WASH AWD Preparedness and Response Plan, May 2019

WASH SectorAcute Watery Diarrheal Disease

Preparedness and Response Plan

May 2019

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WASH AWD Preparedness and Response Plan, May 2019

Contents

1. Purpose of this document.................................................................................................................3

2. AWD Data in host communities and camps.....................................................................................3

3. Prevention and Control of Severe AWD Outbreaks.........................................................................4

4. Estimated Caseloads.........................................................................................................................4

5. WASH and Health Sector Coordination in Preparation and Response to an Outbreak...................6

6 WASH Sector Activities to Prepare for an AWD Outbreak............................................................7

8 Reference documents and further information...................................................................................15

9 ANNEXES.....................................................................................................................................16

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WASH AWD Preparedness and Response Plan, May 2019

1. PURPOSE OF THIS DOCUMENT

In October 2017, the WASH Sector, in consultation with relevant line Ministries, developed a WASH AWD Preparedness and Response Plan to set out the required activities to prepare for and respond to an AWD outbreak. This document was reviewed and updated in June of 2018 followed by a second review in April-May, 2019.

The purpose of the WASH AWD Plan is to ensure a proactive, coordinated, and effective effort to prevent AWD and control it where it does occur. Specifically, this document sets out the preparedness, prevention and response actions that are required in order to prevent or limit the impact of AWD outbreaks in Cox’s Bazar district.

This plan is intended to provide guidance to WASH camp focal agencies in the development of their own AWD preparedness and response plans. It includes information on activities agreed and promoted by the WASH Sector which focus on prevention, preparation and response to an outbreak, and the resources required to address them.

A joint AWD response plan was developed by the WASH and Health, Sectors. The current document reflects this plan but includes additional details related to WASH specific activities.

The current document is divided into three sections: Prevention: Outlines WASH activities which are carried out to prevent an AWD outbreak during

high risk periods. The focus is on access to safe water, sanitation, hygiene items, and information and communications around key hygiene practices for prevention, recognition of signs and symptoms as well as treatment seeking behaviour.

Preparedness: Identifies the steps required to prepare for a severe AWD outbreak, including gap analysis and capacity building activities (training, pre-agreement on standards, messages etc.), pre-positioning of supplies, adapting and pre-positioning IEC materials, identification of camp level emergency response teams (ERTs) and pre-defined agreements for response implementation, among others.

Response plan: Identifies the actions to be taken in response to a cholera outbreak, including who will do what, where, and when.

2. AWD DATA IN HOST COMMUNITIES AND CAMPS

The health of refugee and vulnerable host populations in Cox’s Bazar has been threatened due to poor environmental sanitation conditions, high population density, sub-optimal hygiene practices and challenges around access to chlorinated drinking water. Despite the efforts of the humanitarian community to improve water and sanitation conditions, diarrheal diseases still remain the most common cause of health consultations. As of 31st December 2018, 231,145 cases of AWD were reported in EWARS. In addition, from week 1-52 2018, 1,254 cases were admitted in diarrhoea treatment centres.

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WASH AWD Preparedness and Response Plan, May 2019

Figure 1: Number of AWD cases reported from health facilities and DTCs in 2018 in EWARS, Cox’s Bazar, Bangladesh

3. PREVENTION AND CONTROL OF SEVERE 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, including systematic handwashing with soap at critical times and food hygiene. Once an outbreak is detected, the firstline response strategy aims to prevent mortality and reduce morbidity 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, chlorinated water, adequate and appropriate sanitation and the promotion of key hygiene practices in the current Rohingya context remains critical factors in reducing the impact of AWD outbreaks.

AWD prevention and control should involve multiple sectors including Health, WASH, Communicating with Communities (CWC) and Camp Management. A comprehensive, multidisciplinary approach should therefore be adopted for dealing with potential AWD outbreaks in the Forcibly Displaced Myanmar Nationals (FDMN) response areas as well as in host communities.

