Photo: WHO/Francisco Guerrero TYPHOON YOLANDA HEALTH CLUSTER ISSUE #3 NOVEMBER 26, 2013 HIGHGLIGHTS As of 26 November 2013, the National Disaster Risk Reduction Management Council (NDRRMC) of the Philippines reported 5 240 deaths, 25 615 injured, and 1 613 missing. A total of 9 927 335 have been affected with 3 393 940 displaced. Of the displaced, 240 377 are currently living in 1 092 evacuation centres. Health needs have shifted from immediate trauma care to broader public health issues. The five main causes of illness currently are acute respiratory infection, fever, diarrhea, hypertension and skin disease. A total number of 55 registered Foreign Medical Teams (FMTs) are in the affected areas composed of more than 1 100 medical staff as of 26 November 2013. There are an additional 12 medical teams in country that have not yet registered. Forty-seven of the field hospitals established are type 1. There are 6 teams with type 2 hospitals and two teams with a type 3 hospital. There are five more teams on standby outside of the country. An additional 103 national and local medical teams have also been deployed to the affected areas. Inside this bulletin: Affected population and areas Health cluster action Main public health concerns Next steps Public health risks, needs, and gaps Funding status of action plan 1
AFFECTED POPULATION AND AREAS As of 26 November 2013, the National Disaster Risk Reduction Management Council (NDRRMC) of the Philippines reported 5 240 deaths, 25 615 injured, and 1 613 missing. A total of 9 927 335 have been affected with 3 393 940 displaced. Of the displaced, 240 377 are currently living in 1 092 evacuation centres (Table 1). The government is beginning the process of registration and profiling of the population movements, during which process the vulnerabilities, mobility and protection issues including the risk of child and human trafficking are recorded. Between 17 and 21 November, Department of Social Welfare and Development (DSWD) and IOM registered 1015 persons. It was noted that the majority of the households were incomplete and were missing family members. Many are moving without registration thus the profiling is still not comprehensive. In addition, 3.39 million people are living with host families or in damaged/destroyed houses. The Camp Coordination and Camp Management (CCCM) cluster reports that 33% of sites in Tacloban city lack a camp management structure. Only 35 sites have latrines while 77% have no solid waste removal system. There is on average 1 latrine per 61 persons, and 44% of the sites report having to leave the site location to find clean water. This increases the risk of outbreaks - an increase in the diarrhea cases have already been reported from the affected areas. In Cebu, temporary shelters are being created in anticipation of further arrivals in the near future. In Guiuan an estimated 600 700 persons are leaving the Eastern Samar province per day, by bus and plane, headed mainly to Manila. Reception centers for the displaced have been established in Manila. Number of affected population Table 1: AFFECTED POPULATION (NDRRMC, 26 November 2013) % of total population of the area* Number of Displaced Population % of internally displaced Region IV A 27 076 0.2 Region IV B 425 903 15.5-0.00 3 028 0.11 Region V 656 239 23.7-0.00 Region VI 2 748 780 38.7 2 353 287 33.13 Region VII 2 601 503 38.3 2 386 0.04 Region VIII 3 397 959 82.9 1 035 239 25.24 Region X 19 592 0.5-0.00 Region XI 5 220 0.1-0.00 Caraga 45 063 1.9-0.00 Total 9 927 335 21.0 3 393 940 7.58 Humanitarian Case Load according to Flash Appeal 12 900 000 29.84% 2
PUBLIC HEALTH RISKS, NEEDS, AND GAPS General Issues Assessment and validation of affected sites are of primary concern as more information is needed to plan for adequate response. In Cebu, the evacuation sites for victims coming from Samar and Leyte provinces have reduced from 6 to 3. Each site can cater to 300 individuals. As more population movement is expected in the coming days, the city together with the Red Cross is planning to create a tent city next week. In Ormoc, the regional DoH has designated 22 municipalities as priority areas based on the level of damage to the communities, health system and access. In Region VIII, in view of the extensive destruction to the health services and as a means to sustain the provision of health services, the regional DoHs are encouraging organizations that are able to commit for longer periods to adopt a municipality, and provide services and assist with coordination of actors in their adopted municipality. Morbidity To date, the five main causes of