Vision: Everyone has a right to life with dignity / Our Values
Dialogue
Respect
Trust
Acceptance
Communities vulnerable to Cholera have rights to:
Information
Participate
Be Heard
What this means for:
Vulnerable groups:
Included in the response and have access to essential life saving information.
Communities:
Access to accurate essential life saving information. Know where they can get support. Know what they can do to reduce risks. Know what agencies are planning and doing. Know how, when and where they can dialogue with agencies.
Partners:
Collaborating. Listening to and working jointly with communities. Planning and coordinating with each other.
Long Term Goal: People inSierra Leone free from the threat of Cholera
Short Term Goal: Communities knowing how and acting to prevent, identify and secure proper treatment for Cholera affected people.
Strategies to achieve our goals are to effectively communicate over the next six months to:
- Highlight key risks:
- Communicate with vulnerable groups:
- Encourage safer behaviours:
- Address unsafe rumours & beliefs:
- Communicate our plans:
Location of treatment facilities with health personnel, cholera treatment drugs, admission facilities and free cost for all cholera treatment.
- Communicate through trusted & accessible inter-personal, traditional & mass communication channels:
- Create effective two way communication between partners and communities:
- Monitoring & Evaluating our response by:
UNICEF Sierra Leone Cholera Preparedness and Response Communication Plan
Cholera Risk Conditions / Vulnerable Groups / Unsafe rumours and beliefs / Safer Behaviours / Existing Complementary Initiatives / Opinion/Natural Leaders / Social networks / Communication Channels / Mass Media Access / Referral and Case Management / Agency-Community Communication / Action / Responsible / DeadlinePoor sanitation: sewage disposal, refuse management, ODF contamination / Children / Cases afraid of victimisation especially when the disease is associated with filth / Awareness / District Health & Sanitation Programmes / Religious Leaders (sermons) – Islamic, Christian (Catholic/Protestant/Evangelical/Traditional) / Secret Societies (Bondo, Poro, Wondae, Tamoboro, Kamajors) / Interpersonal / Strong cultural preference for inter-personal communication / Blue Flag Volunteers
a) their existence in the community
b) functionality c) availability of SSS/SSO treatment
d) services free of cost / Communities communicate to BFVs/CHVs to PHUs to DHMT to National Level / Reactivate the national and district cholera task forces / ODM/MOHs / Before end September 2011
Lack of safe access to water (+ poor collection, transportation, storage) / Communities that do not have access to adequate water & sanitation facilities / Belief that lactating mother who has sex with a man can cause the child to experience looseness / Proper hygiene and sanitation practice / CLTS Communities / Paramount chiefs / Associations/Unions (Drivers/Teachers) / Health Talks/Clinic Outreach / Widespread access to local language community radio / 2) Community Authorities (chiefs etc) / Field monitors/field staff report to district level / Share and discuss cholera communication plan at national task force meeting / UNICEF / Before end September 2011
Lack/inadequate knowledge on AWD/cholera prevention/control / Fishing communities / Non adherence to safety/hygiene practices by people including medical practitioners / Correct or proper use of latrines / School WASH Clubs / Ward Counsellors / Institutions (Police, Military, Schools, University) / Community Meetings / National radio and television access in Freetown / 3. Village Health Committee Members
a) presence of the committee / Reports / Form Rapid Verification and Response Team / Cholera Task Force / Before end September 2011
War/Rural-Urban Migration creating slum settlements: / Slum dwellers / Health or disease treatment centres are avenues for contracting/spreading more diseases / Hand washing with soap/ash at critical times / Freetown INGO DFID funded WASH Consortium / Community Health Volunteers (Blue Flag Volunteers) / Peer Groups / Town Criers/Street to Street announcements / Low literacy (higher in Freetown) / 4) Health facilities (PHU's, clinics, hospitals)
a) availability of health personnel
b) availability of cholera treatment kits
c) availability of admission facilities
d) free cost for cholera treatment
e) transport facilities
f) communication facilities / Mobile phone / Alert District Health Officers and Primary Health Units to exercise increased vigilance for cholera cases and to report these to MoHs / MOHs / Immediately
Cholera Risk Conditions / Vulnerable Groups / Unsafe rumours and beliefs / Safer Behaviours / Existing Complementary Initiatives / Opinion/Natural Leaders / Social networks / Communication Channels / Mass Media Access / Referral and Case Management / Agency-Community Communication / Action / Responsible / Deadline
