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Situation Update ◊ As of 19 November 56,901 people had sought care for episodes of cholera, 23,817 cases required hospitalisations and 1344 deaths were reported. All departments are now affected with reports of suspicious cases in Nippes, Grande Anse, and Sud Est (see map page 4). ◊ Tensions around the presidential elections on 28 November led to deterioration of the security situation in the North, causing disruptions to humanitarian efforts over two to three days. Responses have resumed but concerns are high as the situation remains volatile. ◊ While UNICEF is bringing in additional supplies and deploying more staff in the field, lack of partners and human resources including medical staff in an overstretched health system is a serious obstacle in the effort to contain the epidemic and reduce mortality. UNICEF response ◊ Shifting to full office mobilisation mode and working with over 70 partners, UNICEF is investing in nationwide response and prevention efforts—more than following the epidemic as it spreads the focus is on building capacity and readiness nationally to anticipate outbreaks and reduce mortality. To date more than 720,000 bars of soap and 6.45 million aquatabs have been distributed along with other WASH supplies and more than 1.2 million sachets of Oral Rehydration Salts/Zinc. More than 40 health facilities received a combination of support including tents to set-up cholera treatment centres, medical, nutrition and WASH supplies and technical assistance to ensure proper care. 5,000 schools to be provided with supplies to improve hygiene and ensure access to safe water for 1.2 million children. A second round of hygiene promotion, soap and ORS distributions is taking place in residential care centres for children throughout the country, serving more than 30,000 children. On 15 November, a young boy reads a cholera-prevention poster taped on the open door of a dwelling in the impoverished Cité de l’Eternel neighbourhood of Port-au-Prince. The posters includes messages in Creole on the need to immediately refer patients to the nearest health centres, and provides tips on how to prepare home-made Oral Rehydration Salts. It also insists on basic hygiene tips to prevent contamination: regular disinfection of latrines, proper ways to dispose of excreta when someone becomes sick at household level, and the key practices of handwashing with soap and exclusive maternal breastfeeding for infants.
A girl on her way to buy water pushes a wheelbarrow with empty water containers past a garbagefilled gully. With serious gaps in sanitation and risks of contamination in Port-auPrince’s slums, preventing cholera is an uphill battle. UNICEF therefore is working at the community level with partners to ensure blanket distributions of aquatabs to purify water, focusing on where needs are greatest—including here in Cité de l’Eternel.
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Situation Report 1 22 November 2010
Situation Update: Trends, behaviours and growing public health challenges
Epidemiological trends By all accounts Haiti is facing one of the biggest cholera epidemics in recent memory, and the outbreak has yet to peak. Epidemiological data suggests that the peak can be expected as late as end-December, although different partners on the ground are also projecting a peak within two to three weeks. In some areas, including Artibonite where the first cases were reported, the number of daily cases has tended to decline (see below), although there remains concern on community-level under-reporting. Artibonite Trends
600 500 400 300 200
jective was to identify possible bottlenecks at the very immediate level of community behaviours which may contribute to the high case fatality rates observed, the high number of severe cases that are reported, and the continued spread of the epidemic. A small sample of patients were surveyed last week (25 patients, all of them reporting severe cases) and the following behaviours and attitudes were reported: (i) 80 per cent of patients said that they had Oral Rehydration Salts (ORS) at home and had taken ORS, but reported that they had waited to see the effect before seeking care. This behaviour was the single largest reason for people not immediately seeking treatment. Those who had no ORS immediately went to consult at the nearest health centre. (ii) All patients reported that they had considered Daily Fatalities their first symptoms as related to “normal” diarrhoea, delaying health-seeking behaviours. Daily Cases
(iii) 75 per cent of patients said that they did not drink water from bladders, although not out of taste but out of “distrust” and general preference for sachets of water, which are deemed to be “safer” Understanding on what kind and source . of water is safe remains unclear, with one patient reporting that they drank chlorinated water, had stopped eating raw vegetables, but continued to use untreated water from wells for dishwashing. (iv) Two patients reported that fear of stigmatisation had delayed their seeking care. (v) Only 20 per cent of patients surveyed had come from spontaneous settlements. A few members of the community who were not patients were also rapidly canvassed on their knowledge and attitudes vis-à-vis the disease. One belief is that once cholera is contracted there is no cure, while another belief is that Cholera Treatment Centres only provide rehydration and do not cure from cholera, with a belief that rehydration can be done just as well at home. Results from this rapid study, despite the small sample of people surveyed, tend to reveal that misinformed reflexes and gaps in knowledge of key practices are partly contributing to the spread of the disease and the severity of cases. It also raises concerns that even the most basic practices—such as handwashing with soap—are not yet appropriated and systematically practiced throughout Haiti.
