A cholera epidemic in the Katanga province Application of spatial analysis to surveillance system

Democratic Republic of Congo Katanga province, Lubumbashi 2002

Participants copy

Objectives 1) To represent data from surveillance on electronic maps 2) To use the most common GIS for data representation 3) To import data in a GIS from external database 4) To produce thematic maps 5) To develop specific maps according to administrative and geographical

representation 6) To understand the basic format of a database structure 7) To relate spreadsheets 8) To collect points using GPS 9) To represent polygons, points and lines using GPS 10) To represent points on satellite images 11) To Geo-reference Images 12) To develop hypothesis from spatial representation

The case study is not intended to teach about the use of a specific software however it will allow the participants to use .shp files that can be represented in ArcView, ArcGIS, in HealthMapper and with Epiinfo. Through the practical application the participants will learn how to apply GIS to represent spatially the data produced by a surveillance system.

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Introduction

General information on Lubumbashi and Katanga province Katanga is one of the 11 provinces of democratic Republic of Congo. The province is placed in the South-East part of the country and is limited to East by the Tanganyika Lake, to South by the Zambia, to North by the provinces of Kivu and Maniema, to West by Angola and to North-West by the provinces of Kasai Its population is estimated around 7 millions of inhabitants. Almost one million and

half are living in the capital Lubumbashi. After 1997, six district of North of Katanga are affected by a civil war between rebel groups and the DRC army. This war has already caused hundred of thousands victims among the civil population especially due to an internal massive migration and to a drastic reduction of the economic activities in the area. During the last year

is living today in a rural area, at the periphery of Lubumbashi, in

Tableau 1 : population f Lubumbashi district

several thousands of civilians migrated

from the north of the province to Lubumbashi crossing the Zambian state. This population

R.D.C.

some very critical hygienic conditions. The population of the town is estimated at 1.413.869 inhabitants (WHO 2002). The town is organized administratively in 5 Health zones.

oKampemba 383,757

Ken do ya Kamalon 236,707 Lubumbashi 277,375

Rwashi 245,990 Katuba 270,040

he province is crossed from the South to the North by the Congo river that is also

river border where the economic

sent out by truck to the capital of the province Lubumbashi.

Tused as the most important communication system. The majority of towns and villages are located on life is ruled out. The city of Ankoro is considered as the crossing point of all economic activities of the province and the principal river harbor from where fish is

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Katanga is very reach in lakes and rivers that allow to the population to have a food subsistence source through the fishing activity. The river Luapula leave the Mwero

fectious diseases surveillance system in Katanga province

surveillance pidemiology of the ministry of Health in the Katanga province.

osed by one or more ealth zones.

lth zones, situated in the North of the province, because affected by a

centers, hospitals and

provincial health department in Lubumbashi.

the zones faraway from

the 4 health direction but does not have any computerized database.

rge with the surveillance system in Katanga, based in ubumbashi you have to prepare an electronic map to be utilized for your surveillance

1 hat kind of features do you think to represent on your maps?

f administrative level you want to represent on your maps?

Lake going to join the River Lualaba, which is the upper part of the Congo river. The junction between Luapula and Lualaba is located at Ankoro.

In

The surveillance of infectious diseases is organized by the department ofe The system is organized in 40 health zones. One district is comphAfter 1997 only 34 health zones out of the 40 make a report on infectious diseases, the other 6 healong civil war, since several years they don’t report any more. 14 diseases are under surveillance in the present system as showed in Annex 1. Cases are detected and reported by nurses or doctors from the healthhealth posts. In each health zone, data are compiled by the medical officer in charge and sent weekly to the Data transmission is done by radio or by hand, fax and e-mail are utilized only in few zones. Communications are very difficult, especially in Lubumbashi. At provincial level the fourth direction of the MoH (epidemiology surveillance) is carried out by th

Data are collected on spreadsheet forms using MS Execel using the computers provided by WHO. Reports are not produced in a standardized format. Feed back is not provided regularly. As WHO health officer in chaLsystem. QuestionWWhat kind oWhat kind of data do you think to insert in your database?

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Is the first November 2000.

arge to support the 4th health provincial office you are lanning a meeting with the district epidemiologists to give them the regular quarterly

provincial health irection present some data on cholera, shigelloses, Typhoid fever and meningitis

As WHO epidemiologist in chpfeed back meeting on infectious diseases and you are thinking to introduce the district epidemiologists to the application of GIS to the surveillance system During the workshop the medical officer in charge with the 4th dduring the year 2000 in your province

Evolution des cas et decès de choléra par semaine, Province du Katanga, RDC, année 2000. Source: REH des Zones de Santé, Antenne de l'OMS au Katanga.

Données disponibles pour les semaines n° 1 à 37

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Evolution des cas et décès de Shigellose par semaine, Province du Katanga, RDC, année 2000. Source: REH des Zones de Santé, Antenne de l'OMS au Katanga.

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Evolution des cas et décès de F. Typhoïde par semaine, Province du Katanga, RDC, année 2000. Source: REH des Zones de Santé, Antenne de l'OMS au Katanga.

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Evolution des cas et décès de Méningite par semaine, Province du Katanga, RDC, année 2000. Source: REH des Zones de Santé, Antenne de l'OMS au Katanga.

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Question 2 How do you think to represent data about the diseases in term of place? End of the first part

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Second part During the year 2001 the 4th Direction of Katanga province receives several alert about cholera outbreak from different districts. The director of the 4th direction is a bit worried for the information coming from the north of the province and specifically from the district de Kongolo et Kabalo. Unfortunately the data that arrive from these districts are a little limited for security reasons and arrive late. Is seems however that MSF Belgium that is operating in these districts is talking about a cholera outbreak in June. The only data that the 4th direction has are coming from Kabalo, however no actions are taken from the provincial direction.

