Ethiopia

1. Joint cholera outbreak response rapid assessment in
East Bale Zone, Oromia Region
From February 21– 26, 2023

2. Objectives of the assessment
• To asses the current cholera outbreak status and response
coordination
• To identify gaps, challenges and constraints and share with relevant
stake holders at Zonal, regional and national for advocacy and
resource mobilization
• To provide technical guidance to zonal and woreda response task
force

3. Participants
Name Organization Position
Jemal East Bale Health
Department
WaSH Expert
Gemechis Bizuayehu SCI Senior WASH advisor
(CO)
Sultan Ebrahim SCI Health and Nutrition
adviser (CO)
Habtamu Leggese SCI Project manager
Gonfa Regasa UNICEF Emergency Health
Haji Jemal International Rescue
Committee
ERR officer
Mekbib Alemu Wako Gutu Foundation
Mesfin Alemu Kale Howot

4. Response Coordination from Zone to woreda level
Key progress:
 Cholera response task force and different technical committees are established
at Zonal level and at both visited woredas
 Response plan is prepared and shared with different actors for resource
mobilization and response guidance
 How ever, the amount is not enough, Zone and woreda mobilized resource
from government budget, partners working in the area and community
participation.
 Response coordination at Dawe Kachen woreda is better and political leaders,
sectoral leaders, partners and community members are well coordinated in
responding to the outbreak

5. Response Coordination from Zone to woreda level
Gaps to be improved
 Task force and technical committee at Zonal and Ginir woreda are not fully functional and not fully
playing their role.
 This is justified by poor treatment service quality leading to high fatality rate, poor IPC practice at CTC,
poor surveillance system especially at community level, poor community mobilization and awareness
creation.
 The coordination meetings all level not involved all partners such as NGO, Red Cross, other organizations.
 The task force is not valuating impact of control measures, adjust strategy, and review performance to
improve the gaps.

6. Surveillance
Key progress:
 Laboratory confirmation done for firs index cases to confirm the
outbreak in both affected woredas
 Standard line list is prepared and provided to all CTC to record and
report all basic data of the affected individuals.
 Case definition displayed at different public initiations, community is
aware of disease sign and symptom.
 The surveillance data compiled and updated every 30 minutes at Zonal
level

7. Surveillance
Gaps to be improved:
 However, the outbreak is already declared in neighboring Zone and woredas ,the
surveillance system could not detected the outbreak timely ( it takes more than 10 days)
 Poor community level surveillance and the visited health facility and community witnessed
delay in seeking health care, unreported cases in the community
 Gap in analysis and utilization of the collected surveillance data to identify source of
contamination, contact trace , outbreak characteristics to take appropriate action
 Attack rate and case fatality rate is calculated ,but no action taken to see the root cause of
the high case fatality rate.
 The task force and other committee are not strictly using this surveillance data
 Technologies such as GPS which help to map most affected area, where patients are
coming from and source of infection are not utilized.

8. Treatment centres
• When cholera cases are suspected or detected, health workers need to start treatment as early
as possible to reduce potential death and contamination of the environment.
• The organization of cholera treatment centres, their location and staffing should be based on
the national guideline principle.
• Proper case management and isolation of cholera patients is essential to prevent deaths and
help control the spread of the disease.
• But if not managed properly, treatment centres will be the main source of the infection
during the outbreak and even after the outbreak.
Key progress:
• It is appreciated that the Zone and woreda able to open CTC following the emerge of
outbreak using local resources , staff and community motivation.
• Mobilized staff from different facilities to support cholera outbreak response and
• More than 53 staff trained on cholera management through support of different partners.

9. Treatment centres
1. Gaps in Selecting proper type and site, equipping the center and access restriction
 The response focusing only on establishment of CTC and there is no single ORP site
observed .
 Design , size and site selection of the visited CTC have gaps in considering basic criteria
for selecting a cholera treatment facility such as lightening, road access, water supply,
distance from other building, minimum required area and fencing
 Human resource in CTC is not adequate (only 3-4 staff) assigned and most of do not
know their specific job description which they are accountable for.
 There is no clear practice and sources of food, usage and cleaning of utensils & disposal
of leftover food.
 These led to poor CTC functioning and the community responded that health workers
are not available for 24 hours in CTC.

