Report on

Cholera Prevention and Response Training

course programmes

Mbale, 21st – 24th September 2010Jinja, 2-5 November, 2010

Department of Water DevelopmentMinistry of Water and Environment

November 8, 2010

with support from

Cover page photograph:

Participants debating the implications of the F-diagram in preventing and mitigating cholera outbreaks

Han Heijnen, Mbalehanheijnen@gmail.com

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TABLE OF CONTENTSExecutive Summary..................................................................................................................4

Introduction............................................................................................................................. 5

Objectives.................................................................................................................................6

Methodology............................................................................................................................6

Training Programmes...............................................................................................................9

Mbale programme................................................................................................................9

Jinja programme.................................................................................................................12

Common Issues...................................................................................................................13

Conclusions............................................................................................................................ 14

Recommendations................................................................................................................. 14

Annexes..................................................................................................................................15

1. List of resource persons...............................................................................................16

2. List of participants, Mbale...........................................................................................17

3. List of participants, Jinja..............................................................................................19

4. Daily course programme.............................................................................................20

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EXECUTIVE SUMMARY

10 lines + table with participants and their satisfaction

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INTRODUCTION

In the past cholera occurred sporadically within the different regions of Uganda. It was not until 1997/8 when a serious outbreak occurred . This occurrence was witnessed in 43 districts out of the 45 districts then. However, the outbreak was controlled and cases steadily declined until 2002. Due to good preparedness and lessons learnt, the outbreak was localised to only 14 out of the 56 districts. During the following years a few cases were reported. For example in 2008 only a few districts reported outbreaks of the cholera:

• in Eastern Uganda – Budaka, Butaleja, Manafwa, Bugiri,Tororo and Busia • Arua, Nebbi, Kibaale, Bulisa, Hoima, Kampala, Kasese.

In 2010 the disease has been reported in the districts of Moroto1, Kotido, Amudat, Tororo, Pallisa, Kayunga, Luwero and Butaleja.

It is against this background that the Government of Uganda through the Ministry of Water and Environment and in partnership with the Ministries of Health and Local Governments have decided to hold a refresher programme on the prevention and response to cholera outbreaks.

To accommodate the large no of districts potentially affected, it was decided to split the programme into two courses: one held in Mbale from 21-24 September 2010, catering for

1 Daily Cholera Update [12 June 2010], MoH/WHO

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Daily incidence of Cholera in Moroto, 12 July 2010

0

5

10

15

20

25

30

4/21/2

010

4/28/2

010

5/5/20

10

5/12/2

010

5/19/2

010

5/26/2

010

6/2/20

10

6/9/20

10

6/16/2

010

6/23/2

010

6/30/2

010

7/7/20

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Date

No

of c

ases

North-East and Eastern Uganda districts, and one in Jinja, held from 2-4 November 2010 covering other districts.

OBJECTIVESThe training programmes had the following broad objectives:

1. Build capacity of WASH actors (Governments, NGOs, and UN) to: engage in contingency planning and preparedness for cholera/AWD outbreaks; respond to cholera/AWD outbreaks in a variety of contexts (urban, rural,

refugee / IDP camp);2. Increase participants’ understanding of the importance of coordination with

different sectors (e.g. health, nutrition and education) and actors in cholera / AWD preparedness and response;

3. Strengthen common standards and approaches between international humanitarian actors and governments in the area of cholera/ acute water diarrhea (AWD) preparedness and response

4. Increase participants’ understanding of the role of WASH in Uganda in cholera / AWD preparedness and response

5. Offer field-based experience through various practical exercises

Participants were invited from altogether 17 districts. As much as possible representation was sought from the District Health Office (District Health Inspector - DHI), District Water Office (District Water Officer - DWO) and the Community Development promoters at district level (District Community Development Officer). In some cases other government officers attended as well, while relevant NGO staff were also included from severely affected districts.

METHODOLOGYUNICEF and WHO have been concerned for several years now about the regular occurrences of cholera outbreaks throughout Africa. In East and Southern Africa, the last few years have shown outbreaks in South Africa, Zimbabwe, Malawi, Uganda, and Sudan The reason for these occurrences may lie in climatic occurrences, i.e heavy rainfall leading to floods; displacements of large numbers of people due to floods or landslides, or due to local insecurity; poor infrastructure, especially in overcrowded peri-urban areas, in combination with insanitary conditions, poor hygiene and open defecation. While it is difficult to manage a cholera response in an urban setting, it is even more complex in a remote area where human resources and health facilities may find it hard to recognize the disease and muster an initial response.

