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A small girl with a ray of hope in eyes

PAKISTAN HEALTH CLUSTER SITUATION REPORT # 3 – Pakistan/ Floods in Sindh (22-09-11 until 24-09-11)

Highlights: • The health situation in Naushahro Feroze, Sangar, Tando Mohammad Khan, Tando Alla Yar, Tharparkar remains

serious and requires continuous monitoring and assistance from health cluster partners. There is a need to strengthen malaria control program including the provision of bed nets and RDTs in all affected districts. Serious gap exists in nutrition, water and sanitation, MNCH and LHW coverage, immunization and health facilities’ restoration. Gaps in MNCH and LHWs coverage are not only in officially registered camps for displaced population but also for the rest of the population. Local authorities request assistance in further fumigation of affected areas as well as in distribution of mosquito nets.

• The data collected through the Rapid Health Assessment show that32% of affected health facilities have adequate stocks of medicines, vaccines, equipments and other consumables at least for one to four weeks, while 50% of health facilities reported having marginally adequate stocks. However, 18% health facilities have insufficient medicines and consumables to provide PHC services to the affected population.

• The World Health Organization (WHO) facilitated the strengthening of DTC via provision of inpatient beds and treatment was provided to more than 200 AWD cases. Regular emergency response activities continue with a primary focus on the mitigation of communicable diseases outbreaks through intensive surveillance in the affected areas, environmental health interventions and provision of essential medicines and supplies to health facilities and other health care providers and partners.

• WHO along with cluster partners is continuing with its ongoing emergency response activities in the affected districts, addressing the immediate health needs of the population with focus on controlling communicable diseases, including water and vector-borne diseases such as Acute Watery Diarrhea, Dengue Fever, malaria as well as ARI and skin infections WHO has responded to the situation in close coordination with government and other health partners by providing EHKs (46), DDKs (56) and assorted medicines covering population of 304,000. In addition, hygiene kits, Jerry Canes, filters, ASVs, aqua tablets, gas cylinders, mosquito nets (103,000) and basic family kits have also been provided to respond the situation.

• Many heath facilities are surrounded by water, making it difficult to provide health services. There is a further need to build the capacity of Government health workers for better epidemiological surveillance of communicable diseases, (giving priority to those with a short incubation period), water analyses and treatment as well as daily analyses of water

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A. Health Needs A large number of district health facilities throughout the province remain partly damaged but functional with limited resources, especially in rural and remote areas since 2010 floods. A disproportionate distribution of health staff among health facilities and community level persists. Quality provision of health care at the community level (by lady health worker, village volunteer, community health promoter, community mid-wife, traditional birth attendant) remains critical and insufficient in various affected districts throughout Sindh province. There is a continuous shortage of female doctors. A serious need to upgrade the existing system of health information management and statistics as registration records are at low levels is required along with capacity building of health officials. Child health services and needs remain unmet. The integration and introduction of IMCI in the local health system is needed. There is a problem of home-based treatments of many non-reported cases of fever/malaria, ARI/pneumonia, dehydration due to AD. Mass routine vaccination requires significant attention and support for increasing the local capacity. Maternal and Newborn Health issues represent one of the key priorities for immediate support and interventions as there is a continuous a predominance of home deliveries. Nutrition interventions take place at large in areas of support of international and national organizations. The screening of acute malnutrition (MUAC) is a serious concern in most of Sindh districts. Supplementary feeding of moderate acute malnutrition (SFP) is not in place in a predominant number of local health facilities responsible for such care. Community therapy care of severe acute malnutrition is absent throughout Sindh with exception of areas of support of international and national organizations. Major public health threats include water-borne diseases (diarrhea disease, typhoid fever, hepatitis A and E, parasitic diseases), vector-borne diseases (malaria, dengue, etc), air-borne diseases (measles, acute respiratory) and zoonotic diseases (Crimean Congo hemorrhagic fever). Communicable diseases prevention and control is not in place requiring massive support with capacity building, IEC materials, mosquito nets and insecticide spraying. Health facilities do not engage as expected and required with community mobilization in support of mass vaccination. The health situation in Naushahro Feroze, Sangar, Tando Mohamdd Khan, Tando Alla Yar remains critical and requires continuous monitoring and assistance from the health cluster partners. There is a need to strengthen malaria control program including provision of bed nets and RDTs in all affected districts. Serious gap exists in nutrition, water and sanitation, MNCH and LHW coverage, immunization and restoration of health facilities. There are serious gaps in MNCH and LHWs coverage not only in officially registered camps for displaced population but for general population. Local authorities request assistance in further fumigation of affected areas as well as distribution of mosquito nets. The data collected through Rapid Health Assessment shows, 32% of affected health facilities have adequate stocks of medicines, vaccines, equipments and other consumables at least for one to four weeks, while 50% health facilities reported having marginally adequate stocks. However 18% health facilities have insufficient medicines and consumables to provide PHC services to the affected population.

