Evaluation The Activities of Health Control Staff and Laboratories Staff for The Control of Cholera Epidemic In Al-Hilla City

Background: Cholera is one of intestinal disease conceded life-threatening can spread rapidly from place to another and cause epidemic, affecting the population. The causative agent of cholera is gram-negative bacterium called Vibrio cholera. In 2015 Iraq was faced an outbreak of cholera .There are many activities for the control of cholera epidemic that provided by health control staff and laboratories staff which included measuring the ratio of chlorine in the water and the health control. Objective: To evaluate the activities of health control staff and laboratories staff for the control of cholera epidemic in Al-Hilla city, and determine the relationship between the activities of staff with demographic variables Methodology: descriptive study was conducted in primary health care centers of Al-Hilla city, from the period November 4 2015 to March 1


INTRODUCTION
Cholera is an acute intestinal infection caused through the ingestion of bacterium V. cholera present in faecal contamination of food or water.Generally associated lack access to good water and adequate sanitation, its impact can be even more dramatic in areas where essential environmental infrastructures are disrupted or have been destroyed.Countries experiencing difficult emergencies especially risk facing outbreak of cholera.Refugees to overcrowded settings or massive displacement of internally displaced people (IDPs), where water is not potable and bad sanitation , constitutes also a risk factor (1) .Vibrio cholera consider globally significant pathogen because endemic in lots of countries of the world and annually reported 3 to 5 million cases of cholera (2) and estimated that there are 28 000 to 142 000 deaths worldwide (3) .
The world was exposed to 7 th pandemics of cholera.The first pandemic from 1817 to 1824 (Asiatic cholera) began spreading beyond the areas of India where it had long been endemic, especially Bengal and the Ganges river delta to Southeast Asia then China and Japan after that reach to Middle East and Russia.The second pandemic in 1827 to 1835, the wave of cholera move to North American and Europe particularly because of developments in traveling and international industry and increased human's migration through the soldiers (4) .
The third pandemic from 1839 to 1856 brought the disease for the first time to South America, especially Brazil, and to much of North Africa as far west as Tunis.The fourth pandemic from 1863 to 1875, much of sub-Saharan Africa was ensnared in cholera's worldwide net.During 1881 to 1896 the fifth pandemic and sixth pandemic from 1899 to 1923 were less fatal because of high perception of cholera.Egypt and the Arabian Peninsula, India, Persia, and the Philippines were hit hardest during these epidemics while other areas experienced severe outbreaks, in 1892 Germany and from 1910 to 1911 Naples.Indonesia was original of the final pandemic and emergence of a new strain, called ElTor, which often still persists today in developing nations around the world (5) .
From 1965 to 1966 the Eltor biotype was transmitted from Asia and Middle East then Iraq and Iran through trading in 7 th pandemic (6) .Cholera consider in Iraq since 1966 when the first cases appeared and increase to 277 cases which include 20 deaths the fatality rate reached to 8.8%.In the last forty years, all epidemic of cholera appears last months the and in the next year occur the second wave.Data refer to that the seasonality is not available, yet ordinarily cholera started in northern then distributed towards the center and southern region (7) .According to the statistic of Iraqi Ministry of Health, in the last five years, the incidence of cholera was as following in 2010 two cases and not documented any case in 2011.In 2012 the number of casualties 653 cases of cholera.In 2013, one case of cholera and in 2014 not documented any case (8) .
Iraq was faced an outbreak of cholera that started in Sept. 2015 along the Euphrates valley of the country.According to a Nov 26 world health organization statement, from mid-September to November 22, nearly 2800 cases of cholera infection were reported in Iraq.Although WHO reported only two cholera-related deaths in the country, the outbreak fuelled concerns across the region with reports of its spread to other countries such as Bahrain and Kuwait.The cholera outbreak has affected seventeen governorates in Iraq of nineteenth governorates, according to world health organization, with most cases reported in Baghdad 940 cases , Babylon 675 cases , Qadisiyyah 442 cases , Muthanna 287 cases, Karbala 157 cases, and Basra 102 cases (9) (10) .the presence of cholera in the country was because of the warm of climate in Iraq (11) .

OBJECTIVE OF THE STUDY:
1. To evaluate the activities of health control staff and laboratories staff for the control of cholera epidemic in Al-Hilla city.

Study design:
The descriptive analytical study was conducted on primary health care centers in Al-Hilla City.throughout the period of November 4th 2015 to March 10th 2016 to reach the objective of this study.

