Ministry of Health PopulationMinistry of Health PopulationDepartment of Health ServicesDepartment of Health Services

Epidemiology and Disease Control DivisionEpidemiology and Disease Control Division

DR GD THAKUR

Director

Lesson Learnt fromAcute Watery Diarrhea Response

in the West

Every year outbreak of diarrhea occurs through Every year outbreak of diarrhea occurs through out the country. E.g. out the country. E.g. 3137 persons affected (37 deaths) in 20053137 persons affected (37 deaths) in 2005 3136 persons affected (23 deaths) in 20063136 persons affected (23 deaths) in 2006 33746 persons affected (247 deaths) in 2007 (cholera 33746 persons affected (247 deaths) in 2007 (cholera

in Kalikot and Rautahat)in Kalikot and Rautahat) 6515 persons affected (38 deaths) in 20086515 persons affected (38 deaths) in 2008

Case fatality rate of about 1 % is usually observedCase fatality rate of about 1 % is usually observed Rapid response teams are mobilized during Rapid response teams are mobilized during

outbreakoutbreak

Comparision of Cases with previous year

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Cases in 2009

Cases in 2008

Comparision of Deaths with previous year

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s Deaths 2009

Deaths 2008

Diarrhoeal outbreak started in the month Diarrhoeal outbreak started in the month of May 2009 (Baisakh 2066) of May 2009 (Baisakh 2066)

Immediate response was provided by the Immediate response was provided by the District Health OfficeDistrict Health Office

Rapid Response team was mobilized to Rapid Response team was mobilized to the VDCthe VDC

Outbreak was controlledOutbreak was controlled

At the start of July 2009 (Asar 2066), the outbreak was active again.

Jajarkot and Rukum have been highly affected

Initial Response through the DHO Response from Regional Health

Directorate through mobilization of Response team and drugs

Centre aware of the outbreak and homework initiated to respond to it

A central team was mobilized on Asar 18 to Jajarkot district

Honourable Minister for Health and Population Mr. Honourable Minister for Health and Population Mr. Umakant Chaudhary visited the districts on 23 Asar Umakant Chaudhary visited the districts on 23 Asar 2066.2066.

Instruction was given to high level officials for Instruction was given to high level officials for adequate responseadequate response

A high level meeting was held on 28 Asar chaired by A high level meeting was held on 28 Asar chaired by Rt. Hon'able Prime Minister Mr. Madhav Kumar Rt. Hon'able Prime Minister Mr. Madhav Kumar Nepal which took major decisions for responding to Nepal which took major decisions for responding to the outbreakthe outbreak

Right Honorable Preseident Dr. Ram Varan Yadav Right Honorable Preseident Dr. Ram Varan Yadav was briefed about the responses on 1 Shrawan (14 was briefed about the responses on 1 Shrawan (14 July 2009)July 2009)

A High level meeting was called at MOHP for A High level meeting was called at MOHP for effective response, which decided to: effective response, which decided to: Strengthen the Control Room at EDCDStrengthen the Control Room at EDCD Locate the regional response coordinator in Locate the regional response coordinator in

Surkhet led by Dr. L. R. Pathak, DirectorSurkhet led by Dr. L. R. Pathak, Director Local district response coordinators in Jajarkot Local district response coordinators in Jajarkot

and Rukum, namely Dr. P. B. Chand and Dr. G. D. and Rukum, namely Dr. P. B. Chand and Dr. G. D. ThakurThakur

Adequate drugs and supplies were sent to the Adequate drugs and supplies were sent to the districts as well as human resources districts as well as human resources

Trends of Diarrheal Cases

1343315774

57066800

1575 2176505 3690

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3rd August 7th August 11th August 17th August 23rd August 30th August 6th September 15th September

Dates

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52% of tested stool samples have 52% of tested stool samples have Vibrio cholera Vibrio cholera (O1 El (O1 El Tor Ogawa) positive (n=107).Tor Ogawa) positive (n=107).

