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Situation report 7

Photo: Keystone

WHO's overriding concern remains of potential associated disease outbreaks throughout the region. With isolated cases of diarrhoeal disease confirmed in temporary shelter camps in India and Sri Lanka, focus must be on improving hygienic and sanitation conditions for the estimated 3-5 million displaced people. Cases of diarrhoea are reported and are under scrutiny for possibility of cholera and typhoid. Of particular concern is that the situation throughout the region is ripe for cholera cases, a disease not unknown to the region. Lack of adequate clean drinking water and sanitation facilities, stress and psychosocial trauma and overcrowding in camps contributes to heighten the risks of disease outbreaks. Relief efforts are now well on the way, but concerted coordinated action among all health actors is required.

Key Issues

• Relief is reaching more of the affected population but there are still some areas in Aceh that are not reached. Damage to infrastructure in the affected countries has meant that clean water and adequate sanitation is not available to the levels it should be to ensure the risk of disease outbreaks is minimised.
• Aid from humanitarian agencies has been hampered by the immense damage to infrastructure caused as well as the distances required to reach remote areas affected.
• Displaced people suffering from stress and psychosocial trauma are living in cramped conditions without adequate hygiene and sanitation. Proper camp management is required.
• Consistent relief distribution through coordinated action among all health actors is required. "The international system is working," U.N. Emergency Relief Coordinator Jan Egeland said in New York.

Situational Updates

According to media reports a total of 150,000 people are confirmed dead, and half a million have been injured and an estimated five million are homeless in the South East Asia region as a result of the earthquake and tsunami crisis.

In Somalia, 46 are confirmed dead while the communities elders of the affected places are reporting over 252 of fishermen are still unaccounted for. Many people sustained small injuries but only 283 are severely wounded. The majority of the 1,975 damaged / destroyed houses are completely destroyed, including stone houses. The 16,720 affected families are permanent fishers and destitute families affected by drought and torrential rains.

Countries are on the alert and are monitoring for possible disease outbreaks through disease surveillance and verification.

Health Priorities

Communicable Diseases

• Indonesia: No confirmed reports on outbreaks of disease have been received by WHO. The government of Indonesia MoH with technical support from WHO and other agencies has instituted a plan of action for epidemiological surveillance and early warning for outbreaks. A joint coordination team for surveillance will also be established in Banda Aceh as soon as possible.
• Sri Lanka: In Batticaloa district camps 120 cases of diarrhea were reported from 52 camps on 1 January, but upon further investigation this number declined to below 40 in total, which is within endemic levels. Availability of safe and adequate drinking water remains an important issue and a WHO water and sanitation specialist is working with UNICEF and the Water Board. Safe water is being provided through the municipal piped water supply in camps located in temples and schools but in some of the 80 camps in Batticaloa district, toilet facilities are inadequate. WHO actions aim to assist with immediate improvement in camp sanitation, garbage disposal, management and reporting. Laboratory services are being made available in the periphery for prevention and management of outbreaks with deployment of technicians, essential reagents, supplies and equipment. There is a need to promote personal hygiene and educate households in safe handling of drinking water. Chronic diseases and psycho-social support are also being provided at campsites.
• India: So far, no outbreak of communicable diseases has been reported by any of the government agencies operating in the rescue and relief operation. There were sporadic cases of diarrhoeal disease and nine cases of measles reported and the situation is being closely monitored by the MoH. Medical camps/medical teams (75) are functional in Tamil Nadu. A further, 101 stationery medical teams, 72 mobile medical teams and 568 para-medical teams have been deployed to provide medical aid to the victims in Andhra Pradesh. The State Government has deployed 224 doctors in the affected areas and 40 medical camps were conducted in the state of Kerala. The prevention of outbreaks in the Nicobar Islands has been accorded priority; a medical expert team led by the DGHS is presently located at Port Blair for networking health efforts; 80 doctors and 20 nurses of central institutions are deployed in various islands in addition to the efforts of armed forces; 120 bed hospitals are operating on the INS Magar ship; Emergency medicines / disinfections (61.63 tonnes) have been delivered as of 3 January 2005. In the disaster areas of Andaman & Nicobar, 148 specialized medical teams have been deployed.
• Thailand: Cumulative health incidents as of 1 January reported from 6 affected provinces include: acute diarrhoea (167), wound infections (163), food poisoning (33), pneumonia (20), malaria (8) and dengue (7). These are within endemic levels and disease surveillance is functioning through public and private hospitals and all health centres, relief center mobile medical units with the support from the central MOH. Plans are to continue disease surveillance, to carry out measles immunization for about 100 children in one relief center and to control malaria vectors by spraying and destroying potential breeding places. The MOPH (Ministry of Public Health) is issuing health warnings and information to the public on the spread of diseases. The MOPH Epidemiology Bureau is also closely monitoring the situation of possible disease spread in the tsunami stricken areas and is in daily contact with WHO.
• Maldives: Health problems are reported as of 1 January from MoH, including: acute diarrhoea (419), viral fever (287), ARI (73) and vial fever with vomiting (16). The MOH does not foresee a need for mass measles vaccination since the last routine round for EPI was carried out just before 26 December. No significant change in the disease pattern has been observed so far. The MoH is monitoring any possibility of outbreaks of dengue, cholera, typhoid, shigelloses, Hepatitis A&E, scrub typhus and Leptospirosis.
• Somalia: The common diseases observed are mainly water borne diseases, measles, trauma and acute respiratory infections.

