn at all times when handing specimens. The rectal swab should be moistened in the Cary Blair transport medium. The swab should then be inserted through the rectal sphincter 2-3 cm and gently rotated. The swab should be withdrawn and examined to make sure faecal material is visible on the tip. The swab should then be pushed completely to the bottom of the Cary Blair transport medium in a labeled, leak proof container and sent to the laboratory within 2 days, kept at 4-8 degrees Celcius where possible, otherwise at room temperature. Specimens should be properly labeled with patient’s name, date of birth and date of collection. Once an outbreak has been confirmed it is not necessary to collect specimens for all suspect cases. The samples should be sent to the national public health laboratory for culture and sensitivity Specimen collection may vary depending on stage of epidemic and the need for evaluating drug susceptibility patterns during the outbreak. The MOH and partners will issue guidance on specimen collection and testing during the outbreak. At the
7Haiti cholera training manual 2011
end of the outbreak, at least 10 specimens collected consecutively from patients meeting the case definition should test negative for Vibrio AWD/Choleraebefore the outbreak is declared over.
9.2 Rapid diagnostic testing
The RDT has limited utility for the diagnosis or management of the individual patient because its sensitivity (93%–98%) and specificity (67%–96%) are less than optimal. However, in the setting of an outbreak of AWD/Cholera, in which epidemiological and clinical evidence suggest that 10 or more persons are suffering from the same illness; the pre-test prevalence of AWD/Cholera in these persons will either be close to 100% or close to 0%. As the disease prevalence in the test population approaches either extreme, the overall sensitivity and specificity of the test for the diagnosis of an outbreak of AWD/Cholera improve. The proportion of positive tests can then indicate if an outbreak is likely due to AWD/Cholera or not (Table 5). If the cause of the outbreak is AWD/Cholera, most (an estimated 8 to 9) of the rapid test results from the 10 individual patients will be positive; if the outbreak is the result of another cause, most of the rapid test results (an estimated 6 to 7) will be negative. Given the sensitivity and specificity, an RDT should be performed only on patients 5 years old or older for whom a clinician has a high clinical suspicion of AWD/Cholera. The interpretation depends on the proportion of positive tests (Table 5). With the likely poor hygiene and sanitation in an immediate post-disaster setting, a more conservative proportion of ≤2 positive tests out of 10 will be used.
Table 5. Interpreting RTD results8
positive tests of a group of RDTs (minimum 10 samples)
Interpretation Proposed action
>= 80% Highly suspicious for AWD/Cholera outbreak
Activate Regional Emergency Team Await culture results
20-79% Potential AWD/Cholera outbreak
Consider activating Regional Emergency Team Initiate advanced preparedness measures, including Notify Regional Emergency Team partners Establish active surveillance in the area of concern Initiate community-based WASH interventions and
community health promotion activities Assure readiness of public communications team Pre-position IDDKs, tents and other elements of
ZTC as necessary near area of the cluster of suspected cases
Deploy the training team to train health workers in the affected area on case management
Less than 20% AWD/Cholera is less likely
Await lab results Manage cases as per protocols
10.0 Response activities
10.1Emergency Team Activation
The Emergency-coordinator will alert the director of Medical Services who will also alert the Director General will recommend activation of the Emergency team if the findings of the rapid assessment are clinically and epidemiologically suspicious for AWD/Cholera, regardless of RDT results. Once the director general activates the Emergency Team, the Emergency coordinator, should notify regional medical officer and partners through the call chain. S/he should assure the following tasks outlined in Table 6 are carried out through coordination with team leads heading each response component. Key activities include: operationalizing CTCs and ORPs, training staff as necessary, maintaining line lists, implementing community WASH interventions and hygiene promotion strategies, fielding media inquiries, assuring laboratory capacity, and reviewing supply resources and mobilizing additional supplies as necessary. A cascade for activation is summarized in Appendix 1
8 Adopted from the preparedness plan for the Philippines for Acute Watery diarrhea 2014
Table 6: Tasks to be carried out following Emergency Team activation 9
Component Tasks
Logistics
1. Transport IDDK, tents, and beds to designated sites nearby initial cluster for diarrhea treatment centres (CTCs) 2. Assure adequacy of supplies and order additions as necessary
Case management
1. Establish CTCs at designated sites and train staff using standard protocols. (Refer to WHO AWD/Cholera Guidelines) 2. Ensure adequate staffing; mobilize surge staff as necessary 3. Establish oral rehydration points (ORPs) at designated local sites 4. Ensure proper diagnosis of AWD/Cholera and identification of severity of dehydration at ORPs 5. Ensure accurate history taking and documentation 6. Assure proper case management of AWD/Cholera. 7. Practice strict infection control 8. Ensure adequate referral systems between ORPs and CTCs 9. Conduct daily meetings
Water Sanitation and hygiene
1. Increase hygiene promotion based on the agreed key messages ensuring people are mobilized and enabled to take actions to prevent/mitigate outbreak risks by adhering to and practicing safe hygiene 2. Ensure access/distribution of soap (at a minimum) for handwashing at household level 3. Ensure access to safe water supply by ensuring adequate chlorination at the household level. Distribution of household chlorination products and water storage containers. 4. Promote containment of excreta in existing or newly provided facilities, particularly in public places. 5. Ensure functionality of the existing solid waste management system. 6. Conduct water safety assessments at all neighboring drinking water sources and point-of-use sites including household drinking water sources. 7. Ensure that contamination/outbreak source, if WASH related (water and drainage/sewage system) is rehabilitated. 8. Ensuring access to sufficient safe water, sanitation and excreta and solid waste management in oral rehydration points.
