WASH Sector ACUTE Watery Diarrheal Disease Preparedness and Response Plan
October 2017
Contents
1 Introduction 3
2 DIARRHEAL DISEASE IN THE TARGET POPULATION: Host communities and REFUGEES 3
2.1 Prevention and Control of AWD Outbreaks 4
2.2 Estimated Caseloads 4
3 Sector Preparedness Plans 5
Overall Preparedness 5
3.1.1 Wash Sector 5
3.1.2 WASH Sector in a camp 10
4 Response Plan 13
4.1 Scenario 1: Diarrhoea rates remain as they are, i.e. situation unchanged 13
4.2 Scenario 2: Diarrhoea rates escalate 13
4.3 Scenario 3: Cholera is confirmed 14
5 Water Treatment Options 15
Composition of Bucket Chlorination Kit 15
6 Environmental Sanitation and Disinfection 16
Environmental Sanitation Kit 16
ANNEX 1 WASH Sector Major Tasks 19
ANNEX 2 Environmental Health Management during cholera/AWD outbreaks 20
ANNEX 3 Water quality control procedures and targets 21
ANNEX 4 Guideline for Cholera/AWD NFI Kit distribution 22
ANNEX 5 WASH Standard in the CTC 23
ANNEX 6 Key message form 27
ANNEX 7 Household disinfection 28
ANNEX 8 Installation of Oral Rehydration Point (ORP) 29
ANNEX 9 Recommended chlorine solution concentrations per usage and per chlorine source 31
Reference documents and further information 32
1 introduction
High risk for diarrheal diseases and related-outbreaks including cholera and dysentery
o Poor sanitation: Tube well and latrines positioning
o poor hygiene behavior, limited volumes of containers, soap distribution and water treatment
o high population density
Due to the massive population increase following the influx of Rohingya refugees into Cox’s Bazar, WASH facilities in settlements are under immense strain. In spontaneous settlements, there is limited access to water and sanitation facilities, increasing the risk of an outbreak of disease. Across all sites poor sanitation conditions pose a serious public health hazard.
In October 2017, the WASH Sector, in consultation with the relevant line Authorities, developed a joint AWD Preparedness and Response Plan to set out the required stages to prepare for an Acute Diarrheal Disease outbreak in the country.
The purpose of this Acute Diarrheal Disease Preparedness and Response Plan is to ensure a proactive and coordinated approach to AWD response across sectors and stakeholders for this crisis.
Specifically, this document sets out the preparedness, prevention and control actions that are required in order to prevent or limit the impact of AWD outbreaks in Cox’s Bazar.
The plan also includes information on generic response activities, roles and responsibilities in the event of an outbreak, and determines the needs and required resources to address them.
2 DIARRHEAL DISEASE IN THE TARGET POPULATION: HOST COMMUNITIES AND REFUGEES
The health of refugee and vulnerable host populations in Cox’s Bazar has been threatened due to poor environmental conditions, high population density, poor hygiene practices and inadequate clean drinking water. Despite the efforts of the humanitarian community made to improve water and sanitation conditions, diarrheal diseases still remain the most common cause of health consultations. Acute diarrheal diseases pose a very serious threat to the health of refugees and the host community.
Cholera and acute bloody diarrhea are the most severe types of the acute diarrheal diseases. Cholera is an acute diarrheal infection caused by the ingestion of the vibrio cholerae bacterium. Transmission occurs through direct Fecal-Oral contamination or through ingestion of contaminated water or/and food. The disease is characterized in its most severe form by a sudden onset of acute watery diarrhea (AWD) that can lead to death from severe dehydration and organ failure. The extremely short incubation period (two hours to five days) enhances the potentially explosive pattern of outbreaks, as the number of cases can rise and the disease spread very quickly.
About 80% of people infected with cholera do not develop any symptoms or mild symptoms. However, the pathogens stay in the faeces for one to two weeks and are shed back into the environment, potentially infecting other individuals. Cholera is an extremely virulent disease that affects both children and adults. Unlike other diarrheal diseases, it can kill healthy adults within hours if the cases do not receive treatment. Individuals with lower immunity, such as malnourished children or people living with other chronic conditions, are at greater risk of death if infected by cholera.
