AGENCY:___________________ HEALTH FACILITY



COMMUNICABLE DISEASE SURVEILLANCE AND CONTROL IN EAST TIMOR

Report and recommendations of mission to East Timor

4/10/99 – 24/10/99

TABLE OF CONTENTS

1. Background………………………………………………………………………………………….2

2. Initial assessment…………………………………………………………………………………..2

3. Epidemic Preparedness and Response………………………………………………………….2

4. Surveillance………………………………………………………………………………………….4

5. Malaria………………………………………………………………………………………………..5

6. Tuberculosis………………………………………………………………………………………….7

7. Immunisation…………………………………………………………………………………………7

8. Recommendations…………………………………………………………………………………..7

Annex 1 – Terms of reference of mission…………………………………………………………….10

Annex 2 – Map of East Timor…………………………………………………………………………..11

Annex 3 – WHO Weekly Health Report for East Timor…………………………………………….12

Annex 4 – WHO Guidelines for surveillance system for emergency phase in East Timor……..13

Annex 5 - WHO Case definitions for emergency situations………………………………………..15

Annex 6 – Steps for management of communicable disease outbreak in East Timor…………..18

Annex 7 – UN Flash Appeal – Surveillance and Epidemic Response, Roll Back Malaria………19

Annex 8 – Roll Back Malaria in East Timor – POA with IRC and Merlin…………………………..23

Annex 9 – Persons met…………………………………………………………………………………24

Report prepared by:

Dr Máire Connolly

Medical officer

Emergency and Humanitarian Action

WHO, Geneva

Email: connollyma@who.int

[pic]

WORLD HEALTH ORGANIZATION

COMMUNICABLE DISEASE SURVEILLANCE AND CONTROL IN EAST TIMOR

1. Background

Since the announcement of the referendum ballot results on 4/9/99, over 600,000 people out of a total population of 870,000 in East Timor were displaced due to the violence. By the end of October, an estimated 400,000 people remained in mountain areas in the territory and over 150,000 were in camps in West Timor. There had been widespread destruction of all major towns with 70-95% of buildings being razed to the ground.

WHO set up an office in the UN compound, Dili on 25/9/99. One of the first priorities of WHO was to identify the main disease threats, ensure capacity for epidemic response and establish a surveillance system. The terms of reference of the mission are attached in Annex 1.

With the destruction of over 60% of health facilities and the displacement of most local health staff, the international community took on the task of providing health care for the post-emergency phase. In early October, there were thirteen agencies involved in health care activities in East Timor. Nine agencies are providing primary or secondary health care services - MSF-International, MSF-F, MDM-F, MDM-P, Portuguese Government Team, AMI, French Military Force, ICRC, Timor Aid. Goal Ireland is implementing a central pharmacy system with WHO using the SUMA system. Caritas is the lead NGO for TB control with WHO. IRC is the lead NGO for the RBM insecticide treated net (ITN) programme and Merlin is planning to co-ordinate RBM malaria control activities.

2. Initial assessment

The population displacement, collapse of the health services, poor access to health care, breakdown of vector control activities and the impending monsoon season pose serious threats to the health of the population of East Timor. There is also a high risk of outbreaks over the next six months. WHO reviewed the major disease threats and selected priority diseases for epidemic preparedness and surveillance. The main health problems were identified to be upper respiratory tract infection, pneumonia/lower respiratory tract infection, malaria, malnutrition, trauma/injury and tuberculosis. The main diseases with epidemic potential in East Timor were identified: bacillary dysentery, cholera, malaria, measles, meningococcal meningitis, hepatitis A and E, typhoid and paratyphoid fever, dengue fever, scabies, and Japanese encephalitis.

3. Epidemic preparedness and response

The first priority for WHO was to ensure a response capacity in the event of an epidemic. WHO worked with agencies in Dili, local health professionals and with the support of WHO staff at country, regional and HQ level set in place the following measures:

➢ Surveillance system established with mechanism for immediate reporting of 6 diseases/syndromes with epidemic potential agreed

➢ Laboratories identified for confirmation of main diseases with epidemic potential – French Military hospital and ICRC hospital in Dili

➢ Stockpiles of drugs and IV fluids for epidemic prone diseases available in Dili on 19/10/99 are outlined below. These supplies are monitored by SUMA pharmaceutical database.

ORS – 14,500 one litre sachets

Ringers Lactate – 200 litres

Chloramphenicol – 1,000 IM doses

Chloroquine tablets (150 mg): 1,180,000

Primaquine (7.5 mg): 25,000

Quinine (300 mg/ml) 300 ampoules; (60 mg/ml) 2,000 ampoules

Quinine tablets (300 mg)

Sulphadoxine/pyrimethamine (500 mg/25 mg): 28,900 tablets

Ciprofloxacin - MSF have stocks but information on exact quantity was unavailable

➢ Stockpiles of vaccines - MSF provided vaccines for a measles mass vaccination campaign UNICEF are procuring OPV and DPT vaccine, also additional measles for restarting EPI programme

➢ Epidemic investigation kits containing clinical specimen kits, protective equipment were sent by CDS/HQ to WHO Dili in mid October

➢ Case management protocols for the main epidemic prone diseases in East Timor - cholera, bacillary dysentery, meningococcal meningitis, measles, dengue fever and Japanese encephalitis were developed and distributed to agencies

➢ Guidelines for collection of laboratory specimens were developed and distributed to agencies

➢ Contingency plans were agreed with ICRC hospital, Dili and MSF-F hospital, Baccau for isolation wards in the event of a major epidemic

3.1 Laboratory

WHO has worked with the French Military hospital to ensure capacity for testing of specimens for cholera, shigella, salmonella, meningococcal meningitis, TB and malaria. Water testing is also being done by the French Military laboratory. The ICRC hospital agreed to confirm TB, malaria, as well as perform basic laboratory tests. Capacity at district level does not exist due to destruction of laboratories and lack of trained staff, supplies, reagents, equipment and specimen kits. Hepatitis B&C are tested in the emergency blood bank at ICRC hospital. It has been proposed that NAMRU II in Jakarta be approached to confirm samples of dengue and JE. The Royal Darwin Hospital also have the capacity for confirming dengue and JE. International reference laboratory for testing of specimens for polio will be identified by the WHO country office, Indonesia.