Laboratory
1. Correct samples (At least 10) and send them to regional lab for microbiology 2. Confirm the start of a AWD/Cholera outbreak based on culture results 3. Assess need and arrange for surge staff 4. Confirm end of a AWD/Cholera outbreak
9Adopted from AFRO Integrated Disease surveillance and response guidelines 2012
Epidemiology and surveillance
Manage outbreak line list, construct epi curve, continuously analyse data
Investigate cases and identify sources of infection, risk factors, contact tracing
Ensure standard registers and data collection systems are in place and that there is no double counting of patients transferred between structures
Establish active surveillance in the barangays or evacuation centres surrounding the focal area of concern
Continue to monitor for suspected cases through pre-established surveillance channels
Conduct further epidemiological investigations to determine risk factors as necessary
Produce outbreak report
10.2 Outbreakdeclaration
The Minister of health will officially declare an outbreak if one or more cases of laboratory-confirmed Vibrio AWD/CholeraeO1 or O139 is reported. Once an outbreak is declared, the Emergency Team continues to function fully for purposes of outbreak response. Refer to Appendix 1 for activation cascade
10.3 Establishment of AWD/Cholera treatment centers for case management
AWD/Cholera Treatment centres (CTCs) will be established as necessary and managed per WHO AWD/Cholera Guidelines as outlined in Appendix 6. Staff will be allocated as outlined in Appendix 5. A guideline on numbers of personnel and vehicles to staff a 50 bed capacity CTC is shown in Figure 2. Provision of and accountability for WASH facilities within the CTC will be the responsibility of the Health Actor acting in the CTC. Where the Health Actor is not in a position to meet this need they are responsible for ensuring a standby partnership arrangement is in place to ensure a timely response
Figure 2: Personnel and vehicles to run a CTC with a 100 bed capacity10
AWD/Cholera treatment center Community intervention Transport and logistics
1) CTC Coordinator = 1 2) Doctors = 2 ( 01 per 12 hour shift) 3) Nurses = 30 (10 per 8 hour shift) 4) Support staff (at a ratio of 1 to 3 nurses) =10 5) Record keeping = 3 (one per 8 hour shift) 6) Environmental Health Technicians = 3 (oneper 12 hour shift) 7) Laboratory scientist = 2 8) Logisticians = 2 9) Data entry personnel = 2 10) Miscellaneous support staff = 12 (3 per 8 hour shift) Total: 67
1) Environmental health technicians = 2 2) Active Case Finding Team = 10 3) Disinfection team = 5 4) Hygiene Promoters = 10 (1hygiene promoter per 50 House Holds) (Note: The number can be increased depending of the area and size of community to be reached) Total: 27
Vehicles (2) 4X4 Pick Up 2) Motor Cycle (2) 3) Fuel as per estimated travel distance and consumption (Startup volume = 500 liters) 4) For food supplies ‐ see annex 7
10.4Clinical management of cases
Clinical management should be based on the WHO AWD/Cholera guidelines (Appendix 5) and supplemented with the UNICEF AWD/Cholera Toolkit 2013. Basic considerations include: 1. Rehydration
2. Antibiotics
3. Zinc supplementation
4. Vitamin A
5. Nutrition Of note, most patients with AWD/Cholera do not require and should not receive antibiotics. Antibiotic use is reserved for severely dehydrated patients or moderately dehydrated patients with continued fluid losses from profuse watery diarrhea and/or vomiting. Antibiotics have been shown to reduce the severity of illness, duration of diarrhea, and shedding (transmission). However, the mainstay therapy should remain aggressive hydration for those with continued fluid losses from profuse watery diarrhea and/or vomiting, as this reduces case fatality rates from 50% to less than 1%. The clinical guidelines guiding rehydration can also be applied with other diarrheal diseases.
