Report on
Cholera Prevention and Response Training
course programmes
Mbale, 21st – 24th September 2010
Jinja, 2-5 November, 2010
Department of Water Development
Ministry of Water and Environment
November 8, 2010
with support from
Cover page photograph:
Participants debating the implications of the F-diagram
in preventing and mitigating cholera outbreaks
Han Heijnen, Mbale
hanheijnen@gmail.com
2
T ABLE OF C ONTENTS
Executive Summary.................................................................................................................... 4
Introduction ............................................................................................................................... 5
Objectives................................................................................................................................... 6
Methodology.............................................................................................................................. 6
Training Programmes ................................................................................................................. 9
Mbale programme ................................................................................................................. 9
Jinja programme................................................................................................................... 12
Common Issues .................................................................................................................... 13
Conclusions .............................................................................................................................. 14
Recommendations ................................................................................................................... 14
Annexes .................................................................................................................................... 15
1.
List of resource persons ................................................................................................ 16
2.
List of participants, Mbale ............................................................................................ 17
3.
List of participants, Jinja................................................................................................ 19
4.
Daily course programme ............................................................................................... 20
3
E XECUTIVE S UMMARY
10 lines + table with participants and their satisfaction
4
I NTRODUCTION
In the past cholera occurred sporadically within the different regions of Uganda. It was not
until 1997/8 when a serious outbreak occurred . This occurrence was witnessed in 43
districts out of the 45 districts then. However, the outbreak was controlled and cases
steadily declined until 2002.
Due to good preparedness and lessons learnt, the outbreak was localised to only 14 out of
the 56 districts. During the following years a few cases were reported. For example in 2008
only a few districts reported outbreaks of the cholera:
•
•
in Eastern Uganda – Budaka, Butaleja, Manafwa, Bugiri,Tororo and Busia
Arua, Nebbi, Kibaale, Bulisa, Hoima, Kampala, Kasese.
In 2010 the disease has been reported in the districts of Moroto1, Kotido, Amudat, Tororo,
Pallisa, Kayunga, Luwero and Butaleja.
Daily incidence of Cholera in Moroto, 12 July 2010
30
25
No of cases
20
15
10
5
01
0
7/
2
7/
20
10
6/
30
/
20
10
6/
23
/
20
10
6/
16
/
01
0
9/
2
6/
01
0
2/
2
6/
20
10
5/
26
/
20
10
5/
19
/
20
10
5/
12
/
01
0
5/
2
5/
20
10
4/
28
/
4/
21
/
20
10
0
Date
It is against this background that the Government of Uganda through the Ministry of Water
and Environment and in partnership with the Ministries of Health and Local Governments
have decided to hold a refresher programme on the prevention and response to cholera
outbreaks.
To accommodate the large no of districts potentially affected, it was decided to split the
programme into two courses: one held in Mbale from 21-24 September 2010, catering for
1
Daily Cholera Update [12 June 2010], MoH/WHO
5
North-East and Eastern Uganda districts, and one in Jinja, held from 2-4 November 2010
covering other districts.
O BJECTIVES
The training programmes had the following broad objectives:
1. Build capacity of WASH actors (Governments, NGOs, and UN) to:
 engage in contingency planning and preparedness for cholera/AWD outbreaks;
 respond to cholera/AWD outbreaks in a variety of contexts (urban, rural, refugee
/ IDP camp);
2. Increase participants’ understanding of the importance of coordination with
different sectors (e.g. health, nutrition and education) and actors in cholera / AWD
preparedness and response;
3. Strengthen common standards and approaches between international humanitarian
actors and governments in the area of cholera/ acute water diarrhea (AWD)
preparedness and response
4. Increase participants’ understanding of the role of WASH in Uganda in cholera /
AWD preparedness and response
5. Offer field-based experience through various practical exercises
Participants were invited from altogether 17 districts. As much as possible representation
was sought from the District Health Office (District Health Inspector - DHI), District Water
Office (District Water Officer - DWO) and the Community Development promoters at district
level (District Community Development Officer). In some cases other government officers
attended as well, while relevant NGO staff were also included from severely affected
districts.
