Zimbabwe Cholera Outbreaks Coordinated Health and WASH Preparedness and Response Operational

ZIMBABWE – CHOLERA OUTBREAKS

TABLE OF CONTENTS

1. EXECUTIVE SUMMARY...... 1 2. INTRODUCTION...... 3 3. PLANNING ASSUMPTIONS & OPERATIONAL FIGURES...... 5 4. PLAN OF ACTION...... 6

4.1 OUTBREAK DETECTION...... 6 4.2 OUTBREAK CONFIRMATION...... 6 4.3 CASE MANAGEMENT...... 6 4.4 REDUCTION OF MORTALITY...... 6 4.5 ORGANISATION OF THE RESPONSE...... 7 4.6 LOGISTICS...... 8 4.7 SURVEILLANCE AND INFORMATION MANAGEMENT...... 8 4.8 COMMUNITY MOBILISATION AND HYGIENE PROMOTION...... 8 4.9 WATER SUPPLY...... 8 4.10 EXCRETA DISPOSAL...... 9 4.11 SOLID WASTE MANAGEMENT...... 9 4.12 DRAINAGE/SEWAGE...... 9 4.13 DISINFECTION/VIBRIO CONTROL...... 9 4.14 ASSESSMENT AND MONITORING...... 9 4.15 PARTNERS...... 9 5. LIST OF PROJECTS COMPRISING THIS PLAN...... 10

Table I. List of Projects (grouped by cluster), with funding status of each...... 10 Table II. List of Projects (grouped by Appealing Organisation), with funding status of each...... 12

ANNEX 1: DRUGS AND SUPPLIES REQUIRED TO INITIATE A RESPONSE...... 13 ANNEX 2: OPERATIONAL STANDARD FOR A CHOLERA TREATMENT CENTRE...... 14 ANNEX 3: COORDINATION OF OUTBREAK INVESTIGATION, RESPONSE, MONITORING AND EVALUATION...... 15 ANNEX 4: CHOLERA RESPONSE GROUP – CONTACT LIST...... 18 ANNEX 5: RESPONSIBILITIES AND ACCOUNTABILITIES MATRIX...... 19 ANNEX 6: PROTOCOL ON FOOD SUPPORT TO CTCS...... 21 ANNEX 7: FUEL REQUIREMENTS FOR CHOLERA-AFFECTED DISTRICTS...... 22 ANNEX 8: NATIONAL CHOLERA REQUIREMENTS AND GAPS MATRIX...... 23 ANNEX 9: INTERNATIONAL FEDERATION OF RED CROSS AND RES CRESCENT SOCIETIES...... 25 ANNEX 10. DAILY CHOLERA UPDATE 8 JANUARY 2009...... 31 ANNEX 11. ACRONYMS AND ABBREVIATIONS...... 37

ii ZIMBABWE – CHOLERA OUTBREAKS

1. EXECUTIVE SUMMARY

In 2008, Zimbabwe’s economy suffered a serious decline leading to a rise in social vulnerability. During the protracted election period from March through August 2008, election violence and government restrictions halted most humanitarian field activities. Half a year of critical humanitarian service delivery in support of food security, clean water, health, and education services was lost. A third consecutive failed agricultural season in 2008 has also contributed to further deterioration of livelihoods for already vulnerable groups, and increased requirements for humanitarian assistance.

Since August 2008, vulnerable populations in Zimbabwe have also been facing an expanding cholera outbreak and inadequate access to safe drinking water and hygiene. Shortages of medicines, equipment and staff at health facilities throughout the country are threatening the well-being of thousands of Zimbabweans and compounding an already critical humanitarian situation across multiple sectors. As of 8 January 2009, more than 36,600 cases of cholera had been reported, leading to more than 1,800 deaths. Case fatality rates vary by district and reflect issues of access to care, quality of care, and the underlying prevalence of conditions such as HIV/AIDS and malnutrition. Cholera currently affects 55 of Zimbabwe’s 62 districts (88.7%) and all 10 provinces in the country are affected.1

When developing the 2009 Zimbabwe Consolidated Appeal in late 2008, humanitarian partners agreed to step up operational activities in 2009. Planning figures for emergency response and emergency early recovery programs reached a total of US$2 550 million for all sectors, an increase of $235 million from the $315 million initially requested by partners in the 2008 Appeal. An estimated 60% of this total relates to food security.

In November and December 2008, as it became clear that the cholera outbreaks in Zimbabwe were of an unprecedented scale, humanitarian partners decided to review response plans developed within the frameworks of the 2008 and 2009 Appeals and establish this joint Health/WASH operational plan to allow for a predictable and coordinated response to the cholera epidemic. With a planning estimate that at least 50% of the population is at risk of contracting cholera, partners planned to respond to 60,000 cases over a period of 12 months from December 2008 to December 2009.

The Health and WASH Clusters’ response to these outbreaks, alongside smaller components through other clusters, must be viewed as an emergency measure undertaken within the context of a severely deteriorated health care and civil environment. The response is designed to be multi-sectoral in support of the Ministry of Health and Child Welfare (MoHCW) and implementing agencies, including: IFRC, IOM, OCHA, UNFPA, MSF-Spain/Holland/Luxembourg, UNICEF and World Vision for the Health Cluster; and ACF, GAA, OXFAM, UNICEF, World Vision and others for the WASH Cluster, as well as local non-governmental organisations operating in the field.

By indicating the overall amounts required by the Health and WASH clusters to implement the response plans, the operational plan at hand also brings together appeals issued by WHO and UNICEF at the outset of the cholera epidemic. The total requirements for the Health and WASH clusters to respond to the current cholera epidemic amount to $41.3 million. $24.4 million of this amount has already been requested by various agencies through projects in the 2009 CAP for Zimbabwe. The additional resources required to respond to the current cholera outbreaks amount to $16.9 million, bringing the total requested through the 2009 CAP for Zimbabwe to $567 million.

NOTE ON FUNDING TO DATE

During the peak of the crisis in November and December 2008, donors contributed $40.7 for cholera response. This included bilateral and in-kind contributions, as well as support for UN Agencies, NGOs, ICRC and IFRC. These contributions were in addition to other long-standing donor support for health and water and sanitation activities.

Recipients Amount ($)

1 For the most updated figures, including epidemiological figures, situation reports, maps, and assessments, see: http://ochaonline.un.org/zimbabwe. 2 All dollar signs in this document denote United States dollars.

1 ZIMBABWE – CHOLERA OUTBREAKS

Bilateral 1,309,382 ICRC/IFRC/Zimbabwe Red Cross 1,684,710 UN organisations 20,890,422 NGOs 6,537,249 Not yet specified (various UN, NGOs, Red Cross) 10,341,066 Total 40,762,829

The specific agencies requesting funds in this document report more than $12 million pledged or contributed to them for cholera action in late 2008. The 2009 requirements of $41.3 million are net of any 2008 funding. For full details of all cash and in-kind contributions and pledges to the immediate cholera response and to on-going health and WASH activities, please consult http://ocha.unog.ch/fts2/pageloader.aspx?page=emerg-emergencyDetails&appealID=789 (2008) and http://ocha.unog.ch/fts2/pageloader.aspx?page=emerg-emergencyDetails&appealID=841 (2009).

In addition, the International Federation of Red Cross and Red Crescent Societies issued an appeal on behalf of the Zimbabwe Red Cross Society on 23 December 2008 for 10.2 million Swiss francs ($9.2 million) to respond to the cholera outbreaks (Annex 9).

COST ESTIMATE FOR IMPLEMENTATION OF OPERATIONAL PLAN

Requirements and Total requirements project code of Additional Response Area relevant to this plan relevant CAP 2009 Requirements ($) ($) project ($) A. Surveillance, information 1,552,000 2,248,000 management and (ZIM-09/H/21864/122) (increased requirement) coordination B. Equipment and 4,148,000 supplies to strengthen 348,000 outbreak - investigation, (new component of monitoring and existing project) evaluation capacity C. Stockpiling and responding to cholera 929,999 10,304,001 11,234,000 and other health (ZIM-09/H/20937/122) (increased requirement) emergencies 15,382,000 SUBTOTAL HEALTH 2,481,999 12,900,000 (37% of total) 3,987,500 D. Water, sanitation, 21,931,780 hygiene and infection (Additional project to (Includes all WASH 25,919,280 control (including in support WASH activities projects in 2009 CAP) health facilities) in health facilities) 25,919,280 SUBTOTAL WASH 21,931,780 3,987,500 (63% of total)

TOTAL 24,413,779 16,887,501 41,301,280

2. INTRODUCTION Zimbabwe has experienced cholera annually since 1998, but previous outbreaks have never reached the scale of the epidemic facing the country since August 2008. As of 8 January 2009, over 36,600 cases had been reported, leading to more than 1,800 deaths across the country.