3.2 Measles

Three cases of measles were reported by MSF on 10/10/99. MSF are vaccinating all children from 9 months to 12 years in the screening centres for returnees set up in the Dili Football stadium and at Baccau airport. A mass measles immunisation campaign in Dili was done by MSF/UNICEF/WHO on 16/10. Over 3,500 was vaccinated. However the coverage rates were below that targetted and a follow up campaign which will include polio is planned.

3.3 Malaria

The risk of a marked increase in malaria morbidity and mortality during the monsoon season is high. The risk factors are all present - population displacement, destruction of houses, increased man-vector contact, increased mosquito breeding, collapse of health service, delays in finding effective treatment for malaria disease and lack of capacity in hospitals to treat severe malaria. Malaria is dealt with in more detail in section 4.

3.4 Diarrhoeal diseases

Faecal contamination of water is a major risk factor for outbreaks of diarrhoeal diseases in East Timor. Nine water samples from wells in Dili were tested by French Military hospital up to 10/10/99 – there was no residual chlorine in any samples. Enterococcus was isolated in 4 samples which indicated faecal contamination. The population of Dili is accustomed to boiling water. As the water table only 3-6 metres underground, there is a constant high risk of faecal contamination of the water supply. WHO has urged agencies to reinforce health messages to boil water and ensure proper cooking of food to prevent outbreaks of diarrhoeal diseases.

3.5 Dengue fever

Dengue fever has been confirmed in three international staff who had worked in East Timor in September 1999. Serum specimens were tested in Royal Hospital Darwin and were diagnosed by IgM. Aedes aegypti has been identified in Dili in a mosquito survey in 1991. The large numbers of tyres, containers, oil drums waste containers in Dili providing potential ideal breeding grounds for the vector. A French Military entomologist Professor Claude Pierre, has identified larvae of Aedes in a number of sites in Dili including the area of the UN compound. WHO has informed agencies that a major clean-up campaign is urgently needed by international staff and community to properly dispose of tyres and containers before the monsoon season starts.

3.6 Japanese encephalitis

The risk of an outbreak of JE is considered low. However JE outbreaks have occurred in Torres Straits and the vector - Culex vishnuii and Culex quinquefasciatus were both identified in a mosquito survey done by WHO in Dili on 16/10. Pigs are kept by many families and mosquito breeding near pigs occurs especially in rice fields in Baccau district. French and Australian military have been vaccinated. Environmental control measures are crucial particularly where pigs are living close to man.

3.7 Scabies

A total of 86 cases of scabies have been reported since 29/10. Lack of soap is a major problem and the cost of bar of soap in Dili market is now $2. Agencies were urged by WHO to make soap distribution a prioirty.

3.8 Other diseases with epidemic potential

A total of thirteen cases of chicken pox in two clusters were reported by MSF and TimorAid on 15/10/99 in Dili.

4. Surveillance

WHO established an emergency surveillance system for East Timor on 11/10/99 with reporting from the nine governmental and non-governmental agencies providing primary and secondary health care services in East Timor.

4.1 Reporting forms and case definitions

Reporting forms were developed in collaboration with local health professionals, NGOs and UNICEF and distributed at the Health Co-ordination meeting on 11/10/99. Fourteen priority communicable diseases/syndromes and 3 non-communicable diseases were included on the weekly health report form (Annex 2). WHO case definitions for 12 diseases/syndromes adapted for emergency situations were also developed. NGO health co-ordinators distributed forms and case definitions to health workers in the clinics.

4.2 Case reporting

Data is requested weekly, reporting period is Monday to Sunday with analysis done on Monday/Tuesday and report submitted to WHO at the next Health Co-ordination meeting in Dili or Baccau.

4.3 Data analysis

Data analysis is done in WHO Dili office. Weekly reports are produced. The database developed by CDS/CSR for Kosovo using Epi Info and Epi Map has been adapted for East Timor. Data received to date is primarily from Dili as NGOs only began to establish health facilities outside Dili from mid to late October. Four agencies provided retrospective data from 27/10/99 – 10/10/99 to WHO from health facility registers.

4.4 Mortality data

The majority of deaths are occurring outside health facilities and it is difficult to obtain data on these deaths. A total of 34 deaths were reported from 27/9/99 to 17/10/99. The ICRC hospital in Dili reported a number of deaths in the first 3 weeks of activity up to 17/10/99. Exact figures and causes were not available but deaths in children were mainly due to LRTI, diarrhoeal and malaria. Deaths occurred in surgical cases, one death each from pancreatitis, post-partum haemorrhage, chronic anaemia and TB. One death was reported by Portuguese Government Team due to bronchiolitis in a child. A major problem has been late medivac of seriously ill patients from areas outside Dili. MSF-F reported one death due to congenital malformation in a neonate. No deaths were reported by other health agencies.

