Epidemiological Bulletin Number 46 Week 6 (week ending 14 February 2010) Foreword This bulletin provides a weekly overview of the outbreaks and other important public health events occurring in Zimbabwe. It includes disaggregated data to inform and improve the continuing public health response by the various partners. It also provides guidance to agencies on issues relating to data collection, analysis and interpretation, and suggests operational strategies on the basis of epidemiological patterns so far. The bulletin is published weekly. Note that the epidemiological week runs from Monday to Sunday. This edition covers week 6 (week ending 14 February 2010).
The C4 team welcomes feedback. Data provided by individual agencies is welcome but will be verified with MOHCW structures before publication.
Please send any comments and feedback to the Cholera Control and Command Centre
Email: [email protected].
Toll free number for alert by district and province is 08089001 or 08089002 or 08 089000
Mobile number for alerts is 0912 104 257 Acknowledgements We are very grateful to MoHCW District Medical Officers, District and Provincial Surveillance Officers, Provincial Medical Directors, Environmental Heath Officers, and MoHCW's National Health Information Unit, who have helped to gather and share the bulk of the information presented here.
Likewise, we acknowledge agencies, including members of the Health and WASH clusters, who have kindly shared their data with our team. MoHCW recognizes and thanks the efforts made by NGOs and other partners assisting in the response and providing support to MoHCW. Highlights of the week: • Cholera spreads in Masvingo Province • No new reported cases of Pandemic Influenza A H1N1(2009) • More Measles Cases reported in particular from Harare City
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 1 Figures See also summary tables (annex 1), maps (annex 2) and graphs (annex 3). The case definitions can be found in appendix 1 and detailed data by district are shown in appendix 2 Cholera 7 out of the 62 districts in the country have been affected by the cholera outbreak that started on 4 February,2010 compared to 54 districts last year at the same time. 57 cumulative cholera cases, 8 of which were confirmed and 1 death were reported by 14 February 2010 to the World Health Organization (WHO) through the Ministry of Health and Child Welfare's (MoHCW) National Health Information Unit. The crude case fatality rate since the outbreak started stands at 1.7 %. In comparison by week 6, 2009, 75 789 cumulative cases and 3 612 deaths had been reported, with a crude case fatality rate of 4.8 %. This year’s case fatality rate is lower than last year’s by 3.1 % . Week 6 (8– 14 February 2010) 42 suspected cases and 4 confirmed cases of cholera were reported this week. 32 suspected cases were reported from Masvingo Province districts namely; ward 27 and ward 28 Chivi 3, ward 30 ,Masvingo 2 , Mwenezi 1 and ward 16, Chiredzi 26 and one death from Chiredzi. 10 cases were reported from Beitbridge.
Investigation of a rumour of 7 cases of cholera from Zvishavane found that there was no cholera in the area. Geographical distribution of cases The cases reported so far came from the following districts: Beitbridge, Chivi, Chiredzi, Harare, Masvingo, Mwenezi and Shamva. Urban/Rural distribution of cases All of the cases currently reported are from rural areas. In comparison, during the corresponding week in 2009, 42 % cases came from urban areas whilst 58 % were from rural areas Assessments & response Chivi A CTC was set up at Nyahombe Clinic to ensure appropriate infection control and case management. Participatory Health Hygiene Promotion and NFIs were distributed to directly affected households and their neighbours. Residual spraying with HTH at the affected households was also done. Soap and ORS sachets have been provided to the clinic. 2 wells with hand pumps located 1, 300m from Nyahombe Clinic and one in the school 800m from clinic were rehabilitated by ACF. Diesel was given to ZINWA to enable it to pump water to the clinic. Chlorine was provided to the clinic and the clinic’s tanks were repaired.
