South Asia: Tsunami & Health Situation Report # 39

Report
from World Health Organization
Published on 25 Feb 2005
Affected countries like India and Sri Lanka are now focusing on large-scale health education campaigns to promote better hygiene standards among the displaced populations. In Sri Lanka, providing health services to families that have relocated spontaneously is a significant challenge facing health authorities.

Summary

- Coordination of the relief effort is a growing problem in Sri Lanka.

- Finding suitable relocation sites continues to be an issue and is delaying the provision of more permanent health services.

- A probable case of meningococcal meningitis has been reported in Lhokseumawe

- A mass health education campaign has been conducted in Little Andaman to encourage the use of pit latrines and promote good personal hygiene.

Communicable Diseases

India: No communicable disease outbreaks or unusual events have been reported. Health authorities are currently negotiating for Thanjavur Medical College to provide laboratory and epidemiology support to Nagapattinam district, and for the Jawaharlal Institute for Postgraduate Medical Education and Research (JIPMER), Pondicherry, to provide similar support to Cuddalore district. WHO and the Government of India are strengthening the disease surveillance system in the Andaman and Nicobar islands. Larval control measures have been taken in Little Andaman. A medical surveillance team visited Onge camp in Little Andaman.

Indonesia: A probable case of meningococcal meningitis has been reported in Lhokseumawe. Antibiotic treatment has been initiated, and close contacts have been treated with appropriate prophylaxis. Surveillance for further cases is ongoing.

Five new cases of dengue fever have been reported in Lhokseumawe and Aceh Utara, and are being investigated by the public health officials.

A new case of bloody diarrhoea due to Shigella flexneri was reported (location not specified). The bacterial isolate was sensitive to amoxicillin and ciprofloxacin, but resistant to tetracycline and chloramphenicol. Three case of scrub typhus were reported (location not specified). Investigations are ongoing.

Rotavirus gastroenteritis was also confirmed in a patient with suspected cholera (location not specified).

Myanmar, Thailand and Sri Lanka: No communicable disease outbreaks or unusual events have been reported.

Health System and Infrastructure

India: A mass health education campaign has been conducted in Little Andaman to encourage the use of pit latrines and promote good personal hygiene.

WHO's Country Office, in collaboration with the Department of Health and Family Welfare, Government of Tamil Nadu, held a symposium on 23 February 2005, on the management of health emergencies during disasters. The state health sector's response to the disaster is also being documented, both in print and visually.

Sri Lanka: Following a visit to Ampara, Batticaloa and Kalmunai, a WHO expert reported that the hospital laboratory in Batticaloa, and laboratories in Kalmunai, did not have the facilities to perform microbiological tests. Most laboratories needed additional laboratory testing equipment. Five hundred microscopes have been ordered, of which 200 are for tuberculosis (TB) and malaria surveillance. Another 200 are required.

Another challenge facing health authorities is the provision of adequate health services to relocated displaced families, especially those who settle spontaneously. In Jaffna, the Department of Health has stressed the importance of setting up temporary health centers that are easily accessible to displaced families living in camps as well as those staying outside the camps with friends and relatives. Temporary health clinics inside the camps have also been proposed. In the interim, UNICEF has decided to provide family tents for use as health clinics in camps.

Nutrition, Food Safety and Security

Sri Lanka: UNICEF is working with the Family Health Bureau to design training courses on health and nutrition in emergencies. In Hambantotata district, the health authorities have started distributing Triposha (blended food rich in micro-nutrients) to camp children.

Environmental Health

Sri Lanka: In Jaffna, WHO, in collaboration with UNICEF, Action Contre la Faim (ACF), and the Danish Red Cross, has launched a coordinated hygiene promotion campaigns in camps for internally displaced persons (IDPs). This will be followed by the distribution of hygiene kits. UNICEF is also working with a group of NGOs (Merlin, Oxfam, Terre des Hommes, Oxfam UK, ACD and Solidarite) in Ampara district to coordinate hygiene promotion, with 400 volunteers from the district health authorities willing to spread the messages in schools and communities. UNICEF is finalizing a proposal with the Ministry of Health to train public health inspectors on effective health and hygiene promotion in IDP camps in Batticaloa district. Thirty-two government, military and NGO staff will be trained on chlorination.

In most districts, water and sanitation activities are hampered by uncertain relocation plans, and the spontaneous resettlement of families on private lands. Private landowners frequently oppose the construction of toilets and the installation of water points on their land. In Jaffna, the Relief and Response Coordination Committee has allocated four transit centers for UNICEF to provide water and sanitation services. A total of 32 toilets and nine wells will be constructed in these sites.

Well cleaning activities continue. In Trincomalee, 287 wells have been cleaned and dewatered in Kuchaveli, with technical support and food assistance for workers from UNICEF. All wells are now in use. Water supply is planned for the Moraketiara fishery housing scheme, Kirinda semi-permanent houses and Nakulugamuwa primary school in Hambantota district. In Ampara district, a system for monitoring the 18 water bowsers operating in the district is being developed. A total of 44 water tanks with stands and fittings have been distributed in Trincomalee district. In Hambantota, the construction of toilets in two damaged schools and a mosque is ongoing and UNICEF has shared designs for the construction of child-friendly toilets. One hundred and nineteen toilets have been constructed In Batticaloa, while in Trincomalee, UNICEF has installed 140 latrines. One hundred prefabricated units have been provided to the Ministry of Health and 50 plastic squatting plates were given to Oxfam for latrine construction.

Waste disposal is a problem in some districts. In Hambantota, for example, the disposal of plastic bottles and containers is a growing problem.