M ETHODOLOGY
UNICEF and WHO have been concerned for several years now about the regular occurrences
of cholera outbreaks throughout Africa. In East and Southern Africa, the last few years have
shown outbreaks in South Africa, Zimbabwe, Malawi, Uganda, and Sudan The reason for
these occurrences may lie in climatic occurrences, i.e heavy rainfall leading to floods;
displacements of large numbers of people due to floods or landslides, or due to local
insecurity; poor infrastructure, especially in overcrowded peri-urban areas, in combination
with insanitary conditions, poor hygiene and open defecation. While it is difficult to manage
a cholera response in an urban setting, it is even more complex in a remote area where
human resources and health facilities may find it hard to recognize the disease and muster
an initial response.
A major cholera outbreak in Zimbabwe in 2008-2009 with its challenges in provision of
adequate WASH services, prompted Oxfam GB Southern Africa Regional Office and UNICEF
East and Southern Africa Regional Office (ESARO) to develop a cholera / AWD2 training
package targeting in-country WASH practitioners implementing cholera / AWD control
activities. The package was developed in mid-2009 and after feedback from a large number
of experts including the Global Task Force on Cholera Control and the participants of test
2
Acute Watery Diarrhoea
6
courses in Zambia, Uganda and Malawi, the package was finalized at the end of 2009. It is
now available as a CD-ROM.
The WASH Cholera & Acute Watery Diarrhoea Emergency Preparedness & Response
Training Package is a generic package that has all the tools and information to hold a good
course, but to make it attractive and locally relevant, it is necessary to adapt it to the
national/local context.
In the two courses that were held in Mbale and Jinja, this ‘localization’ has been achieved by
obtaining the services of senior national officers from the Ministries of Water and
Environment and the Ministry of Health to ensure updated policy and practice for WASH
and emergency response. Representation of district local government (e.g. the Chief
Administrative Officer of Kaabong district) ensured linkage with roles and responsibilities at
the district level, as per current rules. The Environmental Health Division of the Ministry of
Health and UNICEF, through a consultant currently studying hygiene practices in Karamoja
area with the aim to make health promotion more culturally and socially effective,
contributed important local perceptions that WASH stakeholders need to appreciate in
order to be able to deliver services that make sense and are largely effective. Resource
persons have reflected several of these concepts and issues in their powerpoint
presentations and these have now become part of the course record i.e. included in the CD
ROM provided to all participants as reference.
The package aims to refresh the knowledge that participants have by providing a lot of
information in a series of presentations and working group sessions, as well as through a
very elaborate digital library of recent Health, WASH and Emergency Preparation and
Response information materials on CD.
The method of
delivery of the
materials is very
much
participatory,
acknowledging
that the
participants
themselves are
important
resources for the
course, and for
each other, not
just from a
technical
information point
of view, but also
because of their
insider
knowledge of
what works and what doesn’t, especially at the district level.
7
The daily programme of the course is given in Annex 4. Details can be found on the CDROM, which is available from UNICEF.
The course aims to cover the interests of Health, WASH and Local Government, through
invited participation from District Health Inspectors, Water Officers and Community
Development Officers. Obviously areas in which one is not an expert require additional
effort to capture the essence of the learning and guidance. But on the whole the course
programme can be followed well by over two-thirds of the participants.