10The Zimbabwe Health Cluster, Cholera Outbreaks Coordinated Preparedness and Response
Operational Plan
10.5Establishment of Oral rehydration points (ORP)
During Emergency Team activation, ORPs will be established at designated community areas .ORPs are established to recognize different levels of dehydration and manage appropriately. When severe dehydration is recognized, all cases will be referred to the closest DTC. They can be staffed by trained volunteers under supervision of a nurse. It is expected that 1 ORP site should be established for every 5,000 persons. NGO support teams can staff or train staff for additional ORPs if the local health staff capacity is exceeded.
10.6Considerations for Oral Cholera vaccine (OCV)11 .
From a medical standpoint, Cholera vaccination is safe, effective and acceptable,
and has a role in prevention and control of Cholera, alongside traditional measures12. Since the vaccine is not 100% effective, it should not be considered as a replacement for other preventive interventions. In addition, the two dose regimen, the resource requirements and additional communication required must be taken into account when making decisions regarding appropriate use, especially in a post-emergency setting. The following points should be considered: Evaluate risk, determine whether resources would most efficiently be spent in
an OCV campaign or in the enhancement of service deficiencies including safe water, sanitation, waste management, and hygiene while maintaining surveillance for acute watery diarrhea and ensuring that rehydration treatment is readily available and accessible to those in need.
Discuss how to distribute a limited supply of vaccine in an equitable and publicly acceptable manner to those at greatest risk.
Review the cold chain system for Somalia and make a decision on how the vaccines will be stored and transported. Consider integrating such a campaign in already immunization programs existing in the country
Determine the feasibility of administering the second dose to the same people that received the first dose. In situations of insecurity as is the case of Somalia this may be very difficult
Anticipate possible repercussions of the campaign, negative and positive, including negative media attention which may divert popular opinion in disadvantageous ways, potentially creating political pressure to take actions which may not be in the best interest of the health of the affected communities.
11
Oral Cholera Vaccine stockpile for cholera emergency response, 2013 12 Feasibility and acceptability of oral cholera vaccine mass vaccination campaign in response to an outbreak and
floods in Malawi
A global stockpile of oral AWD/Cholera vaccine (OCV) has been created to support countries to reduce AWD/Cholera risk in vulnerable populations and is used as an additional tool to help control AWD/Cholera epidemics. Appropriate preparation should be made to request for these vaccines form the fund in time.
10.7 Water, sanitation and hygiene (WASH) Coordination 13
Coordination of the WASH response at the local level will be delivered by the WASH cluster in the relevant locality (Table 7), and the response provided by WASH cluster members and regional medical officer, WASH focal points working both within and outside the region based on scale of need. Capacity to respond during an emergency will be discussed at the local level prior to an outbreak and any concerns taken to the WASH Cluster Coordinator. The WASH response will focus outside the CTC in the community. The detailed potential activities based on need to be undertaken by the WASH Cluster are listed in Appendix7. The activities will address Health and hygiene education, Provision of water supply, Excreta disposal, Environment and solid waste management, Disinfection/Vibrio control in the case of AWD/Cholera, and Follow-up/monitoring. These principles can also be applied in other diarrheal outbreaks. Hygienic kits to be distributed at house hold level will contain 200 tablets of Aquatab/Chloro-Floc , 5 pieces of soap,1 jerry can and 1 bucket.The WASH Cluster commits to evaluating and monitoring the WASH response and learning from the response. After the eradication of the outbreak, the lessons will be used to build/update WASH Cluster Contingency Plan accordingly. Table 7. Regional WASH hubs and focal persons
Region Hub centre Hub capacity(HH kits)
Galgadud Cadaado 7000 Hiran Beletwayne 8000
M. Shebelle Jowhar 7000
Bandir Mogadishu 10,000 Lower Shabelle Marka 6000
Juba land Kismayu 5000 Dhobley 5000
Gedo El waaq 6000
Bay Baidoa 10,000
10.8Funerals and Handling of Corpses
Funerals can contribute to the spread of an epidemic due to close contact with the body and community members. If the wake cannot be cancelled, meticulous hand
13UNICEF Cholera tool kit 2013
washing with soap and clean water is essential before food is prepared and handled. The body should be in a sealed casket and buried with no viewing. A designated health worker present at the funeral gathering can be helpful in supervising the use of hygienic practices. It is important to ensure disinfection of corpses with a 0.5% chlorine solution. For transporting corpses of AWD/Cholera patients, corpse-carriers should wear gloves; corpses should be carefully wrapped. If possible, physical contact between the family and the corpse should be prevented. If this is not possible, the family must be made aware of the need to:
Wash hands with soap after touching the corpse
Avoid putting hands in the mouth after touching the corpse
Disinfect the dead person’s clothing and bedding by stirring in boiling water for 5 minutes or by drying them thoroughly in the sun before and after normal washing.
