Health Action in Northern Uganda. World Health Organization Health Action in Crisis Issue 2, April 2005

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1 Health Action in Northern Uganda Health Newsletter INSIDE THIS ISSUE: Holistic approaches to 2 child survival Home Based 3 Management of Fever Epidemic update: cholera 4 Mortality survey 4 Nutrition survey schedule 5 for the Northern region Ministry of Health (MoH) 5 Child Days A Child with an Insecticide Treated Net (ITN) at Africa Malaria Day celebration, Gulu World Health Organization Health Action in Crisis Issue 2, April 2005 IMCI -Integrated Management of Childhood illnesses provides the standards of quality care for sick children at first level health facilities in Uganda. The guidelines provide for a holistic assessment of a sick child using common presenting symptoms of cough or difficulty in breathing, fever, diarrhoea as entry points. The guidelines specifically address malaria, acute respiratory infections, diarrhoea, malnutrition and immunisation and of recent, they have been adapted to enable health workers identify children who are symptomatic or exposed to HIV infection. The guidelines use only clinical signs to come up with a classification without need of laboratory investigation hence its appropriateness in the IDP camp setting where access to functional laboratories is low. Nursing assistants with no formal medical training have been able to correctly use the guidelines to manage sick children after 2 weeks of training, implying that they can be used by persons of little or no basic medical training. In Gulu, a total of 350 nursing assistants and other health workers have been trained by AM- REF, UNICEF, MoH, and CARE in IMCI since Of the 350 trainees only the initial 15 received IMCI materials! The high level of attrition, redeployment in respect to camp establishment has left many health units with inadequate capacity to manage children according to standard guidelines. There is need to support training of health workers in IMCI including recognition and treatment of children with HIV/AIDS and cater for IMCI modules and charts for the trainees to refer to. This training needs to be on-job so as to address organisation of services at health facilities and outreaches at the same time. Sources: WHO Uganda and DHS, Gulu The theme of this edition of the health newsletter is Strengthening Child Survival. This comes before May Child days and 2nd round of SNIDS begin and just after Africa Malaria Day has been commemorated in Gulu. Very apt, because malaria is responsible for a staggering 60% of deaths among under fives and16% among the above 5s (Gulu). Some of the issues regarding child mortality include; access to health services, effective health treatment and general health knowledge and behaviour. Some of these issues have been addressed by Home Based Management of Fever (HBMF), Home Based Care and Integrated Management of Childhood Illnesses. More interventions still need to be made to reduce child mortality. Health interventions are moving from vertical to more integrated approaches to best use available resources to positively impact on the health of as many people as possible. In line with integration is coordination, which in the health sector is at the heart of integration. Welcome, DDHS, Gulu Editorial

2 Page 2 Volume 1 Issue 2 Holistic Approaches to Child Survival: Doing things differently in this year s Sub-National Immunisation Days (SNIDS) Uganda National Expanded Program on Immunisation (UNEPI) was launched in 1983 to provide vaccination services against the six killer preventable diseases. Before attaining 100% coverage, it joined the rest of the international community to eradicate polio by From , six rounds of National Immunisation Days (NIDs) were implemented, reaching over 1 million children every year. A review of polio eradication in Uganda highlighted issues such as increased polio susceptibility due to relatively low routine OPV immunisation coverage (2003/4; Apac, 44%/76%; Lira, 49%/66%; and Kitgum, 30%/66%.) leading to rapid accumulation of unimmunised populations over a relatively short period of time, which was cause for alarm because of reports of an out break of Wild Polio Virus (WPV) in bordering Southern Sudan. Against that background, MoH through UNEPI opted for a revised strategy of building the population immunity of people in districts bordering Sudan. This strategy is being implemented as SNIDs in 15 districts of Adjumani, Arua, Moyo, Yumbe, Nebbi, Gulu, Kitgum, Pader, Nakapirirpirit, Kotido, Moroto, Katakwi, Masindi, Lira and Apac. The 1st round of SNIDs provided not only booster OPV doses, but also booster measles, catch up BCG (TB), DPT-HepB+hib (diphtheria, partussis, tetanus, hepatitis B and haemphillus influenza, pneumonia and meningitis) and TT immunisation to prevent maternal and neonatal tetanus in women