4.5 Morbidity data

Communicable diseases account for over 60% of all consultations at the primary care level. The main communicable diseases reported are URTI (35%), suspected malaria (20%) and watery diarrhoea (20%).

Table 1 Morbidity data reported by health agencies to WHO from 3/10/99 – 17/10/99 on weekly report forms

| |3/10/99 - 10/10/99 |11/10/99 - 17/10/99 |

|Total consultations |2,258 |2,855 |

|Communicable diseases |1,645 |1,170 |

| | | |

|Disease/Syndrome |No of cases (% comm diseases) |No of cases(% comm diseases) |

|URTI |279 (40%) |369 (32%) |

|Suspected malaria |140 (20%) |237 (20%) |

|Watery diarrhoea |180 (26%) |191 (16%) |

|LRTI |40 (6%) |116 (10%) |

|Bloody diarrhoea |23 (3%) |29 (2%) |

|Scabies |25 (3%) |60 (5%) |

| | | |

|Non-communicable diseases | | |

|Malnutrition |23 |8 |

|Wounds |96 |210 |

The size of the population covered by this system is not known as displacement continues. There are no accurate population data available for Dili but rough estimates puts the population at 80,000. As a result, it is not currently possible to calculate incidence rates or assess disease trends. Most NGOs are using mobile clinics with unknown catchment areas to provide health services. Also NGOs are currently expanding the numbers of primary care facilities as the security situation improves and access to the population outside Dili and Baccao is possible. However, proportional morbidity data is useful to monitor the relative number of cases of a disease such as malaria. It is important that as soon as the security situation improves and the population stabilises, population data by district is available to allow calculation of incidence rates.

5. Malaria

5.1 Epidemiology of malaria

Malaria accounted for over 10% of all OPD consultations in East Timor in 1995. This was based on clinical diagnosis as laboratory facilities were not widely available. The parasite rate in malariometric surveys covering only 10% of the total population was 12.25. The slide positivity rate in studies done in 1998 was 49% with a range from 10% in Emera to 55% in Dili to 73% in Manufahi district. Of malaria cases diagnosed by microscopy, P. falciparum accounted for 60-80% with sporadic P. ovale.

5.2 Roll Back Malaria in East Timor

It is a major priority of WHO to ensure malaria control activities are implemented. WHO requested US$1,450,000 for malaria control in the UN Flash Appeal for East Timor (Annex 7). WHO discussed activities with the NGO International Rescue Committee (IRC) and Merlin in Dili on 20/10/99 and a outline plan of action was agreed (Annex 8). IRC will be the lead NGO for the ITN Programme in East Timor. 75,000 bednets funded by OFDA will be distributed in November/December 1999. An additional 100,000 nets were requested by WHO through the UN Flash Appeal. Treatment of the nets with insecticide will be done before distribution. An educational project on use of bednets is a core component of ITN Programme. Merlin agreed to co-ordinate RBM activities with WHO, IRC and other health agencies. AusAid in November 1999 pledged $545,700 for RBM activities in East Timor. The WHO Dili office is currently planning implementation of these activities with NGOs IRC and Merlin using this budget.

5.3 Morbidity and mortality

The WHO surveillance system reported that suspected malaria accounted for over 20% of all OPD consultations in October 1999. Parasite surveys done by Professor Claude Pierre at the French Military hospital have shown over 30% slide positivity rate with 60% due to P. falicparum. Preliminary data from the ICRC hospital showed similar patterns. Four cases of severe malaria were reported in first 2 weeks of October, anecdotal reports of deaths in young children were received but confirmation of this was pending.

5.4 Disease management

The first line treatment recommended for uncomplicated malaria prior to the conflict was chloroquine, with S/P as second line treatment. For treatment of severe malaria, quinine was recommended. However, chloroquine resistance has been documented in neighbouring island of Sumba with 35% early treatment failure. With a marked increase in transmission predicted and health services almost totally collapsed, it has been proposed that combination SP/CQ be used as first line treatment where laboratory confirmation is not available. WHO has recommended confirmation by microscopy or dipstick. However, laboratory facilities are currently available only in hospital facilities. Most NGO health facilities do not currently have capacity to provide basic laboratory services. Rapid diagnostic kits would be very useful but there is a cost issue – the cheapest available are $0.50 each produced in India or Cambodia.

5.5 Vector control

A limited mosquito survey was conducted by the WHO team on 16/10/99 in collaboration with Peter Whelan, medical entomologist with Territory Health services in Darwin. A total of 71 mosquitoes were trapped from two rural and two urban sites in Dili. 48 were trapped from one site – the swamp in the UN compound.

|Species |Number |Vector borne disease |

|Mansonia uniformis | 57 (45 female/12 male) | Potential vector for Wucheria bancrofti |

|Culex annulirostris | 1 female, | |

|Culex vishnui | 8 (7 females/1 male) | Potential vector for Japanese encephalitis|

|Culex quinquefasciatus | 5 female | |

No Anopheles or Aedes aegypti were trapped. This method of trapping not reliable for Aedes but with current dry conditions, the risk of dengue is low. This was a limited mosquito trapping survey done in the dry season. A repeat mosquito survey will be done by Peter Whelan during the monsoon season in early December 1999.

5.6 Malaria chemoprophylaxis in international staff

Mefloquine or doxycycline are the two drugs recommended for malaria chemoprophylaxis. Advice given to international staff in Dili that despite recommendation given in drug packets of mefloquine and doxycycline to continue prophylaxis for 2 weeks after leaving malaria endemic area, WHO recommends 4 weeks of treatment to ensure full protection.

