trea Health Update Eritrea Health Update Issue 2 No.3

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1 Issue 2 No.3 HIGHLIGHTS Outbreak monitoring Malaria control achievement WHO/ECHO Joint Project Highlights of the Eritrea CHAP 2007 Outbreak Monitoring: Week 7 (12 th 18 th February, 2006) Report Completeness and Timeliness All Zobas have submitted reports up to week 7 of the year. The average health facility to Zoba report completeness and timeliness have slightly improved. The national average report completeness and those for Anseba, Maekel, SRS and Debub are optimal (Table 1). However, the timeliness needs to improve especially in Gash Barka, Northern Red Sea and Southern Red Sea. Even though the report completeness and timeliness in these Zobas had improved compared to the previous years, there is still room for further improvement. A strategy to improve this timeliness has already been discussed and consensus reached. Implementation will begin in the coming weeks. Table 1: Average Health facility to Zoba weekly report completeness and timeliness as at week 7 (12 th -18 th February, 2007) Zoba Total Population Number of HFs Timeliness Completeness Anseba 539, Debub 891, Gash Barka 666, Maekel 635, NRS 541, SRS 78, Total 3,353, Cerebro-Spinal Meningitis (CSM) There are no suspected cases of CSM reported so far this year. Malaria The weekly number of cases of malaria did not cross the third quartile threshold at any time so far during the year (Figure 1). Thus no suspected outbreaks have been detected. 1

2 Other Outbreaks: No outbreaks of other diseases have been reported. Diarrhoea and Bloody Diarrhoea: The weekly trend of diarrhoea with blood (dysentery) is presented in Figure 2. The third quartile threshold has not been crossed so far this year. No outbreaks of other diarrhoeal diseases were reported. Measles Situation: No suspected measles cases were reported to the national level so far during the year Figure 1 Eritrea:Malaria weekly trend in rd Quartile Yr 2007 Number of cases week number Figure 2 Eritrea: Bloody diarrhoea weekly trend in rd Quartile Yr 2007 Number of cases week Number 2

3 Malaria control achievements Recognizing malaria as a major public health problem in Eritrea, the Government embarked on implementing Roll Back Malaria (RBM) initiative in 1998 as a strategy aimed at reducing the burden of the disease. A five year strategic plan ( ) consisting of proven and cost effective interventions was developed and implemented. The major interventions used for malaria control in the country during this period were: Prevention through selective vector control (indoor residual spraying and elimination of breeding sites) and use of Insecticide Treated Nets (ITNs); mortality and morbidity reduction through effective case management using trained health workers, trained community health agents and IMCI strategy; early detection and control of epidemics using effective malaria surveillance that monitored monthly rainfall and weekly malaria cases; mobilization of the population particularly at the community level using effective information and communication strategy; operational research to monitor vector evolution and resistance to anti malarial drugs & insecticides and mobilization of resources as a result of strong Government commitment and partnerships. The key to implementing the strategy was community involvement and ownership and the use of Community Health Agents (CHAs) as the first line of treatment. As a result of these interventions, the target reached before the set date of Malaria morbidity and mortality have been reduced by more than 80%. Having realized such impacts, a new strategic plan (2005 to 2009) was developed with the following objectives: 1. Reduce malaria morbidity by 30% by 2009 from 2004 levels 2. Reduce malaria mortality by 50% by 2009 from 2004 levels 3. Prevent malaria epidemics In order to achieve the strategic objectives, annual plans are developed and evaluated. The objectives of the 2006 plan were: 1. Reduce Malaria morbidity by 10% from 2005 levels 2. Reduce Malaria mortality by 25% from 2005 levels 3. Reduce and prevent epidemics of malaria. An annual malaria assessment workshop is held every year to assess the achievements of the previous year and set target for the current year. This year s annual assessment workshop was held in Ghindae Northern Red Sea Zoba from February, The assessment was led by the Honourable Minister of Health of the State of Eritrea and was attended by representatives of the various partners involved in malaria control. The WHO was represented by the three levels HQ, AFRO and the country office. 3