of child bearing age. The second round of SNIDs will be integrated with May Child days, in the selected districts of northern Uganda, 7-9 May nd Round of SNIDs/Child days in selected districts of Northern Uganda, May 7 9, 2005 Age group Antigen/Intervention Remarks 0-11 months BCG For children who are due or have missed their routine dose 0-59 months (under 5 years) Oral polio vaccine * WCBA women of child bearing age Supplemental dose given irrespective of previous immunisation status 6 weeks -11 months DPT-Hep B+ Hib For children who are due or have missed their routine dose 9 months and above Measles (routine dose) For children below and above one year who are due or have missed their routine dose years WCBA* TT vaccine According to routine schedule 6-59 months Vit A, albendazole Vit A for supplementation and albendazole for de-worming In addition health information on clean water, sanitation, nutrition and diseases specifically treatment for malaria, diarrhoeal diseases and pneumonia will be given to participating mothers and children. Generic approaches for policy development and strategies must focus on capacity building and development of genuine operational partnerships between and within government agencies and NGOs to look at the child as a whole. Vertical programming focusing on specific health issues and field interventions will not deliver child survival or reduce child mortality. Logic dictates that interventions targeting children should comprehensively address the health needs of a child. In Northern Uganda, integrated approaches are even more important as access to some children is hampered by security conditions on the ground. It is not uncommon to run vaccination in one camp as another agency runs an HIV/AIDS program there at the same time. Operational costs are hiked and security risks to providers and sometimes services duplicated too. The DDHS needs to map out where children are, minimum packages of intervention and comparative advantages/leverages of health players in a district to enable integration of health services to improve child survival. Sources: EPI, WHO, Kampala

3 Health Action in Northern Uganda Page 3 Home based Management of fever/malaria Strategy MoH and its development partners designed a simple, practical strategy for making effective, easy to use anti malarial drugs available at community level. Community drug distributors are trained at recognizing a sick child (below 5 years), giving the correct drug and referring the very sick to health units, counseling/ advising caretakers. Justification for providing medicine at community level A series of community studies have shown that 60-80% of malaria treatment particularly in children take place outside health units, based on wrong drugs/doses most of the time. This self-medication causes a delay in seeking/receiving appropriate malaria treatment at health units and greatly increases the risk of dying from a malaria attack. In IDP camps, access to health services may be difficult for people living in hard to reach areas and the provision of first line treatment drugs (for malaria) at community level has greatly reduced the chances of children under five from dying of a malaria attack. A feasibility test done in Mpigi, Masaka and Mubende showed that the approach was feasible, accepted and utilized by the population. The key objective of the strategy is to increase the proportion of children under five years who receive prompt and appropriate antimalarial treatment within 24 hours of fever onset. Drugs used in HBMF The drugs used are a combination of chloroquine and sulphadoxinepyrimethamine (SP). The combination is safe and effective and has been prepackaged for use at community level under the name HOMAPAK. It is coded in 2 colours, red for children 2months 2 years and green for children 2-5years. Implementation of HBMF in Northern Uganda was carried out through a partnership consisting mainly of MoH, DFID/Malaria Consortium, Africa Development Bank, UNICEF and WHO. In Gulu, Malaria Consortium distributed (Insecticide Treated Nets) ITNs to mothers at ANC as part of HBMF. Within ongoing HBMF, UNICEF introduced an expanded approach to address other health problems of under fives including; pneumonia, diarrhoea, eye infections, skin diseases and injuries. This program is called Home Based Care (HBC). Under HBMF, 693 Community Resource Persons (CORPs) in 49 camps in Gulu have been trained. 