6. Tuberculosis

TB is a major health issue in East Timor. Of 1,800 refugees evacuated to Darwin in September 1999 and screened for TB, 50 (2.8%) were commenced on TB treatment. The health agencies in East Timor reported high numbers of TB suspects. On 24/10/99, there were 16 TB cases in the ICRC Hospital in Dili on treatment - 9 males, 7 females. All had been diagnosed by sputum microscopy and chest X-ray, eight (50%) were sputum smear positive. All were commenced on category I treatment.

7. Immunisation

Over 3,500 children were given measles vaccination in a mass campaign organised by MSF in conjunction with UNICEF and WHO in Dili on 19/10/99. Vitamin A also given. OPV was planned to be administered at the same time but the vaccines procured by UNICEF did not arrive in time for the mass campaign. The target population was aged 9 months to 5 years. For planning purposes, a total population of 100,000 in Dili was used to estimate vaccine and logistic requirements with 15,000 under fives. Coverage was lower than expected, one of the reasons probably due to an over-estimation of the under five population. In addition, the population may also continue to have reservations about vaccination and accessing government health services. A follow up mass vaccination campaign is being planned for November 1999.

8. Recommendations

➢ Human resources – two epidemiologists Dr Jim Black and Dr Sandra Chaves arrived in Dili in early November. A team of four experts: Dr Vicki Krause, Dr Chris Evans and Dr Withnall from Territory Health Services, Darwin and Dr Nick Anstey from Menzies School of Public Health in Darwin conducted an assessment of the TB, malaria, and laboratory services from 26 – 28 October. A health policy expert is needed for long term, also logistician and administrator to support the Dili office. A WHO sub-office in Baccau will need to be set up to work with NGOs in Baccau and Lospalos districts.

➢ Surveillance system with weekly reporting of communicable and non-communicable diseases by NGOs to be strengthened and involve all districts. Reporting forms and case definitions should be distributed to all healht facilities. Mortality data should be obtained from the hospitals and community through the church. A system for official reporting of deaths through UNTAET should be established. Plans for a long term surveilance system should be developed with local health professionals and NGOs.

➢ Epidemic preparedness and response – immediate reporting of epidemic diseases to be made to WHO for investigation by WHO epidemiologists. Local and NGO health workers in all districts should be trained in epidemic detection and response. Epidemic response kits should be distributed to all districts. On the job training should be done with these health facility staff, it may be possible for NGOs to take on such a role in co-ordination with WHO. Cold chain for specimen transport should be in place.

➢ Malaria - The number of malaria cases are predicted to increase soon following the start of the rainy season in November 1999. The routine use of microscopy or dipsticks for detecting a P. falciparum or P. vivax infection followed by the drug of choice according to plasmodium species detected is strongly recommended. P. falciparum should be treated with one dose SP and P vivax should be treated with chloroquine for 3 days. However it is recognised that it will take time to rebuild the laboratory services and the use of dipstick for routine diagnosis is costly. So for the management of uncomplicated malaria diagnosed on clinical grounds without confirmation by microscopy or dipsticks, WHO recommends treatment with 3-day chloroquine plus SP for all cases with fever. Therapeutic efficacy studies in East Timor are planned for early 200 to guide the future treatment of malaria.

➢ Vector control - There is an urgent need to clear drains in Dili to avoid build up of water during the monsoon season and reduce the risk of outbreaks of malaria and dengue fever. Also to dispose of tyres and containers to prevent breeding of Aedes aegypti.

➢ Laboratory services need to be strengthened. NGOs should be encouraged to build up the laboratory capacity. International reference laboratories must be contacted directly for diseases such as polio.

➢ Tuberculosis – WHO advised agencies that a TB control programme in a post-emergency situation should not be started unless the following criteria are met: a stable population, essential clinical services in place, facilities for sputum smear microscopy and reliable supply of drugs. With continuing population movement, treatment completion cannot be assured and the risk of multi-drug resistant TB (MDR-TB) in East Timor would increase markedly. TB drugs are available in East Timor – drugs in blister packs for 1,860 patients were found in a Government warehouse with an expiry date of 10/2000. Caritas which has been implementing a TB control programme in East Timor for the past 2 years has agreed to be the lead NGO for TB control working with WHO and Dr Nelson, a physician from East Timor. Dr Vicki Krause, WHO TB expert conducted a mission to East Timor from 26-29 October to review the TB situation. Further information on the TB situation is available in the mission report form Territory Health Services.

➢ Immunisation - Routine vaccination schedule recommended by WHO/Jakarta for East Timor

Birth BCG

8,12,16 weeks DPT, OPV

9 months Measles, OPV, HBV

This schedule differs slightly from the WHO recommended schedule which suggests administering DTP, OPV at 6,10 and 14 weeks. This is the Indonesia vaccination schedule policy which East Timorese health workers have been trained to implement. Hepatitis B is endemic is Indonesia and has a high disease burden in East Timor. HBV should be implemented into the vaccination schedule as soon as situation stablises.

A routine vaccination programme must be re-established as soon as possible. Health facilities should be supplied with cold chain equipment. Local health staff should be reinstated are retraining done where necessary. UNICEF will distribute EPI kits to 11 heath facilities in Dili including cold chain equipment.