The WASH Sector has developed this AWD Preparedness and Response Plan to complement the Multi-Sectoral Plan developed by Health and WASH. It includes detailed information on WASH specific activities to guide WASH partners 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.

4. ESTIMATED CASELOADS

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WASH AWD Preparedness and Response Plan, May 2019

A. TARGET POPULATION

According to the February ISCG report, the total number of FDMN population as of March 2019 is 911,000 including new and pre-existing influx1. In addition, 335,930 host community are targeted in this response, as outlined in the 2019 Joint Response Plan (JRP). These figures are shown in Table 1.

Table 1: Population Estimates

Target population breakdown Population

FDMN population* 911,000

Host population^ 335,930

Total population 1,246,930

* Updated population estimates as February 2019^ Joint Response Plan (JRP) population breakdown estimates

B. ESTIMATED CASELOAD

For scenario planning purposes, the following key assumptions were made based on the characteristics of past large AWD outbreaks in refugee camp settings:

• Population attack rate among FDMN population: 2% • Population attack rate for host population: 1%• Average duration of an outbreak: 3 months• Proportion of cases seen during peak week (20%)• Case fatality rate (CFR): with appropriate treatment should remain below 1%• The proportion with severe dehydration: 25% of expected caseload• The proportion with some dehydration: 30% of expected caseload• The proportion with no dehydration: 45% of expected caseload

Two scenarios - “worst-case” and “best-case” are presented. For the worst case scenario a 0% vaccine efficacy is assumed among host and refugee populations. For the best case scenario 65% oral cholera vaccine efficacy is assumed for all vaccinated populations2. These figures, along with the estimated caseload derived from them, are presented in Table 2.

Table 2: Caseload estimates for best and worst-case scenario

1 https://www.humanitarianresponse.info/en/operations/bangladesh/document/situation-report-rohingya-crisis-coxs-bazar-february-2019 2 An estimated 99,160 host community received two doses; and 899,946 refugees received two doses.

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WASH AWD Preparedness and Response Plan, May 2019

Estimated cases Assuming no vaccine protection (worst-case)

Assuming 65% vaccine efficacy among vaccinated populations (best-case)

Estimated cases- refugees (2% attack rate) 18,220 6,521Estimated cases- host community (1% attack rate) 3,359 2,715Estimated cases refugee and host community 21,579 9,235Estimated cases in peak week (20%) 4,316 1,847Estimated cases with severe dehydration peak week (25%) 1,079 462Estimated cases with some dehydration peak week (30%) 1,295 554Estimated fatalities 216 92

The estimated need for treatment facilities and stock in this plan are calculated based on these two scenario case load estimates during the peak week, when the maximum number of resources will be required.

5. WASH AND HEALTH SECTOR COORDINATION IN PREPARATION AND RESPONSE TO AN OUTBREAK

In order to effectively pre-empt and manage an outbreak of AWD the WASH and Health sector need to maintain a continuous dialogue on AWD cases and suspected cases; roles and responsibilities between the two sectors need to be clear and communication protocols constantly updated.

The WASH AWD response plan is based upon 3 scenarios of escalation in terms of diarrhoea cases. Each step in the ladder demands a different level of relationship between WASH and Health sectors and higher level of engagement by WASH actors in the field. To move between the steps in the ladder there is an agreed “trigger” most usually defined by the Health sector but also requiring intervention actions by the WASH section. The ladder is as follows:

Scenario 1 – Situation remains unchanged: AWD rates in camps and host population remain as they are (routine activities over the year). At this time the WASH sector and Health sector are operating preventinve programming including improving service provision according to sector standards. During the this scenario rumours of atypical diarrhoea that come from the PHC, community or other entity would result in further investigation from Health or Health and WASH.

