Major concerns about waterborne diseases, malnutrition, shelter and clean, safe water prevail as teams rush to establish new bases in Hyderabad and Sukkur in a bid to access flood affected communities on either side of the Indus River. Priorities for MSF include water supply, medical care for dehydration, acute watery diarrhoea and distribution of essential non-food items and shelter.

There are 152 international staff are working alongside 1,279 Pakistani staff in MSF’s existing and flood response programmes in Pakistan.

Sindh Province

Sukkur

Officials report more than 4.5 million people displaced in Sindh province alone, including more mass evacuations of regional centres last week. MSF is planning more assessments to identify pockets of vulnerable people.

In Sukkur, in northern Sindh, MSF has been operational for four weeks providing support to the Intensive Therapeutic Feeding Centre (ITFC) ward of the Railway Hospital – the ITFC provides treatment for severely malnourished children under the age of five who have medical complications. In the first five days of being operational 30 children where admitted. MSF is conducting two ‘nutrition’ mobile clinics in surrounding areas and camps, in addition to distribution of non-food item (NFI) and hygiene kits. The treatment of the water plant in Sukkur town has also been completed by MSF including the distribution of 80,000 litres per day has started since Monday (30 August).

Last week 110 consultations were completed in mobile clinics in Sukkur IDP camp and 24 patients were admitted to Railway Hospital with serious medical consultations. 1,247 patients received Oral Rehydration Therapy for diarrhoea and light dehydration; and 2,561 people received health education in camps and at the hospital throughout the week.

Distributions of NFI also took place last week around Sukkur including 265 tents, 453 hygiene kits, 539 cooking sets, 539 tarpaulins, and 539 jerry cans in the following locations: Sukkur Old Airport Rd, Shara-e-Abassi Sukkur and C-Government High School and C-Government College Pir Illahi Bux.

Hyderabad (Jamshoro)

In the last week MSF also arrived in southern Sindh and set up a base in the town of Jamshoro on the western side of the river near Hyderabad. After identifying pockets of displaced people on both sides of the Indus River who had received almost no assistance up to now, MSF started new activities in recent days.. .

The main objective is to tackle the water situation as the priority issue for the region and the aim is to provide five litres per day per person to these small groups of people. On 27th August the MSF team distributed 30 m3 of chlorinated water in Jamshoro town, but in three days our capacity had already reached 180 m3 a day in six locations for approximately 10,000 people.

Daily mobile clinics have also started this week achieving 130 consultations a day per site in the and a further 500 tents have been ordered for the NFI distributions which will also begin this week targeting 5,000 to 10,000 families.

On the northern axis (from Jamshoro, up to Sehwan, on the west side of the river) MSF has located more than 10,150 people in open settings. There are at least seven small pockets of displaced people who are living by the side of the road.

Only one of these small pockets has received any kind of assistance thus far, while shelter is a high priority as groups of people can be seen actively looking for shade. They have no access to water, and healthcare is an obvious question as they are on the main road, and not getting the same attention as in Jamshoro/Hyderabad camps.

In the same region villages are also struggling because of the floods. Approximately 50-70% of the population of the villages that MSF already encountered have been evacuated. As mentioned earlier those who have evacuated have gone to camps in Jamshoro/Hyderabad. However some residents remain with little assistance: often with no access to drinkable water, and with poor hygiene conditions, and poor access to medical care – what is clear is that resettlement of many of these villages will be quite delayed because of flood damage. However MSF has been able to identify potential abandoned structures in flooded districts that may serve as potential locations for a Diarrhoea Treatment Centre (DTC) if needed.

Around Jamshoro there are two types of displaced populations: those who’ve moved to relocation centres and those who remain in open settings. MSF has identified four relocation centres in Government High Schools in which the displaced have found refuge. The conditions are often the same as those that MSF encountered in flood affected regions in north Sindh, where living conditions are extremely unhygienic and susceptible to disease. Many of these centres however have received some assistance but MSF intends to monitor to make sure that further hygiene kits are provided if necessary. As usual a clean water supply might be an issue in coming weeks.

