Epi update week 04/1/08 - 10/1/09

C4 Surveillance and lab group Toll free number for alert by district and province is 08089001 or 08089002 or 08089000 Mobile number for alerts is 0912 104 257

Email: [email protected]. New cholera cases, with case-fatality rates, by week. Zimbabwe, Nov 08 - Jan 09

• * For week 7-13 December, gaps in reporting of data • ** For week 28 December 08- 3 January 09, artefact (Christmas- New Years)

7,000 10.0

9.0 6,000

8.0

5,000 7.0

6.0 4,000 * * 5.0 Cases CFR

Cases * CFR 3,000 4.0

3.0 2,000

2.0

1,000 1.0

0 0.0 16-22 Nov 23-29 Nov 30 Nov - 6 Dec 7-13 Dec 14-20 Dec 21-27 Dec 28 Dec-3 Jan 4-10 Jan Global picture

The cholera outbreak is not yet under control with 9 of 10 provinces reported cases this week.

• Duration of the outbreak: 5 months • To date, cumulative total of 37 806 suspected cases and 1912 deaths have been reported • Number of cases have increased from last week as well as the number of deaths. • CFR increased markedly this week to 6 % similar to the week preceding the Christmas and New year’s holiday, • and CFR still much higher than expected for a cholera outbreak (normally <1%). • This week (4 Jan -10 Jan 2009), 656 cases per day reported and 39 persons are dying every day of cholera. • This week (4 Jan -10 Jan 2009) nearly half of the deaths (41%) are occurring outside treatments centre →unavailability of health care (especially human resources shortage) “Hot spots” this week

• Mashonaland West (increase cases and CFRs > 5% and high attack rates and 1/3 of the total weekly number of cases) • Midlands, (increase cases and CFRs > 5% and high attack rates) • Manicaland (CFRs > 5% and high attack rates) • Mathebeleland South (increase cases) • Chitungwiza (CFRs > 5%) • Masvingo (CFRs > 5%) • Mashonaland central (increase cases) Cumulative cholera cases, with cumulative case-fatality rates. Zimbabwe, Nov 08 - Jan 09

40000 6

35000 5

30000

4 25000

Cases 20000 3 CFR

15000 2

10000

1 5000

0 0 22-Nov 29-Nov 6-Dec 13-Dec 20-Dec 27-Dec 3-Jan 10-Jan CFR (proportion of cases that die of the disease )

• Case-fatality rates (CFR, the proportion of cases that die of the disease) increased markedly this week to 6 % (5.9% exactly) similar to the week preceding the Christmas and New year’s holiday,

• and is still far above the <1% target.

• The CFR for the week 04/10/09 - 10/1/09 is 5.9%, compared to 2.1 % last week CTC and CTU

• 172 CTC/CTU distributed over the country. • 74 of the 172 CTC/CTU so 43% run only by the MoHCW • the others 57 % are runed by MoHCW with support of NGOs/partners.

Table 1. Number of CTC/CTU per province, as of Jan 10th, Zimbabwe

Average catchment Province Population Number of CTC population per CTC (Harare city+ Chitungwiza) 2,012,784 3 670928 Bulawayo 718,278 1 718278 Manicaland 1,665,451 36 46263 Mash Central 1,056,666 25 42267 Mash East 1,196,772 26 46030 Mash West 1,300,012 35 37143 Masvingo 1,401,672 31 45215 Mat North 748,317 0 - Mat South 693,230 7 99033 Midlands 1,554,058 8 194257 TOTAL 12347238 172 211046 CTC/CTU all over country CTC in Harare

Budiriro polyclinics

Beatrice hospital Cases and deaths per day, from week 16/11/08 - 22/11/08 to week 04/01/09 - 10/01/09, Zimbabwe

On average since November 16th 2008, 587 cases per day and 31 deaths per day are reported with a peak of 819 cases per day in 21-27 Dec 2008 and 52 per day in 14-20 Dec 2008

Week Cases Deaths CFR (%) Cases per day Deaths per day

16-22 Nov 2008 2863 99 3.5 409 14

23-29 Nov 2008 3254 136 4.2 465 19

30 Nov 6 Dec 2008 4499 159 3.5 643 23

7-13 Dec 2008 2841 257 9.0 406 37

14-20 Dec 2008 5379 367 6.8 768 52

21-27 Dec 2008 5730 358 6.2 819 51

28 Dec 08-3 Jan 09 3690 79 2.1 527 11

4-10 Jan 2009 4594 272 5.9 656 39

Total 587 31 Cumulative case-fatality rates, by district. Zimbabwe, as of 10 Jan 2008

Districts with cumulative CFRs over 1% are noted in the majority of the provinces (8 of the 10 provinces).

above 5 1.1 - 5.0 0 no cases/deaths Proportion of cases by provinces

This week, Mashonaland West is representing 1/3 of the total weekly number of cases, followed by Manicaland (17.0%) and Harare (10.9%). Since the beginning of the outbreak, most of the cases are coming from Harare (31.1%), then Mashonaland West (24.3%).