Scenario 2 - Situation escalates moderately: Both sectors are mobilised to investigate reports of atypical diarrhoea at PHC and sub-camp level. This is a key stage for preventing or controlling an outbreak. There are clear activities for WASH to undertake including intensifying hygiene promotion, conducting water treatment through bucket chlorination or aquatab distributions, latrine desludging or hazard treatment, decommissioning of dangerous infrastructure. At this stage, the WASH and Health sectors could recognise that AWD cases have reached a critical point and intensify activities to prevent an official outbreak if:

2.1. A verified AWD alert either by positive Cholera RDT or culture positive case is reported without evidence of an increase of AWD in the area – Localised response (Cluster = 5-10 cases/block)

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WASH AWD Preparedness and Response Plan, May 2019

2.2. A 15% increase in AWD cases reported through EWARS compared with the previous 3 weeks (this needs to be verified by WHO) – Localised response

Scenario 3 - Outbreak confirmed: An outbreak could be confirmed by the Health Sector or the Government of Bangladesh:

3.1 Cholera confirmed by either RDT or culture AND a verified increase in AWD cases in EWARS and EBS reports (verified by WHO Epi team/JAT) – Response to be targeted to affected area 3.2. Outbreak declared by government of Bangladesh.

Section 6 of the WASH AWD plan is concerned with the WASH sector activities as they relate to the preparation for an AWD Outbreak (Scenario 1). Section 7 outlines WASH sector activities when AWD cases have reached a critical point (Scenario 2) and once an outbreak is agreed by the Health sector and/or the Government of Bangladesh (Scenario 3).

6. WASH SECTOR ACTIVITIES TO PREPARE FOR AN AWD OUTBREAK

This section describes what, who, when, and required resources by WASH Sector and WASH partners to prepare for an AWD outbreak (Scenario 1):

Preparation Activity Responsible Time ResourcesCOORDINATIONCommunicate the WASH AWD, Joint AWD and JAT documents to WASH Agencies

WASH Sector End May 2019

WASH AWD RPJoint Response Plan JAT operational guidance (Annex 1)

Update WASH CFA, AFA, Sector Contact lists

WASH Sector Immediate

Contact list (A2)

Establish and train WASH ERTs Train ERTs in

preparedness and response activities

AFAsEnd May 2019

ERTs TORs (A3)

JAT assessmentJAT reportingJAT Action plan monitoring

CFAAFAWS

As needed

Assessment Tool (A4)Report format (A5)Tracking sheet (A6)

AWD Preposition stocks Define kits and

locations Stock piling Monitor

AWD TWGAFA/CFAIM

End of June

Stock list definition (A7)

Stock list inventory (A8)

AWD cases review Meet with Health

sector on suspicious or unusual diarrhoea

WS Weekly Health Epidemiological Data

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WASH AWD Preparedness and Response Plan, May 2019

cases Review previous action

plans communicate results to

WASH actors

WSWS

WeeklyBi-weekly

JAT action plans (A9)AWD communique (A10)

Coordinate with WASH partners, Education and Child Protection sector to intensify hygiene promotion and ensure hygienic conditions

WASH/Child protection and education sector Initiated AWD infosheet

WATERRegular monitoring of water quantity and quality of drinking water, particularly free residual chlorine at source and household

Water Quality TWG

Regular basis Water quality surveillance

Train WASH Field staff on FRC monitoring Water TWG May 2019 Any Link?

Establish systems for bucket chlorination and ensure operational capacity

All partners Bucket Chlorination Protocol

TW decommissioning if being flood prone or failing to comply with bacteriological quality including contamination source removal, decommissioning followed by, shock chlorination if relevant and water quality monitoring.