Open settings where the displaced have sought refuge are also common in Jamshoro. For example around the University of Medicine (LUMSH), approximately 2,000 people have gathered from areas as far away as Jacobabad and Balochistan. Fortunately relief teams from the university are already providing food, water and healthcare. This location appears to be a transit stop before people can find somewhere better to settle.

There are many other camps located around Jamshoro where the needs remain high and tension exists amongst the population who are frequently desperate for help.

In Hyderabad one main camp has been identified, New Sabzi Mandi camp where approximately 10,000 people so far have settled. Local organisations have already responded therefore it remains to be seen whether MSF also needs to support.

On the South axis road out of Jamshoro on the way to Karachi on the west side of the river, there is a large displaced population staying in the Khuda Ki Basti colony; a huge compound with around 300 blocks of four houses/apartments each. The complex is completely full to capacity of approximately 6,000 to 8,000 displaced people. This is another site that has poor sanitation and hygiene conditions. Nearby there are two more large tented camps with populations of around a thousand each.

Balochistan Province

Dera Murad Jamali (Nasirabad)

In Dera Murad Jamali or DMJ, in Nasirabad district MSF continues to operate a DTC which on 28 August had 46 admissions. MSF continues to receive information of additional flooded towns and villages where people remain stuck and evacuations not planned in places like Tambu, Babhakot.

Around DMJ MSF hears reports of more diarrhoea-related deaths in IDP camps such as Patfeeder Canal, Degree College, Notal and Model College camps. Clean water is still a major problem in DMJ and tankers continue to supply water that is below emergency standards. MSF will not start distributing water until it is allowed to start the purification of water sources.

MSF is conducting several mobile clinics in the DMJ area and in the past week made 1,047 consultations. The mobile clinics are treating cases of acute watery diarrhoea skin infections, malnutrition, and supplies for women. For malnourished children who are recorded by MUAC in the red-orange scale are provided with a Ready-to Use Food (RUF) supplement for seven days and are followed-up for progress a week later.

In the coming week MSF will change its mobile clinic out-patient strategy to focus more on nutrition/ANC/lactating women. 40 new cases of severe acute malnutrition were recorded in the the past week in DMJ. Ten cases were referred to the hospital ITFC of which six were as a result of the flood (displacement); and 30 in the mobile clinic, plus 23 follow-up cases from the previous last week.

MSF is under the impression that we can more effectively address morbidity through a more focussed approach to nutrition inn its mobile clinics. Pregnant women will also be offered limited ANC (ferfol, albendazole, safe delivery kit) and supplemented with BP5 (high energy biscuits).

In the meantime, after many negotiations, we are in the final stages of signing a contract for 250 latrines in the same camp. MSF is also planning to build latrines in Barchoki (Mangoli Camp) which has a further 2,500 displaced people. We plan to construct more than 125 latrines and install a 15m3 water bladder as soon as our tanker arrives and we produce enough water from the water plant.

In Mangoli Camp there is currently one small filter plant that runs about 300 litres per hour for 12 hours a day. Three deaths related to diarrhoea have been reported in this camp over the last week. Health educators have been dispatched in camps around town and soap will be distributed from this week.

With regards to the water supply in DMJ, MSF tested and treated the water tank last week and on 28th August all tankers were re-routed to this tank which now has an acceptable quality of water. During the past week 265 tents were distributed and the MSF team employed 20 daily labourers to pitch 150 tents at the Degree College. The water and sanitation team will also provide 30 latrines and ensure water is delivered to the site as soon as possible.

Since the beginning of the intervention in DMJ (10 Aug) MSF has achieved 5,117 consultations, distributed packets of 100 aqua tabs to 551 families and supported 1,050 consultations with Ministry of Health clinics.

Punjab Province

Kot addu

Last week, on the 24th August the MSF 35-bed DTC was fully occupied with patients severely dehydrated therefore the centre’s capacity was extended to 75 beds. . During the week more human resources were brought from other projects in the north to reinforce the response. However more patients are coming or being referred by MSF ambulance from neighbouring health centres, so we may have to extend once again the capacity of the DTC to 100 beds.