Proportion of Number cases cases (%) week (4 Cumulative week (4 Jan-10 number Jan-10 Jan Cumulative proportion of Provinces Jan 09) of cases 09) cases (%)

Harare (Harare city+ Chitungwiza) 501 11767 10.9 31.1 Bulawayo 8 383 0.2 1.0 Manicaland 783 4477 17.0 11.8

Mash Central 278 859 6.1 2.3 Mash East 401 3642 8.7 9.6 Mash West 1,565 9168 34.1 24.3 Masvingo 448 2565 9.8 6.8 Mat North 0 2 0.0 0.0 Mat South 438 4272 9.5 11.3 Midlands 172 671 3.7 1.8 TOTAL 4,594 37806 100.0 100.0 Attack rate (AR) per 100 000 inhabitants by provinces

The most affected provinces for this week in term of number of cases are from far Mashonaland West (AR= 120/100 000 inhabitants), then Mathebeleland South (AR= 63/100 000 inhabitants), Manicaland (AR= 47/100 000 inhabitants)

Number cases Cumulative number week (4 of cases (since Weekly AR Cumulative AR Jan-10 Jan beginning of (per 100 (per 100 Provinces Population 09) data collection) 000) 000

Harare (Harare city+ Chitungwiza) 2,012,784 501 11767 24.9 584.6

Bulawayo 718,278 8 383 1.1 53.3

Manicaland 1,665,451 783 4477 47.0 268.8

Mash Central 1,056,666 278 859 26.3 81.3

Mash East 1,196,772 401 3642 33.5 304.3

Mash West 1,300,012 1,565 9168 120.4 705.2

Masvingo 1,401,672 448 2565 32.0 183.0

Mat North 748,317 0 2 0.0 0.3

Mat South 693,230 438 4272 63.2 616.2

Midlands 1,554,058 172 671 11.1 43.2

TOTAL 12,347,240 4,594 37806 37.2 306.2 Cumulative attack rates, by district, as of 10 Jan 2009

Attack Rate (per 100,000) 1,000 and above 500.0 - 999.9 100.0 - 499.9 0.1 - 99.9 0 Proportion of deaths that occur outside CTC, week 04/01/08 - 10/01/09, selected* provinces

•* without taking into account Harare, where community deaths are irregularly (or even not) reported, •This week, more than 1/3 of the deaths (41%) are occurring outside treatments centre. In some districts (Mashonaland East) more deaths are recorded in the community than in the treatments centres.

Deaths within treatment Deaths outside treatment Proportion of deaths occuring outside Province centres centres treatment centres (%)

Bulawayo 0 0 0

Mashonaland West 117 67 36

Mashonaland Central 10 8 44

Mashonaland East 19 20 51

Manicaland 62 59 49

Masvingo 27 20 46

Matabeleland North 0 0 0

Matabeleland South 11 3 21

Midlands 16 11 41

Total 272 188 41 EPI UPDATE PER PROVINCE Chitungwiza

250 50.0

45.0

200 40.0

35.0

150 30.0

Number of Cases 25.0 CFR

100 20.0

15.0

50 10.0

5.0

0 0.0 2-8 Nov 2-8 5-11 Oct 5-11 4-10 Jan4-10 7-13 Dec 7-13 7-13 Sep 7-13 9-15 Nov Nov 9-15 12-18 Oct 12-18 Oct 19-25 16-22 Nov 16-22 Nov 23-29 14-20 Dec 14-20 Dec 21-27 17-23 Aug 17-23 Aug 24-30 Sep 14-20 Sep 21-27 26 Oct-1 Nov 28 Dec-3 Jan 28 Dec-3 28 Sep -4 Oct -4 28 Sep 31 Aug- 6 Sep 30 Nov - Dec 6 - 30 Nov Harare City

3000 25.0

2500 20.0

2000

15.0

Cases 1500 CFR

10.0

1000

5.0 500

0 0.0 16-22 Nov 23-29 Nov 30 Nov - 6 7-13 Dec 14-20 Dec 21-27 Dec 28 Dec-3 Jan 4-10 Jan Dec Harare City Distribution of Cholera Cases by place of residence, City of Harare, Oct - Dec 2008

