Health Cluster bulletin

Bulletin No 11 1-15 April 2009 Highlights: Cholera outbreak situation update • About 96, 473 cases and 4,204 deaths, CFR 4.4% Following a 9 week decline trend in cholera cases, an upsurge was reported during epidemi- • Sustained decline of ological week 15. Batch reporting in three districts may have contributed to this slight in- the outbreak crease. • Cholera hotspots in The cumulative number of Mashonaland west, Cholera in Zimbabwe reported cholera cases was and 17 Aug 08 to 11th April 09 96, 473 and 4204 deaths with 10,000 cities cumulative Case Fatality Rate 8,000 Cases Deaths (CFR) as of 4.4 as of 15 April. During week 15, a 17% de- 6,000 crease in cases and 5% in- 4,000 crease in deaths was re-

Number ported. The crude CFR is 2.7% 2,000 compared to 2.9% of week 14 0 while the I-CFR is 1.8% com- pared to 2.7% of week 14. The w2 w4 w6 w8

w36 w38 w40 w42 w44 w46 w48 w50 w52 w10 w12 w14 CFR has been steadily de- weeks clined although the proportion of deaths in health facilities has increased compared to Cholera in Zimbabw e from 16 Nov 08 to 11th A pril 09 those reported in the commu- W eekly c rude and institutional c ase-fatality ratios 10 nity. CFR 9 This is probably an indication Inside this issue: 8 iCFR 7 of more people accessing 6 treatment and/or the increas- Cholera situation 1 5 ing role of other co- 4 morbidities presenting along- ORPs in cholera 2 3 management percent side cholera. In order to bet- 2 ter analyse the co-morbidities, Update on meetings 3 1 0 it has been suggested that Cholera Treatment Centre Update on C4 4 w48 w50 w52 w2 w4 w6 w8 w10 w12 w14 (CTC) staff will be reoriented Epidemiological weeks cholera response to collect detailed notes on co-morbidities; Harare and Donor response 6 Cholera in Zimbabwe Week 15 from 29th March Chitungwiza will act as senti- nel sites for analysis. It is ex- to 11th April 09 Suspected cases reported by pected that this information province (N=1,169) will be used to inform policy Mashonaland West 455 within the Ministry of Health Manicaland 312 and Child Welfare (MoHCW). Harare 165 Mashonaland Central 158 The percentage of daily re- Mashonaland East 41 ports received from the dis- 24 tricts increased from 50% in Midlands 10 week 14 to 64.6% in week 15. Matabeleland North 4 During week 13, the percent- Matabeleland South 0 age of daily reports received 0 was 60%. The decrease in com- pleteness of reporting was attributed to communication challenges and power cuts. Mashonaland west province (see graph above) accounts for the majority of cases (23%), Harare (19%), Manicaland (14%) and Masvingo (12%). 80% of cases reported during the week are from 6 districts; Makonde (300 cases from ), , , Harare, Chitungwiza and Nyanga. Zimbabwe Health Cluster bulletin