There is a high risk that the outbreak could expand further. It already has a subregional dimension with cases spilling over to neighboring countries. The risks are particularly high in populations already weakened by poverty and poor nutritional status.3

The outbreaks are clearly due to the lack of safe drinking water, the inadequacy of sanitation, and the declining health care infrastructure within an already overburdened health care system. The long-term crisis in the country has resulted in shortages of treatment materials, scarcity of health care providers and overall poor access to care. In addition, the mobility of the population has been identified as a critical factor in the spread of the outbreaks. Cross-border areas are at an elevated risk of cholera outbreaks because of high population movement, commercial and trade activities. Mobile and vulnerable populations are particularly high-risk groups for disease outbreaks of this nature, since they often reside in overcrowded informal settlements characterized by inadequate water and sanitation facilities, poor access to health facilities and high population mobility.

The Zimbabwe Health and WASH Clusters have developed this operational plan in order to mount a predictable and coordinated response to this unprecedented outbreak of cholera.

The main objectives of the Health Cluster response are to control the cholera outbreak in Zimbabwe by:  Strengthening coordination of the national response;  Reducing the spread of the epidemic by:  Strengthening epidemiological and laboratory surveillance;  Ensuring access to safe water and sanitation and safe isolation and infection control practices in health care facilities;  Strengthening community mobilisation activities.

 Decreasing mortality by:  Ensuring early case detection;  Ensuring easy access to health care, including availability of oral rehydration solutions (ORS) at community/ household level;  Ensuring appropriate case management and feeding practices for cholera patients.

The main objectives of the WASH Cluster response are to prevent and control transmissions of cholera in Zimbabwe by:  Strengthening coordination of the national response;  Ensuring/providing sufficient clean, safe water as both preventive and curative measures;  Ensuring/providing sufficient and safe excreta disposal facilities as both preventive and curative measures;  Ensuring/providing adequate solid waste management as both preventive and curative measures;  Ensuring that men, women and children are mobilised and enabled to take actions to prevent/mitigate cholera outbreak risks by adhering to safe hygiene practices;  Preventing contaminations linked with sewage overflow as preventive measures.

While this operational plan focuses mainly on cholera, the framework may also be used to address other outbreaks, such as anthrax, which is suspected to affect a few districts.

3 According to the sentinel sites survey of July 2008, the prevalence of acute malnutrition is 5%. Micronutrient deficiencies such as pellagra are increasing in Matabeleland prisons and hospital. Combined case fatality rates for hospital and community treatment of severe malnutrition stand at 17.7%, well above international standards. The treatment coverage is low. Food insecurity is widespread and already in December 2008 some 5 million people were in need of food aid.

3. PLANNING ASSUMPTIONS & OPERATIONAL FIGURES In order to guide the planning process, the following assumptions were made to estimate the potential evolution of the outbreak:

 Assuming at least 50% of the population (estimated at about 12 million for the purpose of this plan) is at risk of contracting cholera, and estimating a cholera attack rate of 1% (not a conservative estimate, given the prevalence of risk factors for cholera transmission including lack of safe water supply, poor sanitation conditions and the rainy season), the estimated number of cases would be 60,000 (12,000,000 x 50% x 1%). Of course, the effectiveness of the control measures put in place will influence this estimated figure.

 In most cholera outbreaks, approximately 10-20% of symptomatic cases of cholera develop a severe form of the disease which requires vigorous rehydration. Therefore, approximately 12,000 cases would require admission for intensive treatment including antibiotics.

 In order to facilitate the initiation of response and mobilisation of adequate personnel, drugs and material resources, a consensus has been reached to standardise the holding capacity of a cholera treatment centre (CTC), and also the required personnel, kits and finances to operate a treatment centre and implement community and household activities aimed at limiting transmission (Annex 2).

 Accordingly, the agreed holding capacity of a cholera treatment centre for the purpose of this plan is 50 beds. The human resources and material and logistical requirements have been estimated based on this operational figure and are further detailed in Annex 2.

 For each CTC to be established, a cholera kit for 100 people could be used to initiate the response. Additional materials shall be made available as per the request of the responsible CTC coordinator, but kits should no longer be used to run operating cholera treatment centres and cholera treatment units.

 From the WASH perspective the above scenario implies a caseload of six million people (one million households), i.e. those at risk of contracting cholera who need to be targeted for preventive measures. WASH actions will need to be prioritised and strongly informed by health data, and will focus primarily on high-density urban and sub-urban populations where the attack rate is difficult to slow down once the disease establishes itself.

 Particular attention should be paid to cross-border areas and to mobile and vulnerable populations (MVP) as high-risk groups for disease outbreak and the spread of cholera.

 All humanitarian organisations involved in cholera response are expected to contribute to the emergency stock and subscribe to this WASH and Health cluster operational plan.

4. PLAN OF ACTION 4.1 Outbreak Detection Health: A functional early warning system should be established as soon as possible. Within that system, alerts and immediate preliminary assessments should be conducted in accordance with a specific format by Inter-Agency Rapid Assessment Teams (IARAT) made of medical doctors, engineers, microbiologists, hygiene promotion experts, and epidemiologists, supported by MoHCW which should provide timely information. A database of alerts, assessments and feedback should be developed and maintained. This would be conducted in collaboration with all Health Cluster partners and humanitarian agencies with the support of the MoHCW. IARAT will be receiving logistical and financial support.

4.2 Outbreak Confirmation Health: A mapping of the capacities of district and provincial laboratories will be conducted and alternative (external) reference laboratories identified for additional testing. The central reference laboratory will be supported, after and following the recommendations of an assessment mission. Five laboratory technologists will be identified to be on standby for rapid deployment and carry out the tests and will use sets of portable laboratory kits (n=10).

4.3 Case Management Health Cholera treatment centres / units4 (CTC/Us): materials for cholera treatment should be available within 24 hours of confirmation of outbreaks and decision to set up a CTC/U based on assessment. The number and type of personnel required to run a cholera centre (holding capacity of 50) should be mobilised within 48 hours of decision to set up a CTC/U (Annex 3). The overall organisation of treatment centres should comply with agreed standards and with full consideration to infection control procedures. At least 90% of all personnel working in CTCs should have been trained in patient management or their corresponding activities within three days of opening the centre for service. All treatment protocols and other standard operation procedures should be available and visible in various units of the CTC/U and the rational use of antibiotics for cholera patients and rigorous patient monitoring should be particularly enforced. Number of admissions (plan B and C), cure and deaths in the CTCs should be monitored and reported on a daily basis.

Regular Clinics: materials, drugs, technical guidance and supportive supervision will be provided to clinics located in the area of the outbreak. Morbidity, referral and mortality data will be collected, compiled and reported daily from the clinics or other secondary cholera treatment units. Inter-cluster monitoring of all elements of the cholera response and weekly reporting to WHO (and the inter-cluster task force on cholera) by all partners will be encouraged.

Food A major concern at the CTC/Us is the risk of cross-contamination arising from relatives of patients that are preparing food just outside the premises. The major food aid partners have been working in close consultation with the Health and WASH Cluster partners on a food support protocol to guide the requested food assistance to patients and health staff at the CTC/Us (Annex 6). The agencies are currently working out the operational details, including identification of partners operating at the CTC/Us that will be instrumental in preparing the food on site in a safe manner. The food protocol abides by the medical criteria and has mapped out geographical areas of responsibility among the food aid partners.

4.4 Reduction of Mortality Health

4 Cholera treatment centres (CTCs) are set up specifically to manage cholera cases. Cholera treatment units (CTUs) are usually smaller, separate case management units set up in hospitals to treat cholera patients.

In collaboration with district and provincial medical officers, the number, availability and experience of technical personnel for immediate deployment when needed will be documented. A training campaign to all health personnel in districts affected by the outbreak on prevention, diagnosis, treatment and control of cholera will be organized and implemented in coordination with all partners and MoHCW. To improve staff work attendance, an incentive/allowance payment schedule applicable in all contexts by all partners will be developed and implemented. Community sensitization, mobilisation and active case finding will be consolidated using a network of community volunteers. In particular, provision of ORS (10 sachets/volunteer/day) for immediate treatment of cases identified during door-to-door visits will be ensured, and referral of the most severe cases to the nearby health facility will be encouraged.