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B. Health Cluster response 1. Nutrition:

o Nutrition Working Group meeting, chaired by Nutrition Focal person from Department of Health, Dr Dure Shehwar, was held on 18 September 2011 in DG office Hyderabad. Partner mapping and prioritization exercise was carried out. It was decided to immediately initiate nutrition intervention in the eight worst effected districts. A total of 26 organizations participated including WHO, 9 international partners, 14 national NGOs. A 3W matrix was also prepared and distributed to the partners with request to update the matrix on a bi-weekly basis. o Agreements with six partners have been finalized and issued for nutrition supplies and an expedited implementation in the priority districts. o Nutrition interventions have initiated in district Badin since 17 September and a partner -wise update is as follows: o Merlin: started 4 mobile OTPs in four worst affected UCs of Badin District i.e. UC Shadi Large, Pangrio, Khadan, Khadaro. Total number of under five children screened are 608. Out of these 33 were identified as Severely Acutely Malnourished (SAM) and 69 as Moderately Acutely Malnourished (MAM) and registered in OTP and SFP programmes respectively. Out of 181 pregnant and lactating women screened for malnutrition, 23 were registered as MAM. o Save the children: Mobile teams have started Nutrition Activities in six camps. Total number of children screened till date is 1,410. Out of these 71 are SAM and 67 are MAM. Number of PLWs screened is 200, out of which 7 are admitted in SFP programme. 239 participants have been oriented on breast feeding practices. 361 women attended IYCF sessions and 94 women received skilled one-to-one IYCF training. 2. Health Response: WHO facilitated strengthening of DTC inpatient beds and treatment was provided to more than 200 AWD cases. Regular emergency response activities continue with a primary focus on mitigation of communicable diseases which includes intensive surveillance in the affected areas, environmental health interventions and provision of essential medicines and supplies to health facilities and other health care providers and partners. During week 37, a total of 470,024 consultations were reported through DEWS, on which ARI (18.6%) comprising URTI (14.9%) and LRTI (3.8%) had the highest proportionate morbidity, followed by skin diseases (17.6%) and suspected malaria (11.8%). Trends for suspected malaria and other acute diarrhea are on the rise (1-2%) this week. All diarrheal disease comprised 13.6% compared to 12.5%, during reporting week 37 (9 to 15 Sep, 2011), of which other acute diarrhea (12.6%) had the highest proportionate morbidity followed by bloody diarrhea (0.9%) and acute watery diarrhea (0.03%). A total of 63 alerts/outbreaks were received and responded by all districts of Sindh province in week 37. In total, 39 water borne disease alerts including 38 AWD, 1 BD and 9 vector borne disease alerts including 7 Sus. Dengue, 1 Sus. Malaria and 1 Leishmaniasis were reported and responded on time by DEWS teams. Others include 5 NNT, 2 Tetanus, 3 Measles,

