INTERNAL: Ops Update Week 12

DISCLAIMER: This Operational Update is a summary of internal operational information from the 5 MSF Operational Centers. The information contained herein is strictly internal and should not be shared outside MSF.

IRAQ (9 March)

After earlier assessments, we are starting activities in Gulala and Sadiya. Our activities include support to NCD care, antenatal care, and basic support to the emergency rooms. MSF is also working with the displaced population in two camps around Khanaqin. We are, in collaboration with the MoH, setting up clinics in both Alwand 1 and Alwand 2 camps, which are now also hosting the population that used to be in Aliawa.

ETHIOPIA (9 March)

In Tigray we are working in several camps for Eritrean refugees. In Hitsats camp live many young people, including unaccompanied minors. Every day, new refugees arrive, but also refugees leave on a daily basis towards and Europe.  This is in stark contrast to Shimelba camp, where many refugees have been living for a long time. Part of this population have returned from long, arduous journeys, and now find themselves stuck, with very limited hope for a future elsewhere. The MSF project is six months underway and is going well. We are working on expanding access to the medical care.

In Gambella, where we work in several refugee camps with South Sudanese refugees, tribal violence flared up again last week with clashes between Anuak and Nuer groups in Pugnido. Meanwhile, our projects in the area are doing a great job. On an average the dedicated teams are doing 20.000 consultations per month. In Pugnido we just received permission to start up an inpatient department inside the Pugnido hospital.  The water situation remain a concern, however. Other actors have set up a water supply, but still this is insufficient. As a result this has led to increased water related diseases amongst the population. The team is working towards improving this. The UN budget for Ethiopia has been cut by 40%. As a result there will be a 25% decrease in their food rations. The impact of this needs to be closely monitored.

The drought in Ethiopia, while largely reported in the international media, has not reached emergency levels based on what we see on the ground. However, the areas of concern are expanding, and it will be incredibly important that the rain begin in May. Currently the present sections in the country have set up nutritional interventions and continue to assess, monitor and will further respond where needed.

JORDAN (9 March)

After months of negotiating, an MSF team has finally been granted permission for another trip into the Berm, the no man's land near the Syrian border. The situation of Syrian refugees in this barren area is further deteriorating. The team continues to negotiate to start up our medical intervention.

 YEMEN (11 March)
In the besieged enclave of Taiz city in Yemen, the MSF supported hospitals treated 270 war-wounded last week, of which 45 % where civilians including children. About 14 of the wounded were dead on arrival.

In the MSF mother and child hospital in Taiz the team has performed more than 6,500 general consultations for mothers and children under the age of 10 and over 1,500 antenatal consultations. The team has assisted in 120 deliveries, which is a steady incline since the opening of the hospitals. In two weeks the team will start activities in the mother and child hospital's operating theatre, this will be mainly C-sections.

Around 750 women are coming to us for family planning, which is quite significant in this context. The small trauma and stabilisation centre we opened last month, has received 270 patients. They will be treated there or referred to other facilities in or outside Taiz, depending on the severity of the injuries.

MYANMAR (9 March) 
Yesterday we started our first patient on Bedaquilline (pre-XDR-TB) and a second patient who was diagnosed with Extreme Drug-Resistant Tuberculosis (XDR-TB), is expected to be started on Delaminid next week. This is in collaboration with the National Tuberculosis Programme (NTP) and the End TB initiative. We have two confirmed XDR-TB patients in our cohort and five from the Ministry of Health (MoH)/NTP that we are hoping to put on treatment soon.

For more than two weeks now, MSF has been monitoring measles cases in Maungdaw, Northern Rakhine State, with three confirmed lab cases. MSF started to do line listing for patients and did lobbying with the MoH and WHO to start vaccination and management of patients presenting with measles. As numbers are increasing particularly in Inn Din, Southern part of Maungdaw, MSF has been treating patients, not only the complicated measles cases. Because of discussions with WHO, a mass vaccination is planned using MMR (Measles, Mumps, Rubella) vaccine, with concerns from the team that the vaccines may not be enough to cover a lot of people in Maungdaw.

Discussions are on-going with the State Health Director and other actors to support the Ministry of Health not only in setting up an isolation ward in the hospital for severe cases, but also to assist in the vaccination program.