morbidity identified include acute respiratory infection, fever, diarrhea, hypertension and skin disease. In Tacloban, the number of cases needing surgery and inpatient care is decreasing while need for primary health care especially treatment of chronic diseases (e.g. TB, hypertension) is increasing. Additional needs include disease prevention, mental health and psychosocial support, and water and sanitation. There is an increased reporting of disease events from the affected areas through the SPEED (Surveillance in Post Extreme Emergencies and Disasters), Event-based surveillance and response (ESR) system and the Philippines Integrated Disease Surveillance and Response (PIDSR) system. Based on the reports, the rumours are verified and the updated information is provided. There are also increasing numbers of cases with Acute Respiratory Infection (ARI), dog bites and wounds related to debris clearing and reconstruction of houses. Some cases of chicken pox and leptospirosis have been reported and verification is currently taking place. Other areas of concern as reported by the medical teams include treatment of spinal injuries and tetanus. Treatment protocols and tetanus immunoglobulin have been dispatched. In Tacloban city, between 24 and 26 November, the following cases of note were reported: Suspect leptospirosis cases (1 each) from Palo and Tacloban City were admitted to Eastern Visayas Medical Center (EVRMC) Suspect tetanus cases (4 in total) from Tacloban city, Tolosa, and Leyte were admitted to Eastern Visayas Medical Center (EVRMC) Functionality of health facilities DoH reports of initial rapid assessments of health facilities show that 1 150 of 2495 health facilities have been affected. This includes 833 BHS, 235 RHUs and 81 hospitals as well as one CHD-EV. The assessment reports are being compiled by the DoH to be used as a basis for recovery planning. Although further in-depth assessment of the health facilities are needed to determine specific needs and costing, the current analysis gives a good picture of the situations at health facilities by Region. Reports of more detailed assessment of health facilities by health cluster partners have also been received. For example, in Tacloban, assessment shows that there are currently 5 health facilities operational including one public tertiary level hospital and four private hospitals. All five are being supported by public health workers and foreign medical teams that are colocated at the facilities. A secondary level field hospital is operational at the Tacloban airport supported by the Australian government and another field hospital run by a German-Belgian team has been set up at Palo in Leyte province. Overall in Leyte and Samar provinces the operations of health facilities, cold chain system, communications, and other support infrastructure is beginning to be reestablished. Humedica (NGO) has also conducted a rapid structural assessment of Mother Mercy Hospital. Results show that the 4-storey hospital is serving about 130 200 out- 3
patients per day from the community. Part of the ground floor has been converted to a minor surgery centre. The major damage was loss of about 40% of the roof sheeting and the roof structure. This damage has resulted in water ingress into the first and second floors making these floors unusable, particularly with the frequent rains. A similar rapid structural assessment of Bethany Hospital conducted by MSF France in Tacloban shows minor damage to windows and door in one of the operating rooms. One of the three operating theatre remains completely untouched and will be functional for internal fixation surgery once a generator is installed. One of two-storey buildings of the hospital was severely damaged. Over 50% of the roof structure was destroyed in the Typhoon and numerous windows were damaged on the 2nd storey. This has made the entire upper floor unusable. AECID has supported the DoH to develop a referral system for transfer of patients in Tacloban. A specific reporting form for surgical referrals and needs will be developed as part of the system. As of 26 November, surgical cases are to be referred to EVRMC, the Australian FMT and Divine World health facility, dialysis patients are to be referred to RTR, patients needing ventilators to be referred to the Australian FMT and all other referrals including for obstetric care are to be referred to EVRMC. Additional transportation mechanisms are needed to support this system. Currently the Red Cross ambulances stations at EVRMC are the main point of call for transportation of patients. In north Cebu, Daanbantayan