Emergency & Humanitarian Action in Darfurvent a major health catastrophe. Cholera, dysentery, and malaria threaten the survival of hundreds of thousands of internally dis-placed people.

WHO Director General Dr.Lee taking patients temperature in Kass Hospital

age of clean water and the com-ing rains from combining into a recipe for death," said Dr LEE as he finished his mission into ar-eas of South and West Darfur. "We must work urgently to pre-vent a health catastrophe." Dr LEE and Dr Hussein Gezairy, Regional Director of WHO's East-ern Mediterranean Region, also noted that even in the last month, joint action by the Fed-eral Ministry of Health, non-governmental organisations, UNICEF and other international humanitarian agencies have resulted in important improve-ments for health. Good use is being made of the funds available, though logistic challenges still beset major relief operations in Darfur. More peo-ple in more camps have clean water, adequate food, primary health care and proper sanita-tion. More therapeutic feeding centres are being opened and hospital services in Darfur are

being improved. A recent mass mea-sles campaign reaching two million children prevented about 40 000 deaths. Eye care clinics are perform-ing cataract surgery for adults and treating trachoma in children. But the gap between needs and available relief are all too evident. Beyond communicable disease, the physical and mental health of women who have been subjected to sexual violence, and the longer term health needs for children are addi-tional concerns. Continued on P. 2

WHO SUDAN

Emergency & Humanitarian Action in Darfur

Inside this issue Promotion of camp cleaning in Darfur

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Supporting trauma care of war-related injuries

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Disease outbreak preparedness & response

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Measles vaccination campaign

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Khartoum/Cairo/Geneva: In-creased funds, people and sup-plies are still needed now in the Darfur region of Sudan to pre-vent a major health catastrophe. Cholera, dysentery, and malaria threaten the survival of hundreds of thousands of internally dis-placed people. These inputs are essential even though there has been much progress in the provi-sion of relief, particularly health care, in the last few weeks. How-ever, health risks can be further reduced through effective health interventions within an intensi-fied relief programme. This was the conclusion of two top leaders of the World Health Organization as they wrapped up a mission to camps and hospi-tals in South and West Darfur. "People are dying now because they are living in unsatisfactory conditions, but too many more could die in the coming weeks unless we prevent the lack of sanitation, malnutrition, short-

People in Darfur face high levels of disease and death says WHO Director

Othman Digna street (Nile Avenue side)

Phone: (249 1) 83 776471 / 781672 Fax: (249 1) 83 76282

WHO SUDAN

Dr.Lee, Dr Gezairy and WHO Representative Guido Sabatinelli

Technical Assistance Supporting trauma care of war-related injuries

W HO is supporting trauma care of affected popula-tion with war-related inju-

ries in South Darfur.

The plan is to implement a referral system for IDPs affected by war-related injuries between Kass and Nyala hos-pitals. This implies the rehabilitation of Kass hospital, and the upgrading of Nyala hospital with surgical capacity for trauma treatment.

The improvement of Kass hospital was launched with the rehabilitation of the pediatric ward. The project includes the supply of trauma kits, generators, uni-forms and beds.

The upgrading of Nyala surgical/traumatology capacity is currently on-going. This program is carried out in close collaboration with the FMoH or-thopedic team (8 persons) of Khar-toum.

As part of the agreement with the Na-tional Medical Specialization board. The first batch of medical/surgical

registrars has traveled to Darfur and will support eight selected rural hospi-tals in the region where WHO is con-centrating its work: Kass, Buram, El Deein, El Dalfarsan in South Darfur, Garseilla in West Darfur, Kebkabyia and Sarif Omra in North Darfur.

Registrars went through an induction training offered by WHO prior to depar-ture to Darfur.

The registrars will provide preventive, curative and rehabilitative health care in Darfur hospitals and their catchment and will operate under the supervision of one senior surgical surgeon.

A WHO surgeon is currently traveling around the three states to provide technical assistance.

The State authorities has accepted this period as an important part of the for-mal academic training of the registrars to be taken into account during their final evaluation.

Support provided by WHO will consist of daily stipends and travel expenses

incurred by selected registrars in Dar-fur.

According to the Director of the States Affairs Directorate of the Federal Minis-try of Health (FMOH) a total number of 71 registrars in various disciplines will be required to fulfill needs throughout Darfur.

