SOMALIA DART SITUATION REPORT 13 - CHOLERA

UNCLAS SECTION 01 OF 04 NAIROBI 000720 SIPDIS AIDAC USAID/DCHA FOR MHESS, WGARVELINK, LROGERS DCHA/OFDA FOR KLUU, GGOTTLIEB, AFERRARA, ACONVERY, CGOTTSCHALK, KCHANNELL DCHA/FFP FOR WHAMMINK, JDWORKEN AFR/AFR/EA FOR JBORNS STATE FOR AF/E AND PRM STATE/AF/E FOR NGARY STATE/F FOR ASISSON STATE/PRM FOR AWENDT, MMCKELVEY NSC FOR TSHORTLEY USUN FOR TMALY BRUSSELS FOR PLERNER GENEVA FOR NKYLOH USMISSION UN ROME FOR RNEWBERG SIPDIS E.O. 12958: N/A TAGS: EAID PREF PHUM PREL SO SUBJECT: SOMALIA DART SITUATION REPORT 13 - CHOLERA UPDATE REFS: A) NAIROBI 00255 B) NAIROBI 00594 C) NAIROBI 00380 NAIROBI 00000720 001.2 OF 004 SUMMARY ¶1. A suspected cholera outbreak has affected more than 600 people and resulted in as many as 40 deaths in southern and central Somalia. UN and non-governmental organizations (NGOs) working in the health sector have responded to the outbreak quickly, collecting biological samples to confirm the presence of the cholera bacterium, tracking suspected cases, and establishing cholera treatment facilities. However, aid agencies fear that if the current cholera outbreak is not contained, it could spread into Mogadishu, where insecurity limits emergency activities. End Summary. BACKGROUND ¶2. Cholera is a waterborne disease that is endemic to Somalia and usually surfaces in the dry season, when water for hygiene is scarce. However, the latest outbreak was caused by flood waters that damaged water and sanitation facilities in November and December of ¶2006. In late December, the U.N. World Health Organization (WHO) confirmed cases of cholera in Kismayo District, Lower Juba Region, followed by an outbreak in Jilib District, Middle Juba Region. The December cholera cases were quickly contained by health agencies. (REF A) ¶3. Most health services in southern Somalia, including managing disease outbreaks, are provided by WHO, other UN agencies, and NGOs. WHO's role is to undertake surveillance, develop and implement preparedness plans, provide technical support, and coordinate activities focusing on communicable diseases. NGOs manage the actual disease outbreaks by establishing treatment centers and disseminating public information. ¶4. There is some disagreement within the humanitarian community over whether or not the cholera outbreaks in Somalia since January are actually cholera. The USAID- supported NGO International Medical Corps (IMC) has positively identified at least one sample from Hiraan as cholera, but samples from patients exhibiting cholera-like symptoms in Middle Shabelle Region have come up negative in tests. The USG Disaster Assistance Response Team (DART) is referring to this disease as cholera; even though not all cases have tested positive for the cholera bacterium, the signs and symptoms are consistent with the case definition of cholera. ¶5. WHO has advised all health agencies operating in Somalia not to refer to the current outbreak as cholera and to use instead the term acute watery diarrhea. WHO believes that not enough samples have tested positive for the cholera bacterium in all suspected outbreak locations to merit calling it a cholera outbreak. Regardless, the disease exhibits the characteristics of cholera and is being treated as such. ¶6. Cholera can cause dehydration of varying degrees through loss of fluids and electrolytes as a result of diarrhea. Young children and elderly are most susceptible to the effects of dehydration and case fatality rates are usually high in these age groups. NAIROBI 00000720 002.2 OF 004 Cholera is treated by replacing fluids and salts lost as a result of diarrhea. Patients can be treated with oral rehydration solution, a prepackaged mixture of sugar and salts that is mixed with safe drinking water and consumed in large amounts. Severe dehydration cases require intravenous fluid replacement. Antibiotics shorten the course and diminish the severity of the illness, but rehydration is the first line of treatment. HIRAAN REGION ¶7. The number of suspected cholera cases in Hiraan Region's three districts has recently increased to 319 people with 35 deaths. The rise in cholera cases is directly related to the destruction of household and communal latrines and the contamination of water containers and wells during the November-December flooding along the Shabelle River, health agencies believe. ¶8. On January 26, USAID's Office of U.S. Foreign Disaster Assistance's (OFDA) NGO partner IMC reported that one sample from Belet Weyne had tested positive for cholera in the African Medical and Research Foundation's laboratory in Nairobi. ¶9. A total of 151 cholera patients have been treated at the Belet Weyne hospital, where IMC, Medecins Sans Frontieres (MSF)/Belgium, and WHO coordinated treatment.QIMC reports seven cholera-related deaths in their health facility in Belet Weyne. As of February 6, IMC reported that only two cholera patients remain in the hospital, and the Belet Weyne outbreak appears to be nearly contained. ¶10. WHO has reported an additional 16 cholera cases and nine deaths in rural villages in Belet Weyne District that were not reported by IMC because they were not treated at the IMC-managed hospital in town. ¶11. On February 7, WHO reported that cholera has affected 44 people in Jalalaxi District, also in Hiraan Region, with 14 deaths and 108 people in Bulo Burte District with five deaths since the disease first emerged in early January. The Somali Red Cross Society (SRCS),MSF/Belgium, and WHO have established cholera treatment facilities