A major cholera outbreak in Zimbabwe in 2008-2009 with its challenges in provision of adequate WASH services, prompted Oxfam GB Southern Africa Regional Office and UNICEF East and Southern Africa Regional Office (ESARO) to develop a cholera / AWD2 training package targeting in-country WASH practitioners implementing cholera / AWD control activities. The package was developed in mid-2009 and after feedback from a large number of experts including the Global Task Force on Cholera Control and the participants of test

2 Acute Watery Diarrhoea6

courses in Zambia, Uganda and Malawi, the package was finalized at the end of 2009. It is now available as a CD-ROM.

The WASH Cholera & Acute Watery Diarrhoea Emergency Preparedness & Response Training Package is a generic package that has all the tools and information to hold a good course, but to make it attractive and locally relevant, it is necessary to adapt it to the national/local context.

In the two courses that were held in Mbale and Jinja, this ‘localization’ has been achieved by obtaining the services of senior national officers from the Ministries of Water and Environment and the Ministry of Health to ensure updated policy and practice for WASH and emergency response. Representation of district local government (e.g. the Chief Administrative Officer of Kaabong district) ensured linkage with roles and responsibilities at the district level, as per current rules. The Environmental Health Division of the Ministry of Health and UNICEF, through a consultant currently studying hygiene practices in Karamoja area with the aim to make health promotion more culturally and socially effective, contributed important local perceptions that WASH stakeholders need to appreciate in order to be able to deliver services that make sense and are largely effective. Resource persons have reflected several of these concepts and issues in their powerpoint presentations and these have now become part of the course record i.e. included in the CD ROM provided to all participants as reference.

The package aims to refresh the knowledge that participants have by providing a lot of information in a series of presentations and working group sessions, as well as through a very elaborate digital library of recent Health, WASH and Emergency Preparation and Response information materials on CD.

The method of delivery of the materials is very much participatory, acknowledging that the participants themselves are important resources for the course, and for each other, not just from a technical information point of view, but also because of their insider knowledge of what works and what doesn’t, especially at the district level.

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The daily programme of the course is given in Annex 4. Details can be found on the CD-ROM, which is available from UNICEF.

The course aims to cover the interests of Health, WASH and Local Government, through invited participation from District Health Inspectors, Water Officers and Community Development Officers. Obviously areas in which one is not an expert require additional effort to capture the essence of the learning and guidance. But on the whole the course programme can be followed well by over two-thirds of the participants.

The course deals with

Cholera Recent outbreaks and impact (incl. screening of Cholera video of Médecins Sans

Frontières – MSF) Introduction to Cholera (Vibrio Cholerae, mode of transmission, characteristics

and risk factors of disease, developments in prevention and diagnostics) Surveillance, compilation and analysis of epidemiological data Cholera guidelines and manuals and materials

Key Responses Hygiene Promotion (successes and challenges, vulnerabilities, community

participation, priorities in response, information, approaches, key messages) Sanitation (technology options, solutions in different contexts and stages) Water (supply priorities, risks associated with water sources, interventions in

case of contamination, water quality analysis and field tests, inclusive of practical demonstrations, HWTS methods)

Management of Cholera Outbreaks Managing Cholera Treatment Centres (Location of CTCs, WASH within CTCs,

Standard Chlorine Solutions and uses within CTCs) Communication (cholera prevention and response messages, effective

communication during coordination) WASH Monitoring in Cholera (key indicators, analysis and application of

monitoring data) Coordination (strategies for effective coordination, barriers to coordination, roles

in coordination)

Emergency Preparedness and Response Emergency Preparedness and Response Planning – Preparedness Stage (epidemic

response cycle, cholera prevention, elements of EPRP) Emergency Preparedness and Response Planning – Alert, Response and

Evaluation Stages (actions required at each stage)

The training provides participants with the most updated knowledge and best practice on Cholera / Acute Watery Diarrhoea (AWD) Emergency Preparedness and Response. This will

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be done through presentations, discussions, case studies, group work, role plays and practical exercises.

TRAINING PROGRAMMESTwo training programme were executed following the modules and procedures outlined in the CD ROM package. However there are interesting points to record relating to the participants, their expectations and the results of the training programme. These have been dealt with in the two following training course specific sections.

MBALE PROGRAMME

Profession No. Sector No

DHI 10 Health 12

DWO 11 WASH 11

DCDO 9 CD 10Other Government 3

Planning/ Management 4

NGO 4The Mbale course was attended by 37 participants from the North-East (Karamoja) and Eastern districts of Uganda. The participants came from Health, Water and Community Development is more or less equal numbers.