The official prevalence of HIV/AIDS is estimated to be 15.6% of the adult population in Zimbabwe (MoHCW). People Living With AIDS (PLWA) are more vulnerable to opportunistic infections, and it is expected that cholera infection rates among them would be much higher than in the general population, although this has not been scientifically proven. Particular attention needs to be paid to this group.

4.5 Organisation of the Response Health: Procedures are detailed in Annex 3. A minimum ‘start up kit’ with basic treatment and hygiene supplies will be developed to help IARAT initiate responses (see Annex 1). Similarly, national and provincial emergency stocks of medical and WASH supplies will be established to allow for a quicker response, as well as emergency reserve funds to facilitate the deployment of personnel. A standardised bed capacity, personnel, kits, supplies and logistics for a 50 bed CTC has been developed (see Annex 2), including estimated budget needs. Humanitarian agencies dedicated to support CTC/Us will be asked to comply with information management procedures, including daily reporting of activities. Information flow, feedback and dissemination mechanisms as well as inter- cluster monitoring and evaluation will also be organized and share among partners.

It has been established that the highest case fatality rate in a cholera outbreak occurs during the first three days of the outbreak. This is due to a delay in relaying information from the outbreak areas up to district, provincial and national levels. An early warning system has been set up to contact all towns and vulnerable districts on a daily basis to get updates on the situation in these areas. It is envisaged that response will be implemented within 24 hours from the start of the cholera outbreak through this Early Warning System.

Cholera Command and Control Centre (C4) in Zimbabwe: the C4 has a mandate to coordinate the support to the National Health Service of Zimbabwe and other health providers to implement activities related to the Cholera Preparedness and Response Operational Plan in order to bring the epidemic under control as soon as possible. The command centre will focus on providing technical guidance mainly in the areas of surveillance, laboratory and operational research, management of media relations, case management, WASH, social mobilisation and logistics. The C4 will provide technical recommendations to the Health, WASH and other clusters for onward implementation. The C4 will also decentralize the support to the provincial level. Clusters will work closely with the command centre. Finally, the C4 budget is reflected in the overall cholera response requirements.

WASH: Addressing the weaknesses identified will include a series of mapping so as to identify potential gaps and overlaps. For example the existing, ordered and needed stocks/supplies will be tracked while a 3W matrix (‘who does what where’) will be developed and disseminated. Contextualised and agreed cholera response (including monitoring and evaluation) guiding framework and standards will be developed by the sector. In order to improve inter-cluster partnership, collaboration and coordination, a clear sharing of roles and responsibilities between the WASH and Health Cluster will be established. Eventually advocacy efforts will be intensified for quality response delivery as well as for a clear humanitarian space.

4.6 Logistics Health: WHO will purchase all WASH-related items through UNICEF. However, medical supplies and other commodities will be purchased through the normal WHO purchasing procedures. Storage will be at the National Pharmaceutical Company of Zimbabwe (NatPharm) facility in Harare. Transportation of supplies will be provided for by WFP on a cost recovery basis following the service level agreement signed between WHO and WFP. Supplies will be transported from national level down to CTC level.

WASH: As a Cluster Lead and based on proven capacities to deal with procurement (purchase, clearance, delivery and storage), UNICEF is ready to receive funds for and procure all supplies required for the sector. Nevertheless this should not prevent individual cluster members from requesting WASH Cluster funds received if they would like to do their own procurement. Apart from the procurement, each member of the Cluster will deal with its own logistics, such as vehicles and communication, although support can be provided by the Cluster Lead where feasible.

4.7 Surveillance and Information Management Health: Humanitarian organisations involved in cholera response will be asked to provide daily updates of their activities to MoHCW and to WHO. Based on the data received, WHO will compile and analyse the epidemiological data and verify/compare with information gathered through the regular MoHCW Health Information System and humanitarian reports. It is acknowledged that improvements in the overall cholera surveillance (involving community structures making for easy contact tracing, etc) will strengthen the overall WASH and Health Cluster response in terms of strategies and priorities. WHO will provide daily statistical information to OCHA for dissemination to all other humanitarian agencies. Weekly Health Cluster meeting to discuss on situation, response, gaps and action plan will be organized. Twice weekly Inter-Cluster Task Force meeting will also be organized to update partners on the situation, mobilise resources and coordinate response. The C4 will be established. A weekly epidemiological bulletin will be produced by WHO to update all partners and OCHA on the epidemiological situation. An inventory and report on available medical stocks and supplies (national stock, provincial stock and cholera centres) will be made and updated every week. Support will be provided to the MoHCW to handle medical logistics in collaboration with WFP.

WASH: To address the current weaknesses, the cluster will recruit an information management officer who will work closely with colleagues from OCHA and the Health Cluster. With the contextualised and agreed cholera response (including monitoring and evaluation) and the guiding framework and standards, it is expected that overall reporting will improve.

4.8 Community Mobilisation and Hygiene Promotion WASH: On-going activities will improve by feeding back the lessons learnt up until now into the current response – in particular, establishing agreed guidance frameworks and standards, and inter-cluster working groups or task forces which will bring together the health authorities, members from the C4, the Health and WASH Clusters. Among the issues that will be urgently discussed are the establishment of a common working group/task force, the revision and harmonization of incentives for volunteers, and the availability of and access to enabling resources (non-food items, water points, latrines) by the households in the affected areas. Strong advocacy by donors for involvement of all individual stakeholders in the coordination mechanisms is strongly appealed for.

4.9 Water Supply WASH: The water supply authorities do not have the ability to meet the needs of at-risk and affected communities. Rehabilitating the infrastructure in a timely manner goes beyond the operational and financial capacities of most WASH Cluster members. Therefore alternative strategies will need to be sought to address safe water shortages in at-risk and affected areas. Short-term emergency

8 ZIMBABWE – CHOLERA OUTBREAKS strategies will include water trucking and mass water distribution systems. Alternatives to trucking (including drilling and rehabilitation of boreholes, support to the Zimbabwe National Water Authority [ZINWA] when feasible and cost-effective, rain water harvesting, etc.) will be actively pursued to allow an exit from expensive trucking operations. There is also a lack of containers at household level preventing proper implementation of water treatment best practices (boiling or chlorination).

4.10 Excreta Disposal WASH: To increase coverage the WASH cluster strategy will look at supporting national/local NGOs and community structures. Advocacy and donor support for inclusion of excreta disposal components in WASH projects is strongly appealed for.

4.11 Solid Waste Management WASH: In the rainy season solid waste constitutes a high risk factor for cholera. The amount of action needed in solid waste management is overwhelming and beyond the capacities and resources of almost all members of the WASH Cluster. So far only the WASH Cluster Lead has been able to get engaged at a significant level with such activities. Therefore, the strategy will be to support the city councils with resources (materials, equipment, funds), to actively mainstream waste management into hygiene promotion and NFI activities, and to support communities with clean-up campaigns.

4.12 Drainage/Sewage WASH: Contamination of alternative water sources (i.e. aside from ZINWA water supply) by the sewage system has been one of the triggers for the cholera epidemic. Similarly to the water supply system, the scale of the problem may go beyond the capacities of most individual members of the WASH Cluster. So far the strategies being explored include supporting ZINWA with sewage rods, protective clothing for staff and treating open sewage with chloride of lime. The funding gap is included under sanitation.

4.13 Disinfection/Vibrio Control WASH: Improved contact tracing will inform this activity. Coverage will be increased through support to and coordination with health authorities, involvement of community volunteers and disinfection campaigns.

4.14 Assessment and Monitoring WASH: Improvement in these activities will happen as the result of the establishment and enforcement of agreed guiding framework and standards for overall WASH cholera response. Furthermore, the WASH Cluster is discussing the need of having a joint monitoring team for the overall cholera response as a way of systematising and increasing the monitoring scope and activities within the sector.

4.15 Partners HEALTH AND WASH: Humanitarian and development agencies will mobilise funds committed to emergency interventions, while the C4 will establish reserve funds to fill gaps for operational support. It is expected that humanitarian organisations will make an inventory of available human resource and logistic capacity that may be mobilised for emergency response, and notify the Health and WASH Cluster Leads and the IASC of their capacity and geographical coverage in order to enable mapping of capacities and appointment of provincial and district focal points. Humanitarian and development organisations

working in the Health and WASH Clusters commit to participate in assessment, investigation of outbreaks, and initiation of response, monitoring and evaluation anywhere in the country.