Water TWG Decommissioning Guide

Prioritization of drinking TW

HP/Water TWG to finalise tool

WASH partners

Finalized tool: May 2019

Roll-out:July 2019

Drinking Tubewell marking Guideline – under revision

SANITATIONIncrease monitoring of latrine filling. Desludge if needed and repair and clean if presenting public health risks or barriers to use

Partners undertaking desludging

Regular basis

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WASH AWD Preparedness and Response Plan, May 2019

Partners to extend desludging beyond their catchment areas to minimise risks

WASH partners Regular basis

Compilation of information on desludging and latrine repairs and presence of handwashing facilities to be collected and shared

Sanitation TWG May 2019

Install handwashing facilities next to latrines/latrine blocks.

WASH parnters Regular basis

Handwashing design?Designs as per implementing agency pending unified designs

Train Refresher training for field staff on latrine disinfection and ensure all staff coming into contact with sludge are using Personal Protective Equipment (PPE) and disinfecting tools after work

WASH partners May 2019

HYGIENE PROMOTION

Agree on common messages for AWD prevention and response

HP TWG/CHW TWG/CWC (Risk Communications Sub-group)

AWD InfosheetResponse PSA (Emergency response message)AWD Prevention Open Ended Stories (Audio)

Develop AWD prevention and response communication strategies

HPTWG, C4D, CWC (Risk Coms Subgroup)

Design, pre-test, obtain approval and print in sufficient numbers specific WASH AWD IEC materials

HPTWG/CWC AWD IEC

Prepositioning of hygiene kits in DTCs and camps

Health/WASH CFAs/partners June 2019

Train WASH HP staff, HP volunteers/community health workers on AWD prevention, household disinfection, FRC testing at HH level, communication strategy, and referral pathways

All WASH and Health partners June 2019

AWD TOT AWD Training for HP StaffAWD Training for HP Volunteers

Ensure religious and community leaders understand how to prevent

All partners Community Level Communication Flowchart

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WASH AWD Preparedness and Response Plan, May 2019

AWD, and know the communication pathways if there is a suspected death due to AWD at the householdTrain food providers on environmental health and food safety. Ensure food stalls have handwashing facilities and access to regularly supply of soap.

WASH partners Food hygiene for food vendors

7. RESPONSE PLAN

During response, preparedness activities as detailed in the previous section, are assumed to continue as long as the AWD prevalence remains unchanged.

Two response scenarios are foreseen by the WASH/Health Sectors: Scenario 2:

2.1. A verified AWD alert either by positive Cholera RDT or culture positive case is reported without evidence of an increase of AWD in the area – Localised response (Cluster = 5-10 cases/block) 2.2. A 15% increase in AWD cases reported through EWARS compared with the previous 3 weeks (this needs to be verified by WHO) – Localised response

Scenario 3:3.1 Cholera confirmed by either RDT or culture AND a verified increase in AWD cases in EWARS and EBS reports (verified by WHO Epi team/JAT) – Response to be targeted to affected area 3.2. Outbreak declared by Government of Bangladesh.

Scenario 2: AWD alert or 15% increase in AWD compared with previous 3 weeksArea Actions Coordination and management

Rapid Assessment by ERT/JAT in coordination with WASH/Health Sector, AFA, CFA

WASH camp focal points/ERTs develop camp level response activity plans with AFAs

Any suspected diarrhoea or rumours are reported to Health/WASH Sectors

Active case finding is done in AWD affected areas

Twice weekly situation room at camp level led by ERT with the presence

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WASH AWD Preparedness and Response Plan, May 2019

of Health actors presenting the cases of previous day by area, RDT results, clinical diagnosis and rehydration plan, WASH actors present ongoing response, coverage and gaps and discussed

CXB level coordination meeting between WASH/Health Sectors

Water Comprehensive monitoring of microbiological water quality or the water sources in the targeted area by JAT and WASH partners

Identify possible origin of feacal contamination and close down the water sources until contamination issues solved

Assess whether quantitative water supply comply with 15l/p/day

Ensure full coverage of bucket chlorination in concernedareas with increased AWD where possible (A12). If source chlorination is not feasible, reinforce HH treatment accompanied by targeted awareness activities

Monitor Free Residual Chlorine levels of all sources and ensure compliance with 0.8-1 mg FRC/l at tap and 0.2-0.5 mg FRC/l at household level

Sanitation Increase monitoring of requirement for latrine desludging. Desludging team to inform WASH actor of needs to clean and repair

Deploy handwashing stations at all latrines without existing facilities

WASH staff to monitoring all deployed and existing handwashing stations for 0.05% chlorinated water and soap twice per day.