Chipinge back reported 237 cases on 6 April after 6 • the majority of cases were from Rimuka and Ka- days of not reporting, similarly, Bindura reported 90 doma prison, where attack rates of 9% and 7% cases on 6 April after 4 days of not reporting. In Ma- respectively were reported. Within Kadoma city, konde, the increase in cases comes against a back- the highest case loads (above 90 cases, reported drop of a water shortage in the urban area between 14 November and 4 April) were (Chinhoyi) . Kwerete, Chapendeka, Marandu, Zengwe and Almost 80% of the cases reported during week 15 Parirenyatwa. These areas are characterized by were from 6 districts of Makonde, Chipinge, Bindura, overcrowding, water shortages and poor sanita- Harare, Chitungwiza and Nyanga. The same five tion. districts; Makonde, Bindura, Harare, Chitungwiza and • About 89 deaths occurred within health facilities Nyanga, as well as Kadoma and Binga accounted for and 38 at community level. The CFR was higher 81% of all cases during week 14 (see the graphs from among those 6o years and above (13%) and lowest weeks 14 and 15). among those in the 10-20 years age group (0.4%). Among those in the age group 0-10 years, the CFR Cases was 2.8%. Makonde 340 • Actions taken include treatment at CTCs in Lions’ Chipinge 237 club, New CTC and the prison. Case management Bindura 115 was carried out in collaboration with MSF Holland Harare 86 and celebration health. GAA-Merlin set up Oral Chit ungwiza 79 Rehydration Points (ORPs) and staffed them. Nyanga 45 About 52% of all cases were treated at Lions’ 0 50 100 150 200 250 300 350 400 club, 23% at New CTC and 25% at ORPs. Commu- Number of cases nity health promotion was carried out by church youth groups, drama groups, community health volunteers and staff at static health centres. Districts reporting highest case loads (29th March-4th April 2009) Harare, Matabeleland North and Masvingo reported fewer cases in week 15 than in week 14 while Mata- beleland South and Bulawayo reported no cases during Harare City 223 Chitungwiz 17 4 week 15. Makonde 15 0 Nyanga 99 Recommendations Bindura 94 Kadoma 57 • Although the epidemic appears to be coming to an Hurungwe 33 / N 27 end, there are hotspots that still need to be moni- Binga 26 tored closely. These include: Harare city, Chitung- 0 50 100 150 200 250 wiza, Makonde, Bindura and Kadoma. These are No of cases mainly the densely populated urban areas. Contin- ued efforts need to be exerted to increase the avail- This implies that there is a need for targeted inter- ability of safe water and improve sanitation in these ventions in these districts that continue to report areas. new cases and deaths. • Continued laboratory confirmation needs to be car- ried out especially in districts which are now report- The new cases reported in Bindura during week 14 ing fewer cases in order to verify that the outbreak (1-17 April) were mainly from the prison. Actions is actually tapering off in these areas. taken include the set up of two CTCs and the provi- • In districts where no case has been reported for sion of water treatment chemicals by MSF (as part of more than two weeks, materials, equipment and the WASH cluster) to the city which was suffering drugs from closed or closing CTCs should be central- shortages due to lack of chemicals. The upsurge in ized. cases from Binga (week 14) were mainly from Sina- • Vigilance is still required by the public health struc- koma, Siansundu, Pashu and Binga centre. tures so as to pick any resurgence. The rumours veri- An epidemiological report from (14 fication procedure should still be included into the Nov 08-4 April 09) indicates that; daily cholera reporting system, at least until the epidemic has been declared over at national level. • The cumulative number of reported cholera

cases was 4482 and deaths, 127 (by 4 April). Oral Rehydration Points in cholera management The most affected age groups were those be- tween 20-30 years, with more males than fe- by GAA-Merlin males affected in groups above 20 years. This is consistent with the higher case burden re- GAA-Merlin have been involved in the set up and opera- ported from Kadoma prison and the Patchway tion of ORPS (27 January to present). So far, GAA- mine area in Rimuka which are male domi- Merlin have set up 63 ORPs in Harare (19), Chitungwiza nated. (3), Gokwe North (9), Gokwe south (4), Kadoma (21) Page 2 Zimbabwe Health Cluster bulletin and Makonde (7). According to the data, between 3 and 29 years old were more likely to present at the ORP for treatment within 24 hours than other age groups (see graph below).

