CHOLERA SPREADS THROUGHOUT ETHIOPIA

UNCLAS ADDIS ABABA 002164 STATE DEPARTMENT AF/E, AF/PDPA, OES, AND PRM/AFR USAID FOR AFR EGAST, CTHOMPSON DCHA/AA SCROMER DCHA/OFDA CCHAN, ACONVERY, JFLEMMING, PMORRIS, KCHANNELL, CCHRISTIE DCHA/FFP JDWORKEN, PMOHAN LONDON, PARIS, ROME FOR AFRICA WATCHER CJTF-HOA AND USCENTCOM FOR POLAD USDA/FAS FOR U/S PENN, RTILSWORTH, AND LPANASUK NAIROBI FOR OFDA/ECARO GPLATT, JKIMBROUGH, RFFPO NCOX USMISSION UN ROME FOR RNEWBERG NEW YORK FOR DMERCADO USEU FOR PBROWN GENEVA FOR NKYLOH, RMA NSC FOR CPRATT E.O. 12958: N/A TAGS: EAID PHUM SENV EAGR PGOV ET SUBJECT: CHOLERA SPREADS THROUGHOUT ETHIOPIA REF: Addis Ababa 2096 SUMMARY -------------- ¶1. (SBU) To date, seven of 10 regions of Ethiopia have been affected by cholera or acute watery diarrhea (AWD). The percentage of cholera cases is not known but it is expected to be significant. While cholera is an endemic disease in Ethiopia, it is rarely seen in Addis Ababa. However, a recent outbreak in the capital (reftel) has resulted in the activation of a command center at the Government of Ethiopia's (GoE) Ministry of Health (MoH). ¶2. (SBU) Thus far in 2009, the World Health Organization (WHO) and UNICEF are reporting more than 18,000 cases of cholera/AWD and the MoH expects up to an additional 114,000 before the end of the year. USAID's Office of U.S. Foreign Disaster Assistance (USAID/OFDA) has provided $1 million to the International Rescue Committee (IRC) and $2 million to UNICEF for water and cholera interventions countrywide. THE NUMBERS GAME -------------- ¶3. (SBU) WHO and UNICEF reported in a meeting on September 1 more than 4,000 cases of cholera/AWD in Addis Ababa, and an additional 14,000 cases countrywide. The overall Case Fatality Ratio (CFR) for the country is 1.3 percent - just over the emergency threshold of one percent. The CFR in each region is highly variable. UNICEF and WHO report that Afar region currently has a CFR of 3.5 percent. (Comment: Humanitarian actors in country are concerned that the CFR is actually higher than reported due to aggravating factors including significant distances between houses and cholera treatment centers, as well as malnutrition. End Comment.) ¶4. (SBU) The international non-governmental organization (NGO) Medicine Sans Frontiers/Belgium is operating six cholera treatment centers in Addis Ababa and reports that the majority of people arriving for treatment are moderate cases requiring only rehydration on an outpatient basis while 25 percent are severe and requiring inpatient care. WHAT'S IN A NAME? -------------- ¶5. (SBU) At a joint WHO/UNICEF meeting on August 25, significant discussion took place as to whether or not the current outbreak can be called "cholera" or whether it must still be referred to as "AWD." The WHO representative working with the MoH Command Center stated that while at a technical level the term "cholera" is permissible, the GoE is still requiring that all reports use the phrase "Acute Watery Diarrhea." (Comment: This remains a very sensitive issue and using "cholera" publically in any reports, by USG or others, could hinder actions being taken by the humanitarian community. End comment.) ¶6. (SBU) Meeting participants expressed concern that affected populations and their families may be confused as to whether the disease is cholera or AWD. Additionally, participants expressed concern that the media will refer to all cases as cholera which could lead to a hostile GoE response and possible closure of NGO activities. Participants wondered if the MoH reluctance to use the term "cholera" will result in a situation similar to the recent outbreak of cholera in Zimbabwe where containment, resources and education materials were not quickly and adequately mobilized resulting in a large scale, preventable outbreak. ¶7. (SBU) The Acting UN Humanitarian Coordinator (HC) has talked to senior level government officials about this issue and while the MoH is selectively supportive of using the term "cholera," it remains a political issue at other levels of the GoE. USAID has offered to provide advocacy support with other government ministries should WHO and UNICEF feel that it would be of benefit. SPREADING RAPIDLY -------------- ¶8. (SBU) MOH and WHO officials report that part of the reason for the rapid spread of cholera is due to contamination of "holy water" in several locations. Pilgrims who have traveled to holy cites around Addis Ababa and in Amhara region often stay in extremely crowded conditions with little or no sanitation