10. Treatment centres

11. Treatment centres
 No patient flow direction restriction observed and clearly defined
common entry and exit point, with enough personnel stationed to control
traffic flow, limit access, and ensure that staff, patients, and caregivers
wash their hands with soap and safe water at the hand-washing station(s)
when entering and exiting.
 The foot baths are not placed in good size, depth, soil material and
frequent soaking with chlorine twice a day
 No access restriction to critical zones, such as the waste management area
and sever patients, though it should be accessed by authorized personnel
only.

12. Treatment centres
2. Gaps in access to Water, sanitation, and hygiene
 There is no access to sufficient safe water , no enough water storage in the CTC facilities.
 There is no evidence of water quality testing and disinfection
 Drinking water are not available or easily accessible by patients and caregivers in separate,
clearly marked containers.
 In most facilities the available latrines are shared by all admissions, caretakers & staff.
 The latrines are not cleanable and spillages from floors flow out of the blocks
 The is no clear cleaning protocol, cleaning schedule, cleaning product usage.
 No regular monitoring of the hand-washing stations for adequate soap and safe water
levels should be ensured
 Discharged patient sent home without taking full shower and even with uncleaned clothes
 No proper sink and drainage for the grey water and the water flows out over surfaces
 No designated washing places for patients’ cloths, utensils and other infected materials.

13. Treatment centres

14. Treatment centres
3. Gaps in ensuring implementation of proper Infection prevention in
CTC:
• There is no adequate IPC practice is in place and poor precaution practiced
by the staffs, patients, and caregivers.
 The supply of PPEs is not enough, staff are not trained on proper usage of
PPEs, and majority of health workers in visited CTC are not wearing proper
PPE
 These is movement between health facilities and CTC ,sharing common
entrance

15. Treatment centres

16. Treatment centres
3. Gaps in adherence to national guideline in treatment of cholera cases:
 Due to poor quality of case management and other contributing factors the overall CFR as of
February 23, 2023 in east Bale Zone is 9.7% which much higher than the expected case fatality
rate.
 No mortality auditing practice to identify gaps and improve serive
 Some of the identified probable causes of this high death rate are lack of trained at early
stage, poor patient follows up during the night, improper assessment and management of
patients with comorbidity such as cardiovascular problem and SAM cases.
 Gaps in treatment of patient as per the national guideline and exposing the patient and facility
to unnecessary cost.
 Shortage of critical supply such as ORS
 No service monitoring practice
 There is no strong & frequent health education to the patients & caregivers in the facilities
and during discharge .

17. Main challenges/ constraints
 Lack of experience among established committee to monitor the response as per the standard
 Inadequate involvement of political leaders in Ginir Woreda
 Inadequate cholera outbreak response supply such as ORS, cleaning materials, beds, tents, water
storage , PPE and other critical supplies
 Shortage of water supply for facility and at community level, absence of water treatment
chemical.
 Poor coverage of latrine and utilization
 Shortage of human skilled health workers and turnover of rained staff
 Budget constraining to facilitate the outbreak response
 Lack of logistics to monitor the response at different level
 Food insecurity, high malnutrition rate and absence of food support
 High community movement due to current food insecurity

18. Recommendation/way forward
 Prepare comprehensive response plan that prioritized critical needs for life saving using this
assessment finding and advocate for support
 Political leaders to take the lead and ensure accountability in response to the outbreak as per
the national guideline
 Strong field monitoring and action from response task force and established technical
committee
 Arrange experience sharing visit with best performing team such as Sof-umer CTC and less
performing facility
 Establish ORP in all high risk Kebeles/ subkebles to manage
 Strengthen community level surveillance system in both affected and non affected area ,
 Cholera patient house visit and disinfection
 Strong technical support to CTC sites
 Strengthen community engagement for strong community awareness creation and other
prevention activites at community level.

19. Galatoomaa