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Cablegate: Cholera Spreads Throughout Ethiopia

O 040914Z SEP 09
FM AMEMBASSY ADDIS ABABA
TO SECSTATE WASHDC IMMEDIATE 6120
INFO IGAD COLLECTIVE
USEU BRUSSELS
USMISSION GENEVA
AMEMBASSY LONDON
AMEMBASSY ROME
AMEMBASSY PARIS
USMISSION GENEVA
USMISSION USUN NEW YORK
CDC ATLANTA
DEPT OF HHS WASHINGTON DC
DEPT OF AGRICULTURE WASHDC
CIA WASHINGTON DC
DIA WASHINGTON DC
HQ USAFRICOM STUTTGART GE
CJTF HOA
NSC WASHDC

UNCLAS ADDIS ABABA 002164


STATE DEPARTMENT AF/E, AF/PDPA, OES, AND PRM/AFR
USAID FOR AFR EGAST, CTHOMPSON
DCHA/AA SCROMER
DCHA/OFDA CCHAN, ACONVERY, JFLEMMING, PMORRIS, KCHANNELL, CCHRISTIE
DCHA/FFP JDWORKEN, PMOHAN
LONDON, PARIS, ROME FOR AFRICA WATCHER
CJTF-HOA AND USCENTCOM FOR POLAD
USDA/FAS FOR U/S PENN, RTILSWORTH, AND LPANASUK
NAIROBI FOR OFDA/ECARO GPLATT, JKIMBROUGH, RFFPO NCOX
USMISSION UN ROME FOR RNEWBERG
NEW YORK FOR DMERCADO
USEU FOR PBROWN
GENEVA FOR NKYLOH, RMA
NSC FOR CPRATT

E.O. 12958: N/A
TAGS: EAID PHUM SENV EAGR PGOV ET
SUBJECT: CHOLERA SPREADS THROUGHOUT ETHIOPIA

REF: Addis Ababa 2096

SUMMARY
--------

1. (SBU) To date, seven of 10 regions of Ethiopia have been affected
by cholera or acute watery diarrhea (AWD). The percentage of
cholera cases is not known but it is expected to be significant.
While cholera is an endemic disease in Ethiopia, it is rarely seen
in Addis Ababa. However, a recent outbreak in the capital (reftel)
has resulted in the activation of a command center at the Government
of Ethiopia's (GoE) Ministry of Health (MoH).

2. (SBU) Thus far in 2009, the World Health Organization (WHO) and
UNICEF are reporting more than 18,000 cases of cholera/AWD and the
MoH expects up to an additional 114,000 before the end of the year.
USAID's Office of U.S. Foreign Disaster Assistance (USAID/OFDA) has
provided $1 million to the International Rescue Committee (IRC) and
$2 million to UNICEF for water and cholera interventions
countrywide.

THE NUMBERS GAME
-----------------

3. (SBU) WHO and UNICEF reported in a meeting on September 1 more
than 4,000 cases of cholera/AWD in Addis Ababa, and an additional
14,000 cases countrywide. The overall Case Fatality Ratio (CFR) for
the country is 1.3 percent - just over the emergency threshold of
one percent. The CFR in each region is highly variable. UNICEF and
WHO report that Afar region currently has a CFR of 3.5 percent.
(Comment: Humanitarian actors in country are concerned that the CFR
is actually higher than reported due to aggravating factors
including significant distances between houses and cholera treatment
centers, as well as malnutrition. End Comment.)

4. (SBU) The international non-governmental organization (NGO)
Medicine Sans Frontiers/Belgium is operating six cholera treatment
centers in Addis Ababa and reports that the majority of people
arriving for treatment are moderate cases requiring only rehydration
on an outpatient basis while 25 percent are severe and requiring
inpatient care.

WHAT'S IN A NAME?
-----------------

5. (SBU) At a joint WHO/UNICEF meeting on August 25, significant
discussion took place as to whether or not the current outbreak can
be called "cholera" or whether it must still be referred to as
"AWD." The WHO representative working with the MoH Command Center
stated that while at a technical level the term "cholera" is
permissible, the GoE is still requiring that all reports use the
phrase "Acute Watery Diarrhea." (Comment: This remains a very
sensitive issue and using "cholera" publically in any reports, by
USG or others, could hinder actions being taken by the humanitarian
community. End comment.)

6. (SBU) Meeting participants expressed concern that affected
populations and their families may be confused as to whether the
disease is cholera or AWD. Additionally, participants expressed
concern that the media will refer to all cases as cholera which
could lead to a hostile GoE response and possible closure of NGO
activities. Participants wondered if the MoH reluctance to use the
term "cholera" will result in a situation similar to the recent
outbreak of cholera in Zimbabwe where containment, resources and
education materials were not quickly and adequately mobilized
resulting in a large scale, preventable outbreak.