5. LIST OF PROJECTS COMPRISING THIS PLAN

Table I: Cholera Response Projects in Consolidated Appeal for Zimbabwe 2009 List of Projects (grouped by cluster), with funding status of each as of 9 January 2009 http://www.reliefweb.int/fts

Compiled by OCHA on the basis of information provided by donors and appealing organisations. Page 1 of 2

Project Code: Appealing Original Revised Funding % Unmet Uncommitted Project Title Organisation Requirements Requirements Covered Requirements Pledges

Values in US$

HEALTH

ZIM-09/H/20937/122: Strengthen response and management of cholera, other diarrhoeal WHO 929,999 11,234,000 - 0% 11,234,000 357,654 disease and emerging infectious diseases

ZIM-09/H/21864/122: Health Cluster Coordination, disease surveillance and health WHO 1,552,000 4,148,000 - 0% 4,148,000 - information management in the Health Sector

Subtotal for HEALTH 2,481,999 15,382,000 - 0% 15,382,000 357,654

The list of projects and the figures for their funding requirements in this document are a snapshot as of 9 January 2009. For continuously updated information on projects, funding requirements, and contributions to date, visit the Financial Tracking Service (www.reliefweb.int/fts). Table I. List of Projects (grouped by cluster), with funding status of each

Table I: Cholera Response Projects in Consolidated Appeal for Zimbabwe 2009 List of Projects (grouped by cluster), with funding status of each as of 9 January 2009 http://www.reliefweb.int/fts

Compiled by OCHA on the basis of information provided by donors and appealing organisations. Page 2 of 2

Project Code: Appealing Original Revised Funding % Unmet Uncommitted Project Title Organisation Requirements Requirements Covered Requirements Pledges

Values in US$

WATER AND SANITATION

ZIM-09/WS/20548/124: Emergency safe water supply, sanitation facilities and hygiene UNICEF 9,000,000 9,000,000 - 0% 9,000,000 - promotion to affected vulnerable populations in urban and rural areas of Zimbabwe.

ZIM-09/WS/20868/124: PREPARDENESS, MITIGATION AND RESPONSE TO WASH UNICEF 4,000,000 4,000,000 - 0% 4,000,000 - RELATED EPIDEMICS IN ZIMBABWE (DISASTER RISK REDUCTION)

ZIM-09/WS/20868/5120: PREPARDENESS, MITIGATION AND RESPONSE TO WASH OXFAM GB 5,250,000 5,250,000 - 0% 5,250,000 - RELATED EPIDEMICS IN ZIMBABWE (DISASTER RISK REDUCTION)

ZIM-09/WS/20868/5186: PREPARDENESS, MITIGATION AND RESPONSE TO WASH ACF 762,000 762,000 - 0% 762,000 - RELATED EPIDEMICS IN ZIMBABWE (DISASTER RISK REDUCTION)

ZIM-09/WS/21193/8502: Bulawayo Emergency Water and Sanitation Project WVI 1,000,000 1,000,000 - 0% 1,000,000 -

ZIM-09/WS/21268/5162: Prevention and treatment of water-borne diseases in Buhera, Mercy Corps 350,000 350,000 - 0% 350,000 - Chipinge and Chiredzi Districts

ZIM-09/WS/21682/6708: Provision of safe water and sanitation facilities and promotion of PA (formerly 470,000 470,000 - 0% 470,000 - hygiene education in the vulnerable Peri Urban areas of Harare and ITDG) Kadoma

ZIM-09/WS/21685/8818: Hygiene & Rural Water Supply Rehabilitation Programme DT 250,000 250,000 - 0% 250,000 -

ZIM-09/WS/21694/7975: Reducing the incidence of severe diarrhoea, and cholera in Linkage Trust 255,000 255,000 - 0% 255,000 - vulnerable rural families.

ZIM-09/WS/21708/6310: Hygiene Promotion and Home-Based Water Treatment for diarrhoea PSI 594,780 594,780 - 0% 594,780 - epidemic prevention and emergency response in Zimbabwe.

ZIM-09/WS/23888/122: Water, Sanitation, Hygiene and Infection Control in Health Facilities WHO - 3,987,500 - 0% 3,987,500 -

Subtotal for WATER AND SANITATION 21,931,780 25,919,280 - 0% 25,919,280 -

Grand Total 24,413,779 41,301,280 - -% 41,301,280 357,654

NOTE: "Funding" means Contributions + Commitments + Carry-over

Pledge: a non-binding announcement of an intended contribution or allocation by the donor. ("Uncommitted pledge" on these tables indicates the balance of original pledges not yet committed).

Commitment: creation of a legal, contractual obligation between the donor and recipient entity, specifying the amount to be contributed.

Contribution: the actual payment of funds or transfer of in-kind goods from the donor to the recipient entity.

The list of projects and the figures for their funding requirements in this document are a snapshot as of 9 January 2009. For continuously updated information on projects, funding requirements, and contributions to date, visit the Financial Tracking Service (www.reliefweb.int/fts).

Table II. List of Projects (grouped by Appealing Organisation), with funding status of each

Table II: Cholera ResponseTable II: Consolidated Projects in Appeal Consolidated for Zimbabwe Appeal 2009 for Zimbabwe 2009

List of Projects (grouped by Appealing Organisation), with funding status of each as of 9 January 2009

http://www.reliefweb.int/fts

Appealing Project code Sector Project title Original Revised Funding % Unmet Uncommitted Organisation Requirements Requirements Covered Requirements Pledges USD USD USD USD USD

ACF ZIM-09/WS/20868/5186 WATER AND Prepardeness, mitigation and response to WASH 762,000 762,000 - 0% 762,000 - SANITATION related epidemics in Zimbabwe (disaster risk reduction)

DT ZIM-09/WS/21685/8818 WATER AND Hygiene & Rural Water Supply Rehabilitation 250,000 250,000 - 0% 250,000 - SANITATION Programme

Linkage Trust ZIM-09/WS/21694/7975 WATER AND Reducing the incidence of severe diarrhoea, and 255,000 255,000 - 0% 255,000 - SANITATION cholera in vulnerable rural families.

Mercy Corps ZIM-09/WS/21268/5162 WATER AND Prevention and treatment of water-borne diseases 350,000 350,000 - 0% 350,000 - SANITATION in Buhera, Chipinge and Chiredzi Districts

OXFAM GB ZIM-09/WS/20868/5120 WATER AND Prepardeness, mitigation and response to WASH 5,250,000 5,250,000 - 0% 5,250,000 - SANITATION related epidemics in Zimbabwe (disaster risk reduction)

PA (formerly ITDG) ZIM-09/WS/21682/6708 WATER AND Provision of safe water and sanitation facilities and 470,000 470,000 - 0% 470,000 - SANITATION promotion of hygiene education in the vulnerable Peri Urban areas of Harare and Kadoma

PSI ZIM-09/WS/21708/6310 WATER AND Hygiene Promotion and Home-Based Water 594,780 594,780 - 0% 594,780 - SANITATION Treatment for diarrhoea epidemic prevention and emergency response in Zimbabwe.

WVI ZIM-09/WS/21193/8502 WATER AND Bulawayo Emergency Water and Sanitation Project 1,000,000 1,000,000 - 0% 1,000,000 - SANITATION

Subtotal for NGOs 8,931,780 8,931,780 - 0% 8,931,780 -

UNICEF

UNICEF ZIM-09/WS/20548/124 WATER AND Emergency safe water supply, sanitation facilities 9,000,000 9,000,000 - 0% 9,000,000 - SANITATION and hygiene promotion to affected vulnerable populations in urban and rural areas of Zimbabwe.