➢ Health survey - is needed to collect data on burden of disease, immunisation and access to health care. A comprehensive review of all health facilities will also be done. The purpose of the health survey would be:

➢ To assess the health status, health needs and health care seeking patterns of the population

➢ To assess the provision of health services for the population

➢ To identify gaps in meeting health needs

➢ To make recommendations for a plan of action and budget to provide an evidence base for policy development, planning and budgeting of the health services in East Timor

In order for the information to be useful for the future planning of the health services in East Timor, the survey should be done when the majority population returns to their home villages. The possibility of a collaboration with IRC similar to the health survey conducted in Kosovo should be explored.

Annex 1 Terms of reference

Mission to East Timor

4 October – 22 October 1999

Under the supervision of the WR Indonesia and Field office East Timor

1. To develop a health surveillance system for the emergency phase and co-ordinate implementation with operational agencies, specific activities include:

➢ conducting needs assessment for surveillance system

➢ developing standard reporting forms and case definitions

➢ establishing reporting mechanisms

➢ establishing early warning system for outbreaks

➢ assessing laboratory capacity for confirmation of main communicable diseases – identification of laboratory, collection and transport of samples

➢ conducting data analysis

2. To develop a plan for epidemic preparedness and response for main epidemic prone diseases with operational agencies

3. To conduct preliminary assessment of the malaria situation

Figure 2 MAP of East Timor

Annex 3 WEEKLY HEALTH REPORT FOR EAST TIMOR

AGENCY:___________________ HEALTH FACILITY:______________________

REPORTING PERIOD:______TO______ TOWN/DISTRICT:_______________________

POPULATION COVERED:_________ NAME/TITLE OF REPORTER:__________________

| |NEW CASES |

| |Under 5 years |5 years & over |TOTAL |

|*Bloody diarrhoea | | | |

|Watery diarrhoea | | | |

|*Suspected cholera | | | |

|Suspected malaria/ | | | |

|Upper respiratory tract infections | | | |

|Pneumonia/Lower RTI | | | |

|*Measles | | | |

|*Suspected meningitis | | | |

|*Acute jaundice syndrome | | | |

|*Suspected polio/AFP | | | |

|Neonatal tetanus | | | |

|Scabies | | | |

|Sexually transmitted diseases | | | |

|Fever unknown | | | |

|Other communicable diseases | | | |

| | | | |

|Trauma/Injury | | | |

|Malnutrition | | | |

|Mental health problems | | | |

|Other non-communicable diseases | | | |

|TOTAL NO. CONSULTATIONS | | | |

|REFERRALS TO HOSPITAL |Total number: |

|Age and sex of cases Name of hospital |Cause of referral |

| | |

| | |

|DEATHS |Total number: |

|Age, sex, location of death |Cause of death |

| | |

| | |

|BIRTHS Number: |STILLBIRTHS Number: |

Diseases with epidemic potential - report as soon as possible to your Health Co-ordinator

TB cases will be recorded on a separate form, record suspected TB cases as URTI

Please hand the weekly form to WHO at Health Co-ordination meetings

Annex 4 Guidelines for Surveillance System in East Timor[pic]

for use in emergency phase

PURPOSE

1. To describe and monitor health status of the population in East Timor

2. To provide early warning of outbreaks of the following major communicable diseases in East Timor:

Bacillary dysentery

Cholera

Malaria

Measles

5. Meningococcal meningitis

6. Hepatitis A and E

7. Typhoid fever

8. Dengue fever

9. Scabies

10. Japanese encephalitis

In addition to the above epidemic prone diseases, the main health problems are likely to be:

▪ Upper respiratory tract infection

▪ Pnuemonia/Lower respiratory tract infection

▪ Malnutrition

▪ Trauma/injury

REPORTING MECHANISMS

➢ In each health facility, a daily register of consultations should be kept

➢ Suggested lay out of register in health facility:

|OPD no |Date |Name |Location |Sex |Date of birth |New case/ Follow |Diagnosis |Treatment |

| | | | | | |up | | |

| | | | | | | | | |

| | | | | | | | | |

| | | | | | | | | |

| | | | | | | | | |

| | | | | | | | | |

➢ One person in each health facility should be identified as responsible for data collection and notification of potential epidemics to the Health Co-ordinator. In each NGO, one person should be responsible for compiling the data from the daily register for the Weekly Health Report

➢ The weekly form should be filled out from Monday - Sunday and compiled by the NGO Health Co-ordinator on Monday.

HOW TO FILL IN THE WEEKLY HEALTH REPORT

➢ Data should be recorded in two age categories: under 5 years and 5 years and over

➢ New cases/consultations requested for communicable and non-communicable diseases.

➢ All cases attending the health facility should be recorded on the Weekly Health Report Form, including those who are subsequently referred to hospital.

➢ Record only new cases, follow up visits for the same disease episode should not be recorded.

➢ In the case of two communicable diseases for the same consultation, record the most important disease.

➢ If one of the diseases has epidemic potential marked with an asterisk in the form, record this disease as the main cause of consultation.

➢ “Other communicable diseases” include all cases of communicable diseases not mentioned in the list of diseases eg skin infections

➢ “Other non-communicable diseases” include all cases of non-communicable diseases not mentioned in the list of diseases eg gastrointestinal problems.

➢ For diseases with epidemic potential marked with an asterisk in the Weekly Report, it is important to report a case as soon as possible to the Health Co-ordinator and WHO.

TOTAL NUMBER OF CONSULTATIONS

Record total number of consultations in OPD in a week

REFERRALS TO HOSPITALS

Record number, age, sex and cause of referral for referrals to Hospitals

DEATHS

Record age, sex and main cause of death.