district hospital (with 10 beds), Bantayan Hospital (with 25 beds) and Camotes Island hospital (with 25 beds) are fully functional although Camotes Island hospital has suffered damages to the infrastructure. In Ormoc, there are 2 operational health facilities. Carigara Hosptial, originally a level 2 hospital, is only partially functional and is unable to provide essential surgical care services including caesarean. The Ormoc District Hospital is partially functional and is able to deliver emergency surgical care including obstetric surgery, but not all operating rooms are functional and those that do function are doing so under marginal conditions. ICRF and Mercy Malaysia are providing assistance to the hospital in order to improve the situation. The Ormoc Maternity and Children s Hospital is fully functional except for surgical referral. A few private facilities are also functional, with one that is well supplied and has suffered little damage, but only on a paid basis. All hospitals have reduced admission levels due to lack of electric and difficult operating conditions, and one private health facility is planning to close completely to conduct full repairs on its facility. Essential health services An assessment conducted by IMC shows that almost 10% of the typhoon-affected population is in need of reproductive health services. Some of the rural health units (RHU) are able to handle deliveries, but many are referring patients to urban health care centres. This issue is compounded by the lack of proper supplies and clean delivery kits. In Leyte province, although there is good coverage of health care service in most of the affected areas, there is still limited presence of medical teams along the eastern coast. There is also a need to educate the public on the free health care being provided in order to increase access to health care. The need for trauma care teams has decreased and there is now an increase in the need for public health teams that can provide preventive care including prophylaxis and immunization services, as well as health promotion and psychosocial support. 4
HEALTH CLUSTER ACTION Health Cluster coordination The Department of Health is the lead of the Health Cluster, with WHO as co-lead. In addition to the national Health Cluster in Manila, subnational Health Cluster Coordination teams have been established in the following areas: Tacloban City for coordinating health response in region VIII Cebu city for coordinating health response in region VII Roxas City for coordinating health response in region VI Ormoc City for coordinating health response in region VIII in collaboration with the cluster in Tacloban City Borongan for coordinating health response in region VI covering Guiuan In Ormoc city, the local DoH and city DoH have set up an Incident Command System (ICS) for coordination and the health cluster is liaising closely with this system. Assessment Reports from the field show that medical support provided by international and local teams need to increase in geographical area and scope of services beyond the current hubs. As the situation evolves, the need for emergency trauma care is decreasing, and the need for primary health care is increasing, including for essential medical and surgical care as well as preventive health services. It is estimated that 3.2 million women and girls of childbearing age are affected by the crisis. An estimated 233 697 pregnant and 155 798 lactating women need specialized services for prenatal, postnatal, child health, health promotion and family planning, including 7 973 pregnant and 4 716 lactating women. Daily, an estimated 865 births take place in the affected communities, of which 129 will experience potentially life-threatening complications. Priority Setting The health cluster has used the following indicators to identify priority areas of focus: Status of health facilities (structural and nonstructural) Health facility functionality (services) Availability of health human resources Status of health service delivery (clinical) Availability of public health services Availability of medical supplies including cold chain Vulnerability of population, including morbidity data Eight provinces were identified for primary focus. The eight will be prioritized into high (Red), medium (Orange), and low priorities (Green) based on further analysis of the above mentioned criteria. The main public health risks have been identified as follows: Disruption in the health system including lack of health facilities, primary and secondary health care delivery and the subsequent disruption to universal access to