UNICEF ZIM-09/WS/20868/124 WATER AND Prepardeness, mitigation and response to WASH 4,000,000 4,000,000 - 0% 4,000,000 - SANITATION related epidemics in Zimbabwe (disaster risk reduction)

Subtotal for UNICEF 13,000,000 13,000,000 - 0% 13,000,000 -

WHO ZIM-09/H/20937/122 HEALTH Strengthen response and management of cholera, 929,999 11,234,000 - 0% 11,234,000 357,654 other diarrhoeal disease and emerging infectious diseases

WHO ZIM-09/H/21864/122 HEALTH Health Cluster Coordination, disease surveillance 1,552,000 4,148,000 - 0% 4,148,000 - and health information management in the Health Sector WHO ZIM-09/WS/23888/122 WATER AND Water, Sanitation, Hygiene and Infection Control in - 3,987,500 - 0% 3,987,500 - SANITATION Health Facilities

Subtotal for WHO 2,481,999 19,369,500 - 0% 19,369,500 357,654

Grand Total 24,413,779 41,301,280 - 0% 41,301,280 357,654

ANNEX 1: DRUGS AND SUPPLIES REQUIRED TO INITIATE A RESPONSE (Based on the estimated minimum supplies needed to treat 100 patients during a cholera outbreak - WHO, 1994)

Rehydration supplies 650 packets ORS (for 1 litre each) 120 bags Ringer's lactate solution, 1 litre, with giving sets 10 scalp-vein sets 3 nasogastric tubes, 5.3 mm OD, 3.5 ID, (16 French), 50 cm long for adults 3 nasogastric tubes, 2.7 mm OD, 1.5 ID, (8 French), 38 cm long for children

Antibiotics For adults: Cyproflaxacin 500 mg

For Pregnant women and children under 12 years: 400 tablets Erythromycin, 500 mg (1 tablet four times daily for five days for adults) and children @ 6.25-12.5mg/kg

Other treatment supplies 2 large water dispensers with tap (marked at 5- and 10-litre levels) for making ORS solution in bulk 20 bottles (1 litre) for ORS solution (e.g. empty IV bottles) 20 bottles (0.5 litres) for ORS solution 40 tumblers, 200 ml 20 teaspoons 5 kg cotton wool 2 reels adhesive tape

Other remarks  The amount of supplies listed allows enough intravenous fluid followed by ORS for 20 severely dehydrated patients, and the exclusive use of ORS for the other 80 patients.  If Ringer's lactate solution is not available, substitute normal saline.

ANNEX 2: OPERATIONAL STANDARD FOR A CHOLERA TREATMENT CENTRE Capacity = 50 patients

Cholera Treatment Centre Community interventions Transport & logistics

1) CTC Coordinator = 1 1) Environmental health 1) Vehicles (2) technicians=2 2) Doctors = 2 (1 per 12 hour shift) 2) Active Case Finding 2) 4X4 Pick Up Team=10 3) Nurses = 30 (10 per 8 hour shift) 3) Hygiene Promoters = 10 3) Motor Cycle (2)

4) Support staff (at a ratio of 1 to 3 4) (1hygiene promoter per 50 4) Fuel as per nurses) =10 households) estimated travel distance and 5) Record keeping = 3 (one per 8 (Note: The number can be consumption hour shift) increased depending of the area 6) Environmental Health and size of community to be 5) (Start up Technicians = 3 (one per 12 hour reached) volume=500 liters) shift) 6) For food supplies- 7) Logisticians=2 see annex 7 8) Data entry personnel=2 9) Miscellaneous support staff=12 (3 per 8 hour shift)

Total: 67 Total: 27

ANNEX 3: COORDINATION OF OUTBREAK INVESTIGATION, RESPONSE, MONITORING AND EVALUATION

1) Alerts, assessment, initial response and outbreak investigation

2) Organisation of the response

3) Surveillance and information management

ANNEX 4: CHOLERA RESPONSE GROUP – CONTACT LIST

1. Alerts, assessment and response (medical logistics): 1.1 Mr Alex Chimbaru , [email protected], 0912241591 1.2 Mr Stephen Maphosa, maphosas@zw,afro.who.int, 0912279259

2. Case management and surveillance: 2.1 Dr Lincoln Charimari, [email protected], 011406427 2.2 Dr Thomas Aisu, [email protected] , 0912490712 2.3 Dr Stanley Midzi, Director , Epidemiology & Disease Control, MoHCW

3. Data and information management: 3.1 Mr Donald Shambare, [email protected] 3.2 Mr Regis Katsande, [email protected], 011865559 3.3 Mr Chakauya Jethro, [email protected], 0912765828

4. Health Promotion (Information, Education and Communication) 4.1 Ms Dorothy Mtemeli; [email protected] 4.2 Ms Wendy Julias; [email protected]

5. Overall team support and coordination 5.1 Dr Yilma R. Gari, [email protected], 0912546430

6. WHO Country Representative and Team Leader 6.1 Dr Custodia Mandlhate, [email protected]

7. UNICEF Country Representative a.i. / WASH Cluster Lead 7.1 Mr Roeland Monasch, [email protected], 0912266172

8. WASH Cluster Lead Coordinator - UNICEF 8.1 Mr Souleymane Sow, [email protected]

9. WASH Cluster Co-Lead Coordinator - OXFAM 9.1 Ms Penninah Mathenge, [email protected], 0912437566

10. OCHA Head of Office / Inter-Cluster Coordination 10.1 Dr Georges Tadonki, [email protected], +263 11 617 734 / +27 82 908 1324

11. Cholera Control Command Centre 11.1 E:mail [email protected]; International: +47 241 38234; Local: 0808 9000 or 04 253 724 -30

ANNEX 5: RESPONSIBILITIES AND ACCOUNTABILITIES MATRIX This matrix defines the responsibilities and accountabilities of the Health and WASH Clusters during the response to cholera in Zimbabwe in areas of potential overlap. The below matrix is an adaptation of a matrix developed by the Global WASH Cluster with a broad consultation of the Health and Nutrition Clusters. The adaptation of the matrix was jointly done by both clusters during the Health – WASH Cluster meeting in Harare on 24 December 2008. The below matrix will be used with flexibility and revised as needed.

Objectives  Clarify responsibilities and accountabilities among the two clusters, especially as they relate to the prevention and control of cholera.  Improve coordination and collaboration among Health and WASH Cluster partner field staff during emergency operations.

Please note that:  Responsibility means ensuring that the job gets done, not necessarily doing it.

AREA OF RESPONSIBILITY SPECIFIC POTENTIAL ACTIVITY HEALTH CLUSTER WASH CLUSTER OVERLAP Assessment Conduct WASH In health facilities Outside health facilities assessments Monitoring Monitor and share Disease status and WASH WASH indicators (more WASH related indicators in health facilities perception based) outside information with other health facilities clusters WASH Develop and monitor IM Gather, analyze and Gather WASH information Information system disseminate evidence based and share with other clusters. Management health information (health (IM) facilities). Share with other clusters WASH Disseminate, promote In health facilities Outside health facilities Standards and monitor application Agree indicators Provide input Responsible for coordinating agreement Water Quality Identify country testing Fully responsible & Quantity capacity and facilities Ensures testing capacity In health facilities: WASH to Outside health facilities – in support upon request collaboration with national authorities. Provide support to Health Cluster as requested. Testing In health facilities: WASH to Outside health facilities - in support upon request collaboration with national authorities (includes source, storage & distribution) Provide training to other clusters as requested Monitoring In health facilities: WASH to Outside health facilities – in support on request collaboration with national authorities Provide quantity Fully responsible Water facilities Improve access Fully responsible Water Procurement of Responsible for health For other areas Treatment chemicals facilities: WASH to support on request Design systems Fully responsible Hygiene Promote and improve In health facilities To coordinate common hygiene messages between clusters; and to conduct health promotion outside health facilities Excreta Improve access In health facilities: with Outside health facilities disposal support from WASH on request

AREA OF RESPONSIBILITY SPECIFIC POTENTIAL ACTIVITY HEALTH CLUSTER WASH CLUSTER OVERLAP Improving Improve environment In health facilities: with Outside health facilities Sanitary support from WASH on Environment request Disease Assessment, Fully responsible for overall Participate in assessment and Outbreak Surveillance and coordination (with input from Support as requested monitoring (& contact other clusters) tracing), Outbreak control, Communication Waste Maintain, construct and In health facilities Outside health facilities Management renovate Provide support to Health Clusters as requested WASH Prioritise facilities for Fully Responsible Infrastructure renovation and construction. Implement projects WASH-related Procure and share Material used in health Population based material Stockpiles information about facilities. WASH cluster (Bed nets, water treatment stockpiles between support supports as required chemicals (e.g. chlorine), clusters. water testing equipment, soap) Disinfection Disinfection of Responsible; with support household, health from WASH as requested facilities

ANNEX 6: PROTOCOL ON FOOD SUPPORT TO CTCs Within the context of the cholera outbreak and the setting up of cholera treatment centres or units (CTC/CTU), the food aid working group lead, as a cross-contamination mitigation strategy, is looking into the provision of food to CTC's for on site-preparation for staff on shift and to patients recuperated before discharge (and possibly care-takers).

