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Northeast Nigeria Response (Adamawa, Borno & Yobe States) Health Sector Bulletin #28 16th – 31st July 2017

6.9 MILLION

PEOPLE IN NEED OF HEALTH CARE IN; ADAMAWA, BORNO AND YOBE STATES

5.9 MILLION

TARGET BY THE HEALTH SECTOR; ADAMAWA, BORNO AND YOBE STATES

1,496,995* IDPS IN BORNO STATE

2,060,394 POLIO VACCINATED CHILDREN

HIGHLIGHTS HEALTH SECTOR

22 HEALTH SECTOR PARTNERS

HEALTH FACILITIES** 288 FUNCTIONING** (OF TOTAL

749 ASSESSED HEALTH FACILITIES)

262 215 67

FULLY DESTROYED PARTIALLY DAMAGED REHAB/RENOVATED

IDP CAMPS CUMULATIVE CONSULTATIONS

476,884 MEDICAL CONSULTATIONS***

WEEK 18: EARLY WARNING & ALERT RESPONSE

198 EWARS SENTINEL SITES 113 REPORTING SENTINEL SITES

35 TOTAL ALERTS RAISED****

SECTOR FUNDING, HRP 2017

HRP 2017 REQUIREMENTS: 93.8M US 11.2 M US$ FUNDED (12%) 2016 UNMET REQUIREMENTS 11.8 MILLION USD FUNDED (22%) 53.1 MILLION USD REQUESTED

As the Hepatitis E Virus (HEV) Outbreak spreads in Niger, on 18 June 2017, an outbreak of HEV / Acute Jaundice Syndrome was confirmed in three local government areas (Mobbar, Monguno and Ngala LGAs) of Borno State. As part of the outbreak response, a Risk Assessment Surveillance and Outbreak was conducted by WHO experts during reporting period.

MSF-CH conducted a Rapid Retrospective Mortality Survey in Banki camp from April to July 2017. The 4th mortality survey (15-18 July) showed a Case Mortality Rate (CMR) estimated at 0.87 deaths /10,000 people per day (95%CI: 0.70 - 1.04) and the U5MR at 2.08 (95%CI: 1.59 - 2.57). Both rates are at the limit of the SPHERE standards alert thresholds for sub-Saharan African countries. Comparatively to the mortality rates estimated in December 2016, these results might reflect a worsening of the living conditions for the population living in Banki.

The WHO first round of Seasonal Malaria Chemotherapy (SMC) targeting children between 3 and 59 months of age in 4 Borno LGAs, preliminary data shows an estimated 1 million children in the target group. In addition, 1,500,000 Rapid Diagnostic Tests (RDT) for the diagnosis of malaria were distributed to Adamawa, Borno and Yobe States.

BORNO STATE GOVERNMENT

Waiting patients for outpatient care at Dikwa General Hospital (FHI360)

* Total number of IDPs in Borno State by IOM DTM XV April 2017. ** MoH/WHO HeRAMS December 2016.

*** Cumulative number of medical consultations at the IDP camps from 2017 Epidemiological Week 1- 28.

**** The number of alerts change from week to week.

*****Number of Polio vaccinated children in the Outbreak and Response campaign (IPV Inactivated Polio Vaccine & OPV Oral Polio Vaccine) as April 2017

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Situation update:

Medecins Sans Frontieres (MSF) Switzerland issue the Fourth Rapid Rapid Retrospective Mortality Survey in Banki Camp, Bama LGA. The recall period of the retrospective mortality survey was from April to July 2017. As per the survey report extracts’: “Since March 2017, the population in Banki IDP camp has been increasing mainly linked to returnees from IDPs from camps in Cameroon. Since the massive arrival of over 12,000 people in May, the number of reported deaths in the community has been very high. This information is collected by non-health workers and might be inflate (recall period unclear, trying to get MSF to provide health services again) and MSF cannot have access to the local graveyard…” “MSF-Swiss conducted a first rapid mortality survey within the population of Banki camp on September 15th 2016 and found out that during the previous 2 months, the Crude Mortality Rate (CMR) was estimated at 3.0 deaths/10,000/day and the Under 5 Mortality Rate (U5MR) at 5.6 deaths /10,000/day

