Container Contamination as a Possible Source of a Diarrhoea Outbreak in Abou Shouk Camp, Darfur province, Sudan | Diarrhea | Hygiene

Please download to get full document.

View again

of 9
All materials on our website are shared by users. If you have any questions about copyright issues, please report us to resolve them. We are always happy to assist you.
Information Report
Category:

Documents

Published:

Views: 7 | Pages: 9

Extension: PDF | Download: 0

Share
Related documents
Description
Diarrhoea is one of the five major causes of death in an emergency setting and one of the three main causes of death in children. In June 2004, an outbreak of shigellosis was confi rmed in Abou Shouk camp in the Northern Darfur province of Sudan. As water testing showed no contamination, it was assumed that post-collection contamination was happening. The decision was taken to launch a programme of mass disinfection of all water containers in order to break the contamination cycle. Diarrhoea figures from the clinics showed a fall in cases following the cleaning campaign. It is extremely diffi cult to obtain good and statistically rigorous data in an emergency setting, the priority being to intervene rapidly to prevent further cases of diarrhoea. However, the results do appear to indicate that the disinfection programme has had an impact on the prevalence of bloody and watery diarrhoea
Transcript
  ontainer contamination as a possible source of a diarrhoea outbreak in Abou houk camp, Darfur province, Sudan ivien Margaret Waen D, M.Me.Sci, RN,SCM, Eizaet-Anne Lamon REHIS, MLSO, BSc Hons an Say A. Fie MSc, BSc, RN, Oxfam GB Diarrhoea is one of the ve major causes of death in an emergency setting and one of the three main causes of death in children (Curtis and Cairncross, 2003  ). In June 2004 , an outbreak of shigellosis was conrmed in Abou Shouk camp in the Northern Darfur province of Sudan. As water testing howed no contamination, it was assumed that post-collection contamination was happening. The ecision was taken to launch a programme of mass disinfection of all water containers in order to reak the contamination cycle. Diarrhoea gures from the clinics showed a fall in cases following he cleaning campaign. It is extremely difcult to obtain good and statistically rigorous data in an emergency setting, the priority being to intervene rapidly to prevent further cases of diarrhoea. However, the results do appear to indicate that the disinfection programme has had an impact on he prevalence of bloody and watery diarrhoea. eywors: container contamination, iarroea, ispace persons, prevention Introduction iarrhoea in various forms is one of the ve major causes of death in an emergency setting and one of the three main causes of death in children (Curtis and Cairncross, 2003 . Outbreaks of diarrhoeal disease among refugees have been well documented: in 9 , during the ‘months of diarrhoea’ in Somalia, there were 5 , 352  cases in four months, esulting in 2  deaths (Mursal, 19 ; and in 1994 , an average crude mortality rate of 20  –   5  per 10 000  was associated with epidemics of both cholera and shigellosis among wandan refugees (The Goma Epidemiological Group, 1995 ). In June 2004  the World Health Organization (WHO)’s Early Warning System (WHO, 2004 ) conrmed an outbreak of shigellosis in Abou Shouk camp in the Northern Darfur province of Sudan. The outbreak started in mid-May, and by the end of June, 1 ,  40 cases of bloody diarrhoea had been reported, leading to 11  deaths. Of the 13  stool samples ested on 30  June, three tested positive for Shigella dysenteriae type 1  (WHO, 2004 ). This paper describes an intensive and rapid intervention by Oxfam GB to ensure that drinking water containers were disinfected in order to prevent post-collection contami-ation and looks at the impact that this intervention has had on morbidity gures. ackground arfur province lies in the western part of Sudan towards the Chad border. It is divided nto three districts: North, South and West. The province has a history of both internal isasters, 005, 29(3): 213− 21. Overseas Development Institute, 2005 ublished by Blackwell Publishing, 600 Garsington Road, Oxford, OX 4 2 DQ, UKand 350 Main Street, Malden, MA 2148 , USA  ivien Margaret Waen, Eizaet-Anne Lamon an Say A. Fie 214 conict and drought. The present round of conict started in early 2003 . As of mid- 2005 , 700 000  people have been internally displaced, and another 130 ,  00  have ed o neighbouring Chad (ICG, 2004 ). Abou Shouk camp is located on the edge of El Fashar town in north Darfur. opulation gures vary as there is movement in and out