C-SAFE and WFP, as the two main food pipelines in country, agree for the need to come up with a commonly agreed upon model for food assistance to CTC/CTU.

Proposed model for food assistance protocol to CTC/CTU  objective of the food assistance is to reduce the vectors for cross-contamination  modality is hence on-site food preparation only for on-site feeding  ratio to be used for food assistance is one patient to one “other” (all inclusive of staff, care- takers, on-site cooks) across the board  threshold for planning a food support to a CTC/CTU is set at 10 patients per month in rural settings and 50 per month in urban  dispatch plan for a daily average of (patients + 1) for a month to a given CTU/CTC: patients’ average stay varies from 4 (urban) to 7 days (rural), hence feeding days from 3-6. Some 70% of patients present eat on average on any given day, but 100% of “other” category making up for the longer stays  rations to be used (grams/person/day) may vary depending on available basket, as per below – averaging a minimum of 1,900 kcal per person per day:

Ration A Ration B 400 gr CER (mml, mz or wheat) 400 gr CSB 100 gr PUL 60 gr PUL 20 gr VOIL 20 gr VOIL

Related issues  the specific identification of the food operator suitable for food preparation on site in any CTC/U may be problematic – particular attention needs to be given to adherence to minimum hygiene and sanitation standards;  safe water supply needs for food preparation should be considered: the WASH Cluster has confirmed on the Inter-Cluster Task Force meeting of 9 December that these are considered into their protocol for safe water provision to CTC/Us (as per Sphere standards);  basic kitchen and cooking utensils also need to be considered: WHO has confirmed in on the Inter-Cluster meeting of 9 December that such equipment will be added into the “cholera kit”

ANNEX 7: FUEL REQUIREMENTS FOR CHOLERA-AFFECTED DISTRICTS

# Affected Amount per District Total per Province Province Districts Diesel Petrol Diesel Petrol Mashonaland East 8 2000 1000 16000 8000 Mashonaland West 6 2000 1000 12000 6000 Mashonaland Central 8 2000 1000 16000 8000 Midlands 5 2000 1000 10000 5000 Masvingo 7 2000 1000 14000 7000 Manicaland 6 2000 1000 12000 6000 Matabeland South 3 2000 1000 6000 3000 Chitungwiza Urban 1 2000 1000 2000 1000 Harare Urban 2 1000 1000 2000 2000 Kadoma Urban 1 1000 1000 1000 1000 Kwekwe Urban 1 1000 500 1000 500 Gweru Urban 1 1000 500 1000 500 Chegutu Urban 1 1000 500 1000 500 Mutare Urban 1 1000 500 1000 500 TOTAL 95000 49000

NB: The calculation is based on an average of three vehicles per district using an average of 160L per week for 4 weeks

ANNEX 8: NATIONAL CHOLERA REQUIREMENTS AND GAPS MATRIX Quantity Total Item # CTCs Available Gap per CTC required *Erythromycin tablets (250mg x1000 tin) 150 1 180 150 -30 *Ertythromycin syrup (125mg x100ml bottle) 150 150 82 22500 22418 *Ciprofloxacillin tablets (250mg x 1000 tin) 150 12 18 1800 1782 10 men tents with sides 150 5 0 750 750 20 men tents with sides 150 2 0 300 300 4 men tents with sides 150 4 0 600 600 Ground sheets polythene rolls 150 4 0 600 600 20-25 litre water containers with tap 150 7 0 1050 1050 20-25 litre water containers without taps 150 7 0 1050 1050 100 litre bins with taps 150 2 0 300 300 100 litre bins without taps 150 5 0 750 750 *Chloride of lime 25 kgs 150 15 0 2250 2250 *HTH 1 kgs bottles 150 8 0 1200 1200 *Sodium hypochlorite 25 litres 150 8 0 1200 1200 *Aquatabs boxes 14000 tablets 150 10 0 1500 1500 20-25 litre buckets (for cholera beds) 150 40 0 6000 6000 Cholera beds 150 40 0 6000 6000 Spray pumps 10-15 litres(Hudson) 150 10 0 1500 1500 Plastic Aprons heavy duty 150 100 15000 15000 Work suits S 150 50 0 7500 7500 Work suits M 150 50 0 7500 7500 Work suits L 150 50 0 7500 7500 6mm twine camp demarcation (100m rolls) 150 4 0 600 600 Bactericidal liquid soap boxes ( 20 litres) 150 4 0 600 600 Pots 10 litres 150 20 0 3000 3000 Pots 20 litres 150 20 0 3000 3000 Plates 150 50 0 7500 7500 Pans 150 50 0 7500 7500 Dishing Spoons 150 50 0 7500 7500 Tea spoons 150 50 0 7500 7500 Gumbboots 150 100 0 15000 15000 Heavy duty gas stoves 150 10 0 1500 1500 19 kgs gas cylinders 150 10 0 1500 1500 *Batteries 150 150 0 22500 22500 Fuel 0 Diesel 80 3000 189000 189000 Petrol 80 2000 126000 126000 Laboratory Reagents and materials Cholera antisera Districts 0 Polyvalent – 01 2mls/vial 62 2 124 124 Serotype Inaba 2 mls/vial 62 1 62 62 Serotype Ogawa 2mls/vial 62 1 62 62 Serogroup -0139 2mls/vial 62 2 124 124

Media 0 0 TCBS 500g 62 1 62 62 Muller Hinton 500g 62 3 186 186 Kliger Iron Agar 500g 62 1 62 62 Heart Infusion 500g 62 1 62 62 MaConkey Agar 500g 62 2 124 124 XLD Agar 500g 62 2 124 124 Cary Blair 500g 62 1 62 62 Peptone Water 500g 62 1 62 62 Sodium Chloride 500g 62 1 62 62 Rapid API 20E Kit 50 strips 62 0 0

Reagents 0 0 Oxidase Vial 62 5 310 310 0.5% Sodium Deoxycholate 500g 62 1 62 62 Mcfaland Turbidity Standard Vial 62 2 124 124 Sodium Hypochloride 5L 62 2 124 124

Quantity Total Item # CTCs Available Gap per CTC required Other Materials 0 0 Petri dishes 62 2 124 124 Swabs 62 2 124 124 Slides 62 2 124 124 Cotton Wool 62 50 3100 3100 Soap 62 100 6200 6200 Liquid Soap L 62 10 620 620 Cooler Box 62 3 186 186 Stool Containers 62 1000 62000 62000 QC organisms 62 1 62 62 Gloves 62 100 6200 6200 Lab Coats/Gowns 62 10 620 620 Disposable Aprons 62 100 6200 6200 Sensitivity Disc 62 0 0 Cotrimoxazole 62 2 124 124 Tetracycline 62 2 124 124 Chloramphenicol 62 2 124 124 Ciprofloxacin 62 2 124 124 Furazolidone 62 2 124 124 Nalidixic acid 62 2 124 124

ANNEX 9: INTERNATIONAL FEDERATION OF RED CROSS AND RES CRESCENT SOCIETIES

Emergency appeal n° MDRZW004 Zimbabwe: Cholera GLIDE n° EP-2008-000218-ZWE

This Emergency Appeal seeks 10,170,233 (USD 9.2m or EUR 6.6m) in cash, kind, or services to support the Zimbabwe Red Cross Society (ZRCS) to assist 1.5 million beneficiaries. This seven-month operation will be completed by end-July 2009.

A total of CHF 403,302 (USD 359,372 or EUR 269,456) was allocated from the Federation’s Disaster Relief Emergency Fund (DREF) to support this operation.  CHF 203,302 (USD 177,556 or EUR 139,248) allocated on 11 November, 2008. Mr. Zuze works for the Ministry of Environment and Health in Kadoma.  CHF 200,000 (USD Normally he is responsible for running the home-based visit to prevent 181,818 or EUR 130,208) allocated on 12 December, epidemics such as malaria and cholera, including clearing ponds to avoid 2008. mosquito breeding. Since the establishment of a CTC in mid-November, Zuze and his team have been helping with clearing the surrounding Summary: This Emergency environment and off-loading equipment for the CTCs. “Cholera is not new Appeal responds to a request to us, but this year, lack of nurses and medicines in the hospital caused from the Zimbabwe Red Cross the spread of the disease. In the past, cholera is something we could put Society (ZRCS) to respond to a down within the hospital. The Red Cross brought the big change. quickly evolving cholera crisis Patients are now sleeping on beds. The assistance from Japanese Red in the country, and focuses on Cross is excellent” said Zuze supporting the National Society to deliver appropriate and timely action in providing assistance and relief in the water and sanitation (WatSan), health, and hygiene promotion sectors. A vital component of the operation are the Federation’s Emergency Response Units (ERUs) as follows: three Basic Health Care (BHC) ERUs from the Finnish, Japanese and Norwegian Red Cross, two Mass Sanitation ERUs from the British and Spanish Red Cross, and two Water Supply ERUs from the German/Austrian and French Red Cross.

