Angola: Disease - OCHA: 13-Apr-05
OCHA Situation Report
Consolidated Appeals Process (CAP): Flash Appeal 2005
Angola Marburg Hemorrhagic Fever Outbreak Response
13 April 2005
Source: UN Office for the Coordination of Humanitarian Affairs
1. EXECUTIVE SUMMARY
As of 6 April 2005, 181 confirmed and suspected cases of Marburg viral
hemorrhagic fever (VHF) have been reported in five provinces, with the
majority (168) in Uige. Of the 181 cases, 159 have been fatal.1 While
children under the age of five years initially accounted for 75% of
cases, recent cases are including an increasing number of adults.
The epicentre of this outbreak is Uige Province, which remains the
primary focus of outbreak response activities. Two cases have been
confirmed in Luanda. In addition, alert cases have been reported in four
other provinces (Cabinda, Malanje, Kwanza Norte, and Zaire). Three
further provinces (Bengo, Kwanza Sul, and Lunda Norte) ? sharing
internal borders with Uige province ? are considered at increased risk.
As surveillance and reporting mechanisms improve, the number of alert,
suspect and confirmed cases, as well as the number of municipalities
affected, is likely to increase.
The Angolan Ministry of Health (MINSA) is responsible for coordinating
the national response to the Marburg VHF epidemic. The World Health
Organization (WHO) Country Office, Regional Office for Africa /AFRO),
and Headquarters, in collaboration with the United Nations Children's
Fund (UNICEF), the World Food Programme (WFP), Medecins Sans Frontieres
(MSF), and the International Federation of Red Cross and Red Crescent
Societies (IFRC), are supporting MINSA and coordinating the mobilisation
of international technical support.
|--------------------------------+-----------------------|
| Flash Appeal for | |
| Angola Marburg VHF 2005 | |
| Summary of Requirements | |
| By Appealing Organization | |
| as of 12 April 2005 | |
| http://www.reliefweb.int/fts | |
|--------------------------------+-----------------------|
| Compiled by OCHA on the | |
| basis of information | |
| provided by the respective | |
| appealing organisation. | |
|--------------------------------+-----------------------|
| Appealing Organisation | Original Requirements |
|--------------------------------+-----------------------|
| UNICEF | 848,000 |
|--------------------------------+-----------------------|
| WFP | 285,000 |
|--------------------------------+-----------------------|
| WHO | 2,370,000 |
|--------------------------------+-----------------------|
| Grand Total | 3,503,000 |
|--------------------------------+-----------------------|
|--------------------------------------+-----------------------|
| Flash Appeal for Angola Marburg VHF | |
| 2005 | |
| Summary of Requirements - By Sector | |
| as of 12 April 2005 | |
| http://www.reliefweb.int/fts | |
|--------------------------------------+-----------------------|
| Compiled by OCHA on the basis of | |
| information provided by the | |
| respective appealing organisation | |
|--------------------------------------+-----------------------|
| Sector Name | Original Requirements |
|--------------------------------------+-----------------------|
| COORDINATION AND SUPPORT SERVICES | 285,000 |
|--------------------------------------+-----------------------|
| HEALTH | 3,218,000 |
|--------------------------------------+-----------------------|
| Grand Total | 3,503,000 |
|--------------------------------------+-----------------------|
The capacity of the Ministry of Health to implement outbreak control, to
enhance surveillance and data collection, is hampered by lack of trained
human resources, lack of personal protective equipment and supplies,
limited information systems to deal with case finding and contact
tracing, and limited technical and operational coordination and
logistics.
On-going operations on the ground are prioritised as:
Addressing immediate needs in Uige Province, to control the outbreak
through establishment of an effective isolation facility (taken on
board by MSF), intensive case/contact tracing, social mobilisation
for community awareness, and support to epidemic control and
co-ordination of response activities;
Ensuring that Luanda, other provinces in Angola and border areas are
on a heightened state of alert and are adequately prepared to deal
rapidly with any case(s) that may occur;
Investigating events/rumours rapidly in other areas;
Raising awareness among the heath personnel for early detection (in
particular hospitals and other frontline health facilities) and
precautions when taking care of suspected cases;
Sustaining multidisciplinary technical support from WHO and the
Global Outbreak Alert and Response Network (GOARN) in the field
(including clinical management, infection control, epidemiology,
laboratory, social mobilisation, medical anthropology, logistics and
communications).
To effectively support the national surveillance and epidemic
preparedness and response, and to ensure coordination of international
technical support, WHO has mobilised regional networks of experts and
GOARN and has strengthened collaboration and coordination with partners
such as UNICEF, MSF and the IFRC in Angola.