Senior consultants in Medicine and Surgery will be positioned in each state to supervise and train health personnel in states and manage complicated and referred cases at the state hospitals.

WHO is also examining how to offer similar support and facilitation arrange-ments to NGOs working in Darfur.

“Measles is a

killer disease in Sudan claiming

the lives of 15 000 to 30 000 children

annually.”

than 5 years with polio vaccine. Challenges faced by vaccinators overall included inaccessibility to some areas and delay in start-ing vaccination in some remote areas. The WHO led campaign is a significant step in reducing the morbidity and mortally of children now living under precarious conditions resulting from war in Darfur’s three States: Nyala, Al Fashir and Geneina. Contributors to the organization of the campaign on the ground included: Save the Children UK in Tawilla and Malha, GOAL in Kutum, IRC in Abu Shouk and MSF B in Kebkabiya. The measles campaign was funded by the British Government’s Department for International De-velopment, the US Government’s Office of US Foreign Assistance (OFDA), the Humanitarian Aid Office of the European Commission for EUR, the Italian government and the Bill and Melinda Gates Foundation.

A constellation of national and international

aid agencies led by the Ministry of Health, WHO and UNICEF supported a one-month campaign to immunize more than 2 million children from 9 to 15 years of age.

Measles is a killer disease in Sudan which annu-ally kills 15 000 to 30 000 children according to statistics provided by the Ministry of Health. Over the past three years the disease has been reach-ing peaks prompting national authorities to devise strategies aiming at curbing this trend. The Ministry of Health supported by the World Health Organization and UNICEF prepared a plan to reduce morbidity and mortality caused by mea-sles. The plan aims to strengthen routine infant immunization coverage, organize supplemental immunization activities, catch-up campaigns, strengthening surveillance of the disease, ensure appropriate management and administer vitamin A. During the campaign vitamin A capsule supple-mental was administered to children from 6 to 59 months and also covering 90% of children less

Measles vaccination campaign in Darfur Two million reached, 40 000 lives saved

T he World Health Organi-zation with the collabora-

tion of sister agencies and NGOs launched this month a vector control campaign to curb the transmission of malaria in IDP camps throughout Darfur. The campaign spearheaded by the Federal Ministry of Health is being implemented in camps as local epidemics with high mortal-ity may occur among vulnerable displaced populations due to overcrowding, lack of adequate housing and preventive meas-ures against mosquito bites. People with little immunity to the disease and who live near per-manent water bodies face death all year-round and at all ages, with children, pregnant women, malnourished people and pa-tients with concurrent infections most at risk. Malaria in Darfur is seasonal and the states experience higher cases just after the rains usually with peaks and exacerbations in August through October. Malaria transmission increases from north to South. In case of epidemics the follow-ing measures will be imple-mented to contain the spread of the disease:

§ Prompt and effective diag-nosis and treatment with artimisinin-based combina-tion therapy (ACT).

· Appropriate implementation of timely planned, targeted and cost effective vector control that will contribute to reducing the risk of infection and save lives.

WHO coordinated meetings that gave NGOs the opportunity to review and discuss the new WHO recommended Malaria treatment guidelines and the new national drug policy. A one page summary of the treatment guidelines will be available soon and posted in

all health centres treating malaria patients

Following an agreement with NGOs, WHO facilitated and pro-vided the required technical sup-port to start the indoor residual house spraying (IRHS) in Darfur.

WHO has, to this end, ordered the required amount of three tons of insecticides (deltametherin) and 50 Hudson spray pumps for IRHS; provided support to a vector con-trol team of three members from NMCP to spearhead the vector control operations with WHO tech-nical guidance and support for a period of two months. The team will be travelling to Darfur soon to undergo training.

“People with little immunity to the disease and who live near permanent water bodies face death all year-round and at all ages, with children, pregnant women, malnourished people and patients with concurrent infections most at risk..”

Malaria epidemics feared as rainy season begins : WHO and partners launch vector control campaign in IDP camps

A s the rainy season starts, the main threat to survival in these extremely difficult circumstances is communi-cable disease - presenting as local-

ized outbreaks of diarrhea disease (watery diarrhea,) malaria, measles, and respiratory infections (in children).

