Current status
Communicable diseases continue to cause
a high burden of ill health in the Northern Governorates. Poor water and
sanitation are the main cause of transmissible disease, closely followed
by poor general living conditions and a background of inadequate nutrition.
Immunisation rates are low, but they are improving and the development
of mobile epidemic disease surveillance and response teams has enhanced
reaction to outbreaks.
Outbreak surveillance and response
Epidemic surveillance has improved dramatically since the development of mobile sampling, investigation and response teams at the beginning of this year. These teams are a key element in a 'preparedness' programme sparked by the cholera epidemic in 1999.
Using SCR 986* funds, WHO and local clinicians have trained 25 teams of local technicians in sample collection, reverse cold chain and investigation of transmission sources such as food and water. Each team covers 12 health facilities and rented vehicles allow them to make weekly visits even to remoter areas to monitor case reports, take samples, monitor food premises and handlers, carry out public education and institute preventative measures if infectious diseases are identified. The teams work in close collaboration with the local authority prevention department and infectious disease departments WHO has also instigated a weekly technical committee at local authority level to monitor activities and develop plans for action on specific disease threats.
* SCR 986 is the Security Council resolution which authorizes the sale of Iraqi oil to fund humanitarian supplies, commonly known as the 'Oil for Food' programme.
Laboratories
Laboratory investigation to ensure correct diagnosis and treatment of infectious disease is extremely restricted throughout Iraq. Though SCR 986 funds have allowed equipment such as microscopes to be provided and laboratory spaces to be renovated, most work continues to be done manually using old fashioned techniques because purchase of modern equipment has been delayed by concerns regarding 'dual use'. There is also dire shortage of laboratory reagents for the same reason. Some training has been done by WHO to raise the skill level of laboratory technicians in the Northern Governorates, but more is needed.
Immunization coverage
According to UNICEF, the percentage of fully immunised children in the Northern Governorates has almost doubled from 24% in 1993 to 42% in 1999. BCG vaccination rates showed steady coverage from 1993 to 1997 but have dropped substantially this year - from 93% to 77% due to irregular flow of vaccines.
UNICEF is responsible for the distribution of childhood vaccines and accessories in the Northern Governorates, but supplies are procured by the Government of Iraq.
Cholera and other diarrhoeal diseases
A repeat of last year's epidemic of cholera appears to have been averted in 2000, in part due to prevention activities by local health authorities and UN agencies described above. By the end of October, only seven cases of cholera had been reported in Erbil governorate and zero cases in Dohuk and Sulaimaniyah, compared to over 2000 cases in Sulaimaniyah alone in 1999. Accurate records were not kept in the other two governorates.
But the high rate of other diarrhoeal disease continues unabated. In August 2000, health facilities in Sulaimaniyah governorate reported just under 10,000 cases of diarrhoea in children under five with over 2,000 admitted and five deaths. Recent World Food Programme figures for this age group show a population of around 35,000, indicating almost a third of infants had diarrhoea at some time in August. In November 1999, UNICEF research found that over the two week survey period more than 50% of children aged six to 24 months had either diarrhoea, acute respiratory tract infection or both.
Factors for the continued high rates of infection include poor water and sanitation conditions, acute malnutrition, inadequate breast-feeding and high use of infant formula. Children under two born in rural areas or resettled towns particularly to illiterate mothers are particularly at risk.
Lack of diagnostic kits, particularly for cholera, which have been held back by the sanctions committee, also hampers accurate response and management of outbreaks.
Hepatitis B
Estimates for prevalence of hepatitis B range from 1.4 to 5% of the population. However, at present no routine blood screening is possible because antigens are on hold by the sanctions committee. Blood transfusion is usually sourced from family members and given unscreened.
Polio
The polio situation calmed in 2000 after intensive immunisation campaigns in 1999 quenched an outbreak which produced 88 cases of wild polio in the Centre and South. To date in 2000, 180 cases of acute flaccid paralysis have been reported in the Centre and South and 24 in the north. All have proved negative, bar one for which laboratory results are awaited.
Delayed arrival of vaccine due to sanction committee investigation pushed the first rounds of national immunisation days for 2000 from October into November and subsequent rounds will depend on further vaccine arrivals.
Tuberculosis
Tuberculosis continues to increase in the Northern Governorates. New cases of all types of TB in Erbil, for example, have increased from just over 600 in 1997 to over 820 in 1999. The year 2000 has continued this upward trend.
WHO has started to work with local physicians and authorities to plan the introduction of DOTS - Directly Observed Treatment Short course - which involves not only ensuring a consistent supply of drugs and setting up failsafe systems of monitoring therapy compliance, but also training and equipping laboratory technicians.
Malaria
Malaria incidence has decreased substantially in the north over the past five years. Figures from Dohuk, for example, show only 413 cases in 1999 compared to almost 1300 in 1998 and 19,000 in 1995. Local opinion is that this is mostly due to the widespread insecticide spraying which is the main plank of the current malaria control programme. However other factors such as improved housing stability, increased access to drug treatment, reduction of breeding sites through drought, regulations preventing paddy field rice growing near residential areas, improved diagnosis and increased surveillance and public education have played a key role.
Malaria in the Northern Governorates is predominantly plasmodium vivax, a recurring form which has a low fatality rate, but affects families economically. Lack of laboratory materials and skills mean any fever is almost always clinical diagnosed and managed in the first instance as malaria. Even when malaria is confirmed, a WHO survey found 55% of laboratory slides were false positives.
WHO is now working with local authorities to introduce a more rational malaria control plan based on the Roll Back Malaria elements of insecticide-impregnated bed nets, domestic screening, clearing breeding sites, improving diagnosis and laboratory investigation, public education. It is also encouraging local authorities to properly identify areas of high malarial incidence so as to reduce and target spraying activities.
Other WHO Activities
District Team Problem Solving Approach: WHO and local health authorities have used SCR 986 funds to teach groups of local physicians and nurses how to analyse health information from their community and carry out targeted action to address a particular problem without resources from outside the community. Teams in 12 towns have taken part in the year-long pilot project which started in December 1999 and have addressed health issues such as malnutrition, anaemia in pregnancy, typhoid fever and brucellosis primarily via health education activities.
Community public health workshops: held in support of the district teams, these three day workshops covering all aspects of common communicable disease in the community brought together representatives from youth, women and student groups, political and local government, educational establishments, the media, farming communities, veterinary services, municipalities, water and sanitation services, religious groups, Islamic councils, cultural and community centres.
Mass media workshop: this three day workshop in Sulaimaniyah for journalists, TV and radio broadcasters, artists, community leaders, health educators and health centre doctors led to a series of health education programmes in the governorate. How this interest can be continued when incentives are no longer provided, however, is a key issue.
Refresher training courses: in communicable disease identification management have been carried out by local clinicians, themselves updated and supported by WHO. Over 350 doctors and 400 medical assistants have participated this year.
For further information, please contact: Gregory Hartl, Office of the Spokesperson, WHO, Geneva. Telephone: (41 22) 791 2599. Fax: (41 22) 791 4858. Email: hartlg@who.int