Setting of the Study:
The study is carried out at Al-Hilla city in (20) primary health care centers (PHCCs) were selected from (47) PHCCs, These centers were distributed into two health sectors.

The Study Instrument:
The study instrument was rated on Likert Rating Scale (always, sometime, never) for the purpose of the study according to the national annual plan to control of cholera outbreak to measure the underlying concepts in the present study.It is comprised of two forms of questionnaires one directed for health control unit and other directed for laboratories.Reliability of the questionnaire estimated through a pilot study and the validity through (14) experts.Data are collected using interview technique.

The Sample of the Study:
A probability (sample random sampling) the manual selection of (70) participant from health control unit and laboratories units at first and second health sectors of Al-Hillh city.

Data analysis:
Data are analyzed through using the Statistical Package of Social Sciences (SPSS) Version 16 performed through the use of descriptive statistical data analysis approach through statistical descriptive analysis methods (percentages, frequencies, bar graph, mean of score, p-value and Chi square test).Table (4) shows that there is a not-significant relationship between the activities of health control staff and their demographic data at p-value more than 0.05.Except with their occupation, levels of education, and years of services, the study results indicate that there is a significant relationship.Table (5) shows that (42.5%) of the laboratory staff are within the third age group (30-39) years old, (52.5%) are males, (57.5%) are having technical institute graduated, (60%) are having (6-10) years of experience, and (52.5%) are having (6-10) services years.Table (7) shows that the laboratory staff activities toward cholera control is moderate.Table (8) shows that there is a not-significant relationship between the activities of laboratory staff and their demographic data at p-value more than 0.05.

Part I: the health control A. Distribution of the health control staff by their demographic data:
The study results showed that the highest percentages of the health control staff (53%) were within (40-49) years old.The result is supported by Hellemans and Closon, (2013), effect health condition, professional competence, and psychosocial work conditions, among two age groups of employees: (40-49) year old employees and employees 50 years of age or older (12) .
From researcher's point of view, this category has a professional experience in dealing with the community but prefers the younger age groups.
The study results showed that more than eighty percent of the respondents were males, nurses graduated from the medical technical institute.These finding were supported by (Esmail,  et al,.2016) which showed that more than half of the sample were males and highest percentage (70.37%) of the study sample graduated from the medical technical institute (13) .
From researcher's point of view, men staff are important in the health control units because they interaction with the community because of their roles monitor shops and vendors roving , most of the PHCCs have one or two doctors and other staff such as nurses, the need to increase doctors, employ the academic nurses and involved them in health education .The study showed that the majority (83.3%) are having (6-15) years of experience, this result disagree with study conducted by Al-Saidi (2008) which indicated that (22%) of nurses have (6-10) years of experience in a nursing field (14) .
The study showed (46.7%) of the sample have (11-15) years of services, this result disagree with the study conducted by Abed (2016) which showed that the majority (38.0%) of nurses have (1-10) years old of experience in occupation filed.From researcher's point of view, they have a good period of experience and services enable them to work in the health control units.

B. Distribution of health control staff according to their activities about control of cholera:
Through the investigating the activities of the health control in table no.(2), the results of the present study revealed that items number 2,4,9,13,14,15,17 were high satisfied and item number 1,6,7,10,11,12,16,18 were moderately satisfied except with items number 3,5,8,19 were mild satisfied.the distribution overall activities about control of cholera through health control staff in table no.(3), shows that the majority (93.3%) of the health control staff are moderate active toward control of cholera , From researcher's point of view, the reason of this result may be attributed to the following reasons, Lack of emphasis on the following topics educational courses to food handlers from general shops and factory, imposed the health control against the shops selling of the foods and the public restaurants within the geographical area of the health center, follow-up with sewage and coordinate with other departments, Follow-up with ice factory and the factories of R.O. water supply, monitoring street vendors, follow-up the ratio of chlorine in the farthest point in the network should be not less than 0.5 ppm, follow-up the result of water testing from the public health laboratory.In addition to touched for some items was mild signified such be sure provide the requirements of health and safety of the food when asked the staff about this most their answer was the families depend on the ration of food distributed by the government ,also, item be sure to provide health and safety to the environment most staff answered to that the whereabouts of the displaced were in the houses and Husseiniya not camps and good places to some extent, either both items Imposed the health control on the student clubs in colleges and institutes and follow-up to provide the alum material and chlorine to all water projects within the geographical area.mostly answer that tasks of the health sector.

