Issue 2 No.12 9 th 22 nd July, 2007 PROFILES Eritrea Population: 3,447,060 - (1997 Projection) Number of Zobas (Regions): 6 Humanitarian Target population: 2.3 Million Main Sources of humanitarian funding: UN CERF ECHO HIGHLIGHTS Outbreak monitoring Major causes of mortality in the first quarter, 2007 Report of CBTF program in Southern Red Sea Events: o Development of second generation CCS document Outbreak Monitoring: Week 27 (2 nd July 8 th July, 2007) Report Completeness and Timeliness Majority of the 242 health facilities continue to submit timely reports. Available data is as of week 25 of the year (18 th to 24 th June). The average weekly health facility to Zoba report completeness and timeliness has been maintained at optimal levels of above 90% and Table 1: above 80% respectively (Table 1). The main area of concern is Gash Barka where about 1/3 of the 65 health facilities are not submitting the weekly reports on time. This is not surprising at this time of the year when most areas are not accessible. The Zoba has however assured that, there are mechanisms through local administration to report unusual events. Average Health facility to Zoba weekly report completeness and timeliness as at week 25 (18 th 24 th June, 2007) Zoba Total Population No. of HFs Timeliness Completeness Anseba 554552 34 90.06 100.00 Debub 916467 60 97.29 99.65 Gash Barka 684972 65 66.96 87.63 Maekel 653639 31 100.0 100.00 ERITREA HEALTH UPDATE c/o WHO, Adi Yakob street N. 173, House N. 88/89, Geza Banda, P.O.BOX 5561 Asmara, Eritrea. Tel. 291 1 200634, Fax 291125155 NRS 556952 37 79.13 90.16 SRS 80481 15 26.67 99.72 Total 3,447,060 242 82.02 94.87
Cerebro-Spinal Meningitis (CSM) No new suspected meningitis cases have been reported in the last 4 weeks. The total meningitis cases so far reported in the year remain 10 with 1 death, all from Zoba Northern Red Sea and the isolated pathogen was N. meningitidis type A. With the onset of the rainy season in the meningitis belt areas of Gash Barka and Debub, the threats in those areas might be less. The major focus is now the dry areas of NRS from where the sporadic cases were reported. Malaria Even though this is the rainy season, the malaria situation has been under control. The weekly numbers of cases at national level remain well below the third quartile threshold level as can be seen from figure 1. Gash Barka is the remaining Zoba in the country with major malaria problem. However, even in that Zoba, the weekly numbers of cases remain well below the 3 rd quartile threshold level. Figure 1 Eritrea: Malaria weekly trend in 2007 3rd Quartile Yr 2007 3000 2500 Number of cases 2000 1500 1000 500 0 1 5 9 13 17 21 25 29 33 37 41 45 49 Week number 2
Diarrhoea and Bloody Diarrhoea: There has been increase in the weekly numbers of cases of bloody diarrhoea (shigellosis) reported at national level in the last few weeks, making the numbers to reach the 3 rd quartile threshold level at national level even with incomplete reporting (figure 2). Several Zobas including Gash Barka, Maekel and Northern Red Sea have also reported cases approaching or exceeding the 3 rd quartile threshold levels (Figures 3, 4 and 5). There could be foci of un-reported outbreaks in these Zobas. This is not surprising, because with the onset of the rainy season and poor hygiene there could be contamination of drinking water sources. No outbreaks of other diarrhoeal diseases were reported. Other Outbreaks: No outbreaks of other diseases have been reported in the reporting weeks. Measles Situation: No new suspected measles cases have been reported in the last 2 weeks. The total suspected measles cases for the year remain 24, with half of the suspected cases reported from Gash Barka Zoba. All the suspected measles cases tested negative for measles IgM. Three cases tested positive for Rubella. It is also important to note that, so far this year, no suspected measles outbreaks have been reported. Figure 2 Eritrea: Bloody diarrhoea weekly trend in 2007 3rd Quartile Yr 2007 Number of cases 1000 900 800 700 600 500 0 300 200 100 0 1 4 7 10 13 16 19 22 25 28 31 34 37 43 46 49 52 Week Number 3
Figure 3 Gash Barka Zoba: Bloody diarroea weekly trend in 2007 300 3rd Quartile Yr 2007 Number of weeks 250 200 150 100 50 0 1 4 7 10 13 16 19 22 25 28 31 34 37 43 46 49 52 Week Number Figure 4 Maekel Zoba: Bloody Diarroea weekly trend in 2007 Number of cases 200 180 160 1 120 100 80 60 20 0 1 4 3rd Quartile Yr 2007 7 10 13 16 19 22 25 28 31 34 37 43 46 49 52 Week Number 4