Source: Ministry of Health.
There also remains uncertainty on whether the peak of the epidemic will stay localised or reach a national scale. In view of the context and available epidemiological data, the outbreak in Haiti corresponds to no pre-existing model. To date, scenarios for the future course of the epidemic remain under discussion among specialisted technical agencies including the World Health Organization and the Centers for Disease Control and Prevention (CDC). Quick survey on behaviours and attitudes With cases and fatalities still growing and projections that the peak of the epidemic has yet to be reached, UNICEF conducted a quick study on perceptions and health-seeking behaviours among patients in three Cholera Treatment Centres in Port-au-Prince. The ob-
Situation Report 2 22 November 2010
Managing corpses of the deceased While efforts are underway to expand the capacity of the health system for treatment, health authorities and partners are also increasingly concerned on the lack of protocols and options for safe management of corpses of the deceased. According to Haitian law this is the responsibility of Mayors and Town Councils, however there is often serious gaps in capacity and knowledge to handle bodies appropriately to avoid further contamination. In Anse Rouge for instance UNICEF dispatched medical consumables to support not only health structures but also the town council to ensure proper management and burrial of corpses, including supplies for disinfection and personal protective equipment. Temporary storage of bodies at facility level is a growing concern in all affected areas including in Port-au-Prince, creating critical conditions in certain facilities which are already overwhelmed and under-staffed to handle the caseload. Bodies are also at times returned to families with no precautions taken to avoid further contamination, while local rituals associated with burials of the deceased present clear risks for acceleration of transmission of the cholera bacteria (such as community wakes and gatherings around the body of the deceased). Locations where victims of the January 2010 earthquake have been buried meanwhile cannot be used as many of these mass graves are too close to the water table and there are risks of contamination of groundwater sources.
Integrating Responses Nationwide to Reduce Mortality
Today all ten of Haiti’s departments are affected by the outbreak with newly suspected cases reported in Grande Anse and Nippes. Only following the epidemic’s geographic spread will however yield insufficient results. Efforts are rather needed at national level to prevent as much as possible potential outbreaks, anticipate cases, have immediate capacity to prevent high mortality, and halt any acceleration in the pattern of transmission once a new source of contamination is identified anywhere in the country. UNICEF is therefore mobilising supplies to support a nationwide response and all UNICEF staff are now devoted to full-time cholera response, with investments in directly ensuring and building capacity for treatment at the medical level. UNICEF is also fully engaged in support of actors and responses in the WHO-coordinated Health Cluster, which includes supporting more efforts to expand the network of Cholera Treatment Centres/Units, and ensuring that they have the necessary health, nutrition and WASH supplies. Water, Sanitation and Hygiene: Fighting Back at the Community Level In Artibonite a water treatment unit was installed in Grande Saline to provide a safe option for drinking water in one of the areas that was hardest hit by the outbreak from the very first days of the crisis. WASH interventions also continue to scale-up at community level, with UNICEF supporting an initiative by Oxfam GB to implement a fully integrated water, sanitation and hygiene cholera response plan in the commune of Petite Rivière de l’Artibonite including the installation of 20 handpumps across 13 communities in Bas Coursin and Labady, for a total catchment area of more than 90,000 people. In the West Department a similar effort is underway in partnership with the Haitian and Netherlands Red Cross, with distributions of 10,000 bars of soap and 5,000 buckets to 10,000 households in Jacmel, Cayes-Jacmel, Marigot and La Valee. UNICEF is also supporting the Spanish Red Cross to conduct three rounds of disinfections of latrines in Léogane in 14 communities in the Grande Rivière section of the district, representing a catchment population of more than 34,000 people.
On 17 November, a worker burns a cholera patient’s infected clothing, outside a health centre in the impoverished Wharf Jérémie neighbourhood of Port-au-Prince, the capital.
Situation Report 3 22 November 2010
Meanwhile with protests in the Nord Department last week, UNICEF and partners had to temporarily suspend WASH assessments in Cap Haïtien, Limbé, Plaisance and Pilate, although activities could resume as road blocks were cleared over the past week-end in the city and on main highways leading out of town.
Scaling Up Health and Nutrition Responses In La Pointe (Nord Ouest), UNICEF health specialists provided technical assistance for the Beraca Health Centre to set-up a cholera treatment area with proper isolation of patients and proper measures to avoid contamination. In Pilate (Nord), UNICEF supplied the local health centre with 5,000 ORS sachets for rehydration of cholera patients, while 100,000 sachets were dispatched to the Direction Sanitaire de l’Artibonite in Gonaïves for onward distribution in the department’s different health centres.
Men carry emergency medical supplies to a United Nations helicopter, at the airport in Gonaïves in Artibonite. These supplies, which included emergency health kits Ringers Lactate and ORS were airlifted and distributed Anse Rouge and Marmelade in Upper Artibonite.