People who wash and prepare the dead body must:
Wear gloves, apron and mask
Clean the body with chlorine solution (0.5%)
Fill the mouth and anus of the body with cotton wool soaked with chlorine solution
Bandage the head to maintain the mouth shut
Not empty the intestines These recommendations are based on the WHO AWD/Cholera Outbreak Response and Improving preparedness Guidelines.
10.9 Public communications
All media inquiries and public communications regarding the status of an outbreak will be organized by the minister or Director General; all announcements will be made and approved by the regional medical officer. The regional team will work with stakeholders to provide consistent situational messaging to the public at large. Suggested talking points based on pre-tested key messages are in Appendix 3.
11.0 De-activation of Emergency Team and completion of outbreak response If the number of AWD cases returns to baseline for 3 weeks, Emergency Team deactivation can be considered by the regional medical officer. At the end of the outbreak, at least 10 specimens collected consecutively from patients meeting the case definition should test negative for Vibrio AWD/Choleraebefore the outbreak is declared over. Following the end of the cholera outbreak,a restoration of health services will be done by implementing routine health services as was the case before the outbreak
12.0 Evaluationof response activities The comprehensive response to the outbreak should be evaluated once the outbreak has been declared over. Evaluation should be done based on the activities implemented in the work plan. After the response, efforts should be taken to reintegrate control activities in routine services.
13.0 Appendices
13.1. Appendix 1. AWD/Cholera Response and Activation Cascade.
AWD/Cholera Response Cascade
Declaration of outbreak/Activation of National AWD/Cholera task force
HF sends alert to RMO RSO and RRT to verify rumors within 24hrs
If no outbreak continue routine surveillance activities
Regional (State)
Medical Team
Ministry of Health Coordination Committee
AWD/Cholera case definitions Standard case definition Suspected case: In a patient age 5 years or more, severe dehydration or death from acute watery diarrhoea. If there is aAWD/Cholera
epidemic, a suspected case is any person age 2 years or more with acute watery diarrhoea, with or without vomiting.
Confirmed case: A suspected case with confirmatory laboratory diagnosis,
Community case definition for AWD.Any person five (5) years of age or more passing three (3) or more rice water-like pu-pu
National Team lead Contact person Case management/IPC Surveillance/Laboratory WASH Communication Logistics
Community mobilization, Strengthen referral of cases and alerts
RMO to lead coordination of response
RMO to inform Director General when confirmation is done immediately
Rumour and alert, Identification, notification verification
Regional Team Lead Contact person Case management/IPC Surveillance/Laboratory WASH Communication Logistics
Community/IDP (Community Health Worker)
CH
Health facility-OIC
13.2 Appendix 2: Drugs, supplies and materials to require initiating a response (Based on the estimated minimum supplies needed to treat 100 patients during a AWD/Cholera outbreak by
WHO, 1994)
1) Rehydration supplies 650 packetsORS (for 1 litre each) 120 bags Ringer's lactate solution2, 1 litre, with giving sets 10 scalp‐vein sets 3 nasogastric tubes, 5.3 mm OD, 3.5 ID, (16 French), 50 cm long for adults 3 nasogastric tubes, 2.7 mm OD, 1.5 ID, (8 French), 38 cm long for children
2) Antibiotics For adults: 200 tablets of Ciprofloxacin, 500 mg (1 tablet twice daily for five days per severely dehydrated case) For Pregnant women and children under 12 years: 400 tablets Erythromycin, 500 mg (1 tablet four times daily for five days for adults) and children @ 6.25‐12.5mg/kg
3) Other treatment supplies 2 large water dispensers with tap (marked at 5‐ and 10‐litre levels) for making ORS solution in bulk 20 bottles (1 litre) for ORS solution (e.g. empty IV bottles) 20 bottles (0.5 litres) for ORS solution 40 tumblers, 200 ml 20 teaspoons 5 kg cotton wool 2 reels adhesive tape
1. The amount of supplies listed allows enough intravenous fluid followed by ORS for 20 severely dehydrated patients, and the exclusive use of ORS for the other 80 patients.