COORDINATION AND PARTNERSHIPS

Coordination mechanisms currently exist to varying degrees in each of the provinces, with the MoHCW, the provincial Civil Protection Units, the cluster system, UN agencies and other non- governmental organizations. Coordination is crucial for this intervention and the ZRCS’s presence in all provinces and districts will ensure that the Red Cross is represented and participates in all coordinating forums. On the national level, coordination will continue with the MoHCW, the UN and other key partners. This will ensure cooperation and coordination and avoid duplication of activities with other actors on the ground.

The Federation’s Country Representative Office in Zimbabwe is coordinating activities with the Zone Office, Geneva Secretariat, Partner National Societies and the ICRC. The Federation’s Country Office will continue to support the ZRCS in the implementation of this operation with a view to strengthening the capacity of the National Society to face future emergencies, especially in health related emergencies. The Federation’s Southern Africa Zone Office (SAZO) will continue to support the operation by making support and specialist available as needed in the areas of disaster management, health and care, water and sanitation, logistics, finance, reporting, monitoring and evaluation.

RED CROSS AND RED CRESCENT ACTION The International Federation’s Disaster Relief Emergency Fund (DREF) has provided vital support to this operation, with CHF 203,302 to assist with the initial cholera response targeting 20,000 households (100,000 people) in the form of providing materials from existing disaster stocks including cholera kits, household water treatment chemicals, sanitary platforms (SanPlats), soap, jerry cans and blankets. A second DREF of CHF 200,000 was released on 12 December to scale-up the operation. From 11 to 25 November 2008, the ZRCS reached over 11,000 people with health and hygiene awareness messages in seven provinces. The ZRCS produced 40,000 cholera information pamphlets in English and Shona (vernaculars), which are being distributed alerting vulnerable communities to the risk of cholera and the precaution they need to take to prevent infection as well as the treatment required. The ZRCS also distribute 500,000 sachets of water purification chemicals, two cholera kits, and the following support in the provinces and districts:  Mashonaland Central (covering Budiriro, Chitungwiza and Shamva districts) – the ZRCS distributed two cholera kits for 300 patients each, 60,000 water purification sachets to purify a total of 1.2 million litres of water, 500 bars of soap (0.5 kg), 500 jerry cans (20 Litres), 500 bottles of household bleach.  In Midlands (covering Gweru, Mberengwa, Zvishavane, Shurugwi districts) - the National Society seconded volunteers to the cholera treatment centres (CTCs) managed by the MoHCW and provided 500 pairs of latex gloves, 200 disposable masks, 500 water purification sachets (enough to treat 10,000 litres), ten (20 litre) jerry cans, 20 buckets and 680 IEC materials.  In Matebeleland South covering Beitbridge and Gwanda district – the National Society is conducting health and hygiene promotion, home disinfection particularly where cholera related deaths were reported, distribution of IEC materials and has supplied 1,000 latex gloves, and bottles of bleach to the CTCs.  In Masvingo, Manicaland, and Mashonaland West Provinces – the ZRCS is conducting health and hygiene promotion using house to house visits, distribution information, education and communication (IEC) materials and spreading messages in community gatherings and funerals.

With the support of the DREF, ZRCS conducted a rapid assessment in two of the most affected provinces (Mashonaland Central and Mashonaland East). Major gaps were identified in curative health, social mobilisation, prevention, clean water supply and sanitation facilities, to which high morbidity and mortality rates are attributed to. The results of the assessment tallied the gaps identified by the MoHCW and the health cluster.

In order to cover the identified gaps, Emergency Response Units (ERUs) were deployed in areas allocated by the MoHCW and CPU. The ERU assets include three Basic Health Care (BHC) ERUs from the Finnish, Japanese and Norwegian Red Cross, operating as Cholera Treatment Centres and acting as hubs for volunteer activities; two Mass Sanitation ERUs from the British and Spanish Red Cross facilitating sanitation and hygiene promotion activities and two Water Supply ERUs from the German/Austrian and French Red Cross providing clean water for up to 55,000 people. The Canadian and Australian Red Cross are also contributing with staff to support the ERU deployment. The ERUs are working in close coordination with the local ZRCS branches and the communities they serve, and have been deployed in-country as follows:

Location ERU

Harare German/Austrian Water and Sanitation Manicaland Finnish, German/Austrian Basic Health Care and Mass Sanitation Mashonaland West Japanese and Spanish Basis Health Care and Mass Sanitation Midlands British, Norwegian Basic Health Care and Mass Sanitation Midlands Germany/Austrian Water and Sanitation THE NEEDS The joint Federation / ZRCS assessment confirmed the gaps identified by the MoHCW and the UN health cluster, and identified the following immediate needs:

Immediate needs:  Improving case management and strengthening disease surveillance and monitoring;  Ensuring coordination among health partners;  Increasing the availability of oral rehydration solution at community level;  Intensifying social mobilization and community awareness ahead of the holiday period and the possible increase in population movements.

Longer-term needs:  Provision of safe drinking water and sanitation facilities for at least 46 percent (six million people) of the population across the country in both rural and urban areas;  Sustained community health and hygiene promotion;  Training of volunteers in cholera prevention, mitigation and infection control.

THE PROPOSED OPERATION The ZRCS cholera operation will focus on a comprehensive approach to cholera epidemic management including surveillance and active case finding, provision of ORS and cholera kits at the community level, case management, health and hygiene promotion, safe water supply, and sanitation facilities.

Volunteers will be a major force in achieving the needed link between health facilities and the community. By implementing a strong community outreach component into the operation, Red Cross volunteers will provide individuals and communities with the capacity to address the current epidemic and enhance resilience to face future outbreaks. This will happen by enabling volunteers to conduct active surveillance, find and refer cases, disseminate health and hygiene messages, distribute water treatment chemicals and hygiene items and provide ORS within communities. ZRCS will intensify volunteer training in order to empower them for active participation throughout the operation. The National Society will also make use of the IFRC disaster management tools and facilities in enhancing the capacity of volunteers.

To achieve the above, Emergency Response Units (ERUs) have been deployed by the Federation and Partner National Societies. The initial areas of deployment have been agreed with the Ministry of Health and the Civil Protection Unit. They are working in close coordination with ZRCS branches and the communities that they serve. The ERU assets include three Basic Health Care (BHC) ERUs from the Finnish, Japanese and Norwegian Red Cross, operating as Cholera Treatment Centres and acting as hubs for volunteer activities; two Mass Sanitation ERUs from the British and Spanish Red Cross facilitating sanitation and hygiene promotion activities and two Water Supply ERUs from the German/Austrian and French Red Cross providing clean water for up to 55,000 people. The Canadian and Australian Red Cross are also contributing with staff to support the ERU deployment.

Water supply Objective: To improve access to safe and adequate water in four provinces reaching at least 280,000 people by the end of the appeal timeframe. Activities planned:  Provision of clean drinking water for 55,000 affected people to Expected result: Access supply CTCs and local communities through two water and to safe water is improved sanitation ERUs (M40 and M15). for 280,000 households  Distribution of 1 million water purification sachets and promotion of through treatment of correct use to 100,000 people. household and community  Distribution of 40,000 jerry cans and buckets for storage and level water supplies. transport of water at household’s level (Jan – Feb 2009).  Rehabilitation of 200 water points in 4 provinces to benefit 100,000 persons (February – April 2009).  Facilitate water treatment for CTCs and health centres which are

near water source or untreated municipal water supply pipeline.  Drilling of 50 boreholes, equipped with hand pumps or pressure hand pumps to serve the needs of 25,000 people.  Support local municipalities with water pumps spare parts and diesel/petrol.

