VZCZCXRO5109
PP RUEHROV
DE RUEHDS #2096/01 2431333
ZNR UUUUU ZZH
P 311333Z AUG 09
FM AMEMBASSY ADDIS ABABA
TO RUEHC/SECSTATE WASHDC PRIORITY 6030
RUEHPH/CDC ATLANTA PRIORITY
RUEAUSA/DEPT OF HHS WASHINGTON DC PRIORITY
INFO RUCNIAD/IGAD COLLECTIVE PRIORITY
RUEPADJ/CJTF HOA PRIORITY
RUEAIIA/CIA WASHINGTON DC PRIORITY
RUEKDIA/DIA WASHINGTON DC PRIORITY
RUEWMFD/HQ USAFRICOM STUTTGART GE PRIORITY

UNCLAS SECTION 01 OF 02 ADDIS ABABA 002096 
 
SENSITIVE 
SIPDIS 
 
E.O. 12958: N/A 
TAGS: TBIO CASC SOCI KHIV ET
SUBJECT: CHOLERA EPIDEMIC IN ETHIOPIA REACHES ADDIS ABABA 
 
SUMMARY 
------- 
 
¶1. (SBU) Since the emergence of initial reports of cholera cases 
within Addis Ababa around August 10 the number of cases has risen 
sharply.  As of August 26, 2,592 cases and four deaths were reported 
in Addis Ababa to the Ministry of Health (MOH).  The number of cases 
continues to increase, although the case fatality rate appears to 
remain low.  While not yet publicly acknowledging the presence of 
cholera -- the Ethiopian Government (GoE) continues to refer to 
"Acute Watery Diarrhea (AWD)" -- the GoE has stepped up control 
efforts this week and engagement of WHO, UNICEF, MSF, the USG, and 
others is increasing.  Nevertheless, with another month to go in the 
rainy season, we should expect further escalation of the epidemic 
before the situation improves.  To date there are no reported cases 
affecting American citizens and Post has issued a Warden Message and 
internal Management Notice advising the American community how to 
protect itself.  End Summary. 
 
A CHOLERA EPIDEMIC 
------------------ 
 
¶2. (SBU) Cholera cases were first detected in the area of Moyale 
along the Kenya-Ethiopia border in February 2009 and have continued 
to occur in many parts of the country: Afar, Oromiya, Amhara and 
Somali regions in particular, with sporadic reports from other 
regions. It is unclear whether the current situation is the result 
of introduction of the infection from Kenya in the Moyale area or if 
cholera was present at low levels and internal factors, such as the 
current rainy season and poor water and sanitation, have created 
ideal conditions to trigger the current outbreak. Malnutrition and 
water shortages are likely exacerbating the situation in many 
places. 
 
¶3. (SBU) Surveillance and reporting is inconsistent, thus the 
absence of reports does not necessarily indicate absence of cases. 
Laboratory confirmations of Vibrio cholera 01 Inaba by the Ethiopia 
Health and Nutrition Research Institute (EHNRI) have been obtained 
from several locations including Addis Ababa. 
 
¶4. (SBU) Data on the outbreak is also being collected by staff from 
the MOH's new Public Health Emergency Management (PHEM) Unit and the 
first class of trainees from the PEPFAR/CDC-supported Field 
Epidemiology and Laboratory Training Program (FELTP).  Current 
efforts are focusing on determining which sub-cities in Addis Ababa 
are most affected through active case finding in collaboration with 
sub-city administration personnel. FELTP also has trainees 
conducting field investigations currently in West Harerge and West 
Arsi (Shashamene) zones within Oromiya region.  Related cases are 
also being reported from Debre Zeit and Dukem, within 60km of Addis 
Ababa where the outbreak has been particularly persistent. 
 
¶5. (U) On Aug 18 as soon as the first cases were reported, Post 
disseminated a Mission-wide Management Notice and Warden Message on 
the situation and provided guidance on taking appropriate 
precautions against cholera and other diarrheal diseases. The 
Ethiopia Country Specific Information page at www.travel.state.gov 
already has similar language. 
 