NFI Distribution (Aquatabs, Soap, Buckets with taps) for a total of 2100 households has been planned and will be carried out in the next few days . Source: Ministry of Health and Child Welfare Rapid Disease Notification System 2 The water sources available are dominantly turbid surface water. There are very few protected water points (functional or non-functional). Chiredzi Chiredzi District Health Authorities coordinated response by the following partners: Merlin, ACF and Oxfam. Merlin dispatched an emergency response team (vehicle, nurse, EHO) to support emergency health response. They have taken the following items: ORP kits, Cholera beds, IEC materials, Ringers, IV giving sets and cannulae. Merlin has provided 25 litres of fuel to EHT based in Chiredzi for community surveillance. Communities are using river water for drinking. Oxfam has set up Oral Rehydration Point (ORP) in ward 16, Chiredzi District. Pandemic Influenza A H1N1 (2009) By week ending 31 January, 253 cumulative probable 1 cases of Pandemic H1N1 (2009) had been reported in Zimbabwe, 41 of which were confirmed by PCR (Polymerase chain reaction) to be Pandemic H1N1 (2009). Week 6 (8– 14 February 2010) Zero cases of probable Pandemic Influenza A H1N1 (2009) were reported this week. As a result we are now in the eleventh week without a case reported. Geographical distribution of cases The following provinces have reported cases: Manicaland, Harare, Mashonaland East and Midlands. The affected 8 districts are: Harare Urban, Chivhu, Marondera, Goromonzi, Seke, Mutasa, Nyanga and Chirumhanzu. Assessments & response No samples were sent to the National Virology Laboratory this week. Measles Nearly 1350 suspected cases were reported since the start of the outbreak in September 2009. 812 blood specimens have been received by the polio-measles laboratory and 248 cases have been confirmed to be Measles IgM positive. 23 of the total positive cases had dates of last vaccination . The vaccination status of the remaining 225 cases was not indicated. 65 community deaths have been reported. 43(17%) of the positive igM cases were in the below 9 months, 26 (11%) in the 9 – 12 months agegroup, 46 (19%) were in the 1-5 years agegroup, 104 (42.1 %) were in the 5 -14 years agegroup and 28(11%) in the above 14 Years. Hence 205 (83%) of the positive cases were above the routine immunisation age ( 9 months -12 months)
1 See definition of probable case in Appendix 1
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 3 The district measles IgM positive attack rates ranged from 0.4 to 17 per 100 000 and the attack rate for all the affected districts is 3 per 100 000. The lowest attack rate was for Masvingo and the highest was for Bubi. See table 4 for detailed distribution of the cases by age group and district and attack rates. Week 6 (8 - 14 February 2010) 14 specimens out of 134 received were IgM positive. 6 were negative, 1 indeterminate, 54 were not done and 59 had results pending. Hence the weekly positivity rate is 67%(14/21). The positive cases came from : Bindura 2, Goromonzi 1, Harare 6, Marondera 1, Murehwa 1, Mutoko 1, Seke 1 and Zvimba 1. See table 5 for detailed distribution. Geographical distribution of cases Since September 2009, 32 districts out of 62, have had at least 1 laboratory confirmed measles case namely: Bindura, Bikita, Bubi, Buhera, Bulawayo, Centenary, Chegutu, Chirumhanzu, Chipinge, Gokwe South, Goromonzi, Gutu, Harare (including Chitungwiza) ,Hwange, Hwedza, Insiza , Kwekwe, Makoni, Makonde, Marondera, Masvingo, Mt. Darwin, Mutare, Nyanga , Umzingwane, Seke, Zaka, Zvimba and Zvishavane.
Confirmed laboratory Outbreaks 21 Districts had confirmed laboratory outbreaks. The Districts are shaded in table 3. Suspected Outbreaks 30 districts had suspected outbreaks. Assessments & response A National Measles Outbreak Coordination Committee was formed and is mainly constituted of MOHCW, WHO and UNICEF . More other EPI stakeholder will co-opted with time. It met and reviewed the evolution of the current measles outbreak and made plans on doing a risk analysis on districts that have not yet reported measles outbreaks this year as well as establishing the status of the national outbreak. The taskforce will meet again on 22 February 2010. It is expected to adopt effective control measures that are evidence based. Surveillance continued throughout the country.
Buhera District
All children aged 6 months to 14 years are being vaccinated with financial support from UNICEF,MSF and technical support from WHO and the Ministry in 9 wards. At time of reporting, over 25 000 children had been vaccinated.A total of 30 nurses with 5 vehicles are vaccinating in the district. Report from the province indicates that considerable resistance is being experienced among the Johane Marange amongst who the outbreak is more pronounced.
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 4 Seke District(Epworth)
Vaccinations conducted between Friday 12 th to Sunday 14th of February 2010. A total of 439 children were vaccinated (Age group targeted was 6 months to 14 years). A significant number of children was found to be overdue for most antigens in Epworth.
Nyanga District
District awaiting delivery of vaccine from national level to mount a response. WHO has provided some fuel for delivery of vaccine to the district Children 6 months to 14 years will be targeted.
Anthrax
Since the beginning of the year 13 cases of Anthrax were reported and a rumour of 1 case in Seke. The cases distribution is as follows: Kadoma 3, Shurugwi 8 and Chikomba 1 and Mwenezi 2.
Week 6 (8– 14 February 2010) No cases were reported. Assessments & response Vaccination of cattle was undertaken in Seke and Mhondoro Districts.