WHO is coordinating intensive investigation of rumours and alert in
other countries, particularly those countries bordering Angola. National
health authorities in the Democratic Republic of Congo (DRC) and
Republic of Congo have enhanced surveillance in bordering areas. In DRC
? in response to an alert case in Matadi ? a national team supported by
the WHO Country Office is alerting the local population, augmenting
surveillance and performing active case finding. MSF teams in Bas-Congo
are also on the alert and implementing readiness measures. WHO/AFRO is
providing regular situation reports to all WHO Country Offices in the
Region to avoid panic and inappropriate restrictions on travel and
trade.
This epidemic is the latest VHF outbreak in central Africa (previous
ones having occurred in Gabon, Congo Brazzaville, the Democratic
Republic of Congo, southern Sudan and Uganda) and underlines the need to
rapidly strengthen a sub-regional alert and response network focused on
VHFs, and to capitalise on the limited capabilities developed during
outbreak response over the past 5 years. This will be the subject of a
further appeal for financial support.
1.1 Priority Needs
Case management
Establish isolation units for care and treatment in Uige and Luanda,
and any other focus of the outbreak that may occur;
Train and improve safe case management skills of technicians and
health care workers;
Procure and distribute protective materials to health care workers in
Uige and the eight other high-risk provinces;
Procure and distribute emergency kits and essential drugs to Uige and
the high-risk provinces;
Procure and distribute disinfectant materials to Uige and the
high-risk provinces;
Procure and distribute other case management equipment and
consumables to Uige and the high-risk provinces;
Provide cash incentives for case management, infection control, and
burial teams
Surveillance and epidemiology
Set up an active surveillance system in Uige Province, Luanda and
Cabinda able to detect any case in the community;
Set up mobiles team structure to respond to alerts, identify cases,
and follow-up contacts for 21 days;
Provide cash incentives for active surveillance teams;
Train health care workers, surveillance officers and data managers in
all provinces of Angola for surveillance, investigation of alerts,
taking of samples and mobilisation of response;
Provide operation support to maintain the field laboratory in Uige
and enzyme-linked immunosorbent assay (ELISA), ribonucleic acid (RNA)
and molecular biology testing facilities in Luanda, and ensure rapid
transfer of samples for analysis;
Provide sustained international technical support for epidemiological
investigation, training, surveillance evaluation, and outbreak
response activities.
Social mobilisation, risk reduction and health education
To strengthen public confidence in, and cooperation with, the local
and national health authorities and services;
Launch intensive social mobilisation campaign through mass media and
community activists;
Develop tools and appropriate methods (social mobilisation and
information, education, and communication (IEC) materials) to avoid
risky behaviours, particularly associated with burial practices and
customs, and case management at home;
Evaluate the situation in the field regarding social mobilisation,
and to inform and adapt control strategies to take account of local
beliefs and customs;
Develop contingency plans for areas not currently directly affected
by the outbreak;
Provide support to orphaned and widowed family members of health care
workers.
Logistics
Procure and install communication equipment, computers, and other
hardware as per provincial priorities;
Provide transportation support for surveillance and mobilisation
activities (vehicles, motorcycles, bicycles);
Provide support for repair and maintenance of vehicles and equipment;
Provide cash support for WFP air passenger services directly linked
with Marburg VHF response for a minimum of 6 months.
Other priority needs
Document activities and lessons learned, and disseminate accurate
information to all partners.
1.2 Resources Required
|---------------------------------+--------------------|
| Appeal Summary | |
|---------------------------------+--------------------|
| Appealing Organisation | Requirements (US$) |
|---------------------------------+--------------------|
| World Health Organization (WHO) | 2,370,000 |
|---------------------------------+--------------------|
| United Nations Children's Fund | 848,000 |
| (UNICEF)* | |
|---------------------------------+--------------------|
| World Food Programme (WFP) | 285,000 |
|---------------------------------+--------------------|
| Total | 3,503,000 |
|---------------------------------+--------------------|
* The actual recovery rate on individual contributions will be
calculated in accordance with the Executive Board Decision 2003/9 of 5
June 2003.
|---------------------------------+--------------------|
| Financial Summary | |
|---------------------------------+--------------------|
| Sector | Requirements (US$) |
|---------------------------------+--------------------|
| Case Management | 1,007,000 |
|---------------------------------+--------------------|
| Surveillance and Epidemiology | 1,254,500 |
|---------------------------------+--------------------|
| Social Mobilisation | 620,200 |
|---------------------------------+--------------------|
| Logistics (including support | 621,300 |
| for WFP air passenger services) | |
|---------------------------------+--------------------|
| Total | 3,503,000 |
|---------------------------------+--------------------|
1.3 Timeframe of Appeal
The timeframe of the appeal is three months, April-June 2005.