4 The Honourable Minister of Health (3 rd from right) and representatives of agencies at the assessment workshop Cross section of participants at the assessment workshop The strategies used in 2006 were the same strategies that achieved significant malaria control between 2000 and Case management aimed at early diagnosis and prompt treatment of cases was the most important malaria control strategy. In order to achieve early treatment, the training, and use of Community Health Agents (CHAs) was a major activity. In ,923 malaria cases treated at Health Facility (HFs) and community levels, of which 12.4% (10,148) of cases were treated by HFs and 87.8% (71,775) by CHAs at community level. The CHAs treat clinical malaria cases, while all HFs have either a Laboratory or use Rapid Diagnostic Tests (RDTs) and therefore treat only lab confirmed cases. The use of RDTs by CHAs will be piloted starting this year. A CHA with her certificate 4

5 Distribution of ITNs proved to be the most effective malaria control strategy in Eritrea. ITNs are distributed freely to households with children under five years of age and pregnant women. Other vulnerable segments of the population who benefited from free ITN distribution were Internally Displaced Population (IDP), people living in camps. In 2006, 79,336 additional ITN s were distributed bringing the cumulative number of distributed ITNs to 1,063, 000 (Figure 3) for an estimated population of 3.6 million, sixty-seven percent (2.4 million) of which reside in malaria endemic areas. The proportion of ITNs procured by the households has increased from 25% in 2004 to 33% in 2006, which showed that people were understanding the benefit of ITNs and were investing on buying them; a key sustainability factor. A total 738,671 ITNs were reimpregnated. Figure 3 ITNs distributed (Cumulative) Number of ITNs (in 1000s) (cumulative) Year Mosquito breeding sites were used either eliminated or treated with abate. Indoor residual spraying was used to protect the households. Other strategies used were epidemic forecasting and early warning system and establishment of epidemic preparedness and response mechanisms as well as promotion of research to make evidence based decision making in policy and other malaria related issues. 5

6 In 2006, Chloroquine plus Fansidar (CQ+SP) and Artemisine + Amodiaquine (AR+AD) efficacy was studied in 6 sites (Sawa hospital, Tesseney hospital & Dubarwa HC for CQ + SP and Tekombia HC, Goluj HC & Engela HC for AR+AQ). This has led to Drug policy change in 2007 from CQ+SP to AR+AD. Epidemics thresholds were used to monitor weekly trends and 26 Sentinel sites were in place for monitoring malaria situation (Figure 4). The implementation of the strategies has led to further reduction in confirmed malaria cases seen in health facilities by 58% in 2006 compared with that of 2005 (Figure 5). The proportion of hospital admissions from all hospital admissions has decreased to 5.4% in 2006 from 10.7% in The ranking f malaria as a public health problem has also significantly changed. In the year 2000 malaria was ranking as number 1 inpatient cause of death among adult Eritreans, becoming number 10 in 2005 and disappearing from the top 10in 2006 (Figure6). Figure 4 AN SK MA GB DE DK Sentinel-site based alertness for malaria epidemics 6

7 Figure 5 Trend of Health Facility Malaria cases Malaria cases Year Malaria cases Figure 6 Top 10 causes of Adult inpatient deaths Malaria 2. TB 3. Anemia & malnutrition 4. ARI 5. HIV/AIDS 6. Diarrhea 7. Hypertension 8. Other liver diseases 9. Diabetes Mellitus 10. Septicemia HIV/AIDS 2. ARI 3. TB 4. Other liver diseases 5. Hypertension 6. Diabetes Mellitus 7. Anemia & malnutrition 8. Septicemia 9. Heart diseases 10. Malaria * Source: Eritrea Health Profile, ARI 2. HIV/AIDS 3. Anemia & malnutrition 4. Diarrhea 5. Septicemia 6. TB 7. Hypertension 8. Diabetes Mellitus 9. Other liver diseases 10. Heart diseases 7