Water and sanitation under current situation, with large population displacements to overcrowded shelters and settlements with inadequate water and sanitation facilities, can increase the risk of serious AWD outbreaks once the pathogen is introduced or present in the setting.
2.1 Prevention and Control of AWD Outbreaks
Measures for the prevention of AWD mostly consist of ensuring the provision of clean water and proper sanitation to populations potentially affected. Good hygiene practices and food hygiene are equally important. In particular, systematic hand washing should be taught. Once an outbreak is detected, the usual intervention strategy is to reduce mortality by ensuring prompt access to treatment, proper case management and controlling the spread of the disease.
Up to 80% of patients can be treated adequately through the administration of oral rehydration salts (ORS).
The provision of safe water, adequate sanitation and the promotion of good hygiene practices in the refugee situation is a difficult challenge but remains the critical factor in reducing the impact of AWD outbreaks.
AWD prevention and control is not an issue to be dealt with by the health sector alone. Water, sanitation, health and hygiene promotion, mass communication/community mobilization, and camp management are also the important actors in the prevention and control of AWD. A comprehensive, multidisciplinary approach should therefore be adopted for dealing with potential AWD outbreaks in the refugee camps, as well as in the host community, including in informal settlements, collective shelters and other settlement types.
The WASH Sector has developed this AWD Preparedness and Response Plan in order to respond to a potential outbreak in a more coordinated and effective manner. Although the plan primarily focuses on AWD, the same framework can be used to respond to other epidemics and public health emergencies.
2.2 Estimated Caseloads
In order to guide the planning process, the following assumptions have been made based on past large cholera outbreaks in refugee camps with attack rate of 1 - 5%; Peak reached after 2-4 weeks; Proportion of cases seen before peak (40%); duration of epidemic varies from 1-3 months with a CRF 2%
Table 1: The estimation of the incidence of AWD cases in Cox’s Bazar in 2017 in the camps, host communities and areas with shortage in accessing of safe water and sanitation:
Estimated population at risk / Est.Attack Rate / Expected cases
1,000,000 / 4% / 40,000
1,000,000 / 40,000
3 Sector Preparedness Plans
This chapter will review the overall preparedness for WASH Sectors before focusing on the specific case of camps
Overall Preparedness
This section describes what, who, when, necessary resource, and the cost of each action to be completed by WASH Sector partners.
Currently standalone, integration and coordination are paramount with other sectors, such as Health, Nutrition, Communication etc., to make this plan more effective.
3.1.1 Wash Sector
Table 2: Preparedness Actions Plan for WASH Sector
Action plan for WASH Sector /Actions / Responsible Person / Contact of persons responsible / Resources needed / Time to complete / Indicator of completion / Status & Observations / Cost ($) /
Review of National and WASH sector technical capacities in terms of preparedness and response / WASH Sector / 20 October 2017 / The updated preparedness and response updated plan is available / ongoing / -
Procure and pre-position chlorine including Aquatabs (in type and quantity sufficient to be determined) in the camps/areas at risk / WASH Sector / To be determined / The number of type and quantity of chlorine procured. / ongoing
Impose the standard of the dosage type of Aquatab to be distributed. / WASH Sector / WASH sector to advise sector partners according to safe water containers used for storage in the targeted population / done / The standard of The dosage type of Aquatab to be distributed / completed
Make write the instructions on Aquatabs use be printed on the package in local language and pictorially to ensure access to all users. / WASH Sector/C4D/CWC / to be decided / to be decided / The package of Aquatabs has the instruction accessible to all users on how to use it
Set water testing standards / WHO, WASH Sector / 29th Oct / The standards for water test are available / WHO will produce 1 page standard
Plan and implement water testing / DPHE, WHO, all WASH Sector Partners / ongoing / The water testing reports are available.