The course deals with
Cholera




Recent outbreaks and impact (incl. screening of Cholera video of Médecins Sans
Frontières – MSF)
Introduction to Cholera (Vibrio Cholerae, mode of transmission, characteristics
and risk factors of disease, developments in prevention and diagnostics)
Surveillance, compilation and analysis of epidemiological data
Cholera guidelines and manuals and materials
Key Responses



Hygiene Promotion (successes and challenges, vulnerabilities, community
participation, priorities in response, information, approaches, key messages)
Sanitation (technology options, solutions in different contexts and stages)
Water (supply priorities, risks associated with water sources, interventions in
case of contamination, water quality analysis and field tests, inclusive of practical
demonstrations, HWTS methods)
Management of Cholera Outbreaks




Managing Cholera Treatment Centres (Location of CTCs, WASH within CTCs,
Standard Chlorine Solutions and uses within CTCs)
Communication (cholera prevention and response messages, effective
communication during coordination)
WASH Monitoring in Cholera (key indicators, analysis and application of
monitoring data)
Coordination (strategies for effective coordination, barriers to coordination, roles
in coordination)
Emergency Preparedness and Response


Emergency Preparedness and Response Planning – Preparedness Stage (epidemic
response cycle, cholera prevention, elements of EPRP)
Emergency Preparedness and Response Planning – Alert, Response and
Evaluation Stages (actions required at each stage)
The training provides participants with the most updated knowledge and best practice on
Cholera / Acute Watery Diarrhoea (AWD) Emergency Preparedness and Response. This will
8
be done through presentations, discussions, case studies, group work, role plays and
practical exercises.
T RAINING P ROGRAMMES
Two training programme were executed following the modules and procedures outlined in
the CD ROM package. However there are interesting points to record relating to the
participants, their expectations and the results of the training programme. These have been
dealt with in the two following training course specific sections.
M BALE
PROGRAMME
The Mbale course was attended by 37 participants from the North-East (Karamoja) and
Eastern districts of Uganda. The participants came from Health, Water and Community
Development is more or less equal numbers.
Participants expressed their expectations
mainly in terms of ‘learning’ (7 responses):
Profession
‘gain more knowledge & skills on how to
prevent/respond to cholera and other similar
outbreaks in stable and complex emergencies’
and capacity building (6 responses), specifically
to be:
No.
Sector
No
DHI
10
Health
12
DWO
11
WASH
11
CD
Planning/
Management
10
DCDO
Other
Government
9
NGO
4
3
4
‘able to come up with/draw up a cholera/
AWD emergency response plan’
Several participants also expressed their interest to hear how other districts were tackling
the Cholera threat. The possibility of sharing that experience was seen as a good
opportunity. As participants were drawn from neighbouring districts, several knew each
other and this facilitated a good atmosphere right from the start. Facilitators and resource
person were able to employ various games and energizers to further encourage good
engagement and interaction. Ample use was made of short tasks and group work to deepen
the learning.
On a daily basis and in between, as needed, evaluation sheets and tests were completed.
After the modules on the clinical and public health aspects of cholera, a rather substantial
test was done of 19 questions, the day after. Case Fatality Rate and ‘awareness of the
possibility of a cholera case presenting itself’ where understood well by over 90% of the
respondents. Most other questions were answered within a range of 70-90% correctness.
Questions on the WHO case definitions for Cholera, fluid loss and severe dehydration were
answered well enough by the health staff, but others seemed to find these questions a little
hard. Overall a little over 60% answered these questions correctly.
The question on susceptibility was
answered poorly and confusingly and
so it can be deducted that a good
number of participants did not quite
What are the factors that increase susceptibility to
diarrhoeal diseases?






Contaminated water supply
Lack of sanitation facilities such as latrines
Poor hygiene and improper food preparation and storage
Malnutrition
9
Low immunity
Reduced gastric acidity
grasp this concept. As this concept relates to conditions that vulnerable groups in the
community may suffer in larger measure and thus their risks are larger during a diarrhea
outbreak, it is important to review/ repeat this part of the presentation (module 1.3)
Overall, 69% of the participants scored 70% or over in this test.
As is common these days, a reminder session is usually held at the beginning of each
session’s day. This was usually done by the lead-facilitator. On the third day instead a panel
discussion was held with a DWD, MoH, UNICEF and NGO representative trying to answer
questions from the participants, who were acting as local journalists. This proved a very
entertaining session with plenty of questions on roles and responsibilities, and approaches.
Criticism was voiced toward the community leaders. While ordinary people would have
a latrine, their compounds would not yet have a toilet (Karamoja). And what about
fining people for not having a latrine as per the bylaw, when even the courthouse does
not have a toilet! As such it is hard to implement the Public Health Law.