Inadequate sanitation facilities / Night Soil Men / Preferring quack medical practitioners to authorised ones for fear of cost, ignorance, easy access / Proper disposal of refuse/excreta / Mothers Groups (Wi Pikin Groups) / Feasts/Festivals (Naming, Marriages, Funerals, Awujor) / School Health Clubs / Erratic mobile phone coverage / Interpersonal discussion / Finalise and implement the draft MoH cholera preparedness and response plan / Cholera Task Force / Before end September 2011
Poor water sources / Street food eaters / People think that the faeces of babies are free of infection / Drinking water from safe sources / INGO Programmes / Social gatherings / Focus Group Discussions / Poor internet connection / Community meetings / This should include prepositioning of cholera kits/supplies and identification of Cholera Treatment Sites and preparation of CTC job descriptions at district level. / MOHs/UNICEF / Before end September 2011
Open defecation by the sea (where fishing occurs) / Health workers / Home based management for days (stabilisation with ORS & referral is recommended) / Properly wash vegetables/fruit before eating / Associations/Unions (Drivers/Teachers / Mass Media / Finalise key cholera messages and communication materials / MOHs/Partners / Before end September 2011
Flooding: poor drainage/deforestation/climate change / Cleaners/garbage collectors / Witchcraft: That eating food in a dream can cause looseness / Cook food thoroughly and eat hot / Institutions (Police, Military, Schools, University) / National/Community Radio discussions/spots / Integrate cholera awareness into existing WASH messages and health promotion; especially through CLTS and School Sanitation Hygiene Education interventions. / MOHs/ Partners / By end 2011
Poor personal hygiene: not washing hands at critical times / HIV/AIDS affected persons / Predestination: God predestines someone to have a running stomach / Cover all foods / Peer Groups / Jingles / Conduct cholera preparedness and response training at district level – prevention, control and case management. / MOHs/UNICEF/Partners / By end October 2011
Cholera Risk Conditions / Vulnerable Groups / Unsafe rumours and beliefs / Safer Behaviours / Existing Complementary Initiatives / Opinion/Natural Leaders / Social networks / Communication Channels / Mass Media Access / Referral and Case Management / Agency-Community Communication / Action / Responsible / Deadline
Harmful traditional practices: / Palm Wine (Poyo) drinkers / If you go to Government hospitals you may not have quality treatment due to lack of drugs / Re-heat cooked food until hot / Feasts/Festivals (Naming, Marriages, Funerals, Awujor) / Flyers / Conduct cholera communication training and response planning at district level / MOHs/UNICEF/Partners / By end October 2011
Food preparation during burials (Fura) / Plumbers / Funeral rites / Television spot / Refresher medical, communication and WASH training for Cholera preparedness / MOHs/UNICEF/Partners
MOHs/UNICEF/Partners / On-going
Preparation of traditional herbs with unsafe water & dirty containers / Mining communities / Under reporting of outbreaks by Government for economic & social reasons / Print/electronic media
Shallow burial in some communities close to water sources / Travellers / Fear of vilification by medical practitioners / Television discussion
Eating and sharing of unwashed Kola Nuts / Communal eating / Death of two or more family members in a row is a curse / Bill boards/leaflets
Multiple handshaking without washing hands afterwards / Nursing mothers / Failure to perform traditional rites/ceremonies might anger the gods to afflict the community / SMS messages
Cholera Risk Conditions / Vulnerable Groups / Unsafe rumours and beliefs / Safer Behaviours / Existing Complementary Initiatives / Opinion/Natural Leaders / Social networks / Communication Channels / Mass Media Access / Referral and Case Management / Agency-Community Communication / Action / Responsible / Deadline
People who drink water from streams in rural areas / Phone in programme
People living in coastal areas / Public address system
Prisoners (poor sanitation facilities/overcrowding) / Role models to influence community behaviour
Care takers of dead bodies / Traditional
Scavengers of dump sites / Drama
Mortuary attendants / Songs
People who drink well water in urban settings / Comedians
Care givers / Story Telling
Fish handlers
Gardeners using human compost
Emergency Cholera Communication Planning Sierra Leone
Summary
Key Recommendations
- Don’t panic. Face the challenge and take decisive concerted action to put in place the following preparedness measures.
- Reactivate the national and district cholera task forces; share and discuss cholera communication plan at national task force meeting before end September 2011.