and are coordinating health response activities. However, the disease has not been confirmed in laboratory tests. ¶12. The recent rise in water-related diseases in the riverine areas of Hiraan Region has contributed to an increase in malnutrition in the affected communities, according to the recent multi-agency food security assessment released on January 31 (REF B). MIDDLE SHABELLE AND LOWER AND MIDDLE JUBA REGIONS ¶13. According to WHO, 248 suspected cholera patients, with five deaths, have been treated at the Jowhar hospital in Middle Shabelle Region as of February 7. MSF collected biological samples from patients in the hospital that were tested in Nairobi; these samples were found to be negative for cholera. However, health agencies plan to collect and test additional samples in the coming days. NAIROBI 00000720 003.2 OF 004 ¶14. In Jowhar, SRCS, INTERSOS, and MSF/Spain are the lead international health agencies. WHO also has an emergency medical officer in Jowhar. According to WHO, Jowhar hospital has sufficient supplies and it dispatched a cholera treatment kit on February 2, to augment existing medical supplies. (One cholera kit provides oral rehydration salts, medicine, infusion supplies, buckets, and soap to treat 500 patients, including 100 severe cases.) ¶15. On February 7, WHO reported that the Kismayo cholera treatment facility in Lower Juba Region has been re-opened and has treated 36 cholera cases with two deaths since January 30. WHO reports that there are adequate supplies but has requested NGOs to send experienced medical staff to Kismayo to assist with the outbreak. Currently, Kismayo is at UN security phase four due to insecurity and access for humanitarian staff is restricted. ¶16. Additionally, more than 60 new suspected cholera cases have been reported by Mercy Corps and the SRCS in Jilib District, Middle Juba Region. An MSF team is currently responding to the reports in Jilib with additional supplies. The new cases in Jilib are not confirmed as cholera yet and further information is expected in the coming days. FEARS OF CHOLERA SPREADING ¶17. Current levels of insecurity in Somalia, a lack of in-country laboratory facilities, and limited capacity of WHO staff to collect samples, make it unlikely that all areas with an outbreak will have confirmed laboratory results. However, operational health agencies are responding to the outbreak as if it were cholera. ¶18. UN agencies and health sector NGOs fear that if this outbreak is not contained, cholera could emerge in Mogadishu, where security conditions would limit access to health clinics and cholera treatment facilities. If this were to happen, the spread within the city would be expected to be rapid and the number of cases and fatalities high, especially in the many areas with poor access to water and latrines. COMMENTS ¶19. Although Somalia has not experienced a cholera outbreak in the last two years, health agencies were relatively prepared for it. After the flooding, WHO and the UN Children's Fund (UNICEF) pre-positioned cholera treatment kits throughout southern and central Somalia, which proved prescient when the conflict and closure of the Kenya-Somalia border stopped cross- border access (REF C). ¶20. The scale of this outbreak has revealed some weaknesses in the health sector in Somalia. As health sector lead for Somalia, WHO routinely conducts disease surveillance activities and is responsible for collecting, analyzing, and disseminating timely information on diseases. However, the conflicting information on cholera cases coming from WHO and NGOs indicate that the disease surveillance system needs NAIROBI 00000720 004.2 OF 004 strengthening. Some of the confusion on the number of cases of cholera stems from the inadequate knowledge among field staff on cholera case identification and management. This outbreak has revealed a need to retrain field staff in proper case identification and management skills since there has not been a significant cholera outbreak in Somalia for several years and NGOs have experienced high staff turnover. ¶21. The exposed shortcomings will be dealt with by the Somali Support Secretariat health sector agencies, although relations among the lead health sector partners are visibly strained due to disagreement over different agencies' responsibilities in this outbreak. It is also apparent that the WHO network of district polio officers that have been tasked with identifying communicable disease outbreaks do not have the skills or capacity to deal with simultaneous outbreaks of cholera and Rift Valley fever. WHO needs to improve field-level capacity quickly. ¶22. The DART is working closely with WHO and NGOs to ensure that health activities are implemented smoothly, and to identify ways to improve performance. To address cholera and other health issues that impact vulnerable Somalis, OFDA has prioritized flood recovery interventions in the water, sanitation, and hygiene sector for UN and NGO funding. ¶23. The outbreaks in Hiraan, Middle Shabelle, Lower Juba, and Middle Juba regions are worrying, but USAID's partner IMC and other health agencies in the region have responded quickly and sufficiently. Many health agencies were prepared for an increase in water-related diseases following the November-December flooding and the emergence of pockets of cholera is not unexpected in the context of Somalia. However, if the disease spreads to coastal cities experiencing insecurity and political uncertainty, a new level of crisis may be reached. RANNEBERGER