JORDAN-SYRIA (9 March)
Over 40,000 people from Syria are stuck at the border as they cannot enter Jordan. MSF is still negotiating for a permanent permit to start activities. Currently we only have short permits. The team went with a one-day permit to Rugba area. The estimation is that there are more than 40,000 people, health care is practically non-existent, and the situation is very dire and will most likely further deteriorate. MSF could be the only actor who could get in quickly and scale up. Our estimation is that there will be 60,000 people in two months on this location.
 
TURKEY (9 March)
The Humanitarian Affairs Advisor visited the Turkey/Northern Syria mission. The objectives of the visit were to support the team in looking into migration patterns, the Turkish migration detention centre system, and Syrians'/non-Syrians' access to health care. Specific visit to Akcakale project. There are approximately 3,000 Syrians residing in Akcakale transit camp where MSF is providing support to the municipality. The majority have been there between one week and four months. New arrivals' access to basic services is limited due to their "probation period" status.

Psychological trauma related to the situation in Syria, their current situation and uncertainty of what will happen next, is reportedly common. Some women expressed concerns over the security situation in the camp. Most of the people in Akcakale camp are waiting to be relocated to one of the official camps as they do not have the means to travel elsewhere.

Entering Turkey, people should immediately register/apply for asylum. Syrians are provided with temporary protection. Afghanis, Iraqis, Yemenis and Iranians etc. are allowed to stay if registered, but with limited access to any assistance. Majority of people in detention centres across the country are non-Syrians. There are small detention centres in each major city, and eight official detention/removal centres spread out all over the country (six more are currently being constructed with European Union funding).To be detained in Turkey means that there is a high likelihood of getting deported from the country. Access for humanitarian agencies, and any other outsiders for that sake, to detention centres has so far proven to be very difficult (the team is still working on it) hence our knowledge on the actual conditions and access to health care is limited. We spent days in Ankara meeting with Turkish and international actors. Ongoing negotiations between the EU and Turkey to stem the flow of people and to possibly send refugees/migrants back to Turkey from EU will increase pressure on the detention centre system, camps and people's access to assistance in different parts of the country. Something to continue to follow closely in upcoming weeks and months.

DRC KATANGA (9 March) – Missing Maps

Members of the Manson Unit have recently returned from the Democratic Republic of Congo (DRC) where basic geographical information system (GIS) training was carried out with 14 members of the OCA Katanga mission. This covered data collection using smart phones and paper, base mapping, and tools for visualising and analysing data. The trip also focused on implementing a pilot cholera dashboard for Lubumbashi. Using outbreak data, this dashboard facilitates the spatial and temporal analysis of cholera transmission. The dashboard was developed by the Manson Unit in collaboration with the British Red Cross, and was made possible thanks to thousands of hours donated by Missing Maps volunteers who mapped the city. A review and assessment of the training and dashboard are to follow. For more information contact [email protected]

YEMEN (14 March)

In Yemen, Taiz we experienced intense fighting last week, leading to breaking of frontline in the west of the enclave, the main road in the south opened up as a result, 'releasing the siege' as a main road now connecting the resistance held city/enclave with the south/Aden. We expect a flow of goods to increase over the next days, even though the road is still not 100 percent safe. It seems that half of the city is under Houthi control, and half of the city under Resistance control. There are high numbers of WW reported at MSF supported hospitals inside the enclave (more than 400 war wounded and 41 deaths) and in areas newly taken, e.g. Birbasha (145 war wounded and six deaths). Fighting and shelling is ongoing; with landmines left behind. Push back from the Al Houthis and republican guard. We are monitoring the situation, the hospital and trauma and stabilization centre are prepared for an influx of wounded, and we prepositioned more minivans / Ambulances. Teams are trying to get medical supply in the former enclave. From a humanitarian perspective; several people reportedly being arrested in Birbasha, rumours of people being killed due to political/military affiliation.