Figure 5 NRS Zoba: Bloody diarroea weekly trend in 2007 3rd Quartile Yr 2007 Number of cases 80 70 60 50 30 20 10 0 1 4 7 10 13 16 19 22 25 28 31 34 37 43 46 49 52 Week number Major Causes of Mortality in the first Quarter of 2007: In this issue we present the causes of health facility mortality in 3 age groups infants, children less than 5 years and among persons above 5 years of age. These age groups are the age categories used by the Health management information system for reporting. The pattern of mortality indicates the complexity of diseases epidemiology in Eritrea and the need for different program designs to address the health needs of the various population groups. Causes of Infant mortality: The top 10 causes of hospital deaths among infants in Eritrea are presented in figure 6. Together these causes account for over half of all causes of hospital infant deaths. These causes can be divided into two main categories the neonatal causes and the post neonatal causes. The neonatal causes account for about 25% of infant deaths and interestingly are all avoidable through improving delivery practices, thus as shown by this data, improving delivery practices and increasing skilled delivery attendance should reduce health facility deaths of infants by 25%. Improving skilled delivery attendance is one of the priorities of the health partners and the trends in the first quarter of 2007 will be discussed in the next issue of the bulletin. The other top causes of infant deaths in health facilities are diarrhoea, pneumonia and malnutrition together accounting for another 25% of health facility infant mortality. These conditions usually occur in the post neonatal period and are similar to the causes of under five mortality. 5
Figure 6 Top ten causes of infant mortality in 1st Quarter of 2007 in percentage Diarrhoea with dehydration 4.03 4.7 4.03 2.68 5.37 2.68 9.4 11.41 10.07 Pneumonia Septicaemia Neonatal respiratory distress syndrome Complications of preg., deliv. Neonatal post circumcision or uvulectomy bleeding Pending neonatal sepsis Malnutrition Causes of Mortality in children less than five years: The top 10 causes of health facility mortality in children less than 5 years in the first quarter of 2007 are presented in figure 7. Together, these 10 causes account for more than 80% of the mortality figures. Of these causes, 3 namely acute respiratory infections (ARI), malnutrition and anemia accounted for about 60% of all health facility under five mortality. As mentioned above, these conditions also accounted for about a quarter of health facility based infant mortality. These trends have been consistently observed over the years as presented in our previous issues. Reduction in infant and under five mortality is among the targets of both humanitarian assistance and development programs. In order to reduce infant and under five mortality, efforts must be focused on improving skilled delivery attendance as well as strategies aimed at addressing malnutrition, diarrhea and ARI. 6
Figure 7 Top ten causes of mortality in under fives in 1st Quarter 2007 in percentage 2.5 1.3 1.6 1.9 5.3 31 10.6 10.9 17 ARI Malnutrition & Anemia Diarrhoea Septicemia Perinatal resp. distress HIV/AIDS LBW Heart Disease TB Malaria With support from the ECHO and UN CERF, these areas are being addressed from the humanitarian perspective in the coastal and IDPs resettled areas. These efforts however must be supplemented by development programs for the following reasons: 1. The measures are temporary in order to assist those population groups affected by humanitarian emergencies and therefore there must be transition to longer lasting system development to address the issues. 2. The geographical coverage is limited to certain areas of the country coastal and IDP resettled. For bigger impact therefore more areas need to be covered. 3. The interventions being implemented are mostly palliative, with little effort in prevention especially improvement in water quality and level of sanitation among the communities. 7