health care Communicable diseases especially in view of the disruption to the surveillance system and problems related to water and sanitation, overcrowded living conditions and low vaccination coverage prior to the event especially for measles. Cholera, dengue and leptospirosis are endemic in many of the affected areas, increasing the risk of outbreaks of these diseases in view of the increased vulnerability of the affected population. Chronic diseases including interruption of treatment for disease needing long term treatment. This is an increasing problem as chronic diseases including hypertension and diabetes account for a large number of morbidity and mortality Reproductive health high number of pregnant women about to deliver, low capacity of health facilities to deliver obstetric and surgical care Disruption in cold chain and medical provisions Lack of water and low sanitation level, and low capacity for waste management, including medical waste Based on this the main areas of public health response are as below. For areas of high priority (Red) all these public health responses are deemed to be required. For other areas (Orange and Green) the public health response will be adopted locally to the needs. Restoration of primary, secondary and tertiary care as per the health systems. Particular attention should be given to maternal and child health services and obstetric care. This is to 5
ensure sustainability and universal access to health care services, with the aim of rebuilding towards safer health facilities. (Health Systems Approach) Health care waste management Increasing services for mental health and psychosocial support Maternal and Child Health (MCH) care especially for children under 5 Care for non-communicable disease patients with a specific focus on continuation of treatment for chronic diseases (hypertension, TB, diabetes etc.) Restoration of mechanisms for outbreak control including restoring the surveillance and early warning system, cold chain, laboratory and immunization Inter-cluster coordination mechanisms are also functional and in particular with the Water and Sanitation (WASH), nutrition and protection clusters. A Multicluster Initial Rapid Assessment (MIRA) was conducted and is currently being analysed. Public Risk communication Implementation of a nutrition programme including referral to and from health care facilities for severe malnutrition Referral from health care facilities, including patient tracking with specific focus on child protection and responding to gender based violence. Response Health Care Services A total number of 55 registered Foreign Medical Teams (FMTs) are in the affected areas composed of more than 1 100 medical staff as of 26 November 2013 (map). There are an additional 12 medical teams that have not yet registered. Fortyseven of the field hospitals established are type 1. There are 6 teams with type 2 hospitals and two teams with a type 3 hospital. There are five more teams on standby outside of the country. An additional 103 national and local medical teams have also been deployed to the affected areas. All FMTs are required to be completely self-sufficient for the duration of their stay as resources are limited. Provision of fuel remains the main challenge. A guidance note has been issued by DoH on the entry and exit strategy of FMTs in light of the evolving situation and the subsequent shifting of priorities from immediate trauma care to primary and surgical care as well as public health issues. 6
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Essential drugs and supplies The DoH has provided a list of needs for supplies which was transmitted to health cluster partners. The needs are evolving based on the inputs from health cluster partners to fill the gaps. In Cebu sufficient drugs and supplies exist to date. The remaining items in Cebu have been moved to Region VIII to support on-going response activities. This includes 16 solar refrigerators donated by the UK government (DfID) for use in the vaccination campaigns. Following requests for additional antibiotics for use in treatment of wounds and infections, Hope (NGO) has imported large amounts of appropriate antibiotics. Plans are on-going for further distribution of the drugs to the areas where they are needed. Vaccination and cold chain The mass vaccination campaign for measles, polio and vitamin A dosage started today in Tacloban. The campaign is supported by WHO, UNICEF and other health cluster partners. Patients with wounds have been provided with tetanus toxoid as the risk of tetanus still exits. Vaccines are supplied mainly through