Maternal and Child Health

Sri Lanka: In Kalmunai division of Ampara district, the district health authorities have resumed immunization services in four temporary locations for displaced families. They also have a temporary maternity room and labor ward in Marruthumanai where 30 to 35 deliveries are estimated to occur per month. UNICEF will support these activities.

Shelter

Sri Lanka: While identification of relocation sites, and construction of temporary shelters, are well under way in some districts, the situation remains confused in other districts. In several districts, no information is available, nor is there consultation with displaced families about their relocation options. There is pressure on families to move prematurely, and delays in identifying land and building temporary shelters.

The construction of relocation sites is well under way in Kilinochchi and Mullaitivu districts. In Jaffna district, the local authorities are seeking to accelerate the construction of the planned 18 transit centers. It is reported that pressure is being put on displaced families to move out of schools and churches before the transit centers have been completed. Some IDPs have moved out of the temporary camps and are now living in tents without adequate services. In several other districts, families are spontaneously moving and setting up tents on private lands. This creates difficulties in the provision of adequate water and sanitation services, and there are concerns about the physical and psycho-social well-being, and the protection of families living in such conditions.

In the absence of comprehensive relocation plans in all districts, a number of schools continue to be used as temporary shelters. Although lessons are continuing in these schools in some districts, such as Trincomalee and Jaffna, it is generally difficult to run classes in schools being used to house IDPs. There were two reports of displaced families being forced to move out of schools in Thirokovil and Alaydevikbu areas of Ampara. In other districts, such as Mullaitivu, alternative sites have been identified for use as temporary schools, until the school buildings are vacated.

In Trincomalee, land has been surveyed for relocation sites and land allocations proposed, but the information has not yet been made public. In Kinniya, however, the proposed land has been disallowed, so new land will need to be identified.

Other News

Sri Lanka: Coordination is becoming increasingly difficult in Sri Lanka. There are concerns in some districts that decisions are being made centrally without sufficient consultation or communication with the districts. Local coordination structures that were functioning well are being replaced by central coordination mechanisms. UNICEF reported that new organizations are arriving in districts with permission to work from the central government, but without informing the local authorities of their presence or proposed activities. Consultation with affected populations is almost non-existent. In addition, there is the growing problem of coordination between relief agencies. There is also confusion regarding the coordination of the emergency response at the central level following the closure of the Centre for National Operations (CNO) and the establishment of several task forces.

Report of an outbreak of disease amongst crows in the Maldives
( Maldives Tsunami Sitrep No. 39, 17/2/2005)

Background: The first report of an outbreak of "dying crows" was made by the chief of Kedhikulhudhoo Island, Noonu Atoll in the northern Maldives on 28 December 2004, two days after the tsunami struck the islands. The Ministry of Health was particularly concerned about the possibility of West Nile Virus (WNV) transmission occurring in the islands for the first time.

After 2 days of travel, a team consisting of an epidemiologist, laboratory technician, the program manager for vector-borne diseases, and field operators with fogging machines, arrived on Kedhikulhudhoo Island on 8 January 2005. During the next 3 days, they visited four islands which reported the increased occurrence of dying crows, Kedhikulhudhoo, Hebadhoo, Kudafari and Maafaru Islands.

Decomposing crows were seen on the beaches of all the islands. No other bird species appeared to be involved in the outbreak.

The dying crows showed the following signs and symptoms:

- discharge from the eyes and nose,

- bloody diarrhea, and discharge from the cloaca

- some dying crows were blind.

People on the four islands appeared healthy. Most of the islands' populations were exposed to the dead and dying crows. Some crows had been buried by them. People with undiagnosed fever were found, but no rash, neurological symptoms or neurological signs were found amongst any of the fever cases. No cases of fever were found on Kudafari Island.

No major damage was seen on the four islands due to the tsunami, although the water level was estimated to have reached 1.5 meters and stayed for about five minutes.

House-to-house spraying with malathion was performed on the four islands using Ultra Low Volume (ULV) and swing fog machines. Bushes surrounding houses were also sprayed. Dying flies and mosquitoes were seen immediately after the fogging.

Specimens were collected for investigation. Only obviously dying crows were included, and seven of these, from three islands, were caught and sacrificed. Samples of the crows, consisting of brain (one sample), liver (three samples) and cloaca (one sample) were taken. A total of 15 blood samples were collected from febrile patients attending the health clinics on the affected islands. Five blood samples were taken from 12 outpatients at Kedhikulhudhoo Island clinic, five from Hebadhoo Island, and five blood samples from Maafaru Island. No febrile cases were found on Kudafari Island.

Both animal and human blood samples were sent for virus isolation and serological testing. The blood samples were sent to the National Institute of Virology, Pune, India, and the crow samples were sent to the Australian Animal Health Laboratory (AAHL), Geelong, Australia.

Investigation results: All the human blood specimens were negative for West Nile Virus (WNV) and Avian Influenza (AI).

Avian Influenza and WNV were not detected in any of the crow samples. Tests for Nelson Bay virus and Broom virus were also negative. Syncytial cytopathic effects (CPE) were observed in monolayers inoculated with liver and the cloaca samples. Cellular material and supernatant was sent for electron microscopic examination. Viral particles were seen, and the viral structure is indicative of the Family Reoviridae and Genus Orthoreovirus. Further viral characterization is ongoing.

This virus is not usually a human pathogen. It has been responsible for similar deaths among crows in Canada in 2004 and the United States in 2000. The virus is considered an emerging disease of crows.

Since the investigation, islands in the central region of the Maldives island chain, far away from the initial site of the outbreak, have also reported increased deaths amongst the crow population.

WHO Tsunami Task Forces are established at HQ, SEARO and affected countries to support affected Member Countries and respond to emerging issues associated with the region-wide emergency. More information on WHO activities and media are detailed at: www.who.int and http://w3.whosea.org/index.htm.