Situation Report 4 22 November 2010
UNICEF meanwhile dispatched nine tents to expand coverage of health interventions in the Nord (Cap Haïtien, Limbé) and Nord Est departments with plans to set-up Cholera Treatment Centres in Ouanaminthe, Trou du Nord, Terrier Rouge and Fort Liberté. The aim is notably to decongest the structures in Limbé at the Hopital Eben Ezer and Hopital Saint Jean by expanding the capacity of Hopital Bon Samaritain so referrals can be made to one structure, while others can continue to provide regular care for other patients—most hospitals and health centres have indeed been overwhelmed by the number of cases, undermining continuity of care for all other primary health needs. Meanwhile, with cases reported in the Ouest Department on Haiti’s southern peninsula, UNICEF is supporting the extension of the Cholera Treatment Centre in Petit Goave run by MDM-Spain. Fifty beds are planned to extend the capacity of Hopital Notre Dame which to date only had a seven-bed capacity. To date, UNICEF has supported close to 40 health centres, dispensaries and hospitals throughout the country with a combination of tents to set-up CTCs/ CTUs; ORS/Zinc; Ringers Lactate solution; Emergency Health, Diarrhoea and Hygiene Kits; along with WASH items and support to upgrade sanitation and water access at health facility level (see map on previous page). Meanwhile in Nutrition, UNICEF in collaboration with WHO developed a treatment protocol to be used in all CTCs and health centres for appropriate rehydration of children with severe acute malnutrition (considering their physiologic and metabolic aspects). This is particularly important as children with severe acute malnutrition are at higher risk of congestive heart failure and death if inappropriate rehydration protocols are applied, because of electrolyte disequilibrium. UNICEF also supported the Ministry of Health in designing messages to promote exclusive breast-
On 15 November, a water seller gives a resident a packet of aquatabs (water purification tablets), in the impoverished Cité de l’Eternel neighbourhood of Port-au-Prince. UNICEF through several partners, is providing free , packets of aquatabs and cholera-prevention information posters in the neighbourhood.
feeding and is strengthening its partnerships with NGOs to maximize their involvement and contribution to reduce the burden (morbidity and mortality) of cholera on children.
Nationwide Prevention and Preparedness
Ensuring access to safe water and sanitation UNICEF continues to support DINEPA and partners’ efforts to distribute aquatabs in particularly vulnerable neighbourhoods in Port-au-Prince. Some 320,000 aquatabs were newly dispatched to partner GRET (Groupe de Recherche et d’Echanges Technologique) for onward distributions in Bicentennaire in the slums of Cité de l’Eternel and Village de Dieu, 100,000 aquatabs were also dispatched to the International Committee of the Red Cross for distributions in Cité Soleil and 100,000 to GHESKIO for distributions in wells in Cité de l’Eternel and Village de Dieu. Oxfam GB is meanwhile starting distributions of 450,000 aquatabs in Croix des Bouquets and UNICEF is suplying the International Organization for Migration for distributions in 245 private water basins and camps (so far 100,000 have been distributed) in Cité Soleil. To date, 2.5 million aquatabs have been distributed by UNICEF working with DINEPA out of a total of 4.65 million dispatched. Another dimension of the effort has been conducting random testing of water in different collection points and at household level. Fifteen agents
Situation Report 5 22 November 2010
Field missions to bring supplies to hard-to-reach areas were also an opportunity to conduct health assessments in Port-de-Paix, La Pointe, Saint Louis du Nord and Anse-à-Foleur in the Nord Ouest. Weak local capacity, lack of partners and lack of trained health staff remains the main concern in these areas, which continue to report among the highest case/fatality rates from the disease.