BIRTHS AND STILLBIRTHS

Record number of births and still births during the week

CASE DEFINITIONS

The case definitions attached are standard definitions adapted by WHO for emergency situations.

Suspected cases are those diseases which require laboratory confirmation.

The process for laboratory confirmation eg samples to be taken and where to send will be provided in a separate document.

DATA ANALYSIS

Data will be analysed by WHO using Epi-Info. Weekly reports will be produced for dissemination to all NGOs

Thanks for your work on this!

WHO office, Dili

October 11, 1999

Annex 5 WHO CASE DEFINITIONS FOR EAST TIMOR

FOR USE WITH WEEKLY HEALTH REPORT

BLOODY DIARRHOEA

Diarrhoea with visible blood in the stool

To confirm case of epidemic bacillary dysentery:

Isolation of S. dysenteriae type 1 from stools

WATERY DIARRHOEA

Three or more loose or watery stools over 24 hours with or without dehydration.

SUSPECTED CHOLERA

Person aged over 5 years with severe dehydration from acute watery diarrhoea

Person aged over 2 years with acute watery diarrhoea in an area where there is a cholera outbreak.

To confirm case:

Isolation of Vibrio cholera O1 or O139 from stools

SUSPECTED MALARIA

UNCOMPLICATED MALARIA:

Person with fever or history of fever associated with symptoms such as nausea, vomiting and diarrhoea, headache, back pain, chills, myalgia, where other infectious diseases have been excluded.

SEVERE MALARIA:

Person with fever and symptoms as for uncomplicated malaria but with associated signs such as disorientation, loss of consciousness, convulsions, severe anaemia, jaundice, haemoglobinuria, spontaneous bleeding, pulmonary oedema, shock.

To confirm case:

Demonstration of malaria parasites in blood films by examining thick or thin smears or by rapid diagnostic kit for P. falciparum diagnosis

PNEUMONIA/LRTI

Children < 5 years: cough or difficult breathing and

breathing faster than 50/min for child 2-12 months

breathing faster than 40/min for child 1-5 years

Adults 60 years: cough +/- expectoration and breathing faster than 20/min

MEASLES

Person with: fever and maculopapular (non-vesicular) rash, and

cough, coryza (runny nose) or conjunctivitis (red eyes)

or Any person in whom a medical officer suspects measles infection

SUSPECTED MENINGITIS

Person with sudden onset of fever (>38.0 °C axillary) and one of the following:

neck stiffness

altered consciousness

other meningeal sign

or petechial or purpural rash

In children 38 C.

MALNUTRITION

Weight for height index3 weeks or haemoptysis

and significant weight loss

Patients with TB may also have chest pain, breathlessness, fever/night sweats, tiredness and loss of appetite

All TB suspects should have three sputum samples examined by light microscopy, early morning samples are more likely to contain the TB organism than a sample later in the day

TUBERCULOSIS

Pulmonary TB, smear positive

4. Person with at least two sputum smear examinations positive for Acid Fast Bacilli (AFB), or

5. Person with one sputum examination positive for AFB and radiographic abnormalities consistent with active pulmonary TB as determined by a medical officer

Pulmonary TB, smear negative

Person with symptoms suggestive of TB and having three smears negative or a series of two smears negative at intervals of 2 weeks following a course of broad spectrum antimicrobials and a decision to treat by a medical officer.

New case: Person who has never had treatment for TB or took anti-TB drugs for less than

four weeks

Retreatment case: Person previously treated, failure, relapse or returning smear positive after interruption in treatment

Annex 6 STEPS FOR MANAGEMENT OF A COMMUNICABLE DISEASE OUTBREAK IN EAST TIMOR

| |

|PREPARATION |

|Health Co-ordination meetings three times weekly in Dili |

|Surveillance system – Weekly Health Reports to WHO |

|Stockpiles – specimen kits, appropriate antibiotics, IV fluids |

|Epidemic Investigation kits |

|Contingency plans for isolation wards in hospitals |

|Laboratory support |

|( |

|DETECTION |

|If you diagnose a case of the following diseases/syndromes: |

|Bloody diarrhoea |

|Suspected cholera |

|Measles |

|Meningitis |

|Acute jaundice |

|Suspected polio (acute flaccid paralysis) |

|Influenza-like illness |

|Or a cluster of cases of acute watery diarrhoea or fever of unknown origin |

| |

|Inform your Health Co-ordinator as soon as possible |

|Health Co-ordinator should inform WHO (Tel 0872 761 241 750) |

|Take clinical specimen for laboratory confirmation eg stool, serum, CSF |

|Include case in Weekly Health report |

|( |

|3. RESPONSE |

|CONFIRMATION - WHO will investigate cases reported to verify outbreak exists |

|Clinical specimens will be sent for testing |

|WHO will set up Outbreak Control Team with membership from relevant organisations - health NGOs, water and sanitation NGOs, veterinary experts, |

|UNICEF |

| |

|INVESTIGATION - Collect/analyse descriptive data to date eg age, date of onset, location of cases |

|Develop hypothesis for pathogen/source/transmission |

|Develop outbreak case definition |

|Follow up of cases and contacts |

|Conduct further investigation/epidemiological studies |

|CONTROL - Implement control measures specific for the disease |

|Treat cases with recommended treatment as in WHO guidelines |

|Prevent exposure e.g. isolation of cases in cholera outbreak |

|Prevent infection e.g. immunisation in measles outbreak |

| ( |

|4. EVALUATION |

|Assess timeliness of outbreak detection and response, cost |

|Change public health policy if indicated eg preparedness |

|Write outbreak report and disseminate |

Annex 7 UN Flash Appeal

Surveillance and Epidemic Response

|Appealing Agency |World Health Organization |

|Project Number | |

|Project Title |Health Surveillance System and Epidemic Preparedness and Response |