More general epidemics of cholera and dys-entery are increasingly likely. The result could be a huge loss of lives unless a good stock of oral rehydration salts, IV fluids and antibiotics can be built up and properly used, and the case fatality rate can be brought down to less than 1%. This is not impossible with good contingency planning among NGOs, Government and the UN, ef-fective co-ordination and combined rapid response teams working to standard proto-cols.

No epidemic has been reported so far, but surveillance systems are not functioning to full capacity. Given the increasing risks of disease, strenuous and effective prepara-tion is needed. These include prevention, ensuring effective Health Care and enabling hospital services that can be accessed.

Prevention steps include · adequate volumes of water to permit

hygiene - especially when foods are handled,

· proper disposal of excreta, · chlorine-treated water supplies,

· rehydration therapy for those with diar-rhoea,

· insecticide-coated mosquito nets, · easily accessible malaria treatment,

and continued immunisation against measles, polio and - if there are cases meningitis)

· nutritious foods In the last month the efforts have been on improving coordination to plan, monitor ac-tivities, and ensure effective and quality health intervention by all agencies at central and state level. WHO is providing technical guidance in ar-eas such as disease surveillance and vector control to reduce morbidity and mortality due to epidemic disease such as malaria and diarrheal diseases including cholera by putting in place efficient preparedness and response, and targeting vulnerable IDPs camps in the three states. WHO has spearheaded the establishment of an early warning system (EWARN) for moni-toring and responding to disease outbreaks. Across Greater Darfur, a total of 71 medical assistants, nurses and community health workers in the IDP camps together with SMOH personnel were trained in all three states on the EWARN system, on how to report accurately and on preparedness and response on expected outbreaks. Some of the participants will continue to conduct

further training courses in the rural areas in order to strengthen the EWARN system and to increase the numbers of reporting sites.

The EWARN electronic application was devel-oped and installed at the FMOH to collect surveil-lance data from all acces-sible IDP. A report genera-tor was developed to pro-duce regular reports from all the states and FMOH. WHO also trained FMOH epidemiologists to use the application.

Until referral laboratories are upgraded and ade-quately equipped at State level, specimen will be collected by reporting units and sent to the cen-tral laboratory in Khar-toum using the defined private carrier Cary Blair media is now available in the three states. Adequate guide-

lines for specimen collection and transport will be distributed to all reporting units. WHO plans to Upgrade 3 referent hospital laboratories and provide them with the nec-essary equipment, reagents and supplies for a 3 month period to be to able to diagnose and confirm cholera cases and outbreaks. WHO patient management guidelines have been distributed and used at all levels of health services susceptible to deal with chol-era. Use of ORS (or equivalent) will be en-couraged, as it is the most effective treat-ment for cholera and other diarrhoeal dis-eases. WHO is ensuring that drugs and supplies are available and easily deployed against the onset of cholera outbreaks. Response kits, cholera kits, and new emergency health kits for outbreaks are now positioned for an outbreak response. In addition, protocols for malaria prevention and treatment are ready and available to all health partners NGOs with capacity response in case of chol-era outbreak are MSF-B in North Darfur, MSF-F, MSF-H and MSF-Swiss in West Dar-fur, MSF-H in South Darfur. SC-UK is ready for cholera preparedness in North and South Darfur and MedAir have enough stock for cholera and malaria control for 10,000 peo-ple.

Disease outbreak preparedness & Response WHO steps up readiness plans in IDP camps

"T here are two dimensions to the crisis in Sudan; one political and one hu-

manitarian. Hundreds of thousands of peo-ple's lives are now hanging in the balance, and they need help now," said Dr LEE. "The combined efforts of Government and the hu-manitarian community are making a differ-ence. We appeal strongly for more external assistance to fill the gap, to make available the funds still needed for this crisis, and help ensure that threats to health are reduced." If massive humanitarian relief is not immedi-ately brought to the people of Darfur, the numbers of people dying each day will drasti-cally increase. However, if the build up of the relief effort can be sustained and properly supported, the number of deaths can be kept the minimum for an emergency situation. Dr LEE and Dr Gezairy assessed the health situation at Kalma camp outside of Nyala in South Darfur. Home to more than 50 000 people, and with 300 new people coming every day, the camp is particularly lacking sanitation. As the rainy season peaks in the coming weeks, water and mud will wash over the camp, and it will be ripe for a cholera out-break. Left untreated, cholera can kill a per-son in hours. "WHO and health partners could work to pre-vent a cholera outbreak, by pre-positioning supplies and by vaccinating people who are susceptible. This costs money," said Dr Geza-iry. "But I guarantee the costs of an outbreak and the deadly impact it would have on peo-