2. If Ringer's lactate solution is not available, substitute normal saline.
13.3 Appendix 3: Talking points and Key Messages for AWD/Cholera APPENDIX 4: TALKING POINTS AND KEY MESSAGES FOR AWD/CHOLERA AND ACUTE WATERY DIARRHEA
Talking Points
What is AWD/Cholera? AWD/Cholera is caused by the bacteria, Vibrio AWD/Cholerae, that in some people can cause excessive watery diarrhea and vomiting. For some people, they can lose so much fluid from their bodies that it can lead to severe dehydration and death within hours. Acute watery diarrhea has these same symptoms, but is caused by another bacteria or virus.
How do you get AWD/Cholera or acute watery diarrhea?
You get it from eating food and drinking water contaminated with human waste.
Who can get AWD/Cholera or acute watery diarrhea?
Both children and adults can be infected. Fortunately, most people who get it do not get severe diarrhea, but it is important to be able to know when someone is sick.
How can you tell if someone has AWD/Cholera or acute watery diarrhea?
People will usually have sudden onset and frequent passage of watery and loose stools and vomiting.
How can you tell if someone is dehydrated?
Adults and children who are dehydrated will sometimes have symptoms like: sunken eyeballs, dryness of the skin, or lack of energy.
What do you do if you think someone has AWD/Cholera or acute watery diarrhea?
Immediately start giving them fluids with ORESOL or mix ½ teaspoon salt and 2 tablespoons (6 teaspoons) sugar to 1 liter of clean water, and consult a health worker or take them to the nearest RHU/Hospital.
Key Messages: AWD/Cholera and Acute Watery Diarrhea
1. Drink only safe and clean water a. If unsure, boil drinking water; upon reaching boiling point, extend boiling for 2 or more minutes. b. You may also do water disinfection.
2. Wash hands with soap and clean water after using toilet, before eating and preparing food.
3. Wash food with clean water and cook food well. Eat it hot, keep it covered, and peel fruits and vegetables.
4. Use latrines or bury your feces (poop), do not defecate in any body of water.
5. Immediately give fluids and seek medical care if you have watery diarrhea, continue fluids on the way.
6. Continue to breastfeed your baby if they have watery diarrhea, even when traveling to get treatment.
13.4Appendix 4: Technical sub committees Roles and Responsibilities Sub committee Members (Experts, Organizations) Description of tasks
1. Coordination
Members:
National stakeholders including
Ministry of Health
Ministry of Education and social welfare
Disaster preparedness
Security agencies
Media
Water ministry
NGOS, civil society and international agencies
Education institutions
Business community
Coordinate all aspects of the response including:
- Selecting participating organizations and assigning responsibilities,
- Risk assessment
- Designing, implementing and evaluating control interventions
Co-ordination of technical sub-committees and overall liaison with partners
Daily communication through situation report about the evolution of the outbreak
Managing information for public and news media.