Chigupa Oral Rehydration Point, Gokwe South It has been suggested that children below the age of 2 Photo credit: GAA Merlin may not be taken to the OPRs within 24 hours due to the fact that currently, non cholera diarrhea is on the The treatment plans are based on the case definition increase because of the rains. In addition, children be- of three or more episodes of loose stool (whitish wa- low the age of 2 form a smaller proportion of affected tery diarrhea) in the past 24 hours. Patients are screened according to their level of dehydration, with age groups. those who are not dehydrated in plan A. Those who This analysis maybe limited by the fact that; are moderately dehydrated are treated using plan B, ORPs open different lengths of time and ORPs are run and the severely dehydrated with plan C. Patients un- by nurse aids (in Urban areas) or community volunteers der plans A and B are provided with are provided rehy- (in rural areas); making the diagnosis open to the possi- dration therapy using Oral Rehydration Salts (ORS). bility of misdiagnosis and reporting errors. The analysis For Plan C patients in Harare and Chitungwiza GAA- Merlin have facilitated transfers by providing ambu- is however, consistent with the national level data. lances. In other areas of operation, local solutions have been found by communities and GAA-Merlin. In Meetings Most areas ORPs are located close to CTCs/CTUs. A joint health-WASH meeting was held on 15 April and By the end of epidemiological week 14, a cumulative the following were the main highlights; total of 6, 160 patients had been treated at ORPs in Harare, Chitungwiza, Gokwe North and South, Kadoma • A World Bank scoping mission visited Zimbabwe to and Makonde. During week 14 itself, 387 patients were assess the urban water situation for emergency fund- seen at ORPs in the above named districts. The peaks ing. This is part of the transitional WASH program for in data collected at ORPS Harare, Kadoma and Chi- emergency rehabilitation and risk reduction. Under tungwiza are consistent with those in national level the same program, UNICEF is assessing water and data (see graph of aggregated data below). sanitation needs in Chegutu and Kadoma • The evaluation of the WASH cluster response to chol- era is expected to begin in May. • Increases in case loads in Mashonaland West have been attributed to water shortages as a result of power cuts. The power cuts are due to ongoing re- pair of a transformer at the dam which sup- plies power to areas in Mashonaland West including and Chinhoyi. The WASH cluster is in negotia- tions with Zimbabwe Electricity Supply Authority There was no significant difference in distribution of (ZESA) to provide electricity for some hours to facili- treatment plans by age. Most of the patients were tate pumping of water. Blanket distributions of Non treated under plan A (55%), while 40% were plan B and food Items (NFIs) which consist of aquatabs for water 5%, plan C. Patients aged 50 years and over accounted purification, soap and hand washing facilities are for the bigger proportion of Plan C patients. The me- being carried out in Karoi. dian age of all attendees was 26 years, with 25% of all cases in the age group 20-29. This is consistent with Dates to remember: WASH cluster meeting: 24 April data from Kadoma district. Health cluster meeting: 27 April Page 3 Zimbabwe Health Cluster bulletin