- Rapid verification and response team[1]. Identify named staff within organisations who could support immediate mobile emergency verification and response at district and Freetown levels in case of a suspected outbreak between now and October 2011 (end of rainy season). This inter-agency team should have leadership, Cholera, WASH and medical experience and would be a standby emergency back-up measure with clear Terms of Reference drawn up. Attention should be given to verification of cholera; identifying and putting barriers around the transmission reservoirs; community focussed cholera communication; stabilisation, referral and case management.
- Alert District Health Officers and Primary Health Units to exercise increased vigilance for cholera cases and to report these to MoHs immediately.
- Finalise and implement the draft MoH cholera preparedness and response plan before end September 2011. This should include prepositioning of cholera kits/supplies and identification of Cholera Treatment Sites and preparation of CTC job descriptions at district level.
- Finalise key cholera messages and communication materials as the reference point for all agencies before end September 2011.
- Integrate cholera awareness into existing WASH messages and health promotion immediately; especially through CLTS and School Sanitation Hygiene Education interventions.
- Conduct cholera preparedness and response training at district level by end 2011 – prevention, control and case management.
- Conduct cholera communication training and response planning at district level in October 2011.
- Revitalise and train the Blue Flag Volunteers (Community Health Volunteers) as well as mother support group leaders and Red Cross volunteers for surveillance (active case finding), community communication, early administration of ORS and early referral.
- In the event of an outbreak before end of this rainy season if there are too few personnel with appropriate training, health care workers who have previous experience of cholera outbreaks or who have received adequate training should be mobilized to provide on-site training and supervision of the less experienced personnel. A consideration for further validation by the Cholera Task Force would be to support the building of a contact database of Blue Flag Volunteers, Health, WASH and Community Development Workers who have past Cholera experience.
- Use the excellent WHO guideline – “Cholera Outbreak: Assessing the Outbreak Response and Improving Preparedness” (2004) as a practical and useful reference
- The above actions should connect with additional preparedness measures for 2012.
Key Findings
- There is an alarmingly low level of cholera preparedness in Sierra Leone. There was not a single cholera kit in the entire country at the time of the visit. UNICEF has since ordered three and the organisation has played a timely role in bringing cholera risk and preparedness back onto the national agenda.
- Given the lack of/weak coordination consistently raised by key informants,an outbreak in the short term would likely be met by a chaotic and disjointed response before it could be brought under control. The Disaster Management Office has the official mandate to coordinate response and there has been little or no interface between ONS and MoHS. UNICEF can play an important role in facilitating this linkage/conversation.
- The vibrio cholerae bacteria is presumed endemic in Sierra Leone and there is a history of serious outbreaks with case fatality rates usually well above the WHO minimum acceptable rate of 1%. The conditions to create an outbreak are widespread - poor sanitation, poor quality of and low access to safe water, unsafe hygiene practices (high open defecation and low proper hand washing rates) and low public awareness about cholera.
- A new reality since the end of the war is the rapid expansion and creation of slums in the bay areas of Freetown built on compacted garbage or land unsuitable for human habitation with extremely low sanitation and safe water access. These slums are on the receiving end of sewage, flood debris and waste from the hills surrounding Freetown during the April to October rainy season.
- The quality of epidemiological reporting is unreliable and there is no rapid cholera testing facility or kit in the country. After Malaria, “diahorrea with vomiting” is a highly reported incidence of morbidity. It is simply not known whether there have been any cholera related deaths in 2011. Since the last publicly declared epidemic in 2009 key informants felt that this was a question of luck rather than effective prevention measures. The last WHO cholera country profile was updated September 2009.
- Twenty seven key informant interviews and a cholera emergency communication planning workshop (with key actors who would be involved in a response) found highly variable levels of knowledge, experience and understanding of the causes, symptoms, prevention and treatment of cholera. There is a lack of consistency on basic cholera facts and messages.
- There are individuals within the government, UN system and NGOs who had substantial cholera response experience during the serious outbreaks in 1996 and 2006. New health staffs have limited field cholera response experience and variable knowledge of the disease.
Paul O’Hagan UNICEF WCARO C4D Consultant 13 September 2011
[1] Cholera Outbreak: Assessing the Outbreak Response and Improving Preparedness (2004 WHO)
The team might consist of:a physician who will both verify patients’ clinical symptoms and train health care workers in good case management;a microbiologist who will take stool samples (and environmental samples) for laboratory confirmation of cholera and train health care workers in correct sampling procedure;expertise in community based communication and information who will assess how the community reacts to cholera and define and disseminate key health messages;an epidemiologist who will assess data collection and surveillance procedures;a water and sanitation expert to investigate the possible sources of contamination and start the appropriate treatment of these sources.