In this DTC MSF currently receives 150 patients a day, 45 of whom are hospitalised in the DTC. In total 1,138 patients were treated for watery diarrhoea last week (338 were severe and 446 were children under five years of age). There are also increasing cases of malaria seen in triage presenting with fever.. Occasionally severely malnourished children are also seen and treated with therapeutic feeding although these are very small numbers.

MSF is also considering strengthening some neighbouring health facilities where Oral Rehydration Points could be installed to ensure that dehydrated patients can receive treatment as quickly and as close as possible to their homes.

IDP settlements have been assessed North of Kot Addu, where more than 2,000 flood affected families did not receive any relief support so far, so MSF is planning to assist them with NFI and tents.

Rajanpur

This week, MSF teams are also assessing Rajanpur district of South Punjab, one of the most flood affected districts bordering Sindh province. Already our medical teams are observing dozens of IDP settlements which have received almost no assistance at all. A large increase of diarrhoea and malaria cases have been recorded over the last few weeks at local health facilities, and a worrying number of malnourished children under the age of five are also seen. Based on the results of this assessment MSF is considering opening a new project in this area.

Khyber Pakhtunkhwa Province (KPK) former North West Frontier Province

Peshawar

MSF performed 845 consultations in the last week at the three supported Basic Health Units (BHUs), mainly for skin diseases and watery diarrhoea. MSF might handover the daily activities of some of these health facilities to the MoH or other organisation, in order to focus only on the case management of malaria and watery diarrhoea.

MSF is also continuing to distribute NFI and tents where flood affected population are not benefiting from the assistance of other organisations. Therefore NFI and tents were again distributed last week to almost 2,500 families, in some settlements close to the river and north of the district, and to Afghan Refugee Camps south of Peshawar. Since the beginning of the flood response, MSF provided NFI and tents to over 7,000 families of Peshawar district.

New distribution should take place in the coming weeks to cover the needs of the population who were until now living in schools, but who may have to find another refuge as schools may open very soon.

Charsadda

Mobile clinics have been operating this past week in Charsadda making 7,191 consultations since the beginning of the floods. Analysis shows that the majority of cases are for skin diseases followed by acute watery and respiratory infections while four new sites were idenitified this week. In terms of the medical response in Charsadda the mobile clinics will reduce in coming weeks as more people return home and have their immediate primary health needs met. However the MSF team is working on emergency preparedness and set-up of a Diarrhoea Treatment Centre should that be required in the second phase of the disaster.

MSF is distributing an average of 93m3 per day in Charsadda and in the period 15 to 25 August 10,206m3 of water have been distributed. Since the start of the project here MSF has distributed a total of 2,250,000 litres in Painda Khel, Babra, Zoor Bazar, Giddra and Shulgara.

MSF has installed 27 tanks of 500 litre capacity in the ‘Motorway camp’ (on the Islamabad-Peshawar Highway) – they will receive 14m3 per day from MSF. The organisation is still providing 19m3 per day in Hizara Camp and a further 15m3 per day in Utmanzai Camp

A well cleaning program was started last week with two teams operating in the periphery of Charsadda. The first teams work will begin in Zoor Bazar, Babra and Shulgara. The second team started cleaning wells this week in the villages of Tangi area. The hygiene promoters will also join the well cleaning teams to disseminate IEC information.

NFI distributions in Charsadda will be finished this week and in total 4,870 NFI kits have been distributed since the beginning of the intervention. Villages will also be assessed in coming weeks for distribution of reconstructions kits to help 2,500 families begin their return home.

Nowshera

At the beginning of last week, 170 consultations at the OPD and 474 at the Emergency Room of the hospital were performed. But since then, MSF handed over the management of the hospital back to the health authorities, so that resources can be diverted to regions experiencing more urgent medical needs, particularly in the south of the district. However, MSF will set up an epidemiological early warning system in the district, in order to follow up the evolution of acute watery diarrhoea and anticipate a potential waterborne disease outbreak.

As other medical organisations are finally coming to support the area, MSF decided to focus on water and sanitation activities, increasing everyday the amount of chlorinated water provided to the populations, in addition to the ongoing distribution of NFIs.

Between the 9th and 22nd of August MSF has managed to distribute 903,000 litres of chlorinated water. In the past week MSF provided almost 240,000 litres of water per day in 10 locations of Nowshera, such as Pir Sabak, Akora Khatak and Nowshera town. Also, three water points have also been rehabilitated, with automatic chlorination in Pir Sabak.