local procurement but additional donations from international entities are still welcome. Whilst cold chain was brought from other sites for Tacloban to start the campaign, shortages still exit to continue the vaccinations in other parts of Region VIII. UNICEF, in support of DoH, is conducting cold chain assessments for regions VI, VII and VIII. Surveillance and communicable disease control There are currently two main surveillance systems in operation, SPEED and PIDSR, to assist in detection of outbreak prone diseases. SPEED is widely promoted as a system for emergency situations. The system is currently functioning in region VII, however, information received still remains patchy (Table 2). From information received to date, verification has been undertaken for several events including acute respiratory illness and diarrhea. However, no outbreaks have been reported to date. The Health Emergency Management unit of DoH, with the support of UNICEF, has provided an orientation on SPEED to medical teams leaving from Manila to the affected areas in order to sensitize them with the aim to increase the use of the system. WHO is also supporting the DoH to strengthen surveillance through training of public health staff in Borongan on SPEED and provision of SMART sim cards to 17 RHUs in Capiz which will allow those working in remote locations to send information to a central hub for uploading data into SPEED. Such support will increase the reporting rate to SPEED even from locations with low communication access. In addition, senior public health officers are being deployed to all hubs to support the local DoH in surveillance activities (starting with Borognan and Roxas). Maternal, Newborn and Child Health Currently UNFPA and Merlin have provided reproductive health kits which have been sent to Palo and Cebu. The kits include items for management of rape survivors. Additionally, three hospital units with reproductive health equipment have been ordered and one obstetrical surgical unit is on standby for shipping. UNFPA will second a senior reproductive health specialist to the health cluster to support the DoH. If needed, two-day refresher trainings to midwives and health workers on the use of items in the reproductive health kits can be provided. Dead Body Management In the absence of facilities for receiving the dead and undertaking examination, WHO has Table 2: Summary of SPEED Reporting in Typhoon Yolanda affected Areas Region Provinces (#) Municipalities (#) Health Facilities and Reporting Sites (#) VI 2 5 5 VII 1 10 21 VIII 1 5 7 8
developed a kit of materials and equipment for a temporary mortuary to receive bodies in which the forensic staff can undertake a preliminary examination. The kits will be deployed to Tacloban (Baspar and Suhi) and one more location, to be determined. A forensic pathology team of three persons from the University of Manila is also on site to support dead body management. Water, Sanitation and Hygiene (WASH) and Environmental Health Following reports of diarrhoea from Bantayan, Cebu, and Region VII the WASH cluster has coordinated the chlorination of shallow wells dug by the cluster. Laboratory tests are being conducted to test for the adequacy of the level of chlorination. Environment health assessment in health care facilities is being conducted this week by a DoH and WHO in Eastern Samar. Mental Health and Psychosocial Support A rapid assessment by IMC shows that mental health is a significant concern for affected populations and the current response measures are insufficient to meet all the needs. The government is discussing the means to train national health professionals on delivering mental health and psychosocial care to the affected population. A mental health expert from WHO is in Manila to help coordinate the actions in support of the DoH. Planning The DoH has developed a plan to identify short and longer terms needs. The health cluster partners are putting together a similar plan for identifying short (6 weeks) and longer term needs. The possible areas of support and focus include health facilities strengthening to ensure equity and strengthen health care service provision, prevention and control of communicable diseases, coordination with other clusters as well as within the health sector to ensure seamless delivery of services. NEXT STEPS Assessments, tracking and mapping will be continue to: Estimate amount of infrastructure damage and health service availability in detail Better define affected populations and needs, including for pregnant and lactating women and patients with chronic disease, evacuee locations and