DHA-GENEVA 95/0110
(DHA IS ISSUING THIS APPEAL AT THE REQUEST
OF WHO)
I. INTRODUCTION
THE LAO PEOPLE'S DEMOCRATIC REPUBLIC (LAO PDR) IS A LAND-LOCKED COUNTRY BETWEEN THAILAND AND VIET NAM. IT HAS A LAND AREA OF APPROXIMATELY 236 800 SQ KMS AND A POPULATION OF 4.47 MILLION PEOPLE IN 1993. THE LAO PDR RANKS AMONG THE WORLD'S LEAST DEVELOPED NATIONS. ITS PER CAPITA INCOME WAS ESTIMATED AT LESS THAN USD 240 IN 1994 AND INFANT MORTALITY AS 125/1000 IN 1993.
CHOLERA IS ENDEMIC IN LAO PDR, WHERE THERE ARE FREQUENT MAJOR CHOLERA OUTBREAKS. DURING 1993 AND 1994, SEVERAL MAJOR OUTBREAKS OCCURRED WITH ALARMINGLY HIGH CASE FATALITY RATES. GIVEN THE PREVALENCE OF UNSANITARY CONDITIONS FAVOURING THE TRANSMISSION OF DISEASE, THE LACK OF SUPPLIES OF DRUGS AND THE INAPPROPRIATE STAFF TRAINING IN CHOLERA CASE MANAGEMENT, THE COUNTRY IS FACING SERIOUS DIFFICULTIES IN CONTROLLING OUTBREAKS.
A NEW STRAIN OF CHOLERA, DESIGNATED 'VIBRIO CHOLERAE 0139,' HAS SPREAD QUICKLY THROUGHOUT SEVERAL ASIAN COUNTRIES. IT HAS CAUSED HIGH MORTALITY IN AREAS WHERE FACTORS ARE FAVOURABLE FOR TRANSMISSION AND WHERE HEALTH WORKERS AND THE COMMUNITY ARE NOT PREPARED TO COPE WITH MAJOR EPIDEMICS.
THE HIGH CHOLERA ENDEMICITY (DUE TO 'VIBRIO CHOLERAE 0139') AND THE POSSIBILITY OF 'VIBRIO CHOLERAE 0139' SPREADING TO LAOS REPRESENT AN ADDITIONAL AND SERIOUS THREAT.
II. BACKGROUND
THE COUNTRY IS AFFECTED BY FREQUENT MAJOR CHOLERA OUTBREAKS. AS AT 10 OCTOBER 1994, OVER 8 000 SUSPECTED CASES AND 500 DEATHS HAD BEEN REPORTED FROM NINE PROVINCES, WITH AN UNACCEPTABLY HIGH CASE FATALITY RATE RANGING FROM 4 TO 17 PERCENT.
LABORATORY CONFIRMATION AND SEROTYPING OF A SAMPLE OF SUSPECTED CHOLERA CASES WAS CARRIED OUT BY THE BACTERIOLOGY DEPARTMENT OF THE NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY (NIHE) LOCATED IN VIENTIANE. RESULTS HAVE SHOWN THE PATHOGEN TO BE 'VIBRIO CHOLERAE 0139,' BIOTYPE OGAWA.
THE GOVERNMENT HAS RESPONDED TO THE OUTBREAKS BY ESTABLISHING A NATIONAL CHOLERA COORDINATING COMMITTEE. IT CONSISTS OF REPRESENTATIVES FROM THE DEPARTMENT OF HYGIENE AND PREVENTION, NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY, MATERNAL AND CHILD HEALTH INSTITUTE, DEPARTMENT OF PHARMACY AND CENTER OF INFORMATION AND HEALTH EDUCATION.
KEY ACTIVITIES IMPLEMENTED HAVE INCLUDED PROCUREMENT AND DISTRIBUTION OF SUPPLIES AND EQUIPMENT, HEALTH WORKER TRAINING, AND MISSIONS TO OUTBREAK AREAS BY 'MOBILE TEAMS' CONSISTING OF STAFF FROM THE CENTRAL AND PROVINCIAL LEVELS.
III. ANALYSIS OF THE PROBLEM
ACCESS TO AND UTILIZATION OF GOVERNMENT HEALTH SERVICES IS VERY LOW, WHICH IS AN OBSTACLE TO THE IMPLEMENTATION OF THE CHOLERA CONTROL PROGRAMME, AS EARLY INITIATION OF TREATMENT IS CRUCIAL FOR A SUCCESSFUL OUTCOME.