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 5 Annex 1: Summary Tables
Table 1: Cumulative Cholera cases and deaths reported by district for the period week 6, 2010
District Cases Confirmed Cumulative Cumulative Cumulative Attack rate Reported this Cases reported Suspected Confirmed deaths per week this week Cases Cases 100 000
Harare 0 0 0 0.06 1 1 Shamva 0 0 2 0 0 1.88 Mwenezi 1 2 4 4 0 2.93 Beitbridge 10 0 16 1 0 14.25 Chivi 3 2 6 2 0 3.56 Masvingo 2 0 2 0 0 0.70 Chiredzi 26 0 26 0 1 10.26 Total 42 4 57 8 1 2.16
Table 2: Age and Sex Distribution of Cumulative Confirmed H1N1 Cases from July 2009 to 31 January 2010
30 Years and Under 5 Years 5-14 Years 15-29 Years over District Male Female Male Female Male Female Male Female Chikomba 0 0 3 0 4 3 0 0 Harare 0 1 2 0 0 0 0 0 Mutasa 0 0 3 2 0 0 0 0 Seke 0 1 8 4 1 1 0 0 Unspecified District 0 0 5 2 1 0 0 0 Total 0 2 21 8 6 4 0 0
Table 3: Distribution of Measles IgM Positive by Age group and District since September 2009
5-14 >14 Attack rate per District < 9 months 9 months -12 months 1-5 years TOTAL years years 100 000
BIKITA 0 0 0 4 0 4 2.35
BINDURA 0 2 2 0 0 4 2.6 BUBI 0 0 0 6 3 9 17.36 BUHERA 0 1 2 1 0 4 1.68
BULAWAYO 7 5 1 1 2 16 2.18
CENTENARY 0 0 0 1 0 1 0.86
CHEGUTU 0 0 2 4 0 6 2.46
CHIPINGE 0 0 1 4 1 6 1.95
CHIREDZI 1 0 0 0 0 1 0.39
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 6 5-14 >14 Attack rate per District < 9 months 9 months -12 months 1-5 years TOTAL years years 100 000
CHITUNGWIZA 0 0 0 3 1 4 1.14 GOKWE 1 0 4 9 1 15 4.72
GOROMONZI 1 0 0 1 0 2 1.2 GUTU 0 0 2 1 0 3 1.4 HARARE 24 17 11 33 15 100 6.33
HWANGE 1 0 0 0 0 1 0.91 HWEDZA 0 0 1 2 0 3 3.24 INSIZA 0 0 0 2 0 2 2.18 KADOMA 1 0 0 0 0 1 0.39
KWEKWE 0 0 1 2 0 3 1.09
MAKONDE 0 0 0 1 0 1 0.79 MAKONI 1 0 6 3 1 11 4.1
MARONDERA 2 0 2 2 1 7 4.18
MASVINGO 1 0 0 0 0 1 0.35
MT DARWIN 0 0 1 4 0 5 2.31
MUREHWA 0 0 0 1 0 1 0.57 MUTARE 1 0 1 3 0 5 1.18 NYANGA 1 0 2 1 2 6 4.72 SEKE 1 0 0 3 0 4 4.8
UMZINGWANE 0 1 0 0 0 1 1.5 ZAKA 0 0 0 1 0 1 0.5 ZVIMBA 0 0 1 3 0 4 1.67
ZVISHAVANE 0 0 6 8 1 15 13.43 TOTAL 43 26 46 104 28 247 3.01
Table 4: Distribution of Confirmed measles cases by age group by district reported in week 6, 1 -7 February 2010.
< 9 1-5 5-14 >14 District TOTAL months years years years
BINDURA 0 2 0 0 2
GOROMONZI 0 0 1 0 1
HARARE 1 1 4 0 6
MARONDERA 0 0 0 1 1
MUREHWA 0 0 1 0 1
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 7 MUTOKO 0 1 0 0 1
SEKE 0 0 1 0 1
ZVIMBA 0 0 1 0 1
TOTAL 1 4 8 1 14
Table 5: Some Key Measles Indicators as of 31 January 2010
Indicator Value
Suspected Cases 1 347
Blood Specimens received by Laboratory 812
Confirmed Cases 248
Deaths 50
Districts Affected 32
Overall Attack Rate 3/100 000
Cases with Vaccination status 23/248
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 8 Annex 2: Maps
Map 1: Comparison of cumulative cholera cases by district as of week 6, 2009 and 2010
2010 2009
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 9 Map 2: Cumulative probable Influenza A H1N1(2009) cases by district, July, 2009-10 February 2010
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 10 Map 3: Comparison of Cumulative Measles IgM positive cases and Suspected Measles case by district
reported this year, as at 7 February, 2010
Confirmed Cases Suspected Measles Cases
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 11 Annex 3: Graphs
Graph 1:Ranking of District Cumulative Cholera Cases Reported as at week 6, 2010
Chiredzi
Beitbridge
Chivi District Mwenezi
Masvingo
Shamva
Harare Urban
0 5 10 15 20 25 30 Cholera Cases
Graph 2: Logarithmof Cumulative Cholera Cases by week for the years 2009 and 2010
4.5
4
3.5
3
2.5 2008 2009 2
Log of Cholera Cases 1.5
1
0.5
0 w34 w35 w36 w37 w38 w39 w40 w41 w42 w43 w44 w45 w46 w47 w48 w49 w50 w51 w52 w53 w1 w2 w3 w4 w5 w6 w7 w8 w9 w10 w11 w12 w13 w14 w15 w16 w17 w18 w19 w20 w21 w22 w23 w24 w25 w26 w27 w28
Epi Week Number
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 12 Graph 3:Ranking of District Probable H1N1 Cases Reported by July 2009 to 7 February 2010
