Health update for Darfur, Sudan and Chad
Disease surveillance systems in Darfur
31 August 2004 - The main health concerns facing displaced people in Darfur and their host communities include: malnutrition, acute respiratory infections, diarrhoeal diseases, malaria, hepatitis E and conflict-related trauma. The possibility of outbreaks of communicable diseases is particularly elevated. This is due to risk factors including limited amounts of potable water, low standards of environmental hygiene, declining nutritional status, and low vaccination coverage.
Twelve communicable diseases and health events are being monitored by the Early Warning Alert and Response Network (EWARN) established by WHO, and implemented by a network of health care groups throughout the three Darfur States. These include acute watery diarrhoea, acute respiratory infections, malaria, measles, meningitis, acute jaundice syndrome, acute flaccid paralysis, bloody diarrhoea, neonatal tetanus, fever of unknown origin, severe malnutrition and injuries. Over time, more camps and locations are providing data for EWARN - so that it becomes a comprehensive health monitoring system for the whole region.
It is important to note that two outbreaks—Shigellosis and Hepatitis E—have been detected and confirmed through EWARN. However, EWARN does not provide complete information on mortality rates, which are being examined through a region-wide study that is due to conclude in September.
Hepatitis E in Darfur and Chad
Hepatitis E outbreaks in Darfur and in refugee camps in Chad are related to an insufficient supply of clean water and poor sanitary conditions in refugee and IDP camps on both sides of the Chad-Sudan border.
As of 20 August 2004 the number of suspected hepatitis E cases in Darfur has risen to 2,432, with a total of 41 deaths. This is an increase from a total of 625 cases and 22 deaths related to acute jaundice syndrome, most certainly hepatitis E, recorded from 22 May to 30 July 2004. These cases were notified from reporting health clinics in the Greater Darfur Region through EWARN.
The near doubling in the number of reported cases during the past month alone may be due to a real increase of the cases, improved surveillance for the syndrome or an increase in awareness in communities. West Darfur State reported 66% of the total cases (1,640 out of 2,431), compared to 22% and 12% for South and North Darfur respectively. Médecins Sans Frontières and the epidemiological organizations Epicentre and EPIET, in collaboration with WHO and the Government of Sudan, began an epidemiological investigation of the Hepatitis E outbreak in Morni camp, West Darfur on 23 August.
Health actors - including the Ministry of Health, UNICEF, Oxfam, Médecins Du Monde, France, MSF-Holland, the United Nations Joint Logistics Centre (UNJLC), and International Committee of the Red Cross have been working with WHO to scale up mass hygiene education programs and increase the availability of soap. Other materials distributed include a Hepatitis E fact sheet and case management guidelines to medical staff and NGOs working in the settlements. Community health workers have been trained to use standardized educational messages for dissemination in IDP settlements.
Systems to coordinate and monitor the chlorination of water sources, and hygiene promotion, are being set up in each camp. Prompt action will be taken in instances where the risk of faecal-oral disease transmission - particularly at water sources - is deemed to be high. This is the only means through which the further spread of the outbreak can be averted.
Hepatitis E in Chad
Between 26 June and 20 August 2004, a total of 959 cases and 30 deaths linked to acute jaundice syndrome were reported in Goz Amer, a camp of approximately 18 500 Sudanese refugees in Eastern Chad and Goz Beida. Hepatitis E was confirmed in 7 samples by the Val de Grâce, laboratory in Paris earlier this month.
More information is expected this week when the WHO multidisciplinary team (2 epidemiologists, 1 water and sanitation engineer and 2 logisticians), joined by an epidemiologist from the Centers for Disease Control in Atlanta, USA, arrives today to N'Djaména and travels to Abeche and to the Chad refugee camps to conduct additional epidemiological investigations and reinforce outbreak control activities.
WHO, UNHCR and nongovernmental organizations present in the area are currently working with the Chad Ministry of Health to implement control measures. These include water chlorination, improvement in excreta disposal and community health education. Disease surveillance systems are being continuously improved.
Water and Sanitation
Internally displaced people in Darfur are still not - generally - able to access all the water they need for drinking, hygiene and domestic purposes when they need it. Ensuring consistent access to clean water in the challenging environments of Darfur and Eastern Chad continues to pose major challenges for relief agencies.
As of end of July, 47% of potential beneficiaries had adequate access to safe drinking water. This means that although WHO recommends that each person should count on receiving 20 litres of clean water per day, half the population has access to between 5 and 10 litres per day. The safe water coverage for areas with internally displaced people ranges from 57% in South Darfur; 56% in North Darfur to 31% in West Darfur, and hepatitis E is more prevalent in West Darfur. UNICEF and NGOs are working around the clock to improve the situation, by expanding drilling operations for latrines, rehabilitating and establishing new water yards, hand-pumps and hand-dug wells; and increasing tankering operations. WHO has been involved in testing water quality and promoting adequate hygiene practices, as well as working with NGOs and other UN agencies to ensure adequate sanitation facilities.