8 WHO/ECHO Joint Project The implementation of WHO/ECHO joint project has continued. The weekly monitoring meeting under the leadership of the WR was held. The 3 main areas of the project have finalized the development of detailed implementation plan. These areas are Integrated Management of Childhood Illnesses (IMCI), Maternal Health and Immunization. The critical equipment needed to strengthen the health facilities to provide emergency obstetrics services and outreach immunization have been ordered through the WHO procurement system. An assessment team has already visited 2 of the Zobas (Anseba and Gash Barka) and have reached consensus with the Zobas on the areas for the priority interventions. Another team has been to Northern and Southern Red Sea Zobas to support the implementation of outreach services for immunization and MCH. A third team will visit the Northern and Southern Red Sea Zobas this week to agree on details of the implementation plan. Below are the key findings of the Anseba and Gash Barka assessment teams Rapid Assessment Key Findings Anseba and Gash Barka Zobas are two of the six Zobas of Eritrea and have a total population of 1,088,404 accounting for 30.2% of the total population of Eritrea. Anseba Zoba is one of the chronically drought affected areas of the country while Gash Barka is one of the Zobas which was affected by border war and has a great influx of population from Sudan and population movement is high in this region. Poor living conditions and drought predispose to poor health conditions of the population 8

9 Both Zobas are prone to malaria and diarrhoea outbreaks. Safe water supply and latrine use is very low in the two Zobas. The major causes of out patient and in patient visits by the population are ARI, diarrhoea, malaria and malnutrition. The national and regional efforts to bring the outbreaks of diseases under control, to provide adequate safe water supply and sanitary facilities are underway but have not yet brought the desired results. According to the available most recent estimates, national infant mortality rate is 48 per 1,000 live births and the underfive mortality rate is 72 per 1,000 children in that age category. About 23% of children under five are moderately malnourished and 36% are stunted. This high incidence of malnutrition predisposes children to various infections, which in turn predisposes them to worse malnutrition status and death. Maternal anaemia and malnutrition is also common in both Zobas which leads to the outcome of low birth weight children and risk of dying of complication during pregnancy and child birth. The prevalence of HIV/AIDS and sexually transmitted infections (STI) are low, but there is a fear that there might be underreporting of the disease conditions. The possible increase in water-related diseases, especially during the rainy seasons can lead to an increase in malnutrition and related health problems and to long term strain of the existing health system in both Zobas. The availability of safe water supply in both Zobas is becoming very critical due to lack of adequate under ground water reserve as a result of recurrent drought and failure of the water pump and solar system in most of the villages visited. Use of latrine is literally non-existent in all villages and towns visited during the assessment period. This is attributable to the non-existence of the latrine facilities and culture of using open field for human excreta disposal. Non functional and empty solar refrigerator for the last 11 months, in a health facility The availability of safe water supply in both Zobas is becoming very critical due Non functional and empty solar refrigerator for the last 11 months, in a health facility to lack of adequate under ground water reserve as a result of recurrent drought Unsafe water leads to outbreaks of waterborne diseases including diarrhoea. 9

10 The assessment revealed that capacity building in the areas of nutrition interventions including therapeutic feeding training, data analysis and interpretation at lower level health care system, provision of cold chain equipments especially solar refrigerators, steam sterilizers, delivery couches, delivery sets, essential drugs especially ORS, Co-trimoxazole, Amoxicilline and Ampicilline, nutritional supplements for treatment of severe malnutrition (F-75 and F-100) and supplementary feeding (CSB, DMK etc.) are urgently needed. Water supply system is disrupted due to failure of the solar pumping system and lack of maintenance of the hand pumps. Construction of latrines and reinstitution of the EPI outreach services is of paramount importance in the combat against communicable diseases. Table 2 below summarizes the list of villages identified in conjunction with the Zobas for the implementation of the project. All the health facilities will benefit from the capacity strengthening to provide emergency obstetrics services and nutritional surveillance, while 6 villages (3 each from Anseba and Gash Barka) will benefit from community IMCI under the WHO/ECHO joint project. All the 16 villages in the 2 Zobas will benefit from community based surveillance under the CERF project in order to strengthen early warning system for communicable diseases and nutritional emergencies. Table 2 Health facilities and villages selected for the WHO/ECHO project and Community based surveillance (CERF): Anseba Zoba Health facilities Villages 1. Hagaz Health Center 1. Hashishay village 2. Hashishay Health Station 2. Gulia village 3. Kermed Health Station 3. Awonjalit village 4. Hagaz Adi-Omer village 6. Dembe Adi-Tsegai village Gash Barka Zoba Health facilities Mensura Health Center Engerne Health Station Aderde Health Station Hirkuk Health Station Deret Health Station Tenshae Health Station Villages 1. Migrah village 2. Mai-Wosen village 3. Hirkuk village 4. Elkay village 5. Deret village 6. Biet-Bejel village 7. Aderde village 8. Adi Mahmud village 9. Deki Dashim village 10. Gerger Deda village 10