of the camp, but it is be-ieved that approximately 40 ,  00  people live there (June 2004  gures). Unlike most camps for refugees or internally displaced persons (IDPs), this camp was planned and aid out before the IDP population was removed from an unsuitable site that was rone to ooding. This means that the overcrowded and unsanitary conditions so often associated with camps are not so much in evidence. It is also easier to map the area and to conduct house-to-house visits, since all households have a block and com-ound number. Post-collection contamination of drinking water It is now well recognised that the provision of clean drinking water at collection points s not enough to prevent water-borne diseases (Kaltenthaler and Drašar, 996 ). Contami-ation often occurs while water is being collected, including from the handpump ozzles themselves (Clasen and Bastable, 2003 ), from the use of dirty containers, or during storage in the home (Mintz et al., 1995 ). Other factors could be unhygienic ater handling habits or the nature of the household environment, such as the presence of animals in the home (Jagal et al., 2003 ). Although the washing of hands with soap is recommended as ‘the most effective easure to prevent transmission of Shigella’ (WHO, 1995 ), as demonstrated by several eld studies (Curtis and Cairncross, 2003 ), behavioural change strategies take time to mplement, especially in a large camp where soap may not be available and thus has to e distributed to all households rst. To date, hand-washing studies have largely been conducted in non-emergency settings and show behavioural change taking place gradually over the course of a year or more. While hand washing is recognised as a ital component of hygiene promotion, a speedier intervention capable of generating nstant results was deemed necessary for the Abou Shouk outbreak. Chlorination has already been shown to be effective in reducing household diarrhoeal disease in Bangladesh (Sobsey et al., 2003 ), Bolivia (Quick et al., 1999 ), Saudi Arabia (Mahfouz et al., 1995  and Uzbekistan (Semenza et al., 99 ), although some studies ave been inconclusive (Jensen et al., 2003 ). These studies were all carried out in non-epidemic situations. A study conducted in a Malawian refugee camp concluded that ousehold contamination of drinking water signicantly contributed to diarrhoea in he population and that, while chlorination was a cheap and effective way of ensuring otable water, the method was unpopular and therefore rarely used by the refugees (Roberts et al., 2001 ). Drawbacks to chlorination include low acceptance by communities, the taste, re-duced effectiveness in highly turbid water and the importance of issuing the correct dosage (WHO, 1997 ).  Container contamination as a possie source o a iarroea outrea in Aou Sou camp 215 ethodology The intervention presented here was not planned as a research study to measure efcacy; t was simply carried out to stop the diarrhoea outbreak. It was only after the interven-ion was completed that the authors considered it interesting enough to be written up. ence, there are obvious gaps in terms of both the data collected and information about the situation. A control group would have been preferable, but this raises ethical ssues with respect to research of disease outbreaks in IDP camps. Other authors have ighlighted these matters and hence they are not discussed here (Black, 2003 ; CPOP, 2002 . Baseline data were collected two months prior to the intervention from a ve per cent ( 32  households) random sample of the estimated 900  households using ques-ionnaires, which were then analysed on tally sheets. Admittedly, this is a small sample, but data were needed urgently to start a hygiene promotion intervention and a latrine programme. Lack of resources and qualied personnel were also constraints. Results derived from the baseline data showed that: 65 . 6  ( 215 / 328  of all households consumed 15  litres of water per day; 79  ( 259 / 32 ) of households had water containers without lids; ( 150 /  2 ) of households had dirty containers; and 9  ( 321 / 328  of people interviewed had no means of removing drinking water from the storage container in their shelter in a hygienic manner. A dirty container was dened as having one or more of the following: cracks, no lid and visible signs of dirt or slime on the inside. As far as hand washing is concerned: only 27 % of people (/  2 ) washed their ands after using the latrine; 17  ( 5 /  2 ) washed their hands after cleaning children’s bottoms; and 30  ( 9 / 32 ) washed their hands before preparing food. Given that questionnaires