Extend existing desludging beyond current areas of operate to ensure all urgent requests are met.

Increase monitoring of the use of PPE and equipment cleaning by all desludging actors.

Solid waste management, collection and disposal, with particular attention to markets and other public spaces.

Hygiene Ensure soap and water are available at handwashing stations at public sanitation facilities (markets, learning centres, CFS) and next to food vendors.

Increase community based hygiene promotion in at risk communities/blocks (defined by health data), using updated info sheets and materials.

Intensify AWD prevention via listener groups/radio using open ended stories and discussion guide.

Religious and community leaders, community health workers and public

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WASH AWD Preparedness and Response Plan, May 2019

places stakeholders are trained on how to keep people safe at gatherings, they are provided sets of AWD IEC tools and Info sheet.

AWD outbreak rumours or misconceptions are addressed and reported to Health Sector.

Food hygiene Regulate open food/drink shops and hawkers in collaboration with CM Food providers are reminded on environmental health and food safety, hygiene promoters visit food providers every day.

Scenario 3: Severe AWD confirmed by either RDT or culture AND a verified increase in AWD cases in EWARS and EBS reports or outbreak declared by Government of BangladeshArea Actions Coordination and management

JAT/ERT rapid outbreak assessment to area of suspected outbreak, report findings within 24 hours (but should not impede the initial response)

Active case finding in affected and surroundings areas

Daily short situation room at camp level led by ERT with Health actors presenting the cases by block/sub-block, RDT results, clinical diagnosis and rehydration plan, WASH response teams present response coverage for each identified case and scaled up, intensified HP communications, so that guidance can be provided immediately if required.

Line lists shared daily with WASH partners to guide the response.

Regular Cox level meeting between WASH/Health Sectors

Laboratory confirmation of initial cases (but should not impede response actions)

Support WASH Facilities in DTC and health centres receiving AWD patients if necessary.

Support health partners to activate all existing ORPs, ensuring they are supplied with necessary chlorine and ORS

Support activation of new ORPs in AWD areas where coverage is insufficient

Information and communication at Block Level

If AWD cases confirmed, communicate information via all available and relevant channels (as per communication strategy).

Roll out AWD Outbreak Message via mosque loudspeaker, megaphones, radio, etc. as outlined in communication strategy.

Story of Cholera – broadcast via existing institutuions i.e. Women Friendly Space, Learning Centre, Child Friendly Space, mosque, etc.

CwC in coordination with HP/Health to initiate FGDs (with handwashing facility at entrance) to listen to rumours around dead body management,

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WASH AWD Preparedness and Response Plan, May 2019

transmission routes, cultural beliefs, etc. to understand barriers to accessing treatment and concerns as well as identify positive deviants. Adapt communication and report rumours to health Sector.

Water Full coverage of bucket chlorination in AWD areas (A11). If source chlorination is not feasible, reinforce HH treatment accompanied by targeted awareness activities

Monitor Free Residual Chlorine levels of all sources and ensure compliance with 0.8-1 mg FRC/l at tap and 0.2-0.5 mg FRC/l at household level

Take measures to provide a minimum of 15l/p/day of potable water

Sanitation Disinfection of public latrines using a 0.5% solution of HTH which will be sprayed on communal latrines twice daily and ensure all public latrines are equipped with proper handwashing facilities and have soap and water available at all times checked twice daily.

Following referral from HP teams, mobilis of existing WASH teams in areas where there are reported cases of AWD to conduct latrine cleaning, repairs and solid waste clean up campaigns (A12).