(1). MSF continued to increase its activities towards the population of Banki and shared the information on these alarming mortality rates with other actors and stakeholders. A second rapid mortality survey in October 2016 found a retrospective CMR of 0.67 deaths /10,000/day and the Under 5 Mortality Rate (U5MR) of 1.70 deaths /10,000/ day (2). A third rapid mortality survey in December 2016 found a CMR of 0.33 deaths/10,000/day (CI 95%:0.2-0.5) and a U5MR of 1.03 deaths/ 10,000 children/day (CI 95%:0.4-1.6). During both last surveys, the values were below the Sphere emergency thresholds.

The health sector partners during March, after trilateral discussions, MSF-Swiss handed over its health activities to the State Ministry of Health that together with UNICEF have taken the primary responsibility for the provision of health services in Banki. In May after the influx of further returnees, WHO deployed a Hard to Reach mobile team to provide basic medical care and vaccinations. The fourth survey conducted 15-18 July 2017 (attached with this bulletin) more worrying is the doubling of mortality rates for children under 5 years of age. The fourth survey results/concludes: “Within the camp population, the retrospective crude mortality rate was at 0.87 deaths/10,000/day (CI 95% [0.7-1.0]) and 2.08 deaths per 10,000 per day (CI 95% [1.59-2.57]) for children under 5 years old. The main reported cause of death was diarrhea.” Based on the survey, both rates are at the limit of the Sphere project emergency alert thresholds for sub-Saharan African countries. The results of this survey indicates an apparent critical situation, which requires the BSMOH, the Health and WASH sectors partners and MSF- Swiss as a key partner in Banki a join intervention. Besides the deterioration in the living conditions of the IDPs due to continuous influx of new IDPs and increasing number of returnees from Niger and Cameroon, the security situation has not improve. As an example, on 24th July 2017 Dalori Camp suffered a bombing attack. UNICEF health team and Nigeria Air Force health team responded jointly to the crisis. UNICEF supported with the funds for all medical supplies and drugs needed to treat all the patients admitted at the NAF Hospital and UNICEF supported PHC clinic in the camp. A total of 17 IDPs including 8 children and 3 women were affected. On 28 July 2017, two suicide blasts occurred in Dikwa at 20 Housing Estate Camp, also known as Agric Camp. In the hours following the attack, Dikwa General Hospital saw an influx of victims requiring immediate emergency care. With the support from Borno State Government health workers, FHI-360, UNICEF and Red Cross volunteers, a total of 41 victims of the attack were treated with 15 admissions. The attack resulted in 14 deaths, in addition to 14 referrals to Maiduguri hospitals for further care. The insert picture to the right, shows FHI 360’s medical doctor delivering medical care for victims at Dikwa General Hospital.

FHI-360 doctor providing care at Dikwa General Hospital.

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Public Health Risks and Needs

There is a high risk of Hepatitis E spread cross-border to Cameroon. Inter-country and cross border, collaboration will be required in high priority risk areas at the border with Cameroon (Rann, Ngala and Banki) as well as at the border with Niger (Damasak/Mobbar). This includes military border control personnel training and/or general HEV education.

Overcrowding IDP camps, continuous influx of returnees and the limited availability of shelter and WASH services are increasing the risk of outbreaks. Diarrhea and malaria cases are in the raised.

Geographical access remains a challenge and will be worsened shortly by the rainy season. Health partners started prepositioning supplies and drugs in high risk LGA and health facilities to prepare

for mitigation of deterioration of the health situation during the rainy season. There is a serious shortage of skilled health care workers, particularly doctors and midwives, and their

reluctance to work in recently accessible areas is a major challenge for the provision of health assistance.

Surveillance and communicable disease control

Early Warning Alert and Response System (EWARS): In Epidemiological (Epi) Week 28 - 2017, a total of 15 out of 25 LGAs and 113 out of 194 reporting sites (including 20 IDP camps) submitted their weekly reports. Timeliness and completeness of reporting were 68% and 48% respectively at LGA level (target 80% respectively). Of the 35 indicator-based alerts received, 91% were verified.