often prompt respondents to over-report desirable behaviour, the percen-ages may actually be lower. Water situation and analysis In Abou Shouk camp, there are 25  boreholes. Twenty-three of them are tted with andpumps and two are tted with submersible pumps and attached via a T  5  Oxfam ank to tap-stands (six blocks of six taps). In May–June 2004 , Sphere Projectstandards egarding water accessibility had still to be satised: around one-quarter of the popu-lation had to walk more than 500  metres to procure water (personal communication ith Oxfam engineer). Oxfam was not instrumental in providing water to the camp, but eld staff members ere concerned about the lack of water quality testing. ‘In addition to the baseline analysis of water sources, a regular monitoring programme of water quality at source ill act as an early warning system for outbreaks of water related diseases, of which Oxfam GB has the means and capacity to respond’ (Oxfam, 2004 ). After initial baseline testing, it was decided to analyse all 25  sources once every four eeks, making sure that all sites were tested before, during and after the rainy season n order to detect any contamination caused by the rains. The Oxfam Delagua Water   ivien Margaret Waen, Eizaet-Anne Lamon an Say A. Fie 216 TestingKit was employed for this purpose. The standard used was the Sphere/WHO aximum advisory level (MAL) of zero faecal coliforms in 100  millilitres of water. In addition to the water points, a weekly random sample of the storage water of 50 ouseholds was also to be tested. Due to a shortage of experienced staff, however, this did not occur prior to the outbreak of disease. Therefore, no data are available. By mid-May, Oxfam had carried out a baseline survey of 19  of the 25  water sources. esults showed that only one source contained one faecal coliform per 100  millilitres of water (the previous Sphere Projectanual specied a MAL of less than ten faecal coliforms per 100  millilitres of water. According to the Sphere Project’s Technical Focal Point for Water, Sanitation and Hygiene Promotion, Andrew Bastable, ‘while aiming for zero, anything below ve faecal coliforms per 100  millilitres has been for any years the acceptable norm and therefore it is highly unlikely that such a low coliform count could be the cause of such an epidemic’. The remaining six boreholes ere all over 0  metres deep and sealed, so it is reasonable to assume that there was no contamination. Routine inspection, though, revealed that most areas around the water collection points were unsanitary due to the presence of animal dung, ies and stagnant ater. Many of the water containers placed in the water collection queue were situated directly on top of animal dung. The possibility of post-collection contamination was considered high. he epidemic n 29  June 2004 , aid agencies working in Abou Shouk held an emergency meeting o discuss the number of cases of diarrhoea (especially of bloody diarrhoea) being seen at therapeutic feeding centres (TFCs) and at the camp clinics (see Figure below). WHO reported ve deaths in week 25  and six deaths in week 27  (WHO, 2004 ). dults and children were affected. Oxfam was asked to take the lead on controlling he epidemic. In these early stages of camp administration, there was poor reporting of diseases. In he clinics, cases were not disaggregated by age or gender, nor were households or the affected proportion of each household recorded (despite the fact that households were umbered). TFC staff members did do some mapping of the camp and found that TFC cases came from all areas of the camp, making it impossible to pinpoint the source of he infection. However, other sources, such as uncovered food, could not be ruled out. As only one water source had previously been shown to be contaminated and as cases came from all areas of the camp (making a John Snow-type of investigation dif-cult), it was assumed that post-collection contamination was taking place. The possible sources of contamination are listed below: from the use of dirty containers at water collection points or from having dirty ands; from the use of dirty dippers or cups in the household or from having dirty hands; from contaminated food or dirty utensils; and from using rags, wood and bamboo as stoppers instead of container lids.
Recommended
View more...
We Need Your Support
Thank you for visiting our website and your interest in our free products and services. We are nonprofit website to share and download documents. To the running of this website, we need your help to support us.

Thanks to everyone for your continued support.

No, Thanks