ple far outweigh the costs of prevention." "In the short-term, this will alleviate suffering of people who urgently need assistance. But this is also a long-term investment in health for a region which suffers chronically from having too few hospital beds, maternal health facili-ties, surgeons and other specialists," said Dr Guido Sabatinelli, WHO Representative for Su-dan. Overall the UN esti-mates the costs of hu-manitarian relief at US$ 240 million. To date, less than half of that has been pledged. WHO requires about US$ 1.2 million per month to carry out its operations in the three Darfur States. WHO is working closely with the Sudan Minis-try of Health and other partners to coordinate the health response, prevent communicable disease outbreaks, and rehabilitate hospitals. With massive influxes of people around cities and towns in Darfur, the demands on hospi-tals have increased dramatically. WHO is sup-porting the refurbishment of wards, operating rooms, laboratories and training staff in key referral hospitals in the region, and helping to

improve access to care. His Excellency Dr Ahmed Bilal Osman, the Fed-eral Minister of Health, has today committed to a further transfer of 100 million Sudanese pounds (USD 40,000) per State per month to hospitals to provide services without charging user fees, and also committed to assisting with WHO-assisted training in hospital admini-stration. Both the Federal and State ministers of health have undertaken to ensure mainte-nance and management of rehabilitated hospi-tals so they can continue to serve the people of Sudan.

Building up a Response WHO ‘s strategic approach

Constraints & challenges ?? Insecurity and access to vulnerable populations ?? Limited health system capacity and deteriorated infra-

structure ?? Lack of trained health personnel at all levels of ser-

vice delivery points ?? Lack of reliable information and reporting on health

conditions ?? Geographic remoteness, transport and communica-

tion problems ?? Limited resources allocated to health sector ?? residual effects of the conflict e.g. IDPs, Mines etc ?? Many IDP camps scattered over a large area ?? The rainy season and the consequent inaccessibility

of some of the IDPs camps

Immediate health actions ?? Address the public health aspects of camp manage-

ment ?? Facilitate sector coordination and collaboration of all

partners ?? Advise on the environmental health aspects of dis-

ease control ?? Develop and implement cholera prevention measures ?? Ensure identification and monitoring of health needs

of vulnerable populations ?? Detect and respond to any potential outbreaks ?? Ensure access for populations to health care (primary

and hospital) ?? Develop/enhance of the laboratory capacity to diag-

nose and confirm periodic diseases under surveil-lance (EWARN)

?? Strengthen state ministry of health capacity to better respond to growing health needs

?? Develop and implement health partners’ capacity to detect, confirm and investigate any suspected out-breaks

?? Ensure availably of essential drugs and medical equipments in health facilities

The Plan ?? Ensure that hospital service quality is improved (and

this includes making sure that critical hospitals are rehabilitated),

?? Maintaine a high level of public health expertise to

lead on surveillance and epidemics ?? encourage partnerships to improve health care cover-

age and fill the gap, especially primary health care in camps and hospital care

?? provide the back-bone of a medical supply and logis-

tics system and ?? Resolve user charges issues with MOH ?? ensure that priorities are agreed between health part-

ners and establishing a framework for co-ordination and joint action

People of Darfur face high levels of disease and death Cont. from P. 1

A hundred and seventy two environmental health work-ers were recently recruited and trained by WHO to en-sure that vector control, waste disposal measures and health promotion are in place to benefit 310,000 people in four locations: El Mashtel, Abu Shouk, Kalma, and Geneina. In addition, WHO assessed and created guidelines to address environmental threats in displaced persons' camps, as well as supplied 500 household hygiene kits.

In the three camps visited, the assessment of the environmental conditions showed that most water sources are under –chlorinated, household containers contaminated, number of latrines inadequate.

WHO is continuing its support of camp cleaning (garbage and carcass collection, latrines spraying for vector con-trol and water quality testing in Darfur’s three States.

Environmental Health: Promotion of camp cleaning well underway

Dr. Gezairy , WHO Eastern Mediterranean Regional Director and Dr. LEE speaking at press conference in Khatroum