Malaria: In Epi Week 28, 3,863 cases of confirmed malaria cases were reported; representing 16.7% of

reported morbidities. 282 were from EYN (CAN center) IDP camp clinic in MMC; 258 from Gwange PHC in MMC; 198 from 400 Housing Estate Gubio Rd IDP camp clinic A in Konduga; 194 from Farm center IDP camp clinic in Jere; 184 from Gamboru PHC in MMC; 170 from General Hospital in Biu; and 128 from Dikwa MCH in Dikwa. Four deaths were reported, one from Njinand Health Post in Chibok, and three from Biu; Gur dispensary (1), and Gunda dispensary (2) respectively.

Figure 2: Number of Malaria cases, week 35 2016- week 28 2017, Borno State

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Hepatitis E virus (HEV): As of 30 July 2017 (Epi Week 30) a total of 696 cases were reported from Ngala

(471), Mobbar (57) and Monguno (26). In Ngala 47 pregnant women including 4 deaths (CFR= 8.5%) contracted HEV. A WHO mission with Borno State and partners develop a health risk assessment on Hepatitis E and yellow fever as response and preparedness mission.

Yellow Fever: One probable case of Yellow Fever from Ngala was diagnosed on 19 July by the virology laboratory in Lagos. Investigations are ongoing and further laboratory confirmation is pending.

Acute watery diarrhea: In Epi Week 28, the number of acute watery diarrhea has peaked to 2,676 cases

with 71% of cases occurring in children below 5 years. The overall burden of AWD is higher in Epi week 28-2017 compared to the peak observed last year. Of the reported cases, 287 were from Ngaranam PHC in MMC, 273 from Muna Garage Camp Clinic A in Jere, 119 from State Specialist Hospital MMC, and 112 from Madinatu IDP camp Clinic Jere. No death was reported.

Figure 3: Trend in number of acute watery diarrhoea cases, week 35 2016 - week 28 2017, Borno State

Acute respiratory infection: In Epi week 28, 2,163 cases of acute respiratory infection were reported and

no deaths. Of the reported cases, 146 were from Dikwa MCH in Dikwa, 119 from Ngaranam PHC in MMC, 111 from Madinatu camp clinic in Jere, and 106 from Federal Training Centre Dalori camp clinic A in Jere.

Figure 4: Trend in number of acute respiratory infection cases, week 35 2016- week 28 2017, Borno State

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Malnutrition: In Epi week 28, 1,751 cases of severe acute malnutrition were reported. Of the reported malnutrition cases, 301 were from Giwa Barracks clinic in Jere, 147 were from Gwange PHC in MMC, and 136 were from Ngaranam PHC in MMC. There were no reported deaths.

Measles: The cumulative number of cases since January 2017 is 1,994. In Epidemiological Week 28, 19 cases

of measles were reported through EWARS with 90% occurring in children below 5 years. No death was reported.

Figure 5: Trend in number Measles cases, week 35 2016- week 28 2017, Borno State

Neonatal death: One neonatal death was reported this week from State Specialist Hospital in MMC. Maternal death: No maternal death was reported this week.

Health Sector Coordination

Since the beginning of 2017, the NE Nigeria Health Sector partners’ response has conducted 33 regular coordination meetings in the three affected states, 14 in Adamawa, 13 in Borno and 6 in Yobe. The partners has reached over 3.1 million people as of June 2017. From partners supported health facilities 1.4 Million OPD consultations took place and 1.5 Million from the 101 mobile teams. These figures are underestimated, as are solely based in partners regularly reporting to the 5Ws and only two of the three states are reporting. In addition, sub-sector working groups has been activated (as needed) in Reproductive Health, Disease Surveillance and Outbreak Control and Mental Health & Psychosocial. Continued to support the SMOH to coordinate the RH response through the SRH Sub Working group monthly meetings and strengthening the linkages to the GBV Sub Working group.