Advocacy and Resource mobilization
2. Case management and Infection prevention & control
Chair: Physician Members:
Medical/ Clinical Officers
Nurse
Technical Assistants from the Ministry of Health
Partners supporting case management e.g. MSF
Develop SoPs for Case management
Establish isolation facilities and reinforce barrier nursing procedures and standard and risk-based precautions
Provide appropriate medical care to patients
Provide ambulance services – collection of suspected cases from the community
Training of health workers in the isolation facility and other health facilities in the affected area
3. Surveillance and Laboratory
1. Chair: Epidemiologist 2. Co-chair: Laboratory specialist Members:
Surveillance officers from and health facilities
Technical Assistants from the Ministry of Health
Data managers
Partners supporting surveillance & laboratory e.g. CDC, WHO
Revise case definitions ,threshold levels and alert protocols
Conduct active case finding, contact tracing and follow-up
Verification of suspected cases/ alerts/ rumours in the community
Design and conduct implementation research
Ensure filling of case investigation, contact tracing and follow-up forms
Support the collection of samples for laboratory confirmation
Support the use of RDTs in areas with no access to laboratory services
Ensure SOPs for specimen collection are followed
Data management – regular epidemiological analysis & reports
Training of health personnel in disease surveillance
Close linkage community event based surveillance personnel
Supervision of data collection and reporting
Sub committee Members (Experts, Organizations) Description of tasks
4. Social mobilization and Risk communication
Chair: Health educator Members:
Health Educators from the county
Politicians
Psychosocial team
Technical Assistants from the Ministry of Health
Partners supporting communication e.g. UNICEF, URCS
Conduct rapid assessment to establish community knowledge, attitudes, practices & behaviour on prevailing public health risks/events
Review and/or develop materials for social mobilization
Organize sensitization and mobilization of the communities
Serve as focal point for information to be released to the press/public
Liaise with the different sub-committees, local leadership and NGOs involved in activities on mobilizing communities
Water, Sanitation and Hygiene/IPC
Chair:- Environmental specialist Members Water Engineers IPC specialists
Conduct Water quality assessments in the communities
Provide logistics for WASH
Establish the CTC/CTC and ORPS
Training health workers and communities in IPC practices
Support safe waste management practices in the communities
Conduct burial of the dead AWD/Cholera victims
Logistics and supplies
Chair- Logistician Members Relevant technical staff including pharmacists and dispensers Pharmaceutical companies
Planning for logistical requirements for the response
Procuring and distribution of logistics for AWD/Cholera response
Planning for stock piling in most at risk areas
13.5 Appendix5: National AWD/Cholera Treatment Guidelines
REPUBLIC OF SOMALIA Ministry of Health
INTERIM GUIDELINES ON THE PREVENTION AND TREATMENT OF AWD/CHOLERA INFECTIONS AWD/Cholera is a bacterial disease predominantly transmitted through the fecal-oral route and resulting in an explosive onset of diarrhea which could be fatal in a short period of time. Rapid loss of fluids and electrolytes causes hypoglycemia, metabolic acidosis, acute renal failure and death in 48 hours. AWD/Cholera has been endemic in the Somalia with the most common cause of outbreaks being the serogroup 01, Ogawa biotype El Tor. Periodic outbreaks had been known to occur in areas inundated by floods and subsequent contamination of drinking water by bacterium Vibrio AWD/Cholerapresent in sewers and leaking septic tanks. Unsanitary conditions, inadequate toilet facilities and lack of clean water in most evacuation centers as well as in the inundated communities foster the spread of AWD/Cholera. Measures for the prevention of AWD/Cholera have not changed much in recent decades, and mostly consist of sanitation and providing clean potable water for the populations potentially affected. Health education and good food hygiene are equally important in prevention. In particular, systematic hand washing should be taught. The cornerstone of treatment is still fluid replacement at the early onset of the disease. The role of antibiotics is adjunctive since it shortens the duration of illness by rapidly clearing the organism from the body. Once an outbreak is detected, the usual intervention strategy is to reduce mortality by ensuring prompt access to treatment and controlling the spread of the disease.
A) Clinical features of AWD/Cholera AWD/Cholera is a dehydrating diarrheal illness. The symptoms and signs are caused by rapid and profound loss of fluid and electrolytes in watery diarrhea and vomitus. Infection with AWD/Cholera is associated with a range of clinical symptom. Of total persons with infection, 75% are asymptomatic, Most of the 25% with symptomatic infections have mild illness. Approximately 2% of those infected will have severe AWD/Cholera (sometimes called "AWD/Cholera gravis"). Another 5% will have moderate illness that brings them to medical attention, but does not require hospitalization. After the initial intestinal purge, diarrhea becomes very watery with flecks of mucus and has the appearance of “rice water stool.” The person with a severe or moderate case presents with profuse watery diarrhea leading to dehydration and electrolyte loss, vomiting because of acidosis, and having leg cramps because of hypokalemia. Severe diarrhea can be nearly continuous and can exceed 1 liter per hour. Persons most likely to have severe infection are those who ingest a high dose of organisms, those whose gastric acid production has been diminished by gastrectomy or antacid therapy, and those who have blood group O. In addition people with co-morbidities such as mal nutrition and reduced immunity due to HIV/AIDS.