7. (SBU) The Acting UN Humanitarian Coordinator (HC) has talked to
senior level government officials about this issue and while the MoH
is selectively supportive of using the term "cholera," it remains a
political issue at other levels of the GoE. USAID has offered to
provide advocacy support with other government ministries should WHO
and UNICEF feel that it would be of benefit.

SPREADING RAPIDLY
-----------------

8. (SBU) MOH and WHO officials report that part of the reason for
the rapid spread of cholera is due to contamination of "holy water"
in several locations. Pilgrims who have traveled to holy cites
around Addis Ababa and in Amhara region often stay in extremely
crowded conditions with little or no sanitation facilities allowing
any communicable disease to quickly spread among the population.
USAID's public health specialist reports that if a person gets ill
after drinking holy water they believe that the water is working to
remove the illness from their system.

9. (SBU) As a result of contamination at two holy water locations
near Addis Ababa, all pilgrims were evacuated and the sites were
closed for two days. The sites have been re-opened and WHO reports
that significant public health messaging is taking place in both
locations. With additional religious and national holidays
approaching, as well as the beginning of the school year, quick
action and significant public health messages are required. The
Patriarch of the Ethiopian Orthodox Church recently met with the
MoH, UN OCHA and NGO representatives to devise an appropriate
intervention strategy.

FUNDING REQUIREMENTS
---------------------

10. (SBU) WHO recently stated that the 2009 GoE Humanitarian
Requirements Document will soon be revised to reflect an increase of
$2.3 million for the health sector and at least $5 million for the
water and sanitation sector for AWD/cholera. WHO and the MoH are
anticipating 132,000 AWD/cholera cases between now and the end of
December assuming an attack rate of 1 percent. For comparison,
UNICEF reports that the worst recorded outbreaks since the year 2000
occurred in 2006 and 2007 (approximately 50,000 cases each).

11. (SBU) For Addis Ababa, WHO has pledged $30,000 for surveillance,
training of health workers and case management. UNICEF has pledged
$100,000 for training, containment, communication and operational
costs. UNICEF reports that it has about half of the funds needed to
meet the anticipated country-wide case load for the year (UNICEF
estimates 65,000). UNICEF has recently received requests from
various regional governments for an additional $800,000 for response
interventions.

COORDINATION
------------

12. (SBU) Coordination among the GoE, WHO, UNICEF, donor and NGO
agencies needs improvement. WHO is unable to implement activities
or report without MoH concurrence and is addressing the situation
only from the health standpoint. UNICEF and the Ministry of Water
Resources are looking principally at water resource, containment and
contamination issues. WHO has announced several different meetings,
but cancellations have inhibited transparent communication among
stakeholders.

13. (SBU) With support from OCHA and USAID/OFDA, the Acting HC
recently called a joint meeting with UNICEF, WHO, donors and
implementing agencies to discuss a strategy for addressing
coordination, containment, prevention, treatment and control. The
Acting HC continues to encourage government officials to call a
similar meeting of all stakeholders. (Comment: USAID/OFDA is
encouraged by the progress of the Acting HC in talks with GoE
officials. The Acting HC is now requesting that donors also
encourage transparency and coordination when talking with government
officials. End comment.)

USAID RESPONSE
--------------

14. (U) PEPFAR's Supply Chain Management Systems project (SCMS),
supported through USAID, is coordinating with the Federal MOH and
Regional Health Bureaus to provide 2,640 bottles of disinfectant
solution and 900,000 sachets of oral rehydration salts. These
commodities, from supplies on hand procured for HIV-positive
individuals can be spared for this emergency situation without
affecting supplies needed for people living with HIV/AIDS (Reftel).


USAID/OFDA RESPONSE
-------------------

15. (U) USAID/OFDA has provided $1 million in Fiscal Year 2009 to
the international NGO IRC for emergency rapid response programming
including AWD/cholera response. IRC is currently responding to the
outbreaks with USAID/OFDA funding in four woredas in the Somali,
Afar, Oromiya and SNNP regions and is investigating additional
response activities in Afar and Amhara regions. Activities include
distribution of water treatment chemicals and hygiene and sanitation
education. USAID/OFDA partners are also looking at potential
interventions in Addis Ababa and other nearby urban centers.

CONCLUSION
----------

16. (SBU) The cholera situation in Addis Ababa and the country will
be long-term with periodic spikes. Large gatherings of religious
pilgrims, the start of the school season, and traditional movement
of migrant workers are of particular concern in coming months.
USAID is working with UNICEF, WHO and other partners to address
coordination, containment, treatment and prevention activities
countrywide.

MEECE

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