TANZANIA (14 March)
The WatSan Advisor has just returned from a field visit to the new project in Mtendeli refugee camp, which will be home to around 20,000 people. At the moment there are three refugee camps being used for Burundians fleeing their country into Tanzania. In all three locations MSF (OCA and OCG) continue to play a key role in the set-up and running of the water and sanitation infrastructure. The programme in Mtendeli started by focusing on providing the basics in terms of water supply to the population being moved from other sites in the region and involves the design and implementation of a system from source development (borehole drilling) to the point of distribution (tapstand). All activities are being carried out in conjunction with a local NGO (TCRS) and the team will also work with them and UNHCR on improving the sanitation situation in Mtendeli camp. UNHCR also want to open the nearby Karago camp for a further 25-30,000 people and the MSF team will work to install a water network and provide latrines at this site as well. The health status of the population has been hard to quantify due to lack of data from the Red Cross (National Society) run hospital in the camp but we have now started a community based surveillance (CBS) programme within the camp, giving us some much needed information and crucially to track the mortality rates. The team is also piloting some digital tools within the camp – one for water quality monitoring at tap stand and household level and the other for community based surveillance – both of which enable better data collection and facilitate the appropriate follow-up if there are problems. All WatSan and surveillance activities will, when appropriate, be handed over to other actors already working with us in the camp.
 
DRC (14 March)
From the 9th of March on there has been on-and-off fighting west of Mweso in the Mpati area, where MSF was active prior to the suspension-closure. So far we have heard of five wounded, including civilians. ICRC is taking care of the surgical follow up and patients are being referred to Goma. It looks like a new alliance (APRDC) has returned to the area, leadership of this group seems to include ex-M23 and ex-Nyaturas. The fighting has caused mass displacement of the population in the area. Negotiations for a safe return seem to be moving in the right direction, though still ongoing.

On the 11th of March in the evening the BCZ was forced to terminate all BCZ staff contracts that were linked to the MoU. It is yet unclear if MCZ will be able to convince them to remain in Mweso HGR until we can return, but time is of essence here. This is a very worrisome situation and the team is trying to follow closely the context and humanitarian situation.

OCB
CENTRAL AFRICAN REPUBLIC (11 March)

The situation seems relatively stable for now, the transit government’s period ends at the end of the month. Around 20,000 people still live in Mpoko camp, where we might need to keep the project open for longer than the originally planned month of June. In the meantime, the number of consultations is still growing: around 13.000 consultations per month. In general, in the smaller IPD sites in Bangui, where we do mobile clinics, the number of IDPs is dropping which is a good sign. Our maternity project in the III arrondissement that was opened in January is doing around 40 deliveries a month but up to 100 family planning consultations a week already. The HIV project has also been started 2 weeks ago after it was put on standby during the period of violence.

DEMOCRATIC REPUBLIC OF CONGO (11 March)
The situation is very unstable at this moment in the Masisi territory. Rebel groups are moving in the territory and some clashes occurred, including along the road between Goma and Masisi, which could complicate our car movements to Masisi. Nine deaths are reported and a dozen of wounded, who have been transferred to Kirotshe and Masisi hospitals.

In the Tshopo province (former Orientale Province), cholera cases have been confirmed in two health areas. The Pool d’Urgence Congo (PUC) is on spot in Basoko and Yakusu and has started to set up the Cholera Treatment Centre.

GUINEA (11 March)
We have started a free HIV testing in two areas of Conakry and expect to test around 4,000 to 5,000 people in 18 days (150,000 in Conakry for the whole year). After eight days, we have already tested 1989 people (around 3% of the yearly target), with a positive rate of 1, 7% (1% among men and 4% among women) which is coherent with the national figures of prevalence in the country. We need to increase our health promotion activities to encourage women to come to the free testing, as we have been seeing mainly men so far.

BURUNDI (14 March)
Debriefing of the recently-returned Head of Mission
In Burundi, the evolution of the situation is unpredictable: many scenarios are possible. It's very difficult to define a clear strategy. The mission is trying to be prepared in case of major massacres: in addition to the trauma centre in a private clinic and a few beds in another hospital, the team is able to rapidly set up 30 beds and two OTs in the office itself. But the main concern is that this additional capacity would probably not be enough in the worst case scenario of massive massacres. As big international donors have cut theirs funds, another concern is the cuts in the health system budget which could lead to a collapse of the whole system. The team is monitoring the situation (+ opening of a malaria project in the centre of the country). Furthermore, MSF neutrality has been attacked by the government, saying that MSF supports the opposition. After meetings at all levels (politicians, police...), those accusations have not been repeated over the past three months.

MOZAMBIQUE (14 March)
Related to El Nino, a team is going to do an assessment in areas of Mozambique that are considered worryingly food-insecure. There are also similar concerns about some areas in Malawi and Zimbabwe, where a second assessment team will be sent in coming two weeks.

ZIMBABWE (14 March)
In Harare 30 cases of Typhoid fever were identified last Friday. We have a WASH project that is currently looking into a first response, given that Typhoid is a water-borne disease.