400 of those CORPs have been trained to deliver HBC. Achievement (as seen in Gulu) From Sept 2004-March 2005 cases of malaria reported in units reduced by 26%. The number of mothers attending Ante Natal Clinics (ANC) increased by 45%. In 2003, 2486 mothers were treated for complications at ANC, while 4586 were treated in Sources: MoH/WHO Uganda/DDHS Gulu R ecent events 31 March 2005: Launch of the IDP Policy, Gulu 1 April 2005: Health and Nutrition Coordination meeting, Gulu 03 April 2005: Index cases of a new cholera epidemic reported in Jeng-gari decongestion IDP camp, Pabbo 04 April 2005: IDSR workshop for non MoH health workers (WHO/DDHS office) 06 April 2005: Cholera Taskforce Meeting, Gulu 11 April 2005: Meeting for Gulu Health Sector Needs Analysis Mid Year Review/ CAP 2005(MYR) 12 April 2005: Joint assessment of Ome I & II IDP camps (NGOs/District) 13 April 2005: Cholera Taskforce Meeting Multi-sectoral Disaster preparedness Meeting /DDMC 19 April 2005: Cholera Taskforce Meeting held at the DDHS Boardroom 20/21 April 2005: UNICEF Regional Emergency Health, Nutrition and WES planning meeting for Gulu, Kitgum, Pader, Apac and Lira districts Cholera Taskforce Meeting at Pabbo Sub-county Headquarters 25 April 2005: Africa Malaria Day celebrated in Gulu town. Theme: Unite against malaria 28 April 2005: Health and Nutrition Coordination meeting, Gulu 29 April 2005: WFP Results Based Management Workshop, Gulu

4 Page 4 Volume 1 Issue 2 Oral Rehydration therapy, antibiotics, antimalarial drugs, insecticide treated nets, Vitamin A and other micronutrients, breastfeeding, immunisation and skilled care during pregnancy and childbirth / infancy are simple, safe and effective interventions that could reduce 90% of deaths among children under five, according to the World Health Report 2005 Make every mother and child count. For more on this visit:: mediacentre/news/ releases/2005/pr16/en/ index.html Planned Mortality Survey Planned mortality survey in conflict-affected districts: The Ministry of Health, UNICEF, WFP, IRC and WHO have decided to conduct a mortality survey in Gulu, Pader and Kitgum districts. The field work has been scheduled for June The mortality survey is currently under planning and the survey protocol has been drafted by WHO and shared with the above-mentioned partners for review. Survey justification: Mortality data is particularly scarce as the existing Health Management Information System does not capture mortality data and the vital statistics registration system is weak. There is currently no available baseline crude, age and cause specific mortality data in the conflictaffected districts. A number of targeted health and nutritional surveys have documented mortality rates (see page 6) some of them, beyond the emergency threshold in the IDP camps assessed but it is difficult to generalize from these figures. The availability of comprehensive mortality data at district level will strengthen district health authorities capacity for the planning of health interventions and strengthen resource allocation according to measured health priorities. Epidemic Update: Cholera in Pabbo Cholera treatment centre at Pabbo HCIII (above) and a Cholera Taskforce meeting with Pabbo sub-county & camp leaders (below) Gulu district is experiencing a new cholera outbreak in Jeng-gari, Pabbo and Parabongo IDP camps, Kilak Health Sub-District (HSD). This is following the recent outbreak; October 2004 to January 2005 in Pabbo IDP camp, Between 3April and 2 May 2005, 77 cases, including two initial community deaths (CFR 2.8%), were reported from Jeng-gari, Pabbo, and Parabongo IDPs camps. Preliminary analysis indicates that the outbreak is getting under control in Jeng-gari and Parabongo but is stable in Pabbo (population about 64,000). Vibrio cholerae O1 El Tor Inaba has been identified in at least 18 stool samples. Antimicrobial sensitivity pattern: sensitivity to ampicillin, ciprofloxacin, tetracycline, and erythromycin; resistance to chloramphenicol, nalidixic acid, and cotrimoxazole. Laboratory tests of water samples from Jeng-gari indicate faecal contamination of both water sources and water stored at home in traditional pots. Gulu District Cholera Task Force team, comprising Gulu District Directorate of Health Services, MoH, NGOs, OCHA, UNICEF, ACF, Lacor Hospital and WHO, is implementing control measures including: active case search through the mobilisation of Community Owned Resource Persons (CORPs), case management (MSF Switzerland has established a cholera treatment centre at Jeng-gari and another centre is at Pabbo HC III run by Lacor Hospital and DDHS office; and five ORS points in Jen-gari and Pabbo IDPs camps), health education, improvement of water quality and environmental conditions (daily cleaning of the camps, bucket chlorination at water points by ACF in Jenggari). Supplies for case management and sanitation are still adequate, but funds to support health care workers involved in the response are lacking. Prepositioning of cholera kits in Gulu district is underway. Under consideration is sensitization of leaders in the affected camps on responsibility regarding environmental health and other measures that prevent disease spread. Source: Gulu District Cholera Taskforce Team