Participants expressed their expectations mainly in terms of ‘learning’ (7 responses):

‘gain more knowledge & skills on how to prevent/respond to cholera and other similar outbreaks in stable and complex emergencies’

and capacity building (6 responses), specifically to be:

‘able to come up with/draw up a cholera/AWD emergency response plan’

Several participants also expressed their interest to hear how other districts were tackling the Cholera threat. The possibility of sharing that experience was seen as a good opportunity. As participants were drawn from neighbouring districts, several knew each other and this facilitated a good atmosphere right from the start. Facilitators and resource person were able to employ various games and energizers to further encourage good engagement and interaction. Ample use was made of short tasks and group work to deepen the learning.

On a daily basis and in between, as needed, evaluation sheets and tests were completed. After the modules on the clinical and public health aspects of cholera, a rather substantial test was done of 19 questions, the day after. Case Fatality Rate and ‘awareness of the possibility of a cholera case presenting itself’ where understood well by over 90% of the respondents. Most other questions were answered within a range of 70-90% correctness.

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What are the factors that increase susceptibility to diarrhoeal diseases?

Contaminated water supply Lack of sanitation facilities such as latrines Poor hygiene and improper food preparation and storage Malnutrition Low immunity Reduced gastric acidity

The Kampala Declaration on Sanitation (1997) defines ten areas of action to improve sanitation at district and local government levels.

Exemplary leadership commitment Full community mobilization Focus on District and Sub-county and urban

authorities Coordination and multi-sectoral approach Focus on schools Creating fora to address sanitation at districts Central role of women Private sector and NGO participation in

service delivery Capacity building at district level Development of policies and guidelines

Questions on the WHO case definitions for Cholera, fluid loss and severe dehydration were answered well enough by the health staff, but others seemed to find these questions a little hard. Overall a little over 60% answered these questions correctly.

The question on susceptibility was answered poorly and confusingly and so it can be deducted that a good number of participants did not quite grasp this concept. As this concept relates to conditions that vulnerable groups in the community may suffer in larger measure and thus their risks are larger during a diarrhea outbreak, it is important to review/ repeat this part of the presentation (module 1.3)

Overall, 69% of the participants scored 70% or over in this test.

As is common these days, a reminder session is usually held at the beginning of each session’s day. This was usually done by the lead-facilitator. On the third day instead a panel discussion was held with a DWD, MoH, UNICEF and NGO representative trying to answer questions from the participants, who were acting as local journalists. This proved a very entertaining session with plenty of questions on roles and responsibilities, and approaches.

Criticism was voiced toward the community leaders. While ordinary people would have a latrine, their compounds would not yet have a toilet (Karamoja). And what about fining people for not having a latrine as per the bylaw, when even the courthouse does not have a toilet! As such it is hard to implement the Public Health Law.

Questions were raised on the Kampala Declaration on Sanitation (KDS), which has now been lying idle for some 10 years. According to DWD most of the ten areas of action have shown progress.

The NGO representative was asked why many NGOs did not link that well with local government during their regular work. Tough question!

The conclusion of the panel discussion was that we all need a change in mindset to be able to appreciate our own responsibilities and collaborate for the greater good.

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The Panel discussion was a nice change to the daily summary and yielded a lot of relevant interaction on several issues discussed the day before, especially with respect to health promotion and supporting policies and bylaws.

To understand the issues surrounding emergency WASH, a role play was set up on the last morning, with four groups struggling with competing demands of the CAO, limited capability at the District Water Office, communication problems and demands on community mobilization. The spice in the exercise was created by urgent phonecalls from Kampala, urging action from the highest quarters and pressure from community leaders and district councilors. Quite real-life like and stress-full. But a good way of seeing through the issues that crop up in such an emergency.

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Existing practice Open defecation is a tradition. At night they defecate outside the manyatta.

They say this is a sign of abundance food in the community and also a sign of life.

Young single girls cannot use pit latrines in fear that they would not be able to conceive in the future.

If a pregnant woman uses a pit latrine, the fetus would fall into the pit and she would not conceive again.

It’s disrespectful for a young man to see his mother in law going to defecate and or use the same latrine.

They fear the dead and so do not bury especially in kraals. Instead abandon bodies in the forest and leave for vultures. If in a homestead /manyatta two

One of the expectations expressed by one of the participants related to ‘getting a good understanding of basic and practical hygiene promotion approach in rural areas esp. with the difficult-to-change community’. Clearly this questions was an expression of the challenges faced in the Karamoja Region. Ms. Catherine Solomon, a UNICEF consultant, has been looking into this challenge and was able to present some of her concerns an findings during the training workshop.

She also indicated that while there were assumed traditional behaviours unfavourable to heath, some of these can also be changed. The section below illustrates the changes that are possible.