OCBA

MEDITERRANEAN SEA (15 March)

SEARCH AND RESCUE OPERATIONS
Intersectional workshop will be held next Monday and Tuesday in Rome to discuss the last year of sea rescue operations. For the second day external actors are also invited.
Following this workshop a decision will be taken by OCBA regarding whether or not we will continue with SRO next year.

ANGOLA (15 March)

MSF teams are currently supporting Huambo provincial hospital with case management. In the meantime, an ICG request for yellow fever vaccines is being prepared for Huambo province.
An exploratory mission in Cunene province is underway and another explo is planned in Huila over the next week.
Main challenge has been the delay in laboratory confirmations of the yellow fever cases; the current lead time is three weeks. These delays are occurring despite CDC laboratory support.

BURUNDI (15 March)

Rwanda explo on refugees from Burundi ended this week. No intervention is proposed by the team.

BOLIVIA (15 March)

Protocol for the Operational Research on seroconversion of Chagas patients after five years since they completed the treatment has been finally completed. We expect to pass the ethical committee in the coming weeks and immediately after, we will start to contact former MSF patients for the collection of samples.

COLOMBIA (15 March)

Colombian President admitted that the 23th of March deadline for the signature of the peace deal with FARC may not be achieved. Crucial 'end of conflict' issues such as disarmament and the reintegration of guerrillas into civilian life are still under discussion.  

ETHIOPIA (15 March)

There is a measles outbreak in SNNP and Oromia regions. There will be a vaccination campaign in 510 
wards during the month of April and around 25m children estimated to be vaccinated. 
It will be integrated with Polio vaccine and operational cost is from polio campaign. Partners’ 
involvement is requested in the operational areas. 

Acute Water Diarrhoea: There is an outbreaks in at least three regions. UNICEF and Ethiopian Red Cross 
have been responding so far. MSF is strongly pushing for access in these three regions.

Siti: We are launching the first round of vaccination PCV10 + Penta. Two teams will work for 10 days for this first round. Around 3,200 children are targeted. 
 

Fiiq: Still zero report of suspected measles this week in Fik hospital; last reported case was on the 25th of February.

Dolo/Liben: Cases of dengue decreased last week; only three cases were reported from the health centre.

INDIA (15 March)

Our team from Hajipur in Bihar followed up on fire that destroyed houses and property in some villages as a result of clashes between Muslim and Hindu communities. There is no need for MSF support as the government was quick to respond and quick to use the incident for their own political goals and gains.

IRAQ (15 March)

Combats continue in Fallujah and an explosive-filled truck was used in suicide explosion at checkpoint in Hilla City with mass casualties, another truck filled with explosives was caught. Government 
warns of increasing terrorist activity in middle Euphrates.
Team movements are restricted as a result of insecurity, but preparations for household survey in Najaf, Kerbala and Babyl are ongoing.  

JORDAN (15 March)

The opening of Ramtha Non-Communicable Diseases clinic was successful. About 74 consultations 
and 1 referral on day 1 were done. The official inauguration is planned for March 31; an agreement signed 
for external laboratory with Al Takaful.

MALI (15 March)
A measles outbreak was declared in Kidal and request from local authorities, supported from the 
authorities in Bamako. 
MSF’s Flight test and schedule to Kidal has been launched.

Meningitis situation: there is an outbreak in one district 80 km south west of Bamako and one suspected case in a Bamako hospital. The pattern of Meningitis is the same as Niger, 
majority is NmC. The relationship and collaboration with Malian authorities is ok.

NIGER (15 march)
Political tensions are foreseen due to the second tour of the presidential elections between the current president and the opposition candidate who is currently in jail. 
The measles outbreak is above that of meningitis in Niamey. There has been no outbreak declaration 
so far. 

There will be a round table about Boko Haram in Madrid next Tuesday at La Casa Encendida. 
Results of the mortality survey in Diffa city are acceptable, but the results for Dosso and Nguimi are still pending.

NIGERIA (15 March) 

There is an on-going assessment in Jakusk, in Yobe state, for measles outbreak. 
The handing over from the Emergency Unit to the CO2 was finalised this week.

RWANDA (15 March)

Rwanda explo on refugees from Burundi ended this week. No intervention is proposed by the team.

SUDAN (15 March)

 Tawilla: The number of IDPs has increased to 31,000 with the arrival of 10,000 more people 
over the last days. 