Questions were raised on the Kampala Declaration on Sanitation (KDS), which has now
been lying idle for some 10 years. According to DWD most of the ten areas of action
have shown progress.
The Kampala Declaration on Sanitation (1997)
The NGO representative was
defines ten areas of action to improve sanitation
asked why many NGOs did not
at district and local government levels.
link that well with local
 Exemplary leadership commitment
government during their
regular work. Tough question!
 Full community mobilization
 Focus on District and Sub-county and urban
The conclusion of the panel
authorities
discussion was that we all need
 Coordination and multi-sectoral approach
a change in mindset to be able
 Focus on schools
to appreciate our own
 Creating fora to address sanitation at districts
responsibilities and collaborate
 Central role of women
for the greater good.
 Private sector and NGO participation in service
delivery
The Panel discussion was a nice
 Capacity building at district level
change to the daily summary and
yielded a lot of relevant interaction
 Development of policies and guidelines
on several issues discussed the day
before, especially with respect to health promotion and supporting policies and bylaws.
To understand the issues surrounding emergency WASH, a role play was set up on the last
morning, with four groups struggling with competing demands of the CAO, limited capability
at the District Water Office, communication problems and demands on community
mobilization. The spice in the exercise was created by urgent phonecalls from Kampala,
urging action from the highest quarters and pressure from community leaders and district
councilors. Quite real-life like and stress-full. But a good way of seeing through the issues
that crop up in such an emergency.
10
One of the expectations expressed by one of the participants related to ‘getting a good
understanding of basic and practical hygiene promotion approach in rural areas esp. with
the difficult-to-change community’. Clearly this questions was an expression of the
challenges faced in the Karamoja Region. Ms. Catherine Solomon, a UNICEF consultant, has
been looking into this challenge and was able to present some of her concerns an findings
during the training workshop.
She also indicated that while there were assumed traditional behaviours unfavourable to
heath, some of these can also be changed. The section below illustrates the changes that
are possible.
Situational analysis
on communication response to diseases outbreak- Karamoja Region
Existing practice
 Open defecation is a tradition. At night they defecate outside the manyatta. They
say this is a sign of abundance food in the community and also a sign of life.
 Young single girls cannot use pit latrines in fear that they would not be able to
conceive in the future.
 If a pregnant woman uses a pit latrine, the fetus would fall into the pit and she
would not conceive again.
 It’s disrespectful for a young man to see his mother in law going to defecate and
or use the same latrine.
 They fear the dead and so do not bury especially in kraals. Instead abandon
bodies in the forest and leave for vultures. If in a homestead /manyatta two
people die then they move and abandon the manyatta.
Models villages visited were in Kotido( losilang Parish-Jimos, Rengen sub-county Lonejim
village )
The information revealed during the community dialogues was contrary to the above
concerning cultural issues .The community members and their leaders informed us that ;
Changes in practice
•
They have confirmed that those earlier beliefs which caused women not to use the
pit latrine are not true, as they have used them and no one has lost a child or failed
to conceive in the last 3 years
•
They now bury the dead and they even have the priest to preside over the ceremony
as they now believe that the dead would not be happy with them if they are not
buried. It is only in the open field away from the villages that the dead are not
buried.
•
The cultural belief that they hold important to date is that of a mother-in-law not
sharing or meeting her son-in –law while going to the latrine .
11
Generally the Mbale course was well appreciated: participants rated relevance of subject
matter between 89 and 95%, with an average of 92.6%, while presentation/facilitation
ranged from 83 - 95%, with an average of 88.8%. These are surely high ratings, indicative of
the quality of the course, and its relevance to the participants, as well as their interest in the
matter. Interest was and remained
high throughout the course
programme. This was a pointer to
good presenting, and sufficient
variety and diversion to keep
everybody active. It is noteworthy
that the practicals of day 3, water
testing demonstration in the
garden of the Mount Elgon Hotel,
scored highest [see Patrick Okuni
demonstrating a pool tester for
determining residual chlorine in
the water].