|Objectives |To monitor the health status of the population and establish an epidemic preparedness and response system |

|Target Beneficiaries |General population of East Timor |

|Implementing Partners |Local health agencies, UN Agencies, NGOs and ICRC |

|Project Duration |October 1999 – June 2000 |

|Funds Requested |USD 900,000 |

SUMMARY

Population displacement and collapse of the health services in East Timor pose an increased risk to the health of the population. The major disease threats among the population are respiratory tract infection, diarrhoeal diseases, malaria and malnutrition. Monitoring of the disease burden in this vulnerable population is essential over the next nine months. A health surveillance system will be established by WHO for the post emergency phase and implemented in collaboration with local health agencies, UN agencies, NGOs and ICRC. The data collected will be used to identify health priorities and assist in the development of the future health services for East Timor.

The health surveillance system will also ensure the early detection of outbreaks and allow control measures to be rapidly implemented. There is a high risk of outbreaks of cholera, dysentery, dengue, Japanese encephalitis, malaria and measles over the next nine months. The major risk factors for communicable disease outbreaks are all currently present in East Timor: population displacement, malnutrition, a collapsed health system, low immunisation rates and disruption in vector control programmes. Given the likelihood of major outbreaks, the establishment of an epidemic preparedness and response system is a top priority. To ensure that outbreaks are rapidly detected and controlled, this preparedness and response system will be linked to the health surveillance system.

Objectives

▪ To establish an emergency health surveillance system that will monitor disease trends and provide early warning of epidemics.

▪ To provide health data to EHA’s Health Intelligence Network for Advanced Contingency Planning (HINAP) project for dissemination on the web.

▪ To rapidly detect and control epidemics in East Timor.

▪ To ensure laboratory support is available to test clinical specimens for epidemic-prone communicable diseases.

▪ To train national and NGO health staff in early detection and response to outbreaks.

Activities

1. Recruit an epidemiologist to establish and operate the surveillance system.

2. Develop and distribute reporting forms and case definitions.

3. Establish reporting mechanisms from all districts of East Timor.

4. Collect and analyse data on communicable and non-communicable diseases.

5. Design a software package for data entry and analysis using Epi-Info.

6. Recruit local staff for data entry and public information.

7. Train national and NGO health workers on surveillance, data collection and analysis.

8. Establish an Outbreak Control Team (OCT) for East Timor.

9. Ensure stockpiles of supplies for potential outbreaks including IV fluids, vaccinations, and drugs.

10. Develop and distribute standard case management protocols for epidemic diseases.

11. Develop laboratory capacity in East Timor to confirm main communicable diseases.

12. Agree on contract with International Reference Laboratories for testing of clinical specimens for epidemic prone diseases including Japanese encephalitis and dengue.

13. Ensure Epidemic Investigation kits and Epidemic Response kits are on site in all 13 districts.

14. Train national and NGO health workers in epidemic detection and response.

Financial Summary

|Budget Item |USD |

|WHO epidemiologist and technical expertise |200,000 |

|Development, translation and printing of guidelines |125,000 |

|Local support staff including information officer, data entry clerk and secretarial support |25,000 |

|Computer hardware and software for all 13 districts |100,000 |

|Laboratory supplies |75,000 |

|Transport |75,000 |

|Procurement and distribution of Epidemic Investigation kits |100,000 |

|Procurement and distribution of Epidemic Response kits |100,000 |

|Training workshops at all levels for epidemic preparedness and response |100,000 |

|Total |900,000 |

Roll Back Malaria

|Appealing Agency |World Health Organization |

|Project Number | |

|Project Title |Roll Back Malaria |

|Objectives |To reduce mortality and morbidity from malaria |

|Target Beneficiaries |General population of East Timor |

|Implementing Partners |Local health agencies, UN Agencies, NGOs and ICRC |

|Project Duration |October 1999 – June 2000 |

|Funds Requested |USD 1,450 000 |

SUMMARY

Malaria is a major health problem in all 13 districts of East Timor. Four districts including the capital are high transmission areas. The peak transmission period is December to January. The major challenges in controlling malaria are: collapse of the health care services, interruption of vector control activities, poor drainage and environmental sanitation in villages especially in the rainy season and chloroquine resistance. WHO will implement a malaria control programme integrated with the general health services using the Roll Back Malaria strategy (RBM) developed for emergency situations.

Objectives

▪ To reduce the morbidity and mortality for malaria using the Roll Back Malaria strategy.

▪ To conduct an assessment of the malaria situation using experts based in the region and from RBM Complex Emergencies Network.

▪ To conduct surveys to measure parasite prevalence and drug resistance.

▪ To support insecticide spraying programmes.

▪ To procure and distribute 100,000 insecticide-treated mosquito nets in collaboration with the International Rescue Committee.

▪ To ensure accurate diagnosis and effective treatment of malaria in order to reduce morbidity, mortality from malaria.

▪ To implement a health education programme on malaria, targeting those most at risk of disease and death.

Activities

1. Provide technical support using WHO staff, experts in the region and professionals from the RBM Complex Emergency Network.