B) Diagnosis of AWD/Cholera
Clinical presentation is that of voluminous, rapidly dehydrating diarrhea of sudden onset which could be fatal in as short as 48 hours after onset.
Rapid AWD/Cholera Dipstick Test
Dark Field Microscopy
Request for a Rectal Swab for Stool Culture.
C) Case management of AWD/Cholera Requirements: 1. Assessment of hydration status 2. Rehydration therapy 3. Antimicrobial therapy
1) Assessment of Hydration Status (Severity)
Adequate Hydration Moderate Dehydration Severe Dehydration
• No thirst • Skin goes back normally when pinched • Passing urine • Pulse strong
• Restlessness and irritability • Sunken eyes • Dry mouth and tongue • Increased thirst • Skin goes back slowly when pinched • Decreased urine • Infants: decreased tears, depressed fontanels
• Lethargy or unconsciousness • Very dry mouth and tongue • Skin goes back very slowly when pinched (also known as “tenting”) • Weak or absent pulse • Low blood pressure • Minimal or no urine
2. Rehydration Therapy
Successful treatment of AWD/Cholera depends on rapid replacement of fluid and electrolyte losses, for which oral rehydration solution (ORS) is recommended. Before discovery of rehydration therapy, 30–50% of patients with typical severe AWD/Cholera died; now, with proper treatment, mortality is 1% or less. Approximately 80–90% of patients can be treated with ORS, and patients who initially require IV therapy usually can eventually switch to ORS.
2.1) Oral rehydration therapy for patients with no dehydration
Patients who have diarrhea and no signs of dehydration should receive ORS after each loose stool to maintain hydration until diarrhea stops, as indicated below. Because clinical status may deteriorate rapidly, these patients may initially need to be kept under monitoring, especially when they live far from a health facility or treatment center, or when correct home treatment cannot be guaranteed. ORS amounts to prevent dehydration (WHO recommended)
Age Amount of ORS after each loose stool(mls)
ORS quantity needed
Less than 24 months 50-100 Enough for 500mls/day (1 sachet)
2-10 years 100-200`` Enough for 1000mls/day
Over 10 years As much as needed Enough for 2000mls/day
(2 sachets)
If the treatment is administered at home, give enough ORS sachets for 2 days’ treatment and instruct the patient (or caregiver) to prepare the ORS with safe water. (Safe water is water that is bottled with an unbroken seal, has been boiled, or has been treated with chlorine.) Advise patients or caregivers to come back immediately if condition deteriorates (e.g., repeated vomiting, increased number of stools, drinking or eating poorly).
2.2) Guidelines for treating patients with some dehydration
The approximate amount of ORS to give in the first 4 hours to patients with some dehydration is determined by the weight of the person. Use the patient’s age only when you do not know the weight Treat with ORS, 75 ml/kg over ~4 hours. The patient should be kept under observation. The following age-specific plan may be used for giving ORS:
Age Less than 4 months
4-11 months
12-23 months
2-4 years 4-14 years >15 years
Weight (Kg
Age First give 30 ml/kg IV In: Then give 70 ml/kg IV In:
Infants (1 yr.) 30 minutes* 2 ½ hours
Reassess the patient every 1–2 hours and continue hydrating. If hydration is not improving, give the IV drip more rapidly. As much as 200ml/kg or more may be needed during the first 24 hours of treatment. Check for rapid respiratory rate, which can be a sign of possible over hydration. • Also give ORS (about 5 ml/kg per hour) as soon as the patient can drink. • Record liters of IV fluids and cups of ORS administered on a fluid balance chart. Mark quantity consumed per hour on each IV fluid bag. Record the volume and nature of the stool and the presence of urine output. • After 6 hours (infants) or 3 hours (older patients), perform a full reassessment. Switch to ORS if hydration is improved and the patient can drink. 3.0) Antimicrobial Therapy Antimicrobial therapy is very helpful, though may not be required, in the treatment of AWD/Cholera –hydration is the mainstay of treatment. Antimicrobials reduce the total volume of fluid lost, shorten the duration of diarrhea, and reduce the length of carriage of AWD/Cholera in the feces – all of which optimize resource utilization in an outbreak setting. An antibiotic given orally will reduce the volume and duration of diarrhoea. Treatment with antibiotics is recommended for: 1) moderately and severely deh