Sortoni: Total number of IDPs stands at around 61,000.

A measles and polio vaccination 
campaign is planned for this week. We will also provide vitamin A and will screen for malnutrition 
by MUAC at the same time.

Joan Tubau (GD) will visit Sudan over the next 10 days. The main objective is to make a plea for access to more places and also for international staff.

SOUTH SUDAN (15 March)

About 150 people are arriving in Mellut town every day. These are people who originally are not from Mellut but are brought to Paloish by GOSS and from there they move to Mellut. Also the number of SPLA soldiers in the camps has grown over the last weeks with around 1,300 SPLA soldiers being stationed there now. General analysis is that this all fits in pre-positioning of the Dinka tribe in areas that have been allocated to them. 

In Malakal, Dinka IDPs came to collect their personal belongings from the POC. UNMISS assured their security during the three days that this was happening. Shilucks believe the UNMISS is a tool of Government.

Malakal: The River is closed for any transportation of civilians by order of the SPLA. This complicates the referral of Dinka population from Malakal town. We started OPD consultations in Malakal town and will evaluate in a weeks’ time to see if we should/could do something else.
In POC Emergency room activities are increasing with respiratory tract infections being the major morbidity for now.    
Wau Shiluck: Referrals are being done to ICRC in Kodok without difficulties.

Western Equatoria: Test and treat team is going back to Gangura after being absent from the area for more than six months due to security constraints.
We obtained the greenlight to do an assessment in the South of Mundri. This area has been affected by conflict between SPLA and local militia and reports indicate that 20,000 people are being deprived from any health care and other humanitarian assistance over the last months. 
Sexual violence is another area of concern.

SYRIA (15 March)

In South Syria, ceasefire holds except regime artillery targeting Der’a Al-Balad. The regime is offering amnesty to fighters deposing weapons. The leader of an armed group was assassinated in Tall-Shihab.

In Azaz District IS frontline has remained active in the border area, and has been reactivated in the area of Marea. The opposition forces have gained control of two villages from IS close to the border with Turkey.

The January drug was delivered to all clinics except Attaman (going soon), discussing East Dar’a 
vaccination situation with DoH Der’a.

Al Salamah hospital capacity increased to 52 beds. Number of OPD consultations and ER admissions is still very high (2172 OPD and 605 ER from 7 to 10 March). The outreach activities with a shuttle that picks up patients in the camps is continuing.
EPI outreach: started on Monday 7 March, vaccination of 79 children has been done in Al Sham, while in Al Quatari, vaccination will be done on 11 March. Sijo and Shamarek will follow.
We continue with NFI distributions and there will be distribution to around 200 families this week.
We have also started implementing the watsan intervention in an IDP informal settlement (Tal Jebeen). Five water tanks have already been installed. Ten more plus latrines to be installed the next week.

TURKEY (15 March)
Rockets fell in Kilis south west area presumably sent from Syria on 8 February. Official sources have confirmed that there were about four rockets, two deaths and one person severely injured. Retaliation from TK occurred during same day in the evening. There has been no further incidents related to that one in the next 36 hours.

VENEZUELA, BOLIVARIAN REPUBLIC (15 March)
Venezuelan opposition announced its strategy for forcing President Nicolas Maduro to resign. 
The plan calls for mass demonstrations to gain support for a recall referendum or a constitutional amendment to shorten the president's term and to hold new elections in December. 

Street protests and mass demonstrations combining political demands and complains for the disastrous situation in which the country is immersed is seen as the definitive strategy to force Maduro’s resignation under internal pressure from his own party or the military. 
The OCB coordination team has arrived in the country and we are about to finalize the coordination mechanism and joint support services between the two OCs.
Trainings to medical and psychological staff in the Caracas Barrios are ongoing and importation procedures for drugs has started.

YEMEN (15 March)

Cease fire talks between Al Houtis delegation and Saudi Arabia took place. As a result there has been an exchange of prisoners.

There are two cases of suspected meningitis in Abs. The epidemiological surveillance will be reinforced. 
Razeh, well known as an active frontline since the beginning of the war, has been completely calm in the last seven days as a result of the current local/regional deal between the warring parties.

OCG

BURKINA FASO (11 March)

With regards to meningitis, beyond Niger, MSF is keeping an eye on neighbouring countries at risk, in particular Burkina Faso, Togo, Benin and Ghana. In Burkina F, notably where there is no MSF presence right now, we are organizing a visit to assess the situation with the support of our regional Dakar office.