2. Train national and NGO trainers in diagnosis, case management and environmental health.

3. Ensure that laboratories have the capacity to confirm malaria at the district and sub-district levels.

4. Develop, translate, print and disseminate key documents.

5. Organise a public health education campaign in collaboration with key partners.

6. Procure 100,000 mosquito nets with IRC and distribute them with other non-food items in collaboration with UNHCR.

7. Conduct a KAP survey to determine the knowledge, attitudes and practices related to malaria and fever in general.

8. Based on the KAP survey, design and implement an educational campaign using mass media that targets vulnerable groups, particularly children under five and pregnant women.

Financial Summary

|Budget Item |USD |

|Technical expertise including travel related cost for WHO and RBM Network staff |125,000 |

|Drug resistance and malariometric surveys |75,000 |

|Vector control interventions |150,000 |

|Translation and printing of key documents |50,000 |

|Training for local staff in microscopic diagnosis of malaria |150,000 |

|Training of trainers in diagnostic, case management and environmental health |100,000 |

|Public health education campaign |100,000 |

|Purchase and transport of nets |650,000 |

|Epidemic stockpiles including rapid diagnostic kits |50,000 |

|Total |1,450,000 |

Annex 8 Roll Back Malaria in East Timor

1. RBM ITN and social mobilisation programme in East Timor

IRC in collaboration with WHO

Programme activities:

• ITN procurement and of 100,000 permethrin impregnated bednets, to add to 75,000 nets already procured.

• Distribution of bednets in coordination with health clinics, churches, local organisations and international NGOs.

• Conduct a KAP survey to determine community knowledges, attitudes and practices related to malaria and fever.

• Design and implement education campaign on use of bednets targeting vulnerable groups, in conjunction with WHO, local and international NGOs

• Design and implement an expanded health education and community mobilisation campaign about malaria and other high risk illnesses, collaborating with various community groups and international NGO’s using a variety of media and culturally appropriate techniques.

• Coordinate with other agencies implementing disease surveillance and outbreak control, in particular WHO.

• Coordinate with Merlin in its East Timor RBM malaria control program.

2. RBM malaria control programme in East Timor

Merlin in collaboration with WHO

Programme activities:

• Provide technical support and expertise in implementing RBM program in East Timor, in coordination with WHO, IRC and other international NGOs and national organisations

• Improve access to quality antimalarials.

• Conduct parasite prevalence surveys.

• Ensure appropriate diagnosis and case management of malaria by training international NGO and local health workers using adapted IMCI materials.

• Review basic laboratory capacity to confirm malaria at district and subdistrict level, liaising with agencies providing direct clinical care and providing basic materials and equipment where necessary.

• Coordinate with other agencies implementing disease surveillance and outbreak control, in particular WHO and IRC.

• Coordinate with IRC in its East Timor RBM ITN and social mobilisation programme.

• Coordinate with other agencies implementing environmental management, health education and community development programs.

• Implement indoor residual spraying and other emergency vector control activities in temporary shelters and other settings where appropriate.

WHO Dili, IRC, Merlin

20 October 1999

Annex 9 Persons met

WHO Regional Office for South-East Asia (SEARO)

Dr Uton Regional Director

WHO, Indonesia

Dr Georg Petersen WR, Indonesia

WHO, Darwin

Mr Stephenson Administrator

Dr Bipin Verma Head of Darwin office

WHO, East Timor

Dr Diego Buriot Special Envoy of the DG

Dr Elio Giombini WHO Technical Co-ordinator

Mr. Eddy Matos SUMA

Mr. Victor Martinez SUMA

Mr. Gerardo Quiros SUMA

Dr Steven Rosenthal EPI, WHO Indonesia

East Timorese Health Professionals Working Group

Dr Sergio Lobo

Dr Nelson Martin

OCHA

Mr Ross Mountain Humanitarian Co-ordinator a.i.

Ms Lise Grande Political Advisor

Mr Mikael Elmqvist Head of Office

Gilbert Greenall CIMIC

Bob Churcher DFID liaison

Andre Dehondt Chief Admin

UNICEF

Mr Rodney Hatfield Officer in charge

Dr Sam Hari Project Officer, Health

Dr Myo Project Officer

Mr Paul Martin, Programme officer, NY

UNHCR

Mr Bernhard

WFP

Peter Scott Bowden

Maria Abad Zapatero Agronomist

Peter Iskander Senior Logisitic officer

DFID

Mr James Brown Camp manager, Team Leader

ECHO

Dr Josep Vargas ECHO Co-ordinator, Jakarta

OFDA

Justin Sherman Regional Advisor

Territory Health Services, Darwin

Mr Peter Whelan Director, Medical Entomology branch

Dr Vicki Krause Director, Center for Disease Control – TB expert

Dr Nick Anstey Menzies School of Health Research – malaria expert

Dr Jay Withnall Laboratory expert

Dr Chris Evans Epidemiology registrar

ICRC

Ann Aerts- Novara Health Services Unit, ICRC, Geneva

UNDP

Joe Comerford Officer in charge UNDP mission to East Timor, Darwin

Merlin

Stuart Shepard

Nadine

International Rescue Committee

Jesse Rattan Medical Co-ordinator

Lisa Periera

OIKOS

Enda Byrne, Project Co-ordinator

Concern

Niall Roche

Goal

Ann Jones

Ken Ryan

Eoin O’Suillabhain

Caritas

Cathy Georgeson

AMI

Sandra Vieria

MDM-F

Laurent

MDM-P

Emma

Mario

Joachim

MSF - International

James

Heidi Quinn

MSF-F

Susanna Christophani

Mags Mc Guinness

Timor Aid

Ken Baker

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