Last week, MSF distributed NFI to 1,780 families and tents to 350 families. Since the beginning of the flood response, MSF provided NFI to almost 5,800 families in Nowshera district.

Swat

In Mingora hospital there is a slight decrease in the number of activities in the emergency room but after the bridges are repaired and access to health care returns, MSF expects an increase of patients. Blood bank training has been given to all senior nurses and laboratory technicians in the hospital for the care and transport of blood and transfusions.

Mobile clinics continue in the Mingora area and MSF has started to refer surgical patients from our mobile clinics to Timurgara because the bridges on this side are cut off and Kabal and Matta patients can easily access Timurgara. With a return of a number of actors in Swat health structures, MSF is now spreading its mobile clinics to new areas with populations where no other actors are present. The new locations for MSF mobile clinics include Manja, Kalagei and Tarkani which are all close to the border of Dir district.

MSF plans to extend mobile activities for a further two weeks while waiting for better access to Mingora for patients still cut off. Since the beginning of the flood intervention MSF made 1,600 consultations in the region.

The Diarrhoea Treatment Centre in Mingora last week was still receiving close to 100 patients a day but most of the cases are watery with mild to moderate dehydration. The emergency phase is most likely reducing in the DTC. However MSF is still sharing data with its Health promotion and Water and sanitation team in order to respond to where suspected cholera cases are coming from. Since the beginning of the flood response MSF has treated 1,262 patients.

MSF’s water distribution activity has continued in the past week in Swat making the total distributed 4,500,000 litres. Our water treatment unit has also provided a further 2,000,000 litres of water that has been distributed by other non-government organisations (NGOs). The Health Promotion team in Mingora continues to join the water and sanitation team that is cleaning wells doing hygiene promotion and hygiene kit distribution. Thus far MSF’s water and sanitation team has cleaned 26 wells (averaging three wells per day).

MSF has recently ceased its NFI distribution work in Swat which managed to distribute 50 kits for 50 families in the area.

Timurgara (Lower Dir)

Last week MSF did an assessment of the DTC at the District Headquarters Hospital (DHQ) in Timurgara (Upper Dir) and plans to assist in terms of drugs, quality care and human resources, improve hygiene, implement ORS corner and provide infusions.

MSF has just started to support the Rural Health Centre (RHC) in Munda and our staff support the emergency room and manage suspected cholera cases (average six per day). MSF’s mobile clinics are also continuing in this region to Summerbagh and Tauda China taking the number of consultations to 109. In Tauda China MSF has also managed to distribute NFI kits to 55 families and 8,000 litres of water at the Khazana bypass.

Dargai (Malakand)

The acute phase of the emergency is over in Dargai where the DTC is now averaging just two cases of acute watery diarrhoea per day. NFI distributions are now also completed in Malakand with kits delivered to 466 families in the region. Mobile clinics in Dargai have now reached a total of 624 consultations. MSF continues to distribute water in Dargai reaching a total of 450,000 litres so far.

In the last week the mobile clinics in Kalangi performed 105 consultations for diarrhoea, respiratory infections, skin infections and some malaria. The mobile clinic have stopped as there are no serious medical conditions that can not be treated by access to our mobile clinics on the other side of the river in Dir. Access is possible through a traditional suspended chair. Medical staff stationed in Dargai have been sent on to Sindh where they are much more needed.

Hangu

In Hangu MSF has been responding to an outbreak of Acute Watery Diarrhoea since July, and treated more than 1,800 cases in less than two months in the 80-bed DTC. It seems since last week that the outbreak is now almost over, as from a high of 55 patients per day two weeks ago, MSF is only seeing five patients per day now.

Federally Administered Tribal Areas

Sadda, Kurram Agency

In Sadda, Lower Kurram, in a project run by MSF since 2006, an Acute Watery Diarrhoea outbreak has been confirmed therefore MSF has decided to set up a 30-bed DTC, which is now fully operational. MSF currently receives 20 patients per day, five of them on average being severely dehydrated and needing hospitalisation.