-Health sector bulletins, updates and reports are now available at http://health-sector.org

Health Sector Action

FHI-360 General Hospital Dikwa is currently being run by the Borno State Ministry of Health (BSMoH) with support from FHI 360’s through the Integrated Humanitarian Assistance for Northeast Nigeria (IHANN) project funded by USAID’s Office of Foreign Disaster Assistance (OFDA). The hospital is currently providing general primary and reproductive health services. The outpatient department provides care for an average of 100 patients per day. The hospital is also providing laboratory and pharmacy services as well as inpatient admissions and maternity care. Additionally, the hospital provides critical emergency medical services for mass causality cases related to suicide attacks, gunshot wounds and other violent injuries.

Premiere Urgence Internationale (PUI) continues the support to the Herwa Peace PHC and three mobile health teams in Bayan Texaco, Jajeri Kantudua and Fillin Bayan Makaranta. In Herwa PHC, the number of RDT confirmed malaria cases have been increasing dramatically during the previous two weeks, from 83 RDT confirmed cases in week 28 to a total of 326 confirmed malaria by week 30. This is the highest record of confirmed malaria in this

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facility. The total number of consultations also have increase, 5,066 patients were seen in the last two weeks of July, which is a rise by 700 patients as compared to total consultations on patients seen in June 2017, which stood at 4,366. The mobile teams reported a cumulative total of 2,478 patients in OPD consultations in two weeks with 69 referrals to the clinic. The agency continues as well to provide antenatal care services and regular immunizations as key activities. In the month of July, Herwa Peace PHC Clinic underwent the following rehabilitations/revitalization:

- A double purpose patient waiting area, which is also use as a health awareness hall, was constructed. It can accommodate up to 300 patients at a time.

- The waste management area of the facility is fully functional, as the slab for the incinerator has just been done. There is functional power system in the facility from generator.

- The drainage system was built in order to protect the structure from flooding. - A solar direct-drive battery-free technology refrigerator was also acquired.

Health awareness was done more routinely on different health topics and it reached 3,044 people with health talks addressing seasonal as well as local endemic ailments, malnutrition, Hygiene and other evolving health related topics. SIPD in July vaccinated 1,095,065 children 0-59 months with oral polio virus (OPV) in Adamawa state. 2,722 children were reached by their mobile team in weeks 27 and 28 for MNCH services and 3,834 for RI services during the same period. Borno State Agency for the Control of HIV/AIDS & Malaria (BOSACAM) in Baga - Kukawa LGA (from 3rd May - 19th July) the agency tested 1,327 people of which 683 were HIV positive; yet to be placed on anti-retroviral therapy (ARV). In Ante-Natal Care attendance 609 pregnant women were tested of which 215 were positive. (this figures must be verified with the agency) UNFPA continues to support the humanitarian response in Borno through provision of quality and timely live saving SRH interventions. During the reporting period the agency completed the distribution of RH kits to cover an estimated 1,525,000 people for 3 months in health facilities in MMC, Jerre, Biu, Konduga, Monguno, Kaga, Gwoza, Mobbar, Ngala, Chibok, Kala Balge, Dikwa and Mafa LGAs. Additional RH Kits have been prepositioned as contingency stock to respond to emerging needs. 3,300 Dignity Kits were distributed to support mothers in the Post Natal Care period in the same facilities.

In partnership with the SMOH and Action Health Incorporated, UNFPA completed a MISP training of 30 health workers from MMC, Jerre, Konduga and Monguno LGA health facilities from the 24th-28th July 2017 in Maiduguri. In collaboration with the SMOH, the agency provided equipment (hospital beds, delivery beds and kits) to Muna Garage Camp Maternity Clinic; the facility is now able to conduct deliveries and will help address the SRH gaps in this populated IDP camp.