facilities allowing any communicable disease to quickly spread among the population. USAID's public health specialist reports that if a person gets ill after drinking holy water they believe that the water is working to remove the illness from their system. ¶9. (SBU) As a result of contamination at two holy water locations near Addis Ababa, all pilgrims were evacuated and the sites were closed for two days. The sites have been re-opened and WHO reports that significant public health messaging is taking place in both locations. With additional religious and national holidays approaching, as well as the beginning of the school year, quick action and significant public health messages are required. The Patriarch of the Ethiopian Orthodox Church recently met with the MoH, UN OCHA and NGO representatives to devise an appropriate intervention strategy. FUNDING REQUIREMENTS -------------- ¶10. (SBU) WHO recently stated that the 2009 GoE Humanitarian Requirements Document will soon be revised to reflect an increase of $2.3 million for the health sector and at least $5 million for the water and sanitation sector for AWD/cholera. WHO and the MoH are anticipating 132,000 AWD/cholera cases between now and the end of December assuming an attack rate of 1 percent. For comparison, UNICEF reports that the worst recorded outbreaks since the year 2000 occurred in 2006 and 2007 (approximately 50,000 cases each). ¶11. (SBU) For Addis Ababa, WHO has pledged $30,000 for surveillance, training of health workers and case management. UNICEF has pledged $100,000 for training, containment, communication and operational costs. UNICEF reports that it has about half of the funds needed to meet the anticipated country-wide case load for the year (UNICEF estimates 65,000). UNICEF has recently received requests from various regional governments for an additional $800,000 for response interventions. COORDINATION -------------- ¶12. (SBU) Coordination among the GoE, WHO, UNICEF, donor and NGO agencies needs improvement. WHO is unable to implement activities or report without MoH concurrence and is addressing the situation only from the health standpoint. UNICEF and the Ministry of Water Resources are looking principally at water resource, containment and contamination issues. WHO has announced several different meetings, but cancellations have inhibited transparent communication among stakeholders. ¶13. (SBU) With support from OCHA and USAID/OFDA, the Acting HC recently called a joint meeting with UNICEF, WHO, donors and implementing agencies to discuss a strategy for addressing coordination, containment, prevention, treatment and control. The Acting HC continues to encourage government officials to call a similar meeting of all stakeholders. (Comment: USAID/OFDA is encouraged by the progress of the Acting HC in talks with GoE officials. The Acting HC is now requesting that donors also encourage transparency and coordination when talking with government officials. End comment.) USAID RESPONSE -------------- ¶14. (U) PEPFAR's Supply Chain Management Systems project (SCMS), supported through USAID, is coordinating with the Federal MOH and Regional Health Bureaus to provide 2,640 bottles of disinfectant solution and 900,000 sachets of oral rehydration salts. These commodities, from supplies on hand procured for HIV-positive individuals can be spared for this emergency situation without affecting supplies needed for people living with HIV/AIDS (Reftel). USAID/OFDA RESPONSE -------------- ¶15. (U) USAID/OFDA has provided $1 million in Fiscal Year 2009 to the international NGO IRC for emergency rapid response programming including AWD/cholera response. IRC is currently responding to the outbreaks with USAID/OFDA funding in four woredas in the Somali, Afar, Oromiya and SNNP regions and is investigating additional response activities in Afar and Amhara regions. Activities include distribution of water treatment chemicals and hygiene and sanitation education. USAID/OFDA partners are also looking at potential interventions in Addis Ababa and other nearby urban centers. CONCLUSION -------------- ¶16. (SBU) The cholera situation in Addis Ababa and the country will be long-term with periodic spikes. Large gatherings of religious pilgrims, the start of the school season, and traditional movement of migrant workers are of particular concern in coming months. USAID is working with UNICEF, WHO and other partners to address coordination, containment, treatment and prevention activities countrywide. MEECE