5 Health Action in Northern Uganda Page 5 Nutrition assessments to be carried out in Northern Uganda, Karamoja and Teso regions 2005 Schedule Month Methodology District Implementing partner Co-funders Ongoing (April 2005) Camp by camp assessment Kitgum Pader IMC GOAL Pader & SciU UNICEF & WFP May X 30 survey Teso: Soroti, Katakwi, and Kaberamaido UNICEF & WFP Under discussion (2 nd quarter) Camp by camp assessment Gulu ACF (USA) & SCiU UNICEF & WFP Under discussion (3 rd quarter) 30 x 30 survey Karamoja UNICEF & WFP Under discussion (3 rd quarter) Camp by camp assessment Lira ACF (USA) UNICEF & WFP October 2005 Camp by camp assessment Gulu ACF (USA) & SciU UNICEF & WFP Oct Nov 2005 Camp by camp assessment Kitgum UNICEF & WFP Oct Nov 2005 Camp by camp assessment Pader GOAL Pader UNICEF & WFP The above is on the basis of conducting bi-annual nutrition assessments in the Northern districts (Gulu, Kitgum, Pader and Lira) and annual assessments in Apac district, Karamoja and Teso regions. Source: WFP Kampala Bi-annual Child Days In an effort to increase coverage of priority child health interventions, the MoH with support from partners adopted the strategy of child days which are implemented during the months of May and November every year. During the two months districts pro-actively ensure that priority services reach children in all communities either through static units or by outreaches. The services include: catch-up immunization, bi-annual Vitamin A supplementation, de-worming and promotion of selected key family care practices. They are organized as part of routine health services but in an accelerated manner that ensures universal coverage including reaching the underserved and hard to reach communities. Additional resources are normally required for increased drugs, vaccines and other supplies to cater for the increased demand. It also entails enhanced social mobilization. The table below shows the performance of Gulu, Kitgum and Pader for the May and November 2004 child days using selected indicators Supplement District May 04 November 04 Vitamin A (6-59mths) Gulu 71% 73% De-worming (1-14yrs) 87% 43% Vitamin A (6-59mths) Kitgum 58% 108% De-worming (1-14yrs) 48% 83% Vitamin A (6-59mths) Pader 78% 52% De-worming (1-14yrs) 73% 62% State Minister for Health (PHC), Dr Alex Kamugisha, giving a child Oral Polio Vaccine (OPV) during Sub- National Immunisation Days 26/27 February SNIDs will take place again from 7-9 May 2005.

6 Health and Nutrition Statistics Global & Severe Acute Malnutrition in selected IDP camps in Northern Uganda All rights are reserved by the organization. The document may, however, be freely reviewed, abstracted, reproduced or translated in part or whole, but not sold or used in conjunction with commercial purposes. 7.00% 6.00% 5.00% 4.00% 3.00% 2.00% 1.00% 0.00% Apac Gulu Lira Pader Mortality Rates in selected camps in Northern Uganda GAM SAM This newsletter is not an official WHO publication. The views expressed in it do not necessarily represent stated policy of WHO. For more information contact: Ms. Ida-Marie Ameda Gulu Sub-office 17 Eden Road, Gulu, Gulu Municipality PO Box 1054 Uganda Mb: Tel: Tel/Fax: In Kampala: Ms. Helene Cunat WHO Kampala PO Box Kampala, Uganda Tel: / Tel: /6 Mob: Fax: The contributors to this newsletter include: GOAL, ACF (USA), WFP, UNICEF, MoH, DHS Gulu, WHO Country office District Under 5 Mortality (U5MR) Crude Mortality Rate (CMR) Gulu 3.4/10,000/day 2.23/10,000/day Apac 52.8% of CMR 1.4/10,000/day Lira 0.5% of CMR 0.7/10,000/day Pader 1.5/10,000/day 0.7/10,000/day The graph and table above are summary data of nutritional anthropometric surveys carried out by WFP/MoH/UNICEF, SCiU/MoH, GOAL Pader, ACF Lira/Apac. For each of the surveys, the target was 6-59 months. In Apac, 8 IDP camps in 3 sub-counties Minakulu, Ngai and Otwal were covered by the survey, in Lira 25 IDP camps were covered, in Gulu, one survey (SCiU/MoH) covered 13 newly gazetted camps, while the other (WFP/MoH/ UNICEF) covered 33 IDP camps and finally in Pader the survey was carried out in Kalongo town, Wol, Omiya Pacwa and Paimol mutto IDP camps. The sample sizes (U 5s) were as follows: Gulu, 7845; Apac, 956; Lira, 965 and Pader, Note that:: the ACF Lira and GOAL surveys were carried out in March 2005, while ACF Apac Feb 2005, WFP/MoH/UNICEF, Sep/Oct 2004 and SCiU/MoH, Nov The above surveys were carried out by different agencies at different times using different methodological tools, therefore caution should be taken before comparing district results. Paimol mutto Omiya Pacw a Wol Kalongo IDP camps Vaccination Status (Pader district) 0.0% 20.0% 40.0% 60.0% % w ith history of vaccination * % not vaccinated % Fully vaccinated confirmed w ith a card * History of vaccination was verified by the mother/guardian of the child because many IDPs have lost their cards or have them stored at a different place. Source of the data for the above graph: GOAL Pader Nutritional Assessment, April 2005