In Adamawa with implementing partners, UNFPA successfully distributed Reproductive Health kits to 19 Health facilities which can reach an estimated 760,000 woman and girls in Yola North, Yola South, Hong, Madagali, Mubi, Fufore, Gombi, Geire, Michicha and Maiha LGAs. 1,201 pregnant women received clean delivery kits, 18 Rape cases received post rape treatment and 9 Caesarean Sections supported as part of the comprehensive assisted deliveries. In Yobe State the UNFPA partners engaged 18 Medical outreach team and they provided MNCH services in the 16 most affected communities. 2,136 IDPs Women and 3,198 IDP Girls, and 14,104 children were provided with MNCH medical services and referrals in the last 6 months. 7,021 different Family Planning Options was distributed to 179 health facilities in Yobe. Procure MNCH drugs, consumables and supplies (1,000 Doses of Oxytocin Injection, 430 doses of Misoprostol, 1,000 doses of magnesium sulphate injection, etc.) and other supplies worth 1.2 Million Naira to support medical outreach teams.

MISP training closure group picture. (UNFPA)

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UNICEF: During the reporting period, a total of 184,988 women and children were reached with integrated PHC in the UNICEF supported health facilities in the IDP camps and host communities in Borno and Yobe States. A total of 84,105 consultations were reported with malaria being the major cause of morbidity [malaria (23,829), ARI (14,113), AWD (13,542), Measles (250), other medical conditions (32,418)]. For prevention services: 63,633 children and pregnant women were reached with various antigens (including 4,403 children 6months-15 years vaccinated against measles); Vitamin A supplementation (9,369), Albendazole for deworming (11,889), ANC visits (12,839); delivery (1337); Post Natal Care (1816).

As 26 July 2017, Borno State MOH finalized the distribution of the 112,200 long lasting insecticide treated nets (LLITNs) donated by UNICEF with financial support from USAID. During the reporting period 3,250 LLITNs were distributed in Borno State and 22,556 LLITNs were distributed and in Yobe State giving a total of 12,903 families reached, (each family is provided with 2 LLITNs). UNICEF donated 170 Nigeria Health Kits to Borno SMOH for the health facilities in the IDP camps and host communities. This includes the outreach activities to reach both IDPs and vulnerable host community members accessing health services in UNICEF supported health service delivery points. UNICEF health team, on mission in Yobe State (23-26 July 2017), met the WHO State Coordinator and agreed on a collaboration project using WHO Hard to Reach platform to deliver minimum primary health care package with special focus on strengthening routine immunization. This partnership will improve the health service delivery to the communities in the hard to reach locations. UNICEF will provide drugs (Nigeria Health Kits), LLITNs and VCM network to WHO HTR teams. In this regards, UNICEF donated 30 NHK to WHO to support the Hard to Reach Team outreach interventions.

WHO with grants from USAID and the Bill & Melinda Gates Foundation, WHO has trained and deployed 56 mobile teams across 25 local government areas in Borno state to offer a package of basic health services that include vaccines, medicines, screenings and referrals when required. So far, the teams have seen more than 400,000 beneficiaries, and referred nearly 40,000 to health facilities when greater care is required. The teams have treated some 83,000 people for different ailments, and more than 50,000 for malaria. For more than 300,000 children, the mobile health teams have administered vitamin A supplement, provided deworming and screened for malnutrition. They have also vaccinated over 1 million children against polio.

In a bid to improve access and quality of health services in remote and security-challenged areas in the state,

WHO in Yobe has recruited additional 11 HTR teams through a rigorous selection process, increasing the number

of HTR teams to 35. Hitherto, 24 teams have been working and providing MNCH and RI services in remote areas

thus helping to reduce the burden the maternal and child health morbidity and mortality. The recruitment of the

44 health workers was immediately followed by an intensive day-long training to improve their skills and

attitude viz-a-viz services delivery in challenging environments. Provision for adequate stocks drugs,

commodities and working materials are being made for all teams, and the newly recruited teams are set to be

deployed in the first week of August.