Manage and share test result. / DPHE, WHO, all WASH Sector Partners / WHO and sector partners to share their WQ results / ongoing / The number of results share by week
Develop an inventory of key water sources and update regularly their status at camp level, in high risk areas. / WASH Sector Partners and Focal Point agencies to compile information / . / The inventory document is available
Ensuring disinfection of all drinking water sources (testing at source and end user) / WASH Sector Partners and Focal Point agencies / Chlorine, trained personnel, pool tester, reagents (DPD) / Water quality at source respects the emergency standard
Elaborate distribution strategy for a common and comprehensive response: disinfection tablets, hygiene kits, jerry cans / WASH sector to draft the distribution strategy / To unpack / The strategy to distribute Household water treatment is available
Organize a distribution of chlorine tablets to households in quantity enough to cover their needs during the AWD emergency / all WASH Sector Partners / Financial resource to procure the Aquatabs. Logistics and trained staff to distribute the Aquatabs / The number of households that has received Aquatabs. The number of Aquatabs distributed
Assess current WASH situation in PHC and improve it to meet the minimal WASH standards in order to cope with AWD cases. Regularly update this assessment document and use it to develop a sustainable and adequate WASH in Health Centres program. / MSF, IFRC… / WASH Trained personnel in health facilities / When needed / The data about the WASH conditions in the PHC / Mapping of Partners working in Health centers
Assess current WASH situation in all the schools in AWD at risk areas and establish the needs of each of these schools to have sustainable and adequate WASH conditions. / UNICEF, SCI, BRAC / Trained personnel in WASH in school / When needed / The data about the WASH conditions in the schools and how to improve to meet the minimum standard is available
Have agreement on common messages for cholera/AWD prevention / CWC, C4D, hygiene WG / Bill Fellows / Trained personnel in communication / To be agreed - urgent / The number of messages validated
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3.1.2 WASH Sector in a camp
The tables below describe the necessary actions in term of coordination, preparedness that WASH Sector need to take in a camp regarding AWD
Preparedness
Table 3: Preparedness actions plan of WASH Sector in a camp
Preparedness actions plan of WASH Sector in a camp /Actions / Persons responsible and persons associated / Contact of persons responsible / Resources needed / Time to complete / Indicator of completion / Status & Observations / Cost ($) /
Provide vulnerable households with two 10 liters safe water storage containers and toilet jugs, soap and disinfectant / WASH Sector Partners / Focal point / Ongoing + replenishment / Quantity of WASH NFI kits distributed
Disinfect areas and materials soiled with faeces and vomit / WASH Sector Partners / Focal point / The document on procedures for decontamination is approved / Unpack
Assess all pit latrines, septic tanks and cesspools. Desludge if needed, repair/decommission if presenting a public health risk / WASH Sector Partners / Focal point agencies to identify latrines which needs decommissioning. / Ongoing / The number of pit latrines, septic tanks and cesspools improved and the number remaining to be improved
Assess, and ensure WASH in Health Care facilities is improved (Handwashing stations, toilets, infection prevention and control, supply of WASH supplies such as soap, chlorine, disinfectants, capacity building of health staff involved in AWD Response etc.) / Health sector partners to ensure WASH services. / Focal point / Report on the needs to improve WASH conditions to the standard level for each facility visited / Mapping of Partners working in Health centers
Define mitigation measures for self-built latrines / WASH Sector/TWG on sanitation to find a solution??? 15% of existing HH- – Focal identify HH latrine- Use reach data. / Report on the measures to improve the self-built latrines
Preposition chlorine products (HTH, NaDCC…) and WASH Cholera/AWD kits (soap, Aquatabs,…) and other contingency materials (sprayers, safety equipment for operators, …) / UNICEF & WASH Sector Partners / Report on the quantity of material dispatched at each area
Design awareness campaigns on AWD prevention and treatment protocol through community based approach / CWC, C4D, hygiene WG / Bill Fellows / The document on the designed campaign
Have agreement on key messages through community based mechanisms to ensure efficiency and relevance / CWC, C4D, hygiene WG focal point / Bill Fellows / Report on the pre-tests
Design, pre-test, obtain approval and print in sufficient numbers specific WASH Cholera/AWD IEC materials / UNICEF/CWC/Partners / Bill Fellows / The report on the material designed, pre-test, and printed
Train WASH field staff on cholera prevention, disinfection procedures, communication techniques, use of IEC materials, and referral pathways / CWC/C4D MSF, IFRC, WHO / The number of persons trained
Train religious and community leaders, community health workers, public places stakeholders on how to keep people safe at gatherings / UNICEF, CWC/C4D and WASH Sector Partners / The number of persons trained
Train food providers on environmental health and food safety / MoH with support of UNICEF and WHO, Food Sector/CCCM / The number of persons trained
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