needs of displaced people Evaluate resources currently available and what will be required in the short to mid term Refine understanding of health partners location and activities including availability of logistics and supplies Better understand the needs for longer term relief and recovery in the next 6 to 12 months FUNDING STATUS OF ACTION PLAN As of 26 November 2013, the action plan is 28% funded for the health sector (table 3). The percentage covered has decreased compared to the last bulletin due to the addition of 2 projects. As of 26 November 2013, WHO received firm commitments from Australia, Canada, Norway, Japan, the United Kingdom and the UN Central Emergency Response Fund (CERF) for a total of US$10.7 million. Rapid deployment of staff and medical supplies has been made possible thanks to contributions made earlier in 2013 to enhance WHO s surge capacity for acute emergencies from the governments of the Russian Federation, Sweden and the United States of America, and from the European Commission Humanitarian Aid and Civil Protection (ECHO). 9
Table 3: FUNDING STATUS OF ACTION PLAN FOR HEALTH (US$) Project Appealing Agency Amount Required Funding % Covered Saving Pregnant Women and Newborn lives and support to Super Typhoon Haiyan affected provinces of Leyte, Capiz, Iloilo and Aklan Adolescent and Sexual Reproductive Health in Emergency Services and Support to typhoon Haiyan affected provinces of Leyte, Samar, Iloilo, Aklan and Capiz Ensuring Access to Reproductive Health Services for IDPS affected by Typhoon Haiyan Provision of emergency health services to Typhoon affected populations Emergency Health for Children and Families Affected by Super Typhoon Haiyan in the Philippines Providing Mental Health and Psychosocial support to children and pregnant and lactating women and Primary Health Care Interventions in population affected by Typhoon Haiyan (Yolanda) Provision of life-saving interventions for health to children 0-59 months affected by Typhoon Haiyan Save the Children Save the Children 570 310 0 0% 1 926 000 800 000 42% UNFPA 3 000 000 592 077 20% WHO 15 000 000 8 816 481 59% Save the 1 070 000 206 612 19% Children ACF- 3 000 000 0 0% Spain UNICEF 13 500 000 182 041 1% (Yolanda) emergency TOTAL 38 066 310 10 597 211 http://fts.unocha.org/reports/daily/ocha_r32_a1043 26_November_2013_(03_00).pdf Health Cluster Partners National- Manila: AECID, Americares, Australian Aid, CDN- DART, CFSI, Child Fund, DFID, DOH, FPOP, Handicap International, HuMa, ICRC, IFRC, IHP-UK, ILO, IMC, IOM, IRC, ISAR- Germany, JICA,MERLIN, MDM, MSF, National Bureau of Investigation, PHE, Philippines Red Cross, Relief International, Plan International, Project Hope, PU-AMI, SCI, UNFPA, UNICEF, USAid, US Forces, WHO, World Vision. Sub-national- Tacloban: AECID, ACF, ACTED, Action PompiersUzgenceInlanaVionus, ARC, ASEAN, ASYA SAR/KYM, B-FAST, AUs, BomberosUnidos SP, Care, Christian Aid, DFID, DOH, ECHO, Emergency.LU, Ericsson Response, EUCPT, First Relief Fund, First Response Radio, Fuel Relief Fund, German Embassy, German Red Cross, Globalmedic, GOAL, Good Neighbours Intl., Good People Intl., HUMEDICA,IFRC, International Disaster Relief, Internews, IOM, IsraAid, JICA, KIHI, KOICA, Leger Foundation, Miral Welfare Foundation, MSF/F, OCHA, Oxfam, Philippine Red Cross, PompiersHumanitaires France, PUI France, Samaritan 119 Korea, SC, SCDN, Solidarities International, Spanish Red Cross, TGCFI, RTR hospital, UNDAC, UNDP, UNFPA, UNICEF, USAID, US OFDA, Vodafone foundation, WFP, WHO, WISAR, World Vision. Sub-national- Cebu: AmeriCares, ASB Germany, Canadian Emergency Response Unit, Canadian Medical Assistance Teams, CFSI, ChildFund, DOH, Embassy of Israel, Eversly Child Sanitarium, GOAL, ICRC, IFRC, International Medical Corps, JICA, MDM, Med Japan, Merlin, MSF, NYC Medics, PNA, Samaritan Purse, SC, SCI, Spanish Red Cross, Saint Anthony Mother and Child Hospital, Talisay District Hospital, UNICEF; Vicente Sotto Memorial Medical Center, WHO Sub-national- Roxas: ACF, Action Aid International, Canada DFAT, Child Fund, CRWRC, DoH, GOAL, IOM, Japan Heart Foundation, Philippine Rural Reconstruction Movement, MSF-Swiss, NETHOPE, Save the Children, UNDAC, UNICEF, Welt Hunger Hilfe, WFP, WHO, World Vision International 28% 10
Health Cluster Contacts National- Manila: haiyanhccmanila@wpro.who.int Sub-national- Tacloban: haiyanhcctacloban@wpro.who.int; hcctacloban@gmail.com Sub-national- Cebu: haiyanhcccebu@wpro.who.int Health Cluster Website:http://www.wpro.who.int/philippines/typhoon_haiyan/en/ Please send any information on potential disease outbreaks to: haiyanops@wpro.who.int 11