IN 1994, THE OUTBREAKS OVERLAPPED WITH THE RAINY SEASON, WHICH IS NORMALLY FROM APRIL TO OCTOBER. DURING THIS TIME, HEAVY RAINS AND FLOODING CAUSE MAJOR DIFFICULTIES WITH TRANSPORTATION, DELIVERY OF SUPPLIES AND EQUIPMENT, AND WITH OVERALL ACCESSIBILITY TO HEALTH SERVICES.
THE MAIN CONSTRAINTS INCLUDE THE LIMITED AVAILABILITY OF SAFE WATER AND THE RELATIVELY POOR SANITARY CONDITIONS AND PRACTICES. ACCESS TO SAFE WATER WAS ESTIMATED TO BE 42 PERCENT IN 1987, WITH ONLY 11 PERCENT OF THE POPULATION HAVING ADEQUATE SANITARY FACILITIES IN THE HOME OR IMMEDIATE VICINITY. IN ADDITION, IN VIEW OF THE COMMON PRACTICE OF DEFECATING ON THE GROUND, FLOODING AND HEAVY RAINS FACILITATE THE CONTAMINATION OF GROUND WATER WITH FAECES.
MANY OF THE CUSTOMS AND PRACTICES, PARTICULARLY IN CERTAIN RURAL AREAS, ARE FAVOURABLE FOR CHOLERA TRANSMISSION. THESE INCLUDE FUNERAL PRACTICES IN WHICH DEAD BODIES ARE WASHED AND 'TOUCHED' BY THOSE WHO MAY THEN BE RESPONSIBLE FOR PREPARING FOOD. IN SOME AREAS IT IS CUSTOMARY TO THROW THE CADAVERS INTO THE RIVER. OTHER HARMFUL PRACTICES INCLUDE THE DISPOSAL OF CHILDREN'S STOOLS BY BARE HANDS.
SUPPLIES OF ORS FOR GOVERNMENT HEALTH FACILITIES HAVE BEEN INADEQUATE. THE CURRENT DISTRIBUTION AND MONITORING SYSTEM OF ORS APPEARS NOT TO BE FUNCTIONING ADEQUATELY OR EFFICIENTLY AND THEREFORE REQUIRES URGENT REVIEW AND FURTHER DEVELOPMENT. NEITHER EMERGENCY NOR BUFFER STOCKS HAVE BEEN CREATED AT ANY STAGE OF THE DELIVERY SYSTEM.
THE EXISTENCE OF NUMEROUS ETHNIC TRIBES LIVING IN REMOTE AND DIFFICULT TO ACCESS AREAS, WHERE DIFFERENT LANGUAGES ARE SPOKEN, CAUSE SPECIAL CONCERNS AND CONSTRAINTS FOR HEALTH EDUCATION AND THE USE OF MASS MEDIA. EXPANSION OF THE HEALTH EDUCATION MESSAGES AND THE MEANS TO DISTRIBUTE THEM AS WIDELY AS POSSIBLE WILL REQUIRE FURTHER ATTENTION, RESOURCES AND ADDITIONAL FUNDING.
UNLESS URGENT ACTION IS TAKEN TO ADDRESS THE ABOVE PROBLEMS, LARGE CHOLERA OUTBREAKS WILL CONTINUE TO RESULT IN HIGH CASE FATALITY RATES IN THE COUNTRY.
IV. RESPONSE TO DATE
THE GOVERNMENT HAS RELEASED APPROXIMATELY 23 MILLION KIPS (USD 32 000) FOR THE SUPPORT OF CHOLERA CONTROL. THE FUNDS WERE MAINLY USED FOR THE PROCUREMENT OF SUPPLIES AND EQUIPMENT.
WHO REGIONAL OFFICE FOR THE WESTERN PACIFIC (WPRO) HAS DONATED USD 9 100 FOR THE PROCUREMENT OF EMERGENCY SUPPLIES (ORS, IV FLUIDS, ETC.), TRANSLATION AND REPRODUCTION OF THE WHO PUBLICATION ENTITLED 'GUIDELINES FOR CHOLERA CONTROL,' AND FOR A NATIONAL CHOLERA CONTROL WORKSHOP.
WHO HAS CONTINUED TO PROVIDE TECHNICAL AND FINANCIAL SUPPORT FOR THE ACTIVITIES OF THE NATIONAL DIARRHOEAL DISEASE CONTROL (CDD) PROGRAMME, WHICH IS BEING IMPLEMENTED BY THE INSTITUTE OF MATERNAL AND CHILD HEALTH.