The final evaluation form was completed by 31 of 37 participants. Of these 35% qualify the
course experience as excellent, 58% as very good. Two participants felt that course was
good. In aggregate terms, 93.4 % of respondents were pleased with content, materials
provided, the participatory approach and coverage of the course material by the resource
persons.
Participants indentified (1) the capacity to respond to a cholera epidemic and (2) how to
plan for an emergency preparedness and response plan, as important things participants
learned during the course. Relevance of multi-sectoral collaboration was also mentioned.
A negative point that came up from several evaluation forms, was the concern about the
long and intensive programme. The schedule assumes that the daily programme starts at
08.30. That is nearly impossible in the Ugandan context, certainly when participants are not
staying at the venue of the course. When the day starts late by 30-45 minutes, then it is
difficult to stop much before 18.00 hrs with the current schedule.
J INJA
PROGRAMME
12
C OMMON I SSUES
13
C ONCLUSIONS
R ECOMMENDATIONS
14
A NNEXES
15
1. L I ST
O F R ESO UR C E P E R S O N S
Names
1 D.Mukungu Mukama
2
3
4
5
6
7
8
9
10
11
12
Dr. Bwire Godfrey
Otai Justin
Dr. Lukwiya Michael
Jan Heeger
Mark Choonoo
Catherine Solomon
Han Heijnen
Patrick Okuni
Samuel Madul
Stephen Wandera
Harriet Kajubi
Title
PHS/Sanitation
Coordinator
S.M.O
S.H.E
NPO
Regional Advisor WASH
Emergency Specialist
Consultant CD Karamoja
Lead Facilitator
WASH Officer
WASH Officer
WASH Officer
SPA-WASH
Organisation
MWE/DWD
MoH
MoH/EHD
WHO
UNICEF ESARO
UNICEF
UNICEF
UNICEF
UNICEF
UNICEF
UNICEF
UNICEF
16
2. L I ST
O F P A R T I CI P AN T S ,
Name
MBALE
Title
District/Organisation
1 Sylvia Awor
DCDO
Abim
2 Buteraba Mathias
DHI
Abim
3 Oluka Edmond
DWO
Abim
4 Nyeko Simon
Prog. Mgr
ACF- Moroto
5 Ogwang George
DHO
Amudat
6 Elimu Frank
DHI
Amudat
7 Onono Michael
DWO
Amudat
8 Amuron Freda I
DCDO
Amudat
9 Kaniala Fred
DHI
Bududa
10 Shibale Tom
DWO
Bududa
11 Nabwire Miria
DCDO
Bududa
12 Wepondi Herbert
P/Director
BUSIDEF
13 Nesihwe Betty
DCDO
Butaleja
14 Moga Hamisi
DWO
Butaleja
15 Isogol Henry
DHI
Butaleja
16 Angom Florence
Field Officer
CAFH
17 Engwau Nicholas
Health Officer
IRC- Moroto
18 Lochokio Moses
CAO
Kaabong
19 Kibwota Godfrey
DHI
Kaabong
20 Nasur Charles
DWO
Kaabong
21 Kedi John Paul
DWO
Kotido
22 Lukong Israel
DHC
Kotido
23 Ongom Alex
M.C.O
Kotido
24 Ochieng G.M
DHI
Kotido
25 Nachan Lily
CDO
Kotido
26 Eyura Martins
DDHO
Moroto
27 Lokokol Moses. S
DWO
Moroto
28 Lowot Musa
DWO
Moroto
29 Chakura Andrew
MO
Moroto
30 Munyes Esther
CDO
Napak
31 Omara P.O
DWO
Napak
17
32 Ilukol Andrew Rews
DHI
Napak
33 Lokiru Charles
DWO
Napak
34 Lomongin J
ACDO
Napak
35 Wadinda Julius
DHI
Sironko
36 Cathy Mugoya
CDO
Sironko
37 Buyi
Ag. DWO
Sironko
18
3. L I ST
O F P A R T I CI P AN T S , J I N JA
19
4. D AILY
COURSE PROGRAMM E