N

W E Hatcliffe S Institute Of AgriculturalHogerty Hill Engineering

Philadelphia BorrowdaleHellensvale Brooke Umwindzidale Mount Pleasant Heights Quinnington New Marlborough Glen lo rne Northwood Marlborough Reylands VainonaPomona Greystone Park Glen Wood Borrowdale Adylin Kambanji Shawasha Hills AvonleaAshbrit tle Mount Pleasant Gl et wyn Borrowdale West The Grange Bluff Hill Little Norfolk Rolfe Valley Emerald Hill Gro ombridge Greencroft Colne ChisipiteValley North Avondale WestUniversity CampusBorrowdale Racecource Mabelreign New Alexandra ParkLewisam Mandara Dzivaresekwa Extension Mayfield Park Chisipite AshdownCotswold Park Hills Gu n H ill Dzivaresekwa SrathavenAvondale Chikurubi Tynwald Alexandra Park Highlands MeyrickMonovale Park Glaudina BelgraviaBorrowdale Road Government Block Merwede Haig Park Milton Park Greendale Avenues Belvedere North Eastlea Donnybrook Warren Park City Centre Belvedere South Athlone MabvukuTafara Railway YardHillsideCoronation ParkGreen Grove Braeside Cleveland Ridgeview Msasa Amby Crowborough North Arcadia Beverly Westwood Workington Magaba Wilmington Park Chizanje Graniteside QueensdaleChadcombe KambuzumaRugare Cranborne Msasa Park Marimba Park Mbare St Mart ins Mukuvisi East Southerton Zimre Park Lochinvar Sunningdale Aspindale Park Park Meadowlands Ardbennie Ventersburg NewHoughton Ardbennie Park Logan Park Hatfield Prospect Highfield Parkt own Epworth Mainway Meadows Midlands Glen Vie w Gl en No rah Kutsaga Village Gro bbi e Pa rk Uplands Airport Waterfalls Number of cases Hopley 1 - 100 Shortson 101 - 500 501 - 1000 1001 - 2000 Over 2000 No cases reported Bulawayo

140 12

120 10

100 8

80

6 Cases 60 CFR CFR Cases

4 40

2 20

0 0 16-22 Nov 23-29 Nov 30 Nov - 6 7-13 Dec 14-20 Dec 21-27 Dec 28 Dec-3 4-10 Jan Dec Jan Week Mashonaland West

3500 9

8 3000

7

2500 6

2000 5 Cases

CFR CFR Cases 1500 4

3 1000

2

500 1

0 0 16-22 Nov 23-29 Nov 30 Nov - 6 7-13 Dec 14-20 Dec 21-27 Dec 28 Dec-3 Jan 4-10 Jan Dec Week Mashonaland Central

350 25

300 20

250

15 200 Cases

CFR CFR Cases 150 10

100

5 50

0 0 16-22 Nov 23-29 Nov 30 Nov - 6 7-13 Dec 14-20 Dec 21-27 Dec 28 Dec-3 Jan 4-10 Jan Dec Week Mashonaland East

600 50.0

45.0

500 40.0

35.0 400

30.0

Cases 300 25.0

CFR CFR Cases

20.0

200 15.0

10.0 100

5.0

0 0.0 16-22 Nov 23-29 Nov 30 Nov - 6 7-13 Dec 14-20 Dec 21-27 Dec 28 Dec-3 Jan 4-10 Jan Dec Week Midlands

200 16.0

180 14.0

160 12.0 140

10.0 120

Cases 100 8.0

CFR CFR Cases

80 6.0

60 4.0 40

2.0 20

0 0.0 16-22 Nov 23-29 Nov 30 Nov - 6 7-13 Dec 14-20 Dec 21-27 Dec 28 Dec-3 Jan 4-10 Jan Dec Week Masvingo

1000 35.0

900 30.0 800

25.0 700

600 20.0 Cases 500

CFR CFR Cases 15.0 400

300 10.0

200 5.0 100

0 0.0 16-22 Nov 23-29 Nov 30 Nov - 6 Dec 7-13 Dec 14-20 Dec 21-27 Dec 28 Dec-3 Jan 4-10 Jan Week Manicaland

1600 40.0

1400 35.0

1200 30.0

1000 25.0

Cases 800 20.0

CFR CFR Cases

600 15.0

400 10.0

200 5.0

0 0.0 16-22 Nov 23-29 Nov 30 Nov - 6 Dec 7-13 Dec 14-20 Dec 21-27 Dec 28 Dec-3 Jan 4-10 Jan Week Matabeleland South

1400 25.0

1200 20.0

1000

15.0 800 Cases

CFR CFR Cases 600 10.0

400

5.0 200

0 0.0 16-22 Nov 23-29 Nov 30 Nov - 6 7-13 Dec 14-20 Dec 21-27 Dec 28 Dec-3 Jan 4-10 Jan Dec Week Matabeleland North

• No further cases or deaths were reported this week like the week before. Only 2 cases have been reported in week 21-27 Dec 08 for Matabeleland North.