The pattern of the top causes of health facility based under five mortality varies from Zoba to Zoba. Table 2 shows the top 3 causes of facility based mortality by Zoba. In all the six Zobas, ARI appears among the top 3 causes and being the most important cause in the highland Zobas (Debub and Maekel) and in Gash Barka. Malnutrition is the most important cause of facility based mortality in the coastal Zobas (Northern Red Sea and Southern Red Sea). The Maekel Zoba which is basically the capital city Asmara reported vehicle accident as the number 3 cause. One important observation is that, malaria has ceased to be a major cause of mortality among children less than five years. About five years ago, it used to be number 1 cause of mortality. In the first quarter of 2007, only Gash Barka Zoba reported malaria among the top 10. In that Zoba, malaria was number 4 cause of death accounting for 9% of all health facility reported deaths in children less than 5 years. Table 2: Top 3 causes of Death in first quarter 2007 by Zoba: Zoba Position Condition Proportional Mortality (%) 1 Septicemia Anseba 2 ARI 27 3 Malnutrition 17 1 ARI 31 Debub 2 Malnutrition 31 3 Septicemia 10 1 ARI 43 Gash Barka 2 Diarrhoea 14 3 Malnutrition 12 1 ARI 43 Maekel 2 Malnutrition 14 3 Vehicle Accident 14 1 Malnutrition 38 NRS 2 Diarrhoea 21 3 ARI 14 1 Malnutrition 50 SRS 2 ARI 25 3 Septicemia 25 Causes of Mortality in persons five years and over: Unlike in infants and children under five, the top 10 causes of mortality in persons five years and above as presented in figure 8 are HIV and non-communicable diseases rather than ARI, diarrhoea and malnutrition. Recent studies and publications have indicated a change in disease epidemiology among adults in Eritrea, with a shift towards non-communicable diseases. The current efforts to address HIV in the country must also include efforts to control non communicable diseases through diet, exercise, use of tobacco and alcohol consumption control. 8
Figure 8 Top ten causes of mortality in persons above five years in the 1st quarter 2007 in percentage 2.18 2.45 2.72 3.27 4.09 14.99 HIV Disease Other liver disease Respiratory TB Hupertension, Pneumonia Diabetes mellitus 4.63 4.9 5.18 5.45 Septicaemia Severe pneumonia Renal failure Heart failure Report of Community Based Therapeutic Feeding (CBTF) Program in Southern Red Sea Community based therapeutic feeding (CBTF) program was implemented for the first time in Southern Red Sea Zoba in May, 2007 with the support of ECHO funding. Southern Red Sea is one of the Zobas with high levels of malnutrition. The activities implemented included: 1. ToT Workshop for 32 Health workers from May 15-18, 2007 2. Training of community volunteers from May19-21, 2007 3. Screening all Children 6-59 months from May 22-23, 2007. 4. Admission and implementation May 24-25, 2007 The field activity was implemented in Wade town and the surrounding villages and involved 8 health workers, 20 volunteers and 2 village administrators. After training 6 teams were formed, each composed of one nurse and 3-4 volunteers to cover 1-2 villages depending on a number of households. 9
A total of 519 children between 6-59 months were screened, those with abnormal mid upper arm circumference (MUAC) were reevaluated using weight for height and the following results obtained: 1. A total of 20 children with severe malnutrition were admitted to the CBTF. And one child severely malnourished with medical complication was admitted in the stabilization center (Therapeutic Feeding Center). 2. A total of 52 children were found to be moderately malnourished and were admitted into the supplementary feeding program. Children admitted to CBTF were given plumpynut for one week according to their weight and were asked to revisit the clinic after one week. Also a strong message was given on how to feed the child with the plumpy-nut and on the importance of feeding the child the whole amount during the week period. In order to avoid sharing of plumpy-nut by siblings of the severely malnourished child, a ration of 3 kg Unimix was given to every family with a child admitted to the CBTF. It was strongly advised that plumpy-nut is medicine for treatment of severe malnutrition and should not be shared between children as this is going to elongate the course of the treatment of the severely malnourished child. Every child with moderate malnutrition was given 8kg of Unimix as a one month ration and they asked to revisit to the health center in four weeks time. The volunteers were introduced to the families of the malnourished children for follow up. Events: Development of Second Generation Country Cooperation Strategy (CCS) Document: focus on for the next five years and which all The process of developing the second assistance and partnership should focus on. generation CCS document has commenced. One of the key areas identified for health The CCS document identifies priority areas of intervention is the Emergency and health interventions that the Government will Humanitarian Action (EHA). This corresponds to the WHO s strategic objective 5. ERITREA HEALTH UPDATE c/o WHO, Adi Yakob street N. 173, House N. 88/89, Geza Banda, P.O.BOX 5561 Asmara, Eritrea. Tel. 291 1 200634, Fax 291125155