Environmental Health (access to safe water and hygiene, sanitation situation)

• Sri Lanka: So far, safe water is being provided through the municipal piped water supply system in the camps located in temples and schools in those places where medical teams visited. As per WHO team assessment, in at least four out of over 80 camps in Batticaloa district, toilet facilities are extremely inadequate. These are the high risk camps. WHO teams returning after rapid health needs assessment reports that sanitation and garbage disposals are the important public health issues which needs to be addressed in planned manner. WHO and UNICEF are supporting local authorities in coordinated action in respect of provision of safe water and sanitation in camps. The immediate response stage is over now and current focus is on short and medium-term responses. There is need for hygiene and health education promotion in camps. Prevention of disease outbreaks by improved water and sanitation is a key concern.
• India: Except for the Nicbar Islands, the drinking water supply in most affected areas is reported normal. Adequate quantities of bleaching powder/halogen tablets have been made available to the affected areas in the mainland. It is reported that 80% piped water supply has been restored in Port Blair. Three water points have been established with DG sets in Car Nicobar. On other islands, water is available through wells/springs and efforts are on-going to restore piped water systems. 248 mt. of water have been delivered to the the Nicobar Islands.
• Maldives: Severely affected atolls and islands continue to report contamination of water and/or salinity in water. Almost all affected atolls also report blocked or broken sewage systems.
• In Somalia, there is one water system and 120 shallow wells. Water systems and sources in all areas visited were partially destroyed. Almost all of the shallow wells observed were completely buried or contaminated by sea floods. The majority of coastal villages do not have latrines due to rocky ground. Villagers use an open ground as a latrine. No health posts/MCHs were seen in all of the visited areas except Bayla and Eyl. Pressing needs are: provision of food aid for six months period; shelter, utensils and clothing, specially for those families who lost their houses; rehabilitation of water systems and shallow wells. Some areas will need water trucking; construction of latrines to improve sanitation; provision of medicines; awareness on sanitation and marine guidance for resettlement.