Graph 3:Ranking of Confirmed Measles Igm Cases by District Reported from September 2009 to 14 February 2010
HARARE BULAWAYO ZVISHAVANE GOKWE MAKONI BUBI MARONDERA NYANGA CHIPINGE CHEGUTU MUTARE MT DARWIN ZVIMBA SEKE CHITUNGWIZA BUHERA BINDURA District BIKITA KWEKWE HWEDZA GUTU INSIZA GOROMONZI ZAKA UMZINGWANE MUREHWA MASVINGO MAKONDE KADOMA HWANGE CHIREDZI CENTENARY
0 20 40 60 80 100 120 Measles IgM Cases
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 13
Graph 4:Ranking of Suspected Measles Cases by District Reported from September 2009 to 7 February 2010
Harare Makoni Buhera Mutare Marondera Gokwe Kwekwe Nyanga Zvishavane Bikita Bulawayo Chegutu Seke Goromonzi Bubi Beitbridge Zvimba Hwedza Chitungwiza Mt Darwin Makonde Gwanda Chipinge Mudzi Binga Bindura Mutasa District Insiza Gweru Centenary Shurugwi Gutu Umzingwane Mazowe Kadoma UMP Tsholotsho Mutoko Murehwa Masvingo Hwange Hurungwe Chivi Chinhoyi Bulilima Zaka Nkayi Lupane Kariba Chiredzi Chimanimani 0 50 100 150 200 250 300 350 Suspect Measles Cases Graph 5:Distribution of Suspected Measles Cases by Week September 2009 to 14 February 2010
140
120
100
80
60 Suspect Measles Cases
40
20
0 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 1 2 3 4 5 Week Number
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 14 Appendix 1: Case Definitions
Cholera The Zimbabwe cholera state definition states that "In an area where there is a cholera epidemic, a patient aged 2 years or more develops acute watery diarrhoea, with or without vomiting". ‘’A confirmed cholera case is when Vibrio cholerae is isolated from any patient with diarrhoea”. This is adapted from the WHO case definition for cholera. The inclusion of all ages in the case definition somewhat reduces specificity, that is, inclusion of more non-cholera childhood diarrhoea cases. It, however, does not impede meaningful interpretation of trends. Teams should monitor any shift in the age distribution of cases, which might indicate a changing proportion of non-cholera cases among patients seen. Influenza A H1N1 Influenza A and B are two of the three types of influenza viruses associated with annual outbreaks and epidemics of influenza. Only influenza A virus can cause pandemics. The Zimbabwe IDSR technical guidelines define influenza case by a new sub type (including Avian flu Influenza A H5N1 and Swine flu Influenza A H1N1) as; ‘’Any person presenting with unexplained acute lower respiratory illness with fever (>38 ºC ) and cough, shortness of breath or difficulty breathing AND notion of exposures in the 7 days prior to symptom onset.’’ Probable case definition: Any person meeting the criteria for a suspected case AND positive laboratory confirmation of an influenza A infection but insufficient laboratory evidence for H1N1 infection. Confirmed H1N1 case : A person meeting the criteria for a suspected or probable case AND a positive result conducted in a national, regional or international influenza laboratory whose H1N1 test results are accepted by WHO as confirmatory. There may be difficulty in telling apart mild cases of pandemic influenza from the seasonal influenza. Suspected measles : Any person with fever and maculopapular rash and cough OR Coryza (running nose) OR conjunctivitis (Red eyes) OR clinician suspects measles. Measles Outbreak Definition : A suspected outbreak is where you have a cluster of at least 5 suspected measles cases in a facility or district within a month whilst a confirmed outbreak is where you have a cluster of at least 3 confirmed measles IgM positive cases. Lab confirmed: Suspected case of measles with positive serum IgM antibody, with no history of measles vaccination in the past 4 weeks. Confirmed by epidemiologic linkage: Suspected case of measles not investigated serologically but has possibility of contact with a laboratory-confirmed case whose rash onset was within the preceding 30 days (same / adjacent districts with plausible transmission) Source: Ministry of Health and Child Welfare Rapid Disease Notification System 15