C. Relationship between the activities of health control staff toward control of cholera and their demographic data:
The study results indicated that there was a non-significant relationship between the activities of health control staff and their demographic data, except with subject occupation, levels of education, and years of services was a significant relationship with the activities of health control staff.The researcher's point of view is the work at a health control units need to be occupational experience and the appropriate level of education in order to deal with the community.In explanation of the reason for non-significant relationship between the activities of health control staff and their demographic data that may be more than half of the sample was relatively high age and the gender was a small proportion of female 16.7% and the years of experience were 43.3% in both groups 6-10 and 11-15.The study used variables for the first time and there are no studies to support the findings.

Part II: the laboratories: A. Distribution of the laboratory staff by their demographic data:
The findings of the present study show that the majority of the studied the laboratory staff are in the age group (30-39) years.This result is almost similar to that of Oladele and et al. (2010)  in Nigeria whose findings indicate that the majority of the studied subjects were (29-39) years (15) .
Regarding the gender, the majority of the study sample 52.5% was males.This result is supported by Bwire, and et al (2013) study in Uganda that more half of sample of participants with regard to gender were male (16) .
Concerning the level of education, the findings of the present study reveal that most of studied subjects (57.5%) were having technical institute graduated.
Regarding to experience the majority of sample (60%) were six to ten years of experience, and regarding to services (52.5%) were six to ten years of services in occupational field.This results agree with the study that conducted by Abed and Kadhim 2013 which show the similar in the categories of the sample 15.8% have (6-10) years of experience in the occupational field and 10% of them have (6-10) years of service in the occupational field (17) .
From researcher's point of view, they have a good period of experience and services enable them to work in the laboratories.

B. Distribution of the laboratory staff according to their activities about control of cholera:
The statistical analysis for the present study involved a statistical percentage, frequencies, and the mean of scores that used to divide the activities of the laboratory staff to control of cholera into mild satisfied, moderate satisfied and high satisfied .The activities of the laboratory staff to control of cholera including 7 items.On investigating the activities of laboratories in table no.( 6), the results of the present study revealed that items number 1, 3, 4, 5 high satisfied and item number 7 "Follow-up provide the materials for laboratory diagnosis" was moderately satisfied except with items number 2 & 6, they were mild satisfied .thedistribution overall activities about control of cholera of the laboratory staff in table no.(7), shows that the majority (93.3%) of the laboratory staff are moderate active toward control of cholera this results From researcher's point of view, the reason of this result may be attributed to the following reasons, some labs of health centers are followed provide material for lab and connected with health sector and the other depend on the health sector provide material of lab, some lab staff does not adhere to take the samples before giving antibiotics and most lab collecting samples from the infected person and people close to him (His family) but most of the health centers do not take samples from the people far away from the infected person (His neighbors) in the region.

C. Relationship between the laboratory staff activities and their demographic data:
The results show there is a not significant relationship between the activities of laboratory staff and their demographic data.From researcher's point of view, In explanation of the reason for not significant relationship between the activities of the laboratories staff and their demographic data that may be because the activities of the laboratories are fixed in the primary health care centers and registered high significant included open a record in the laboratory to document all the information needed to investigate V. cholera, Send the samples to the central laboratory to verify testing, When the results of the stools are positive for V. cholera, visit the house of the infected person and his neighborhood for the discovery of other undetected cases and When the results of the stools are positive for V. cholera, take samples of stool from all family members who have direct contacts with the infected person.The study used variables for the first time and there are no studies to support the findings.

CONCLUSION
Most of the staff of the health control units were men and the laboratories of primary health care centers do not investigate any sample ,collect the samples and send it to laboratory of public health, This may be delayed the emergence of the results

RECOMMENDATION:
1.More emphasis should be put on the importance of the activities for control the epidemic of cholera, especially the activities that provided by primary health care centers because it is the first line of defense and the closest to the community.2. The provision of materials for the investigation of samples in primary health care centers and out the results of the initial then sent it to the laboratory of public health for confirm .3. The need to increase female staff work in health control units to deal with women when visiting homes or places for women, such as bathrooms in schools, Institutes and colleges.

Table ( 2
) based on statistical cut-off point (0.66) the study results indicate that the health control staff activities toward control of cholera distributed differently in term of mild, moderate, and high significant of activities based on the intervals of mean of scores.

Table ( 6
) based on statistical cut-off point (0.66) the study results indicate that the laboratory staff activities toward control of cholera distributed differently in term of mild, moderate, and high significant of activities based on the intervals of mean of scores.