Situational analysison communication response to diseases outbreak- Karamoja Region

Models villages visited were in Kotido( losilang Parish-Jimos, Rengen sub-county Lonejim village )The information revealed during the community dialogues was contrary to the above concerning cultural issues .The community members and their leaders informed us that ;

Changes in practice

• They have confirmed that those earlier beliefs which caused women not to use the pit latrine are not true, as they have used them and no one has lost a child or failed to conceive in the last 3 years

• They now bury the dead and they even have the priest to preside over the ceremony as they now believe that the dead would not be happy with them if they are not buried. It is only in the open field away from the villages that the dead are not buried.

• The cultural belief that they hold important to date is that of a mother-in-law not sharing or meeting her son-in –law while going to the latrine .

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Generally the Mbale course was well appreciated: participants rated relevance of subject matter between 89 and 95%, with an average of 92.6%, while presentation/facilitation ranged from 83 - 95%, with an average of 88.8%. These are surely high ratings, indicative of the quality of the course, and its relevance to the participants, as well as their interest in the matter. Interest was and remained high throughout the course programme. This was a pointer to good presenting, and sufficient variety and diversion to keep everybody active. It is noteworthy that the practicals of day 3, water testing demonstration in the garden of the Mount Elgon Hotel, scored highest [see Patrick Okuni demonstrating a pool tester for determining residual chlorine in the water].

The final evaluation form was completed by 31 of 37 participants. Of these 35% qualify the course experience as excellent, 58% as very good. Two participants felt that course was good. In aggregate terms, 93.4 % of respondents were pleased with content, materials provided, the participatory approach and coverage of the course material by the resource persons.

Participants indentified (1) the capacity to respond to a cholera epidemic and (2) how to plan for an emergency preparedness and response plan, as important things participants learned during the course. Relevance of multi-sectoral collaboration was also mentioned.

A negative point that came up from several evaluation forms, was the concern about the long and intensive programme. The schedule assumes that the daily programme starts at 08.30. That is nearly impossible in the Ugandan context, certainly when participants are not staying at the venue of the course. When the day starts late by 30-45 minutes, then it is difficult to stop much before 18.00 hrs with the current schedule.

JINJA PROGRAMME

13

COMMON ISSUES

14

CONCLUSIONS

RECOMMENDATIONS

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ANNEXES

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1. L IST OF RE SOURCE PERSONS

Names Title Organisation1 D.Mukungu Mukama PHS/Sanitation

CoordinatorMWE/DWD

2 Dr. Bwire Godfrey S.M.O MoH3 Otai Justin S.H.E MoH/EHD4 Dr. Lukwiya Michael NPO WHO5 Jan Heeger Regional Advisor WASH UNICEF ESARO6 Mark Choonoo Emergency Specialist UNICEF7 Catherine Solomon Consultant CD Karamoja UNICEF8 Han Heijnen Lead Facilitator UNICEF9 Patrick Okuni WASH Officer UNICEF10 Samuel Madul WASH Officer UNICEF11 Stephen Wandera WASH Officer UNICEF12 Harriet Kajubi SPA-WASH UNICEF

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2. L IST OF PARTICIPANTS , MBALE

Name Title District/Organisation

1 Sylvia Awor DCDO Abim

2 Buteraba Mathias DHI Abim

3 Oluka Edmond DWO Abim

4 Nyeko Simon Prog. Mgr ACF- Moroto

5 Ogwang George DHO Amudat

6 Elimu Frank DHI Amudat

7 Onono Michael DWO Amudat

8 Amuron Freda I DCDO Amudat

9 Kaniala Fred DHI Bududa10 Shibale Tom DWO Bududa11 Nabwire Miria DCDO Bududa12 Wepondi Herbert P/Director BUSIDEF13 Nesihwe Betty DCDO Butaleja14 Moga Hamisi DWO Butaleja15 Isogol Henry DHI Butaleja16 Angom Florence Field Officer CAFH17 Engwau Nicholas Health Officer IRC- Moroto18 Lochokio Moses CAO Kaabong19 Kibwota Godfrey DHI Kaabong20 Nasur Charles DWO Kaabong21 Kedi John Paul DWO Kotido22 Lukong Israel DHC Kotido23 Ongom Alex M.C.O Kotido24 Ochieng G.M DHI Kotido25 Nachan Lily CDO Kotido

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26 Eyura Martins DDHO Moroto27 Lokokol Moses. S DWO Moroto28 Lowot Musa DWO Moroto29 Chakura Andrew MO Moroto30 Munyes Esther CDO Napak31 Omara P.O DWO Napak32 Ilukol Andrew Rews DHI Napak33 Lokiru Charles DWO Napak34 Lomongin J ACDO Napak35 Wadinda Julius DHI Sironko36 Cathy Mugoya CDO Sironko37 Buyi Ag. DWO Sironko

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3. L IST OF PARTICIPANTS , J INJA

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4. DAILY COURSE PROGRAMME