Staff operating the desludging equipment are provided with manual sprayers and chlorine to be used to clean the area around latrines which have been desludged.

All mechanical desludging vehicles equipped with chlorine 2% chlorine sprays for cleaning vehicle after each collection, lime based spill kits and 0.5% sprays for disinfecting latrines after collection.

All manual desludging teams to carry lime spill kits and 0.5% sprays for disinfecting latrines after collection.

Rapid training to all FSTP operators on PPE and tool cleaning prior to leaving the site each day.

Hygiene Promotion

Support health partners to deliver light hygiene kits (Aquatabs and Stickers (5L, 10L, 15L, 20L), soaps, ORS) to patient relatives at the health facilities, accompanied by hygiene promotion/demonstrations/communication of key information.

Distribution of AWD kit (A13) including body, laundry soap and disinfectant for at least one month to HH around case – i.e. 30 HH radius

Target HH in the target area with AWD specific prevention messages, including handwashing with soap at critical times, exclusive use of latrines, food hygiene, recognition of AWD signs and symptoms, treatment seeking behaviors, dispel any myths or rumours.

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WASH AWD Preparedness and Response Plan, May 2019

If there are food providers (incl. small restaurants), fruit and vegetable vendors in affected blocks, ensure they receive information on AWD prevention,, install handwashing stations/ensure soap is available, assess the feasibility of installing produce washing stations nearby (chlorinated water).

Dead Body Management (DBM)

Ensure religious leaders, Site Management, and other stakeholders are familiar with Health Sector DBM Protocol

Ensure communication pathways are established and fully functional Address rumours as they arise

Outbreak Alert

24 to 48 Hours 72 Hours 30 days• Rapid Joint

Assessment

• Determine affected and at risk population and immediate needs

• Report end of day on the day of assessment

• Start emergency safe water supply interventions

• Distribution of hygiene kits

• Initiate emergency sanitation interventions

• Scale up on-going hygiene promotion activities

• Roll out response communications

• Initiate emergency communal/institutional water systems rehabilitation

• Initiate emergency sanitation systems rehabilitation

Monitoring and evaluation, including joint coordination and review meetingsOn-going post distribution/intervention monitoring

Table 3: SCENARIO 3 - RAPID RESPONSE TIMEFRAME

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WASH AWD Preparedness and Response Plan, May 2019

8. REFERENCE DOCUMENTS AND FURTHER INFORMATION

1. UNICEF Cholera toolkit 2013: http://www.UNICEF.org/cholera/Cholera-Toolkit-2013.pdf

2. MSF Cholera guidelines 2004: http://water.care2share.wikispaces.net/file/history/MSF+-+Cholera+guidelines,+2004.pdf

3. MSF Cholera guidelines 2017: https://samumsf.org/sites/default/files/2018-10/Management%20of%20a%20Cholera%20Epidemic.pdf

4. WHO fact sheet on cholera: http://www.who.int/mediacentre/factsheets/fs107/en/

5. Global Roadmap to 2030 to end Cholera from the GTF: https://www.who.int/cholera/publications/global-roadmap-summary.pdf

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WASH AWD Preparedness and Response Plan, May 2019

9. ANNEXES

Annex # Title / content Resource

1 JAT operational guidance – draft to review

2 Contact list of WASH and Health Focal Points

3 Emergency Response Team ToRs – draft to review

4 Assessment Tool – Health/WASH

5 Report format – health sector – do we want to change it for WASH?

6 Tracking sheet

7 Stock list definition Done? Asif to confirm8 Stock list inventory Done? Asif to confirm9 JAT action plans To be developed?10 AWD communique What is this?

11 Water treatment options for emergency response

12 Environmental sanitation and disinfection

13 Guideline for AWD NFI kits

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WASH AWD Preparedness and Response Plan, May 2019

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