Other health issues (Mother and child health, mental health etc)

• In Sri Lanka, provision of psychosocial mental health programs to those traumatized is needed. Programs that engage children and especially those who have lost parents need to be identified and a program developed at the camp setting. In one camp setting the camp administrators have allowed for a shuttle transportation service for those in camp with relatives and family injured in hospital. These types of simple initiatives facilitate resilience and promote positive mental health. Preliminary result from Galle district indicates the total number of children affected are 228 out of which 28 lost both mother and father, 126 lost their mothers and 74 lost their father. The Government is considering installing a facility for psychosocial counseling depending upon the type and degree of stress factor. The Government is also considering mobilizing: 28 Sri Lanka psychiatrics, 100 students undergoing psychiatry courses, NGOs as well as expatriat specialists, and foreign institutions to impart quality counseling and create a team of psychosocial counselors that are not available in adequate numbers in Sri Lanka.
• India: Government staff members are currently visiting affected areas to continue health assessments. There is need to provide counselling and social support to victims especially those who are bereaved. WHO is in discussion with the National Institute of Mental Health and Neurosciences (the WHO Collaborating Centre for Mental Health), Indian Psychiatry Society and the Vidyasagar Institute of Medical Sciences, New Delhi to help the agencies in the affected Districts as soon as possible.
• Thailand: Many people have been traumatized and have expressed unwillingness to return back to their villages. The Ministry of Public Health (MOPH) Mental Health Team has been attending to groups of these people. A university psychosocial care expert has coordinated with the MOPH and has mobilized counsellors to provide counselling to the affected people.

Health system and infrastructure (functioning health facilities, access etc)

Immediate WHO priorities are to deploy more staff (experts areas including, disaster & health, disease and surveillance, water and sanitation, psycho-social, logisticians, etc) in the affected countries quickly. WHO is building up substantial teams in its country and sub-country offices, which have 24hr operations rooms. WHO is working to support national authorities, in collaboration with UNICEF and other major health actors at country and field level. WHO's Global Outbreak Alert and Response Network (GOARN) has been mobilized and is currently establishing an Early Warlning Alert and Response Network (EWARN) for surveillance, verification and response to disease in Indonesia, Sri Lanka, the Maldives, Thailand and India.

• Sri Lanka: Many people who were suffering from minor injuries were channeled to hospitals and essential medicines in health institutions were made available.
• Maldives: Constraints continue to be transport and access to the population disbursed on the islands covering 900 kms. Only small quantities of aid can be transported to islands by boat, sea plane or helicopter. Weather over the past two days has hampered aid assistance. Small groups of residents have preferred to remain on heavily damaged islands and continue to remain vulnerable to the effects of the disaster. Permanent resettlement of some islands is under discussion. Reconstruction of health facilities will be determined subsequent to decisions on permanent resettlement.

WHO and Coordinated Aid Actions

WHO strategy in response to the crisis in South East Asia is:

Inter agency and global developments

• The Director General is currently in Aceh visiting Sri Lanka and Indonesia to assess the situation and WHO operations.
• The UN Flash Appeal will be launched and an information meeting will take place on 6 January in New York. The Secretary General is in Jakarta in order to launch the Flash Appeal for the relief and recovery efforts.
• The ASEAN Summit with heads of states will take place in Jakarta on 6 January. The agenda includes aid coordination, long term recovery and proposed early warning system for the Region.
• A special meeting on the tsunami disaster will be held on 7 January of the European ministers of health, foreign affairs and development.
• An information meeting will take place on 11 January in Geneva with missions of WHO member states at ministerial level.
• Daily coordination has been established with UNICEF at WHO headquarters and joint action is under way in most country settings.
• The Joint Task Force (JTF) Core Team is gearing up and will work out of Bangkok. Jan Egeland has become a member of the Core Group and daily teleconferences between OCHA, the field, the Core Group and military disaster units are taking place.
• IASC information meeting on Indian Ocean Earthquake/ Tsunami in Geneva took place on 3 January 2005 and was attended by representatives from FAO, ICRC, World Vision, ICVA, WFP, IFRC, UNHCR, UNDP, UNICEF, WHO and various OCHA desks. The next IASC information meeting will take place on 5 January.
• Margaret Wahlstrom the Secretary General’s Special Coordinator for Humanitarian Assistance to affected countries has concluded her visit to the Maldives.