Progress: The German/Austrian ERU conducted rapid assessments in Gweru of Midlands Province and in Harare. With the findings, the German/Austrian ERU has deployed M40 equipment to support the Zimbabwe National Water Authorities (ZINWA) at the city water reticulation centre 20 km outside of town. The water treatment facility has not been working due to broken pumps, lack of chemicals for flocculation and dysfunctional sand filtration. The ERU team will provide tanks for chlorination and enhancing storage capacity. The British Red Cross mass sanitation ERU is also operating in Gweru supporting the Norwegian Red Cross BHC.

The Japanese Red Cross BHC and Spanish Red Cross and Mass Sanitation ERU conducted a joint rapid assessment in Karoi and Chirundu in Mashonaland West Province. Basic health and sanitation equipment have been stationed in Karoi to support the CTCs and hospitals. The French Red Cross WatSan ERU has handed over two bladders and tap stands to complement Spanish Red Cross Mass Sanitation ERU in response to the water needs at Karoi Hospital. However, the bladder tanks will be used at the CTCs since UNICEF has already delivered bladder/tanks at the hospital.

Another assessment was conducted in Kadoma (Chidamoyo district) during which were identified are the needs for sanitation activities, upgrade of the water supply system at CTCs and hygiene promotion; activities will be carried out by Spanish Red Cross ERU team. The French Red Cross WatSan ERU will complement the efforts by providing some bladder tanks and tap stands. In addition, British and Finnish ERU conducted assessments in Mutare, Manicaland Province and plans to establish a service centre are underway. French Red Cross ERU made four assessment trips to Mutare, Gweru district, Musengezi (Chegutu), Karoi and Chirundu (with Japanese RC). The team has yet to identify an appropriate location for its water treatment units.

Sanitation and hygiene promotion Objective: Improved hygiene awareness and sanitation for 1,500,000 people (300,000 households) in 8 cholera affected provinces, and increased access to latrines in health centres and schools. Activities planned:  Provision of hygiene promotion activities to Expected result: 1,500,000 people through training and activating  Appropriate sanitation, including volunteers at the community level. excreta disposal, solid waste  Distribution of hygiene kits to 20,000 vulnerable disposal and drainage, is households in cholera affected areas. Hygiene kits provided to affected households are designed for this operation and include soap over the next seven months. and other items.  Disease transmission is reduced  Provision of Sanitation facilities, excreta and solid through raised awareness of waste disposal for CTCs and communities. These communities and improved activities will be supported by the two Mass hygiene behaviour. Sanitation ERU’s which can reach 20,000 people  The scope and quality of the each. Zimbabwe Red Cross Society  Training of staff and volunteers on cholera water, sanitation and hygiene response, reporting, and household water promotion services are improved. purification  Production and distribution of IEC materials in local languages.

Progress: British Red Cross Mass sanitation ERU and Norwegian Red Cross BHC ERU have been deployed in Midlands province and their equipment and teams are focused on hygiene promotion and sanitation. In Manicaland Province, Finnish Red Cross BHC is supported by a German Red Cross ERU team (Canadian and Austrian team members) who have conducted a joint assessment focusing on sanitation and hygiene promotion needs in medical institutions, CTC and in rural areas.

Spanish Red Cross Sanitation ERU is covering Mashonaland West province, providing support to the

Japanese BHC ERU. The operation base is in Karoi, which is close to various CTCs with strong Red Cross branch and active volunteers, of which the majority are trained in community mobilization. Further assessments will be carried out in other parts of the province to establish the needs and possible support to the CTCs. The planned hygiene promotion campaign at community level is at an advanced stage while training of volunteers in underway. Spanish Red Cross ERU also has plans to distribute hygiene kits tailormade for this operation to cover 20,000 families throughout the country.

Health and care Objective: To reduce cholera-related morbidity and mortality through a comprehensive health approach including surveillance, case finding, health promotion, ORS distribution and case management and to improve Zimbabwe Red Cross capacity and the resilience of communities. Activities planned:  Provision of 40 volunteer modules of the cholera kits, Expected result: to support with community based activities at cholera  Health services are supported treatment centres and in the community under the to meet the health needs of the Ministry of Health and Child Welfare. population.  Mitigate the effects of cholera by developing the  The resilience of the capacity of eight provincial Red Cross Offices in active community is improved through case finding correct preparation, use and distribution better health awareness, of Oral Rehydration Solution (ORS) and in knowledge and behaviour. surveillance.  Training of volunteers in target branches in Community Based Health and First Aid (CBHFA) and on Epidemic Control for Volunteers training package.  Orientation of 800 volunteers and staff on the correct use and preparation of ORS.  Orientation and reorientation of 30 staff members directly responsible for project implementation.  Develop a first response plan at provincial Red Cross branches, through the establishment of ORS distribution outlets at community level.  Distribution of 80,000 ORS sachets through community level outlets.  Establishing 3 Cholera Treatment Centres (CTCs) using Basic Health Care ERUs with cholera treatment kits that will provide case management for affected population functioning in health facilities and using additional capacity from local health professionals. Those CTCs will also serve as centres for community- based activities performed by ZRCS volunteers.

Progress: With the increase of cholera cases in Kadoma town, Mashonaland West Province, part of the Japanese Red Cross ERU supported Spanish Red Cross counterparts in supporting the CTC (distributing tents, beds, blankets, jerry cans, buckets, water purifiers and ORS). As one of the first deployments at the onset of an outbreak, this provided an opportunity to assess the effectiveness of IFRC systems in emergency situation. In Kadoma, the Red Cross in close collaboration with MSF Spain and MSF Holland are working through the office of the provincial medical director (PMD) and the local ZRCS branch. All cholera cases are referred to the CTC and according to the Germany/Austrian M40 visit to the CTC in Chisangano area near Kadoma, the centre is in need of waste disposal facilities, construction of latrines, installation of additional water pints, improvement on the drainage system, provision of body bags, food, bedding for patients, detergents and protective clothing. The Red Cross volunteers are assisting with hygiene promotion during burial proceedings, which is a potential source for the spread of the disease.

How we work All International Federation assistance seeks to adhere to the Code of Conduct for the International Red Cross and Red Crescent Movement and Non-Governmental Organizations (NGO's) in Disaster Relief and is committed to the Humanitarian Charter and Minimum Standards in Disaster Response (Sphere) in delivering assistance to the most vulnerable.

The International Federation’s Global Agenda Goals: activities are aligned with its Global Agenda, which sets out  Reduce the numbers of deaths, injuries and impact from four broad goals to meet the disasters. Federation's mission to  Reduce the number of deaths, illnesses and impact from "improve the lives of vulnerable diseases and public health emergencies. people by mobilizing the power  Increase local community, civil society and Red Cross Red of humanity". Crescent capacity to address the most urgent situations of vulnerability.  Reduce intolerance, discrimination and social exclusion and promote respect for diversity and human dignity. Contact information For further information specifically related to this operation please contact:  In Zimbabwe: Emma Kundishora, Secretary General Email [email protected]; [email protected] , Phone: Tel: +263.4.332638; +263.4.332197; Fax +263.4.335490  In Zimbabwe: Farid Abdulkadir ;Acting Head of Operations, Zimbabwe, Harare; Email Farid.Aiywar @ifrc.org .Phone: Tel: +263.4.705166; +263.4.720315, Fax +263.4.708784  In Southern Africa Zone: Françoise Le Goff, Head of Zone Office, Johannesburg; Email [email protected]; Phone: Tel: +27.11.303.9700; +27.11.303.9711; Fax: +27.11.884.3809; +27.11.884.0230  In Geneva: John Roche, Operations Coordinator for Africa, Email: [email protected]; Phone: +41.22.730.4400, Fax: +41.22.733.03.95

ANNEX 10. DAILY CHOLERA UPDATE 8 JANUARY 2009

ANNEX 11. ACRONYMS AND ABBREVIATIONS

ACF Action Contre la Faim

CFR case fatality rate CTC cholera treatment centre CTU cholera treatment unit C4 cholera command and control centre

GAA German Agro-Action

IARAT Inter-Agency Rapid Assessment Teams IFRC International Federation of the Red Cross and Red Crescent Societies IOM International Organization for Migration

MoHCW Ministry of Health and Child Welfare MSF Médécins Sans Frontières MVP mobile and vulnerable populations

NFI non-food item NGO non-government organisation

OCHA Office for the Coordination of Humanitarian Affairs ORS oral rehydration solution

PLWA People Living With HIV/AIDS

UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund

WASH water, sanitation and hygiene WFP World Food Programme WHO World Health Organization

ZINWA Zimbabwe National Water Authority