UNICEF is supporting in DINEPA are conducting an average 100 tests a day throughout Port-au-Prince, with SMS technology introduced recently to feed back timely information on residual chlorination levels. Latest reports show that 42 per cent of bladders and reservoirs tested and 73 per cent of household samples still do not meet DINEPA and WASH Cluster defined standards of a minimum 0.5 mg per litre of chlorine to ensure water is safe from any contamination from cholera bacteria. Bacteriological testing will also begin this week by this same team with technical support from the Centers for Disease Control (CDC). UNICEF is meanwhile working with DINEPA and UNOPS to dedicate a fleet of five de-sludging trucks for work exclusively in Cholera Treatment Centres in the city. UNICEF and DINEPA have also convened private de-sludging companies and will ensure training of staff on sanitary protocols for de-sludging of liquid wastes from cholera treatment sites. Looking at the entire cycle to ensure all steps are done safely, UNICEF is also advocating with DINEPA and Port-au-Prince’s solid waste management authority SMCRS (Société Mixte de Collecte des Résidus Solides) for the establishment of sanitary protocols for disinfection of trucks exiting the Truttier dump and disposal site. Mobilising Partners for Prevention Side by side with the Ministry of Education UNICEF is launching a nationwide effort to assist 5,000 schools representing a total 1.2 million children with interventions geared towards prevention and upgrading of water and sanitation facilities in schools. This also includes support for disinfection in schools when cases of cholera are reported, so school facilities can be disinfected and learning can resume as soon as possible in a safe environment. Distributions of supplies has started in Artibonite where UNICEF is working with the Haitian Red Cross in Gonaïves for the distribution of 60,000 bars of soap, 510,000 aquatabs and 1,350 hygiene promotion posters, targeting 450 schools and 135,000 children. UNICEF is also assisting the Ministry to strengthen the capacity of teachers and schools supervisors on
A worker sets up tents in the impoverished Cité Soleil neighbourhood of Port-au-Prince. The tents are among a total of fifteen that UNICEF is providing to Medecins Sans Frontieres at a 300-bed cholera treatment centre in Sarthe which is serving as a referral facility for all severe cases in Cité Soleil.
cholera prevention in the targeted schools at nationwide level. Training started on 22 November and will span over the next month in all of Haiti’s ten departments and 3,000 teachers and school supervisors will be skilled up on the detailed curriculum which was revised to include a component on sensitization messages for prevention of cholera in schools. Under this effort, twenty-six trainers already specialised on psychosocial training were trained in the Ouest Department on 20 November and will now roll-out training on psychosocial support and cholera prevention in schools to reach 2,400 teachers and school supervisors. Another wave of trainings will start on 25 November for 600 teachers and school supervisors in Sud Est. Overall, between 22 November and 23 December, 46 trainers, 6,040 teachers and school supervisors will be trained in Haiti’s ten departments which will benefit 300,000 children. At the same time, to protect the most vulnerable children living in residential care centres, UNICEF has started a second round of distributions of soaps, Oral Rehydration Salts, bleach and chlorine along with hygiene promotion posters to all residential care centres throughout the country. According to official numbers more than 35,000 children reside in over 750 residential care centers throughout the country, but many centres are not
Situation Report 6 22 November 2010
registered and numbers are likely higher. Over a period of one week more than 30,000 bars of soap, 2,000 gallons each of bleach and chlorine, and 61,000 sachets of ORS/Zinc are being distributed to these centers for all children to be reached within the next seven to ten days. With the effort involving nine NGO partners, including Save the Children, World Vision, Heartland Alliance, Catholic Relief Services, International Rescue Committee, Terres des Hommes and International Medical Corps and others. UNICEF and partners will reach more than 35 000 children, including more than 20,000 children in the Port-au-Prince metropolitan area. UNICEF has also conducted training of trainers in hygiene promotion and cholera prevention for more than 100 social workers and NGO staff which will be replicated in all the 750 residential care centers all over the country. The anniversary of the adoption of the Convention on the Rights of the Child on 20 November was meanwhile a further opportunity to bring partners together and organise sensitisation. Over 20-21 November Catholic Relief Services, IBESR and UNICEF conducted hygiene promotion sessions in 7 residential centres in Gonaïves reaching close to 700 children with sensitization on the theme of Child
Rights to Health in the context of cholera. UNICEF has meanwhile approached Church networks and community leaders to start sensitisations and hygiene promotion during week-end services over the past week-end. UNICEF appeal and requirements On 20 November, only 10 per cent of requirements are met against the Inter-Sector plan launched on 11 November. As part of this response plan, UNICEF appealed for US$ 19.4 million for WASH and US$ 5.8 million for Child Health and first pledges have been made for US$ 2 million by Canada and US$ 100,000 by the French Embassy in Haiti. Sector Child Health Water Sanitation and Hygiene Total Requirements
5,808,341 19,418,566 25,226,907
For more information please contact: Jean Jacques Simon, Chief of Communication firstname.lastname@example.org Stephanie Kleschnitzki, Reporting Manager email@example.com Jeremy Shusterman, Reports Specialist firstname.lastname@example.org
On 15 November, a boy heads back home with a container of water he is bringing back home, in the Cité de l’Eternel neighbourhood of Port-auPrince. Customers at these different water kiosks—there are close to 300 which UNICEF is supporting—are now receiving for free a packet of five water purification tablets for each bucket of water. One tablet helps ensure five to ten litres are purified, and agents operating water kiosks make sure that people who come to purchase water systematically use one tablet for the buckets they have just bought. The extra tablets handed out come with a leaflet explaining how to use them, and are distributed so households can build up a small stock at home so there is always a way to make sure water is safe.
Situation Report 7 22 November 2010
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