2. CONTEXT AND HUMANITARIAN CONSEQUENCES
2.1 Context
MINSA and its partners (WHO, UNICEF, the Centre for Disease Control
(CDC), and MSF) have created a National Technical Commission to combat
the Marburg outbreak. The Commission has strengthened coordination
mechanisms in the areas of logistics, epidemiology, and social
mobilisation to prevent the further spread of the virus, and to direct
isolation and treatment interventions in Uige, Luanda, and other
locations where there are now confirmed or suspected cases. The
Commission and Sub-commissions of Epidemiological Surveillance,
Logistics and Social Mobilisation meet daily. A case definition of VHF
has been adopted to enhance knowledge of the disease and promote
accurate identification of suspected cases. The Commission has sent a
protocol to all Provincial Health Departments to provide orientation for
health workers on how to identify alert and suspected cases. Intensive
training for health workers is ongoing in Uige and Luanda and now
includes staff from private clinics. In addition, the Government has
mobilised US$ 3 million and has announced that the Armed Forces of
Angola (FAA) will provide logistics support and medical staff to help
prevent the further spread of the virus. Angola has eased customs and
duty procedures for donor vehicles and shipments of equipment and
supplies for the control of the outbreak.
Over 60 international experts in various fields representing WHO, MSF,
UNICEF and other partners in GOARN have now been mobilised to Angola.
Outbreak response teams are in the field in Uige Province, in Cabinda
and in Luanda. These teams are providing rapid technical support for
case management, intensified contact tracing and surveillance, infection
control and to improve public understanding of the disease and its modes
of transmission.
In Luanda, MSF Holland is supporting MINSA to open a preventive
isolation unit in Americo Boa Vista Hospital and a transitory isolation
unit will be set up at the Paediatric Hospital to allow for safe
screening of potential cases there.
In Uige, a WHO outbreak response team is proving technical and
operational support to local health authorities and is carrying out
intensive case finding and contact tracing, and burying bodies. MSF
Spain has established an isolation ward in the Provincial Hospital,
which is now operational. MSF Spain has sent 18 staff members to the
province who are now fully in charge of case management and infection
control and are providing intensive care for patients at the Provincial
Hospital. The occurrence of unreported cases in communities is still of
concern and case-finding and contact tracing is the priority activity to
end the chain of transmission in Uige city and other surrounding
municipalities. Five mobile surveillance teams are now working in Uige,
following up 100 contacts.
Social mobilisation efforts are critically important to the control of
VHF outbreaks. Currently the population is - rightly - wary of
hospital-related infection, and other local beliefs (linking the disease
with witchcraft practices) play an important role. WHO has a team of
medical anthropologists working closely with social mobilisation experts
and the response team to incorporating these complex elements into the
overall control strategy and to adapt social mobilisation activities.
Social mobilisation at national level will be stepped up with a
multimedia campaign designed by MINSA and UNICEF. Information leaflets,
posters and a series of TV and radio spots are under production. In
addition to the general population, target groups are health workers,
children and people attending funerals. Two social mobilisation
specialists from WHO and GOARN have arrived in the country. Traditional
partners such as international and national non-governmental
organisations (NGOs), as well as the Scouts of Angola are also being
trained to support the essential interpersonal communication aspect of
the social mobilisation program.
Partners are also focusing on increasing the readiness and preparedness
of high-risk provinces neighbouring Uige, as well as Luanda and Cabinda.
The existing provincial early detection network for Measles and Polio is
now ensuring surveillance for identification and classification of
Marburg cases. WHO and UNICEF will shortly pre-position protection
equipment and medical supplies for health workers in health facilities
in all high-risk provinces, with WHO developing similar plans that will
eventually include all 18 provinces. MSF and the NGO liaison group, the
Consortium of NGOs in Angola (CONGA), are mapping existing NGO capacity
in order to optimise the response in Uige and elsewhere.
Multidisciplinary response teams from WHO (including the country office,
inter-country program, regional office and headquarters), together with
Collaborating Centres and GOARN partners are providing the additional
technical expertise and capability to support the MINSA in the control
of this outbreak rapidly. WHO will continue to mobilise and support
field teams of epidemiologists, medical anthropologists, infection
control specialists, barrier-nursing trainers and supervisors, risk
communications and behavioural change experts, sanitation technicians
and engineers, information and data managers, laboratory technicians,
and many other categories of health and public health experts. It is
critically important to sustain the necessary level of technical support
and ensure strong coordination until the epidemic is ended.