Update on Cholera Command and Coordination Cen- of epidemics it is important to verify that cases being tre (C4) activities reported are in deed cholera. it is also necessary to know whether patients are still sensitive to antibiot- Case management: ics in use as resistance to antibiotics sets in particu- larly in protracted outbreaks such as this one. • Training of health workers including doctors and nurses from Mashonaland West and the medical ser- • Of the 40 stool samples taken, over 80% were posi- vices team from the uniformed forces (Military and tive for cholera , all confirmed to be the type Vibrio police) was carried out by the case management cholerae El tor Ogawa except two samples that were working group of the C4. A total of 53 participants Vibrio cholerae El tor Inaba. attended the workshop. This is the final in a series of case management workshops carried out at pro- • All samples tested were found to be sensitive to vincial level. The workshop was carried out in col- common antibiotics, that is; tetracycline, ciproflox- laboration with the team from the International acin, doxycycline, erythromycin and azithromycin. Centre for Diarrhoeal Diseases Research, Bangladesh Further testing of samples will facilitate the inform- and other members of the C4 case management ing of policy regarding what drugs to use in the treat- team. ment of severe cholera cases. According to national cholera guidelines, treatment of cholera is mainly through rehydration, only severely dehydrated pa- tients are given drugs. CTCs (through provinces) are encouraged to send stool samples to the Central Mi- crobiology Reference Laboratory to verify that the cases are cholera. This is due to two reasons; • Due to the rainy season, there are non cholera cases reported especially among children below five years of age, and • the fact that when the outbreak is reaching its tail end it is necessary to verify whether all re- ported diarrhea cases are cholera or not. C4 multidisciplinary team visit to Kadoma, New Urban CTC Logistics Photo credit: Dr Islam, ICDDR, B A member of the logistics team visited • In light of the cholera cases being reported in pris- (Mashonaland East) to; ons, the Director of Epidemiology and Disease Con- trol in the MoHCW met with the Director of Medical • Assess logistical gaps services in prisons to discuss improvement of health that can be met by services, particularly cholera response, in prisons. In the C4, addition to training of prison medical staff, the C4 is • Prepare the position- providing through provincial medical offices and the ing of the Provincial central prison medical services, emergency supplies cholera emergency for prisons. Non governmental organizations includ- response kits. ing Medicin du Monde (MDM), Médecin sans Frontière Holland and GAA-Merlin, are working with various • Organize PUSH imple- prisons to provide the following services; set up of mentation at district level Oral Rehydration Points (ORPs), provision of food with provincial authori- including supplementary foods like plumpynut, pro- ties. The PUSH is aimed at Members of the logistics team vision of drugs, IV fluids and other medical supplies positioning emergency preparing cholera materials for for treatment of patients and water chlorination. cholera supplies for treat- distribution Photo Credit: P. ment of 200 patients at Baudry Laboratory district level. • A team from the C4 (International Centre for Diar- The findings were as follows; rhoeal Diseases Research, Bangladesh and National Microbiology Reference Laboratory) visited a number • The province was informed about the C4 roll out of CTCs across the country including Seke south and had meetings planned; they have a cholera co- (Chitungwiza), Beatrice Road Infectious Diseases ordination mechanism in place. There were no ac- Hospital (BRIDH), Chinhoyi and Kadoma prison. tive CTCs-the last was being closed as there had They met with case management teams at CTCs and been no patients for two weeks. While the district also took stool samples for testing. Towards the end had a working generator and an internet connec- tion, it lacked printers, computers and stationery, situation which the C4 equipment will solve. Proper Page 4 Zimbabwe Health Cluster bulletin

stock management has been hampered by inaccurate • Following the national trainer of trainers workshop data collection which is in turn affected by unreli- for provincial health promotion focal points, the able electricity and communication. Radio communi- social mobilization working group is working on cation is non functional mainly due to lack of mainte- plans to cascade the training to districts and ward nance. level in collaboration with provincial medical • Members of the Provincial C4 were briefed on the teams and partners . The first six districts are ex- positioning of a Provincial Cholera Emergency Kit as pected to begin training in the last week of April. part of the emergency preparedness. Recommenda- • The social mobilization working group, working tions were made regarding necessary preparation for through the Ministry of Health and Child Welfare, the transfer of the kits. shall in the coming weeks meet with Members of Recommendations parliament to advocate for their support and com- mitment in the cholera response for this outbreak • Communication being the key of any emergency pre- and in future health programmes. A package of paredness and response, it is necessary to re- advocacy materials including situation updates on establish a reliable communication network between health and WASH by province, is being prepared by provinces and districts. This may be initiated by as- the working group. sessment of HF communication system between prov- ince and remotest districts and support to the repair • In response to the recent re-opening of schools, or replacement of the non functional systems. the working group developed and produced IEC materials for school children. The working group is • The C4 plan is procuring equipment including com- liaising with the education working group in order puters and printers to support provincial medical of- to ensure that school social mobilization strategies fices; this will solve the problem of lack of office and materials are appropriate, widely available equipment reported in Mashonaland East . and reach all target groups. • Stock management: The nationwide prepositioning of cholera kits requires centralization of stock monitoring and the establishment of a monthly reporting system. For this to work, a database and monitoring tools need to be introduced or re- introduced, training in stock management carried out and a focal point put in place. • The repair of existing vehicles will go a long way in solving the transport challenges that exist in the province. • In response to an upsurge in cases in Binga reported during week 14, the logistics team sent out emer- gency supplies for treatment of cholera, disinfectant and chlorine to Hospital as part of the PUSH strategy. Mobilizing members of the Apostolic sect for cholera response activities Photo credit: P. Garwood • PUSH strategy: the PUSH is part of a strategy by the C4 to move emergency cholera supplies from the • A national clean up campaign covering 42 districts centre (Harare) to provinces and districts where they is being planned by the social mobilization group. can be easily accessed. The cluster had by 17 April Details about the dates and activities to be carried delivered an emergency basic cholera kit for the out are being finalized. treatment of 200 patients to the following districts; Bindura, Binga, , Centenary, Chegutu, Chi- • The working group is also working on reviewing komba, Chimanimani, Chipinge, Guruwe, Goromonzi, social mobilization strategies and materials in or- Kadoma, Makonde, Makoni, Marondera, Mazowe, der to ensure that all sections of the population Mount Darwin, Mureva, , Mutasa, Nyanga, are reached with the cholera prevention message. Shamva, Seke, Rushinga, UMP and Wedza. • Guidelines on the use of Oral Rehydration Salts • In addition, cholera kits were distributed to all prov- (ORS) and Salt and Sugar Solution (SSS) were re- inces (one each) except in Harare and Bulawayo, cently agreed upon by members of the group. which shall receive kits in the coming weeks. ORS will be distributed in health facilities or by trained Village health workers until it is available Joint health-WASH social mobilization working group on a large enough scale for sustainable use at • The joint health-WASH social mobilization working household level. In the meantime, communities group issued an alert for travellers and tourists for are encouraged to continue to make SSS solution the Easter season in all the major newspapers in Eng- to treat diarrhea. lish, Shona and Ndebele. Page 5 Zimbabwe Health Cluster bulletin