Adult population are mostly affected.Adult population are mostly affected. Cases progressed to Severity within few hours.Cases progressed to Severity within few hours. 10-15 % of cases have severe dehydration.10-15 % of cases have severe dehydration. Death toll is high, although CFR is 0.6%. Death toll is high, although CFR is 0.6%. Cholera is endemic in Nepal. High case fatality and Cholera is endemic in Nepal. High case fatality and

severity in past also have cholera outbreaks (Eg- Kalikot, severity in past also have cholera outbreaks (Eg- Kalikot, Rautahat).Rautahat).

Polluted water is the main source of disease Polluted water is the main source of disease transmission. transmission.

Hygiene and sanitation and poor socioeconomic Hygiene and sanitation and poor socioeconomic conditions are predisposing factors.conditions are predisposing factors.

Tetracycline is sensitive in all cases and co-trim is Tetracycline is sensitive in all cases and co-trim is resistantresistant

At central level: Central Control Room at EDCDAt central level: Central Control Room at EDCD At regional level: Located in Surkhet and DipayalAt regional level: Located in Surkhet and Dipayal At District level: Jajakot and RukumAt District level: Jajakot and Rukum Responsible Persons: Responsible Persons:

Surkhet: Dr. L. R. Pathak/Dr. S.S. TiwariSurkhet: Dr. L. R. Pathak/Dr. S.S. Tiwari Dipayal: Dr. S.S. MishraDipayal: Dr. S.S. Mishra Jajarkot: Dr. Padam B. Chand/Dr. Bhim AcharyaJajarkot: Dr. Padam B. Chand/Dr. Bhim Acharya Rukum: Dr. G. D. Thakur/ Mr. Arjun B. SinghRukum: Dr. G. D. Thakur/ Mr. Arjun B. Singh

Nepal ArmyNepal Army Nepal PoliceNepal Police Armed PoliceArmed Police Nepal Medical AssociationNepal Medical Association HELBITAS NepalHELBITAS Nepal Nepalgunj Medical CollegeNepalgunj Medical College Nepal Health Research Nepal Health Research

CouncilCouncil INF NepalINF Nepal SMNFSMNF CWIN/SCFCWIN/SCF Water AidWater Aid AMDAAMDA CWIN/SCFCWIN/SCF CARE NepalCARE Nepal Concern worldwide NepalConcern worldwide Nepal TUTHTUTH NAMSNAMS Medicare HospitalMedicare Hospital

Nepal Red-crossNepal Red-cross UNICEFUNICEF WHO NepalWHO Nepal WHO/IPDWHO/IPD WHO/SEAROWHO/SEARO Deprocs NepalDeprocs Nepal ADRA NepalADRA Nepal MSF HollandMSF Holland NEWAHNEWAH Health workers from UNCPMHealth workers from UNCPM Hill developmentHill development ENPHO/Paschim pailaENPHO/Paschim paila Alka HospitalAlka Hospital NRNNRN National Medical CollegeNational Medical College NCCINCCI GRACE hospitalGRACE hospital

TopographyTopography Scattered settlementScattered settlement Difficult TerrainDifficult Terrain Transport /CommunicationTransport /Communication Traditional practices and beliefsTraditional practices and beliefs Low level of awarenessLow level of awareness Poor hygiene and sanitationPoor hygiene and sanitation

Lessons LearntLessons Learnt

Strengthening of Surveillance SystemStrengthening of Surveillance System Strengthening of Case Management Strengthening of Case Management