Further deployment of WHO personnel to Sri Lanka, Indonesia and the Maldives is under way. A total of 190 New Emergency Health Kits (NEHK), 100 surgical kits and 40 diarrhoea kits are in the pipeline to the South East Asia region. Coverage by these kits total:

• Early warning - Tracking patterns of life-threatening diseases among those at risk through prompt set-up of a surveillance and early warning system with daily epidemiological reports (immediate mobilization and deployment of GOARN)
• Public health - Providing guidance on critical public health issues (including response to disease outbreaks, water quality, excreta management, chemical threats, chronic disease management and mental health) and filling critical gaps until others are able to take on the task
• Access to essential health care - Work with all partners to ensure equitable access to adequate quality of essential health care through key hospitals and health centres
• Medical supplies - Contributing to ensuring that medical supply chains function as efficiently as possible and respond to the needs of end-users
• Coordination - Joint action of health actors at local, national and international level with agreed strategies and joint action

Country information

Indonesia: Director General is in Aceh today. WHO and UNICEF staff have established a base in Banda Aceh. WHO staff (12) have arrived in Aceh (including disaster coordinators, three epidemiologists, two logisticians, a journalist and an administration officer). The challenging issue is logistics and telecommunications in Banda Aceh. The security situation is posing some difficulty. Currently, there is one warehouse in place. Transport, two vehicles and office facilities will also be set up. VSATs will be installed in country as soon as possible. Ten NEHKs have arrived meeting basic health needs in crises situations for a total of 100,000 people for three months. There is some concern of the security in Meulabo (west Indonesia).

Sri Lanka: WHO team on the ground, now counting 9 staff, has been strengthened with staff including disease specialist, water and sanitation experts, epidemiologists. Further deployment of personnel is arranged during these days. Three sub offices are being established in the affected areas. Four NEHK are available providing basic emergency health needs to a total of 40,000 people for three months. WHO rapid health assessment teams returned from the northern districts reported that there are 80 camps of displaced people scattered in the three affected districts. Daily coordination meetings take place at the President Secretariat presided by the Advisor of the President. The MOH held the weekly coordination meeting and thanked the international community particularly WHO. The MOH reported that the health situation in camps is under control with joint efforts of Government health delivery system and the international community. The MOH requested assistance from the international community on rehabilitation and reconstruction. The MOH will provide field medical teams particularly in those places where health facilities are damaged. Six foreign field hospitals are likely to be established in the most peripheral areas with generous contribution from the different countries.

• NEHK - 1,900,000 people;
• surgical kits - 10,000 interventions/operations; and
• diarrhoea kits - 40,000 cases

India: WHO has supported immunization in the last 24 hours in Cuddalore District (Tamilnadu), Pondicherry and Karikal U.T. A total of 3,172 children have received measles vaccine, Polio OPV and Vitamin A.

Maldives: Four additional staff have strengthened the country office (logistics, three disease and surveillance experts). Five NEHKs have arrived providing emergency basic health needs for a total of 50,000 people for three months. Ten surgical kits are on the way.

Myanmar: WHO is involved in health coordination, information sharing and needs assessments with the Ministry of Health, UN agencies and NGOs through the UN-Disaster Preparedness and Management Group. WHO continues to provide the Ministry of Health, embassies and INGOs with regular updates and with the relevant WHO normative documents and technical assistance.

Through the Emergency Health Action Programme for South-East Asia, the financial requirements for WHO’s health response over the forthcoming three-months period is assessed at US$40 million. WHO thanks the Vienna Philharmonic Orchestra (cash) and the governments of the United Kingdom (DFID for cash and in-kind), Italy (in-kind), Switzerland (inkind), France (cash), and Norway (in-kind), Canada (in-kind), China (in-kind) Finland (in cash) Germany (in kind) for recent and early contributions. Expressions of support from individuals around the world are overwhelming.