Cas de cholera dans le district de Kabalo dans les semaines 1-23 2001

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During the 40th week of 2001, from 01 to 07 October, MSF France and MSF Belgium have alerted about an epidemic of cholera in the district of Ankoro in the North center of the province. The surveillance system of the province confirms with its reporting system the occurrence of an epidemic as showed in this retrospective analysis of the data collected by the surveillance system.

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Ankoro cas de choléra depuis la semaine 40, 2001

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Is the end of the 2001, last week of December. At this point, even if it seems a bit late, you suggest to your national counterpart to organize the data collection in a way to facilitate their export in your GIS to represent them spatially and see the progression by time and by space.

Question 3 What counseling would you give to the provincial data manager to facilitate the relation between the data collected in Excel files and your GIS database? End of second part

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Third part The 18 November 2001 a 10 years old boy, coming from the periphery of Lubumbashi is admitted to the central hospital of Lubumbashi as suspected case of cholera. The medical doctor on duty send a sample of the boy stools to the Lubumbashi laboratory to confirm the suspected case of cholera. The local laboratory confirm the diagnostic of cholera 01 sero-type Ogawa the 19 November. The analysis of the data of the surveillance system for the 52nd week in 2000 and 2001 put in evidence the following situation in the district of Kenya Kamalongo.

ccording to the surveillance data and the laboratory confirmation the provincial nce

tial

hen you go to visit the district of Kenya Kamalongo, the local medical officer

Cas de Cholera 2000-2001 dans le district de Kenya Kamalongo

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Aepidemiologist declare that a cholera epidemic is going on in Kenya Kamalongo siseveral months. He decide therefore to go in Kenya Kamalongo and carry out an investigation in the area to organize an appropriate response. You as expert in spaanalysis are requested to join the mission and to apply your competencies to the situation. Wconfirm the data as from the surveillance system and show to the mission the present condition of the water supply in the district :

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Photo 1 : « Kishimpo » traditional well

Photo 2 : water collection from the

kishimpo

The pipeline for the water supply are soaked completely by the dirty waters coming out from the broken sewages. Thus the risk of contamination between black waters and drinkable water is very high (photo 3). The hygienic conditions in the area are very critical, during the raining season the situation is becoming more dangerous because all the dirty waters come out from the canals and flood the whole area contaminating all Kishimpos.

Photo 3 : potable water and sewages Most of the foods are sold in a free market without any hygienic control.

There are not electronic maps of the area and the only resolution that exist is the maps with district administrative level.

Question 4 Facing this situation what do you will suggest to do with your expertise on Geographical Information System to support the epidemiological investigation?

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Fourth part The 26 April 2002, The situation of cholera epidemic in Katanga was the following :

Katanga suspected cholera cases 2001-2002

0100200300400500600700800900

1000110012001300140015001600170018001900200021002200230024002500

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Logaritmic scale :

Katanga suspected cholera cases 2001-2002

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weeks

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Question 5 A: Could you describe and discuss the two graphics above in terms of progression of the epidemic? B: Can you represent spatially and temporally the data collected along the weeks. C: Looking at the final map with the appropriate spatial representation discuss the results and suggest eventual hypothesis of the transmission and source of the epidemic.

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ANNEX 1

R. Lualaba

Ankoro Lac Tanganika

R. Luapula

Lac Mwero

Route vers la province du Kasaï Lubumbashi

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Historical revision of the events before and during the epidemic: On the back of each boat (baleniere) there are some toilettes that are discharging directly in the river water only few meters from the river border where people is living and is using the same water to take bath, washing their dress and themselves and to cook. In addition to that in these same waters fishers have a very intensive fishing activities to provide food in th e area as well as to export this fish to the other districts. In the old miners cities as Lubumbashi, Likasi or Kolwezi, the sewage system has deteriorated quickly in the last years because the abandon of the mines companies as for example in the area of Kenya Kamalongo. The latrines are totally inexistent, the pipeline of the drinkable water are soqked in the dirty waters, thus the risk of contamination between drinkable water and dirty water is very high. In spite of the fact that the cholera epidemics are recurrent every year, especially during the rains season, the local authorities did not have organised a crisis committee to manage this situation until the visit of the Minister of health the 27 February 2002. The local authorities, at the time of this epidemic did not also took into consideration the laboratory results of the local Lubumbashi laboratory who confirmed the epidemic, without taking any action to control and respond to the outbreak. The preparedness to the epidemic prone diseases was completely absent during the dry season that usually comes before the reins season. During the meeting held in Lubumbashi, everybody recognised that no preparedness activities were done to provide the peripheral health centres with the necessary cholera kits to respond immediately to the first cases of cholera. In addition to that no distribution of chlorine has never been organised to control the environmental contamination neither educational programme for the population how to use at home the chlorine. The absence of training programme for the health workers on the front line to prevent and control cholera epidemics and for the case management has also been one of the reason of a very high case fatality rate especially among the most peripheral population. The absence of formal exchange of information among the different actors on the fields as hampered the rapid sharing of information in the province among the

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different districts. MSF France and MSF Belgium detected an epidemic of cholera in the health zones of Kabalo and Kongolo, in the north of the province from the week 17, 2001. These data are not available in the provincial surveillance system, because these two zones are affected by a civil war since long time and thus there is noe a regular transmission of data.

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