Nutrition

PUI 1,888 children between six months and five years were screened with MUAC for malnutrition and 3.5% of the total screened represented SAM cases who were admitted to the program. This is the highest rate of SAM reported in terms of percentage since their program started screening children. On average, the MAM cases stand at around 40% of those screened with MUAC. 172 children are currently on treatment for SAM, of which 92 are females. There were 47 new admissions to the program during the reporting weeks. Training on CMAM was given for the PHC staff by the nutrition advisor to build the capacity of the staff, both in diagnosing and treating SAM cases. WHO Hard to Reach Teams in Borno screened 37,918 children 0-59 months for acute malnutrition using MUAC and checking for bilateral pitting oedema in 25 LGAs. The teams identified 270 (1%) children with severe acute malnutrition (SAM) and 1,442 (4%) children suffering from moderate acute malnutrition. The SAM children were referred to nearest OTPs to their homes for treatment. During the reporting period, four LGAs reported to have higher SAM rate than the emergency threshold of WHO. The teams recorded a SAM rate of 4% in Guzamala and

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Mobbar; and 2% in Nganzai and Magumeri LGAs. More than 16,000 mothers and caregivers were reached with key messages on appropriate infant and young child feeding practices. To prevent and control micronutrient deficiencies, WHO teams reached 2,710 children 6-23 months with micronutrient powder supplementation. As well, in the last two weeks, WHO HTR teams in Yobe have provided 13,940 consultations, dewormed 10,021

children, provided ANC services to 1,608 pregnant women and conducted nutritional screening (MUAC

measurement method) to 11,226 children across the state. In June, the COPRS in various communities have

treated (consultation) up to 1,825 children and conducted nutritional screening for same number of children.

MSF-Spain has established three stabilization centres and FHI-360 is willing to set up a SC in Banki. WHO confirmed full support in terms of provision of essential drugs and technical assistance to FHI-360.

Gaps in response

Revitalization and strengthening of the health system is vital. Re-establishing functional, staffed and equipped health facilities to deliver health services to vulnerable populations is the Health Sector priority during 2017-18 response.

Secondary health care and referral services is a big challenge population facing in the remote areas due to lack of ambulance services and specialized health care providers. Most of the secondary health care facilities are damaged/destroyed and non-functional.

Mental health and psychosocial support need more efforts to help the population affected by the insurgency and the detrimental conditions as displaced populations.

Low vaccination coverage due to access and security issues as well as challenges ongoing polio outbreak, Hepatitis E and meningitis outbreaks.

Insufficient number of skilled and appropriately trained health care staff. Malaria has become endemic in the northeast region increasing the risk in child mortality in malnourished

children. Nutrition screening is not regularly conducted in all the catchment areas to timely detect severe acute

malnourished children with complications. NGOs medicines importation is a long process, which significantly hampers their programme implementation

and timely health service delivery. The rainy season, overcrowding IDP camps and the limited availability of WASH services will increase the risk

of outbreaks such as cholera.

Resource mobilization

The latest funding overview of the 2017 HRP reports shows that health sector is currently 12% funded of the required appeal of 93.8 M US$ (FTS/OCHA, 30/07/17).

Health Sector Partners

- Federal Ministry of Health and Adamawa, Borno and Yobe State Ministries of Health - UN Agencies: IOM, OCHA, UNFPA, UNICEF, UNDP, WHO, OCHA - National and International Partners: ALIMA, Action Against Hunger, Action Health Incorporated, MSF

(France, Belgium, Spain and Switzerland), ICRC, Medicines du Monde, Premiere Urgence Internationale, International Rescue Committee, FHI-360, International Medical Corps, Catholic Caritas Foundation of Nigeria, SIPD, Nigeria Centre for Disease Control, BOSEPA, BOSACAM, WASH & Nutrition Sectors, Nigerian Armed Forces, Nigerian Air Force & others.

For more information, please contact: Dr. Haruna Mshelia Dr. Abubakar Hassan Commissionner for Borno State Ministry of Health Permanent Secretary, BSMOH Email: harrymshelia@gmail.com Email: abubakarhassan60@gmail.com Mobile: +23408036140021 Mobile +2340805795680 Dr. Jorge Martinez Mr. Muhammad Shafiq Health Sector Coordinator-NE Nigeria Technical Officer- Health Sector Email: martinezj@who.int Email: shafiqm@who.int Mobile +23408131736262 Mobile: +23407031781777