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2 AFP, 1 Meningitis and 1 Pertussis alerts. In total, 177 people were affected, 49.7% of cases were aged <5years. WHO along with Cluster Partners is continuing with its ongoing emergency response activities in the affected districts, addressing the immediate health needs of the population with a focus on control of communicable diseases, including water and vector borne diseases such as Acute Watery Diarrhea, Dengue Fever, malaria as well as ARI and skin infections. The risk of disease outbreaks may further increase as a result of the current flood. WHO in collaboration with the department of health is monitoring the local epidemiological trend to timely investigate, respond and control epidemic prone diseases through effective control measures. From the onset of current emergency (12 August 2011) until to date a total 203 alerts for different DEWS priority diseases were generated, investigated, and 21 outbreaks were identified, responded and controlled effectively. WHO has responded to the situation in close coordination with government and other health partners with EHKs (46), DDKs (56) and assorted medicines covering population of 304,000. In addition, hygiene kits, Jerry Canes, filters, ASVs, aqua tablets, gas cylinders, mosquito nets and basic family kits have also been provided to respond the situation. Health Cluster Response Strategy was submitted through a Flash Appeal. A total of 34 health and nutrition projects are included in Flash Appeal. The overall cluster requirement for the 6 month period is USD 40,520,000, broken down as follows: Health (US$ 26,920,000); Nutrition (US$ 12,500,000); Health Protection (US$ 1,100,000). The coordination structure was put in place by Sindh Government Departments with the Clusters and UN lead Agencies for an immediate response in their respective clusters to achieve an effective and efficient 2011 response. The government co-chair for Health is Mr Rizwan Ahmed, Secretary Health, contact number: 0300-2260691. A second National Health Cluster meeting was held in Islamabad on 15 September. First provincial Health Cluster was held in Karachi on 9 September. Health Cluster Partnersorganisations monitor the situation development in each of Sindh districts. Major types of interventions by INGOs and NGOs include set up of mobile medical teams and fixed health points in and around EDOH managed health facilities and flood affected population temporary settlements. DG Health Sindh monitor and update the health situation in 12 Southern Sindh and 3 Northern Sindh districts. Main health concerns are linked to AWD, diarrhea, dysentery, ARI, Malaria, Dengue fever, various skin diseases. Most of present INGO and NGO activities have been focused in nine Northern Sindh districts. There is on going effort to expand activities to worst affected districts in the South. The following Sindh districts are covered by nutrition projects: Dadu, Ghotki, Hyderabad, Jacobabad, Jamshoro, Kashmore, Khairpur, Larkana, Shikarpur, Thatta, Kambar, Sukkur, Tando Muhammad Khan. The remaining districts as Tharparkar, Umerkot, Tando Allahyar, Sanghar, Mirpurkhas, Badin, Matiari, N.Shah and Naushahro Feroze require nutrition projects. WHO developed links of the website of the WHO country office in Pakistan containing set of maps generated based on results of Rapid Assessment conducted in 22 flood affected districts in Sindh in relation to NDMA official figures of affected population.

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http://www.whopak.org/index.php?option=com_content&view=article&id=363&Itemid=177 http://www.whopak.org/index.php?option=com_phocadownload&view=category&id=28:monsoon-2011-maps&Itemid=113 Environmental Health Response: • In response to Alerts/outbreaks, WHO environmental health team tested more than 294 water sources, over 96% of these were found contaminated, necessitating some remedial actions being taken, including distribution of water disinfectant supplies; • 51 Alerts potential outbreaks were detected investigated and majority of these were controlled prior to becoming full-blown outbreaks and during the same period 12 outbreaks were timely identified, responded and controlled effectively and major health hazards averted; • provided 1,700,000 Aqua tabs, 2085 family size Hygiene Kits, 4110 jerry cans for safe storage and collection of drinking, 1354 water filters, 10 Wagtech water testing lab-kits to TMAs/PHEDs and DOH; • 161 staff of health and WASH cluster, PHED/TMAs, and DOH staff were trained on emergency water quality monitoring, treatment and sanitary surveys; • 72 hygiene sessions (with around 3600 participants), have been conducted in flood affected areas; In addition WHO provided 300 colour comparators to WASH Cluster partners, TMAs/PHED supplying water to the affected communities for regular monitoring of residual chlorine; Health Cluster Partners Response:

Save the Children have reached 72,200 beneficiaries through emergency interventions. Three mobile health teams are operating in Badin district and one in Mirpur Khas. The teams performed a total of 1,661 OPD consultations including 431 children under 5 years of age and 619 women. In Nutrition, 1,180 children were screened using MUAC, of which 43 were found with moderate acute malnutrition and 25 were found with serious acute malnutrition. Health and hygiene sessions were held in six villages in Badin for the benefit of 469 people including 195 boys, 185 girls and 89 men. In addition, Save the Children is working in 17 UC’s in Jacobabad and 13 UC’s in Shikarpur districts. Mercy Corps is expanding its presence in Badin district. Recruitment of local staff is underway as well as procurement of assessed drugs/medicines/supplies. Two mobile teams will become operational focusing around Chabrello and Tendo Bago. Helping Hand for Relief and Development HHRD is providing emergency relief in worst flood affected districts since 7th Sep 2011, including food, NFIs, clean drinking water and primary health care services in flood affected areas in Sindh and Balochistan. The organisation covers the following locations: District Badin (Mobile Unit), District Mirpurkhas (Mobile Unit), District Tando Allah Yar (Mobile Unit), District Tando Muhammad Khan (Mobile Unit), District Nawabshah (Mobile Unit), District Jacobabad (Static Unit), District Kashmore (Static Unit), District Shikarpur

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(Static Unit), and District Jaffarabad, Balochistan (Static Unit). 19 camps are covered by mobile teams. A total of 2298 patients received medical assistance. More than 2871 patients were treated through OPD consultations in fixed health points (time period – 10 days). NATPOW has launched mobile service unit project with the support from UNFPA and WHO. Four MSUs in Benazirabad and 3 MSUs in Khairpur (Dodo Mari UC Sikandar Abad, Allah Dino Ibupoto UC Sikandarabad, Jahanyanabad UC Choondko, Lal Bux Nizamani, UC Choondiko, village Muhammad Panah Nizamani, UC Choondiko) started functioning in Sindh. The rest of MSUs will start working soon with the support of NATPOW and local implementing partners. Seven functioning MSUs treated a total of 1950 patients, including 300 pregnant women and 1000 children. UNFPA provided 4000 save motherhood delivery kits for distribution. ARC with support of WHO implements a comprehensive project on provision of PHC services and reproductive health needs and psychosocial support to flood affected population of Jacobabad, Sindh on the premises of BHUs of Suhno Khan Rind (Jacobabad); Bahadarpur (Thull), Mubarakpur (Thull) and Dispensary Abdul Rasool Khoso (Thull) District Jacobabad. Health Net TPO started the project of “renovation/reconstruction of damaged basic health units (BHUs) in the flood affected areas of districts of Jacobabad and Kambar Shahdadkot in Sindh. In response to 2011 floods organization plans to set up mobile medical teams to be be mobilized in the catchment areas of health facilities with the collaboration with the EDO-Health and PPHI. Shifa Foundation has established two mobile medical & nutrition teams, one for each UCs in Jamal Shah and Bucheri of district Shaheed Benazirabad. Teams will provide general OPD care, screening of malnourished population and EMoNC services. Distribution of mosquito nets, aqua tabs, safe delivery kits, hygiene kits, new born kits to most vulnerable population is also expected. UNICEF is scaling up its assistance to the affected children and women through health, nutrition, WASH, education and protection activities, while maintaining momentum on polio eradication. By September 18 in 14 affected districts in Sindh, approximately 33,400 children received measles vaccine, 13,800 received vitamin A supplementation, 45,300 received OPV drops, 7,600 BCG immunizations and 15,800 Penta vaccine. In addition, 11,600 women were vaccinated against tetanus. UNICEF is reaching over 51,700 people through daily water tank trucking to temporary settlements and groups of IDPs in 5 districts. Three UNICEF partners (SRSO, PU/AMI and Johanniter) are mobilized to cater the needs of flood affected population in Khairpur district. Rapid assessments are being conducted in Khairpur by UNICEF partners (SRSO and PU/AMI). In June 2011 UNICEF pre-dispositioned EDOHs of all 9 Northern Sindh districts a total of 60 IEHKs 2006. UNICEF health programme addresses flood affected through mobile outreach clinics and primary health care activities. The key interventions include immunization of children, pregnant women, and women of reproductive age; provision of reproductive health services - antenatal/postnatal care, and clean delivery kits, new born baby kits; deworming of children 2-5 years age; health and hygiene sessions and distribution of insecticide treated mosquito nets to prevent malaria. In nutrition UNICEF supported CMAM program in 8 districts of Northern Sindh through 10 partners. All four core components of CMAM program are covered focusing on children and PLWs to reduce mortality and morbidity. Screening and enrolling take place under national nutrition guidelines and protocols. UNICEF expects new 6 health and nutrition partners to cover 72 uncovered UCs of North Sindh. Currently there are 10 PCAs in process and 6 PCAs are in pipeline. Capacity building