Capacity at sub-national levelsCapacity at sub-national levels• How to set up a Diarrhea Treatment UnitHow to set up a Diarrhea Treatment Unit• Use of standard diarrhea treatment for Cholera Use of standard diarrhea treatment for Cholera

and Shigellaand Shigella• How to collect rectal swabs for laboratory How to collect rectal swabs for laboratory

confirmationconfirmation• How to use Cholera rapid test if providedHow to use Cholera rapid test if provided• Basic health education messages for the affected Basic health education messages for the affected

populationpopulation

Lessons LearntLessons Learnt

Strengthening of Laboratory CapacityStrengthening of Laboratory Capacity Vacant posts must be fulfilledVacant posts must be fulfilled Buffer stock of medicines should be Buffer stock of medicines should be

prepositioned prior to monsoonprepositioned prior to monsoon Ensure logistics for epidemic prone Ensure logistics for epidemic prone

diseasesdiseases Strengthen the supply chain managementStrengthen the supply chain management Maintenance of logistic management Maintenance of logistic management

information systeminformation system

Response CapacityResponse Capacity Strengthen the Rapid Response team at all level (district, region and Strengthen the Rapid Response team at all level (district, region and

centre)centre) Make the rooster of experts and RRT members for immediate Make the rooster of experts and RRT members for immediate

mobilization and regularly update themmobilization and regularly update them Develop the Disease specific response plan for all possible Develop the Disease specific response plan for all possible

outbreaks.outbreaks. Case management guidelinesCase management guidelines Logistic managementLogistic management Monitoring and EvaluationMonitoring and Evaluation

Develop the plan for transportation of human and other logisticsDevelop the plan for transportation of human and other logistics Ensure the financial resourcesEnsure the financial resources MOHP has to ensure sustainability of medical team deployed in an MOHP has to ensure sustainability of medical team deployed in an

outbreak area. The sustainability should include: Incentives, outbreak area. The sustainability should include: Incentives, guarantee foods and tabs for water purification and help in find guarantee foods and tabs for water purification and help in find shelters. Medical team need to have a turnover depending on shelters. Medical team need to have a turnover depending on nature of outbreaks to avoid psychological and physical breakdown.nature of outbreaks to avoid psychological and physical breakdown.

Response Capacity ContResponse Capacity Cont

Train the medical team in the following critical aspect:Train the medical team in the following critical aspect: How to set up a Treatment Unit for different How to set up a Treatment Unit for different

outbreaksoutbreaks Use of standard treatment guideline for Use of standard treatment guideline for

different outbreakdifferent outbreak How to collect sample on different outbreaksHow to collect sample on different outbreaks How to use rapid test if providedHow to use rapid test if provided Basic health education messages for the Basic health education messages for the

affected populationaffected population Enforce the rational use of antibiotics for cholera Enforce the rational use of antibiotics for cholera

patients and rigorous patient monitoringpatients and rigorous patient monitoring

Prevention and environmental control Prevention and environmental control (particular to diarrheal diseases)(particular to diarrheal diseases)

Safe water supplySafe water supply Good hygiene and sanitation practicesGood hygiene and sanitation practices

Hand washing practicesHand washing practices Use of LatrinesUse of Latrines Availability of SoapAvailability of Soap Communication MessagesCommunication Messages

The place where safe water supply cannot be The place where safe water supply cannot be guaranteedguaranteed::

Coordinate with HEALTH and WASH cluster for health Coordinate with HEALTH and WASH cluster for health education messages and distribution of chlorine and education messages and distribution of chlorine and aquatab at household levelaquatab at household level

Organize community mobilization to boil the water.Organize community mobilization to boil the water.

Lessons LearntLessons Learnt

Coordination and CollaborationCoordination and Collaboration Between ministriesBetween ministries Between national and international partnersBetween national and international partners Between security forcesBetween security forces With political partiesWith political parties With MediaWith Media

““Prevention is better than cure”Prevention is better than cure”Need to work on Need to work on

Decreasing level of ignoranceDecreasing level of ignoranceStrengthening of safe water supplyStrengthening of safe water supply

Improve hygiene & SanitationImprove hygiene & SanitationStrengthening of Timely detection andStrengthening of Timely detection and

response capacityresponse capacity

Could prevent these kind of disasterCould prevent these kind of disaster

with multi-sectoral approachwith multi-sectoral approach

Thank you.Thank you.