11 Highlights of the Eritrean CHAP 2007 (Source: Draft Common Humanitarian action plan CHAP, 2006) Humanitarian space The overall humanitarian space in Eritrea has been reduced substantially following the government s introduction of a new policy on self-reliance, in April 2006, shifting focus from emergency to recovery interventions, including cash for work programmes. The measures taken included The issuance of the NGO proclamation aimed at regulating the operations of NGOs in the country; The introduction of a travel authorization system; The decision to discontinue Eritrea s participation in the Consolidated Appeal Process (CAP) as well as its participation in the Regional Horn of Africa Drought CAP. As a result of the new measures, the number of NGOs operational in the country has reduced from 37 in early 2005 to 11 presently. The remaining NGOs face new challenges, including the inability to carry out assessments and hence absence of reliable data for planning purposes; delays in government approval of programmes; fuel shortages, etc. Consequently, the in-country humanitarian response capacity has been considerably reduced. Strategic Priorities for Humanitarian Response: Priority 1: Address emergency needs resulting from the unfavourable climatic conditions by identifying areas where there is food insecurity. Priority 2: Reduce mortality and morbidity including but not limited to the displaced, refugees and in other emergency situations Priority 3: Support livelihoods Priority 4: Disaster mitigation and preparedness Priority 5: Mainstream cross-cutting issues (HIV- AIDS, Gender-based violence, Reproductive health, and Environment) in programming. Specific Objectives for 2007 The UNCT and its partners have agreed on the following key objectives for 2007: Effective targeting of beneficiaries and communities resulting in a positive impact on livelihoods; Reduction of morbidity and mortality related to emergency; Reduced vulnerability to food insecurity; Reduced morbidity and mortality among livestock; People s coping mechanisms reinforced; Support return, resettlement and sustainable reintegration of returnees and IDPs; Strengthened capacity of local counterparts to deliver humanitarian assistance; Strengthened coordination among partners. 11

12 Health Component: The common immediate goal for all health partners is to reduce the avoidable mortality and morbidity due to food insecurity, communicable diseases and risks linked to pregnancy and delivery. Objectives of the Health Component To achieve 80% timeliness of weekly reports of communicable diseases and nutritional surveillance by the end of 2007 To provide 60% health facilities in the target area with capacity to provide emergency obstetrics care, growth monitoring and immunization by end of 2007 To fully vaccinate at least 70% of the children less than 1 year of age in the target communities by the end of 2007 To establish community IMCI and health promotion activities in at least 30% of the districts in the target areas by the end of 2007 Implementation Strategy: The implementation strategy will involve joint assessments by all partners in the health cluster to identify the most vulnerable groups. For the life saving interventions, the agencies will administer the finances and monitor the implementation progress. In addition, the Ministry of Health at the central level as well as the Zoba levels will be required to provide logistical and political support. For planning and execution of interventions the communities through the health management committees will play a key role. Current Partners: Include, WHO, UNICEF, UNFPA, Ministry of Health Target Groups: Catchment Population: 1,219,457, while direct beneficiaries number 768,258 (63% of the catchment population), broken down as 548,756 women of child bearing age and 219,502 children under the age of 5 years. 12