CENTRAL AFRICAN REPUBLIC (11 March)

The second round of Multigènes vaccination campaign started on 23 February. After five days, 14,000 children had been vaccinated in Berbérati town and periphery. The campaign is now moving towards external axis in highly remote areas.

CAMEROON (11 March)

We have done water trucking for more than a year now as our proposal to build a network of water gathering system had been rejected. Now we are in dry season, and the system the government had planned to build with UNHCR for April this year is not ready. UNHCR and the Cameroon government therefore validated the first part of the system that we would build to limit water trucking. It is very heavy work. After more than a year, water trucking for a 50,000-people refugee camp is simply not acceptable.

DEMOCRATIC REPUBLIC OF CONGO (11 March)

About 1,800 children are still being taken care of in Manono but the number of cases entering our programme is decreasing.

DEMOCRATIC REPUBLIC OF CONGO (11 March)

In Bunia, the PUB responded to a cholera outbreak, declared end of January. A Cholera Treatment Centre was put in place and 12 patients have been attended to. A total of 203 cases were registered between 21 January and 3 March 2016, with five deaths. Today we still have five patients in our CTC and the number of cases is decreasing.

GREECE (11 March)

We are starting our project on sexual violence in Athens in the coming days in partnership with other sections and local NGOs. The idea is to provide support to victims of sexual violence. 

More than 30,000 refugees are stuck in Greece today, in precarious situation. OCG could intervene at the border if needed.

NIGER (11 March)

In two districts of Niamey, the meningitis outbreak is being confirmed, although not declared. Vaccines are insufficient. The team is following the situation (surveillance), also doing training, PEC kits distribution.
Measles cases are also reported and an explo is ongoing in North area of Niamey.

SOUTH SUDAN (11 March)

Tensions in Mayom last week-end pushed us to prepare for evacuation. Lots of movement have been observed. The team is closely following the situation.
Next week, a workshop will take place in Nairobi with all sections involved in South Sudan with the idea to review the obstacles and difficulties faced in this context and to make concrete proposals in terms of synergies, resources sharing, mutualisation for a best PEC of patients and a better continuity of our operations in such a challenging context.

TANZANIA (11 March)

We now have a vector control specialist, who is also an entomologist, present there and who should be able to make a proposal with regards to vector control related preventive activities.

YEMEN (11 March)

A week ago, attackers killed 16 people, including nuns, inside Catholic facility established by Mother Teresa's charity in Aden. The motive of the gunmen, who fled after the attack, was not immediately known. No group has yet claimed responsibility.

There was no major impact on our activities so far. However, it raises concerns about security and we’ve seen an overall deteriorating situation in the last weeks.

ZAMBIA (11 March)

We’ve been approached by OCBA regarding the cholera outbreak in Zambia, where annual cholera outbreaks in the capital Lusaka have been recurrent since 2011. Since then there was no major outbreaks, therefore there is some risk of having this year an explosive cholera outbreak particularly in the slums of the capital city. OCBA has worked a lot on the protocol for OCV vaccination. We are discussing a potential OCG intervention with OCV vaccination.

We are speaking of two slums in Lusaka affected simultaneously by new cases. We sent a team to examine the possibility with the WHO to vaccinate preventively and latest news seems to show good will for a vaccination.

OCP

BURUNDI (14 March)

We now have a team in Burundi where we have been registered for several weeks. We have decided to support the provincial hospital in the north of Kirundo province that borders Rwanda. The first objective is to organise the surgical unit, the second, provide support to the maternity unit to reduce female mortality that is fairly high in the hospital, the third, work with the paediatric unit on responding to malaria peaks and the fourth, support the town’s blood bank, probably with supplies and managing the various departments but this has yet to be decided. As for the situation on the ground, little has changed and there is still violence. President Nkurunziza is digging in his heels and refuses to step down. The opposition remains mobilised. OCG and OCB also work in Burundi. OCB has observed an increase in casualties arriving at the hospital it supports in Bujumbura.