The Canadian National Microbiology Laboratory has set up a mobile
laboratory in Uige to help with the rapid identification of cases and
for clinical management. In Luanda, the CDC has established ELISA2 and
RNA testing facilities at the National Institute for Public Health in
Luanda. In addition to the CDC, the European Program for Intervention
Epidemiology Training, the Swiss Agency for Development and Cooperation,
Department of Humanitarian Aid are mobilising epidemiologists, infection
control experts and communications officers to join the WHO/GOARN team.
Experts from the Department of Infectious Diseases, North Manchester
General Hospital, United Kingdom and Johannesburg Hospital, South Africa
are providing assistance in infection control in Luanda, where training
is being provided for health care staff from all provinces in the
country. Expert resources and material have been mobilised from across
WHO's African Regional and Country offices, including the Republic of
Congo/Brazzaville, the Democratic Republic of Congo, and Mozambique. The
Brazilian Ministry of Health has mobilised the services of two technical
experts who will travel to Angola within the first week of April.
Additional resources have been volunteered and are currently on stand-by
from France, Norway, South Africa, Sweden and the United Kingdom.
2.2 Humanitarian Consequences
Marburg VHF has no specific treatment other than re-hydration and
supportive care; there is no licensed commercialised vaccine at present.
The Angola epidemic is now the worst known outbreak ever, surpassing the
previous total number of Marburg VHF cases (148) recorded in the
Democratic Republic of Congo in 1998-2000. When it became apparent to
the local community that the epidemic was centred in Uige, specifically
Uige Hospital, and when health care workers that had been in contact
with infected patients also began dying, the Provincial Hospital
effectively shut down and patients were abandoned, as health care staff
were too afraid to report to work, knowing that they lacked the most
basic protective clothing and equipment. Family members of the sick were
exposed to further risk because patients could not be isolated and were
cared for at home. In addition, those that had been in contact with
patients avoided quarantine measures out of fear that if they were not
already infected by the virus, they soon would be if they remained in
the proximity of the hospital or confined to their homes.
The analysis of the epidemiological situation of Marburg VHF in Angola
and the response to the epidemic reveals major public health concerns.
Five provinces have had alerts related to suspect cases of disease
originating from Uige Province. To date case fatality is very high
(91.8%) and most of the cases are children (61%). The case incidence is
increasing and in-migration patterns suggest that at least nine
districts (municipalities) are at high risk or already have
confirmed/suspected cases of the virus.
Although a national epidemic control management committee is in place
and functioning, provincial structures are not yet ready in all
high-risk provinces. Health and public health staff in Uige remained at
risk of acquiring the infection because of the lack of specialised
training and protective equipment. Technical guidelines are now being
distributed, including information on how the community can participate
in case reporting and verification, social mobilisation, and to promote
safe burial practice, and avoid other risky behaviours. Until active
surveillance and social mobilisation is effective in all high-risk
provinces, new, perhaps preventable cases will continue to be
identified. As the virus spreads and affects more parts of the country,
effective case management and isolation becomes even more complicated,
and humanitarian consequences more dire.
Given the impact of the outbreak on movement into and out of Uige
Province, and the disruption of normal commercial activities, food and
other consumer prices in the city of Uige have skyrocketed. Anecdotal
reports indicate that the price of household bleach, if it can be found,
has increased by ten times, as residents implement their own
disinfection methods, following the advice of public health officials.
In the coming days, more communities, including those in other provinces
that depend on Uige for trade, may face some difficulty with shortages
of basic commodities In addition to the loss of life, family members of
those infected by the virus, as well as the general population of Uige
Province, have been stigmatised due to a lack of understanding of how
the virus is spread and who is at risk.
TABLE OF CONTENTS
1. EXECUTIVE SUMMARY
1.1 Priority Needs.
1.2 Resources Required
1.3 Timeframe of Appeal.
2. CONTEXT AND HUMANITARIAN CONSEQUENCES.
2.1 Context.
2.2 Humanitarian Consequences
3. RESPONSE PLAN.
3.1 Expected Results
4. ADDITIONAL ROLES AND RESPONSIBILITIES.
ANNEX I. ACRONYMS AND ABBREVIATIONS
Footnotes
1 Cumulative totals since cases of VHF were first reported in Uige in
October 2004 (source MINSA/WHO).
2 Enzyme-linked immunosorbent assay. ELISA tests are widely utilised to
detect substances that have antigenic properties, including hormones,
bacterial antigens and antibodies.
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