¶6. (U) Taskforces have been reactivated at the Addis Ababa health 
bureau and at all sub-cities.  The City Council, chaired by the 
Mayor, now meets on a daily basis and the State Minister of Health 
Kebede Worku and Dr. Daddi, Deputy Director General in charge of 
MOH-PHEM, have joined the taskforce.  Public radio reports and 
advisories continue and the head of the Addis Ababa Health Bureau 
issued a radio alert on August 25 instructing people to seek medical 
care early if they develop symptoms, to consume only treated water, 
and avoid eating raw vegetables, etc. that could be contaminated. 
 
¶7. (SBU) There has been concern among officials about the role of 
"holy water" in the spread of disease as Orthodox Christians go to 
religious sites on holy days and drink unpurified water.  Although 
there are a number of these sites around Addis Ababa, the site at 
Maryam Kaliti just south of Addis, has been the main focus.  Large 
numbers of "pilgrims" congregate at these sites for varying periods 
of time; they have now been evacuated from the holy water sites and 
very few (30-50) are said to currently remain there.  Police have 
reportedly been assigned to keep people from obtaining this water. 
Some pilgrims, however, have traveled from as far as Gambella and 
Benishangul-Gumuz in the far west of the country. 
 
¶8. (SBU) Despite the positive laboratory tests, to date the MOH has 
labeled the outbreak(s) as "Acute Watery Diarrhea" instead of 
"cholera."  This is likely due to governmental fears of broad 
restrictions on agricultural exports to the Middle East, decreased 
 
ADDIS ABAB 00002096  002 OF 002 
 
 
regional and local travel, and potential panic in the community that 
could result in significant economic losses and social disruption. 
An association between "holy water" and cholera, if indeed proven, 
could undermine the immense stature of the Orthodox Church in the 
Ethiopian community. 
 
TREATMENT AND CASE MANAGEMENT ACTIVITIES 
---------------------------------------- 
 
¶9. (SBU) Case Treatment Centers (CTCs) in outdoor tents have been 
established in Addis Ababa at Ras Desta and Zewditu Hospitals.  An 
additional two CTCs operated by Medecins Sans Frontieres (MSF) (at 
the TB center and Menilik Hospital) were to be functional as of 
August 26.  A new site has been identified for MSF to establish at 
Kaliti.  Six additional sites (youth centers) have been identified 
by the City Council and will be ready as resources are availed. 
Currently, all CTC sites have adequate drugs and medical supplies. 
 
EMERGENCY FUNDING 
----------------- 
 
¶10. (SBU) The World Health Organization (WHO) estimates a funding 
requirement of USD 2.3 million to address the 132,000 new cases 
which are predicated to occur in Addis Ababa alone in the coming 
five months.  There will be a need for drugs, medical supplies, CTC 
supplies, strengthening surveillance (field epidemiology and 
laboratory), public communication and training.  CDC has offered 
additional surveillance support to the FELTP trainees and is 
awaiting a response from the MOH. 
 
¶11. (SBU) 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. 
 
COMMENT 
------- 
 
¶12. (SBU) The MOH'S weak public health infrastructure and capacity 
are being challenged by the growing magnitude of the outbreak.  The 
Addis Ababa Regional Health Bureau (AAHB) had difficulty providing a 
daily breakdown of the cases but seems be improving. Communication 
and coordination between MOH and AAHB has been problematic.  With 
WHO expected to provide technical support and NGOs providing 
assistance, there are a number of players involved in the response 
further complicating coordination and comprehensive assessment of 
the situation.  There has been no official confirmation that the 
outbreak is due to cholera, although laboratory confirmation in a 
number of cases has been obtained.  To facilitate trust and 
productive government-to-government working relationships, until the 
GoE itself acknowledges a cholera outbreak, the USG should continue 
to utilize publicly the same language used in the Warden Message; 
i.e. "increased risk of acute diarrheal illnesses, including 
Salmonella, Shigella, Cholera, and others."  End Comment. 
 
MEECE