In June 2004, a WHO/UNICEF/MOH-backed mass measles vaccination campaign for 2.26 million children in the Darfur led to an overall decline in measles incidence. But continued vigilance is necessary: some children are at risk because they did not receive vaccine during the campaign. The recently reported four wild polio cases from West and South Darfur States indicate the vital need for widespread and comprehensive polio immunization that covers more than 95 per cent of the at risk children.
WHO, UNICEF and their partners implemented the first round of polio immunisation on 28 July 2004. The second round - mop-up - Polio campaign, started on 28 August in the three Darfur states and West Kordofan. It targeted 1.4 million children under five. The campaign is scheduled to end today.
Health agencies are now embarking on a measles "mop-up" vaccination campaign in order to reach some 200 000 children missed in North Darfur during the campaign in June. WHO and partners are also advancing preparations for measles and polio mass vaccination campaigns in early September, which will cover areas currently controlled by the Sudan Liberation Army (SLA). The campaign was scheduled to start on 28 August but has been delayed while further preparations are undertaken.
Risk factors for cholera outbreaks are people living in overcrowded camps, a lack of safe drinking water and sanitation facilities. Fortunately, as of today, no cholera cases have been confirmed in Darfur.
In South Darfur, cholera "kits" - containing vital rehydration salts, intravenous fluids and other consumables essential to reduce cholera case-fatality rates - have been distributed in anticipation of cholera cases during the current rainy season. More than 20 kits, each of which contain all that is needed to treat 100 severe cholera cases, have been pre-positioned in Geneina for West Darfur, in El Fashir for North Darfur with additional kits in reserve in Khartoum.
An Oral Cholera Vaccination Campaign took place in the high risk Kalma camp, fourteen kilometres from Nyala, in South Darfur in July and August and covered 42 000 of the 47 000 people living in the camp. The cholera vaccination campaign in Mussei camp, in South Darfur begun last week and vaccinated 7500 people in the first round. The second round takes place this week.
Cholera in Chad
A total of 2,046 cases and 98 deaths have been reported from 14 June to 22 August 2004 in Central Chad, some distance from the refugee camps in the east of the country. The outbreak started in Massaguet (Hadjar Lamine) North of N'Djaména; from there it spread to Lac and Kanem provinces as well as to the capital city N'Djaména. The previous week a total of 453 new cases occurred in N'Djaména.
No cases have been reported from the Eastern part of Chad where the refugees from Darfur are gathering, though they are seen to be at high risk. They have only limited access to water and proper sanitation is scarce, with the rainy season ongoing.
The previous big outbreak occurred in Chad in 2001 with a total of 5,244 cases. Usually outbreaks occur in the western part of Chad (Chari Bagurimi, Lac and Kanem provinces) The last known outbreak in the Abeche area (Eastern Chad) occurred several years ago.
Access to health care
WHO is concerned by the lack of primary health care services, including insufficient supplies of essential medicines and lack of health personnel to provide essential health services, in both Darfur and Eastern Chad. Access to hospitals is extremely limited outside of the State capitals. The living conditions within IDP camps also exposes those living in the vicinity to communicable diseases like malaria, acute respiratory infections and sexual transmitted infections - potentially including HIV/AIDS.
There are some encouraging signs that humanitarian assistance being provided through the United Nations and NGOs is making an impact. For example, access to basic health care, including reproductive health services, is improving, although there is still an important gap in assistance and quality remains poor in some locations. As a result, the estimated infant mortality rate of 120 per 1,000 births is very high. Maternal mortality rates are also extremely high: while the national average is 509 per 100 000, estimates in Darfur are as high as 600 per 100 000 women.
WHO is supporting effective essential services in eight hospitals in Darfur, each with an average of 120 in-patients at any time and 150 outpatients. WHO is also part of a collective effort to reactivate five hospitals and six Primary Health Centres as well as strengthen the capacities and functionality of 17 hospitals and 43 Primary Health Centres.
In July, the UN estimated 83% of IDPs are accessible to UN staff in North Darfur, 44% in South Darfur and 52% in West Darfur. However, many internally displaced people in Darfur still do not have access to Primary Health Care because the UN and NGOs are unable to ensure the consistent provision of health care in all IDP settlements. WHO estimates that 69% of the conflict-affected population has access to some health care compared to 45-50% of the population covered in May. This upwards trend needs to be sustained but that means that UN and NGOs need adequate resources to ensure that services are provided. WHO has deployed staff to the three Darfur states and also to Abeche in Eastern Chad.
Darfur: WHO estimates that US$ 1 million per month will be required to maintain its operations in Darfur. The funds currently available will permit the continuation of present operations until the end of September. The African Development Bank, the Governments of the UK, the Netherlands, Italy, Norway, Ireland, and USA currently support WHO work in Darfur. More funds are urgently needed, especially if the demands increase due to further disease outbreaks.
Chad: Current estimates indicate that US$ 200 000 per month will be required for WHO to maintain a minimal operation. WHO has borrowed internally to finance operations for refugees in Chad: no donor support has been forthcoming so far. Additional resources are also urgently needed for disease control programmes that straddle the Sudan-Chad border in coming months. The scale of the current hepatitis E outbreak demonstrates the fragility of the present situation and the size of the need.