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trainings of health department on CMAM is put in plan. UNICEF partner AKF plans to provide B.Emonc services in 36 UCs in 3 districts of Northern Sindh. There is continued provision of LLITNs to reduce risk of malaria and hemorrhagic fever. IRC continues provision of health and nutrition projects in the districts of Shikarpur (BHU Haji Khan Kalhoro in UC Shabirabad and RHC Mian Jo Goth in UC Mian Sahib)and Kambar Shahdadkot (one mobile clinic in UC Hazarwah; RHC Qubo Saeed Khan in UC Qubo Saeed Khan (one mobile clinic working in UC Bago Dero is shifted to RHC since 13th September 2011). The following health services are provided daily general OPD consultation, basic EmOC services including deliveries, antenatal, postnatal and family planning services, screening of children 6 months to 59 months for malnutrition; health education sessions, laboratory services, medicines, referrals of cases with severe diseases. IRC supports further malaria control program in districts through equipping malaria labs (microscopes, basic lab equipments and furniture), provision of RDTs, deltamethrine and fogging machines, malaria awareness campaign, indoor residual spray and capacity building of relevant district health staff on malaria microscopy, RDTs, malaria surveillance and malaria case management. IRC trained health and hygiene promoters (HHP) provide health education sessions in the community on safe handling & storage of drinking water, water purification methods, hand wash, environmental health, use of latrines and safe disposal of house holds; MUAC screening of children age 6-59 months and referral of malnourished children, patients with severe ARI, diarrhea and malaria to health facility. World Vision continues provision of primary health care services throughout district of Khairpur through operation of 9 mobile medical team and 4 fixed health points (a medical team is composed of doctor, LHW, health promoter and dispensor). One mobile team and all 4 fixed health posts provide required nutrition services. D. Gaps & Constraints: Many heath facilities are surrounded by water, making it difficult to provide health services. There is a further need to build the capacity of government health care providers for better epidemiological surveillance of communicable diseases, (giving priority to those with a short incubation period), water analyses and treatment as well as daily analyses of water samples, with priority given to schools and health institutions, health education and informing the general public.

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Health Cluster Contacts List: 1. Lead Organization: World Health Organization (WHO) 2. Cluster Website: www.whopak.org 3. Focal Point Contact Details: • Alfred Dube (Health Cluster Coordinator, Islamabad; 0300 4005934, dubeal@pak.emro.who.int)

• Dr. Mohammad Dauod Altaf, (Head of WHO/EHA, Sindh, Hyderabad; 0303 5552279, altafm@pak.emro.who.int) • Dr. Azret Kalmykov (Head of WHO, Sukkur; 0303 5552269, kalmykova@pak.emro.who.int 4. Health Cluster Editorial Board • Mohammad Shafiq (shafiqm@pak.emro.who.int; 0303 5552270) • Dr Assia Jazairy (jazairya@pak.emro.who.int 0308 5559645) • Laleh Najafizadeh (najafizadehl@pak.emro.who.int 0303 5552282) • Usman Hafaz (hafazu@pak.emro.who.int 0301 8551446)