UNICEF HAS PROVIDED APPROXIMATELY USD 6 600 FOR THE PROCUREMENT OF ORS FOR ON THE SPOT SUPPLY, AND USD 1 500 FOR THE NATIONAL CHOLERA WORKSHOP.
JICA HAS COLLABORATED IN BOTH THE STRENGTHENING OF THE CAPACITY OF THE REFERRAL LABORATORY OF NIHE AND IN FIELD INVESTIGATIONS, AND HAS PROVIDED USD 2 000 FOR THE NATIONAL CHOLERA WORKSHOP.
V. REMAINING NEEDS
IN ORDER TO ADDRESS THE CURRENT CHOLERA ENDEMICITY, AND IN PARTICULAR THE HIGH MORTALITY AND THE THREAT POSED BY THE OCCURRENCE AND THE FAST SPREAD OF 'VIBRIO CHOLERAE 0139' IN ASIA, EFFORTS MUST BE MADE TO FURTHER STRENGTHEN CHOLERA CONTROL IN LAO PDR.
IN ORDER TO BE ABLE TO MAINTAIN THE HIGH LEVEL OF COMMITMENT, WHICH THE GOVERNMENT OF LAO HAS SO FAR DEMONSTRATED IN ITS EFFORTS TO PREVENT AND CONTROL CHOLERA EPIDEMICS, ADDITIONAL EXTERNAL FUNDING WILL BE NECESSARY.
THE AREAS REQUIRING ADDITIONAL FUNDING ARE AS FOLLOWS:
1. SURVEILLANCE: OUTBREAK INVESTIGATIONS, REPORTING, LABORATORY SUPPLIES AND EQUIPMENT.
2. CRASH TRAINING: TRAINING OF PROVINCIAL AND DISTRICT LEVEL HEALTH WORKERS IN CASE MANAGEMENT, PREVENTION, OUTBREAK RESPONSE AND HEALTH EDUCATION.
3. SUPPLIES AND EQUIPMENT: PROCUREMENT, DISTRIBUTION OF ORS, IV FLUIDS, ANTIBIOTICS, ETC., CREATION OF EMERGENCY AND BUFFER STOCKS.
4. MOBILE TEAMS: LOCAL COST FOR TRANSPORT AND SUPPLIES, DSA, ETC.
5. HEALTH EDUCATION AND COMMUNICATION: DEVELOPMENT AND REPRODUCTION OF HEALTH EDUCATION MATERIALS, USE OF MASS MEDIA (RADIO)
6. OUTBREAK RESPONSE ACTIVITIES: LOCAL COST FOR TRANSPORTATION, SUPPLIES AND EQUIPMENT, ETC.
VI. PROPOSED BUDGET
|
PROPOSED
BUDGET |
AMOUNT REC'D.
(IN US DLRS) |
OUTSTANDING
| |
| 1. NATIONAL WORKSHOP |
6 000
|
6 000
| |
| 2. SUPPLY, EQUIPMENT |
83 600
|
27 600
|
56 000
|
| 3. HEALTH EDUCATION |
20 000
|
20 000
| |
| 4. LABORATORY SUPPLY |
20 000
|
20 000
| |
| 5. TRANSPORT SUPPLY |
23 000
|
23 000
| |
| 6. COMMUNICATION |
20 000
|
500
|
19 500
|
| 7. CRASH TRAINING FOR FIELD WORKERS |
100 000
|
3 000
|
97 000
|
| 8. OUTBREAK RESPONSE |
40 000
|
10 000
|
30 000
|
| 9. STAFF (11 MAN/MONTH CONSULTANCY) |
110 000
|
110 000
| |
| TOTAL |
422 600
|
47 100
|
375 500
|
DONORS SHOULD ADDRESS THEIR CONTRIBUTIONS TO THE WHO DIVISION OF EMERGENCY AND HUMANITARIAN ACTION (EHA), GENEVA, FOR CASH DONATIONS AND DIRECTLY TO THE OFFICE OF THE WHO REPRESENTATIVE IN VIENTIANE FOR DONATIONS IN KIND.
WHO ORGANIZATION, GENEVA
TELEPHONE: +41-22-791-2752
TELEGRAMS: UNISANTE GENEVA
TELEX: 415416
FAX: +41-22-791-4844 EHA, ATT: DIRECTOR,
EHA
WHO REPRESENTATIVE IN LAO PDR, VIENTIANE
DR. NESBIT
TELEPHONE: +856 21 41 3023
FAX: +856 21 41 3432