DEMOCRATIC REPUBLIC OF CONGO (14 March)

The Watsan project in Kalemie – a town in the north of Katanga viewed as a cholera-endemic zone – is set for completion. A cholera prevention project opened in 2011 included several initiatives such as vaccinating 51,000 people against cholera and distributing 2,600 housing filters in July 2014, constructing 13 sand filters to facilitate effective chlorination and, most important of all, setting up a water distribution network with the support of Fondation Véolia. The system is comprised of a 500,000-litre reservoir set up on the top of a hill connected to REGIDESO’s (DRC’s water utility) supply network which pumps and treats water from Lake Tanganyika. MSF has installed over 7,000 metres of primary water pipes. Distribution is via a secondary network that has 10 fountains and 7 fountains (equipped with reservoirs) installed at strategic places around the town. The project was held up several times in 2015 due to problems with the company tasked with constructing the reservoir and leaks observed in the reservoir once the work was completed. The leaks are now repaired and the reservoir was recently filled and handed over to REGIDESO. All the standpipes have been entrusted to management committees set up by MSF. We now need to learn from the project by conducting a review of the process, drawing up a list of the main issues encountered, leveraging the domestic filters, implementing epidemiological monitoring, working with Epicentre to finalise the survey on vaccination effectiveness and identifying WatSan indicators to monitor the project. The project is scheduled for completion towards the end of March.

ETHIOPIA (14 March)

A MoU with RHB in Oromiya region has been finally signed by all relevant authorities for a nutrition intervention for nine months this morning (Monday). The situation there is not catastrophic in terms of nutrition but really concerning in term of food insecurity. It means that OCP is now officially operational again in the country, means we can now proceed with the renewal of our national registration and work permit requests. Our team has been assessing other wards in Oromiya and is preparing further assessments in Amhara region joined with other sections from next week. OCBA has done assessments and started intervention in other parts of the country.

Overall, the situation in the country seems it’s not yet a nutrition crisis (or we haven’t found yet where), but we are concerned about other locations. We will find out more in the coming months. It is important to be on the ground to offer already a light support where it is needed, but mainly for surveillance, and to facilitate access to other places. It took us a bit more than two months to get this Babile MoU. A part of this delay is due to us not knowing enough about the process. Process for MoU can be very different from one region to another (it is fully decentralized country for this kind of stuff), and can be quite unclear when you don’t work already in the concerned region. Oromyia is definitely not the easiest one. For diverse reasons, we expect the MoU process in Afar and in Amhara regions to be a lot fastest (some estimation between 10 days to 2 weeks…), to be confirmed of course in case we find more concerns there and decide to intervene. Furthermore, the authorities are insisting that OCBA pay taxes on international staff salaries (those with work permits who spend more than 6 months in the country). We began paying these taxes last year, but the authorities also want us to pay the tax retroactively. We do not yet know many years back, but we will have to try and negotiate.

MALAWI (14 March)

Cholera broke out at the end of December in three districts around Lake Chilwa on the border with Mozambique in southeast Malawi. We are taking action on three fronts: providing treatment (900 cases treated in treatment units set up by MSF in the three districts – 25 reported deaths, with 10 in the community); distributing domestic water filters to fishing communities living in floating houses on the lake and those living on islands; vaccinating around 80,000 people who live around the lake. 

Different strategies have been adopted for this vaccination campaign to facilitate delivery of the two doses of vaccine at an interval of 14 days as this provides enhanced protection. In the case of the people living around the lake, both doses are administered according to standard practice (supervised administration); in the case of the island communities, the first dose is supervised and the second is handed over to community leaders to distribute on the 14th day; in the case of the fishing community, the second dose has been distributed to the people themselves for self-administration on the 14th day. The latter two strategies are new to cholera vaccination campaigns targeting mobile populations. In order to compare the different strategies, Epicentre will conduct a study on coverage, acceptance and effectiveness.

YEMEN (14 March)

On 5 March, 16 people were killed in an attack on a hospice run by nuns from a religious congregation founded by Mother Theresa. The hospice is in the north of the town in a neighbourhood not far from the MSF hospital. The bodies were taken to our hospital and we treated the one nun who survived the attack. Whereas up until now security incidents have been assassination attempts on politicians or the security forces, this attack, which nobody has claimed responsibility, is particularly worrying because of its nature and unprecedented scale. Immediately after the incident, the armed group controlling the district where we are established set up a checkpoint and initiated patrols. We are in close contact with the team in Aden and the coordination who are talking with representatives of groups with influence in the area in order to try and understand what happened, evaluate the risk for our teams and put in place appropriate security measures, including the evacuation of some or all of our team.