• In response to a request by the WASH cluster, a draft exit strategy for cholera response volunteers has been agreed upon by members of the working group. • The working group has recently merged with the community based management/development working group. Members of the group include: Celebration health, GAA-Merlin, GOAL, Institute of Water and Sanitation develop- ment, Ministry of Health and Child Welfare, Oxfam, PSI (Population Services International), UNICEF, WHO and ZinRe. The organizations work in partnership with provincial and district health promotion focal points and com- munity based organizations. They have partnerships with private sector organizations including EcoNet and City Residents Associations.

For more information, please contact: For more information on the cholera outbreak, see the WHO and OCHA websites Dr Custodia Mandlhate, listed below: WHO Representative to Zimbabwe http://www.who.int/hac/crises/zwe/en/ Tel: +263 4 253 724-30, http://ochaonline.un.org/Default.aspx?alias=ochaonline.un.org/zimbabwe email: [email protected] Dr S.M. Midzi, More information on the Health Cluster may be accessed online at; Director, Epidemiology & Disease Control http://ocha.unog.ch/humanitarianreform/Default.aspx?tabid=75 Email: [email protected]

Please send contributions for next edition by COB on each Wednesday to Ida-Marie Ameda at [email protected]

Donor response to the cholera crisis

Donor Partner (s) Cluster Funds

African Development Bank WHO Health $984,111

AusAid IOM Health $129,000

Government of WHO Health $130,410 Botswana

Central Emergency WHO Health $1,805,595 Response Fund (CERF)

Government of China Government of Zimbabwe Health worker retention $500,000

DFID Crown Agents, UNICEF, WHO & others Health and WASH £3, 950,000

ECHO ACF Health & WASH €734,120

ECHO GAA Health and WASH €595,533

ECHO GAA-Merlin Health & WASH €1,641,801

ECHO GOAL Health & WASH €924,258

ECHO MSF-Luxembourg Health & WASH €490,000

ECHO MSF-Holland Health & WASH €2,994,000

ECHO MSF-Spain Health & WASH €958,810

ECHO World Vision Denmark Health & WASH €600,574 Government of Greece WHO Health €250,000 Republic of Korea WHO Health $99,405

SIDA IOM Health $628,000

OFDA IOM Health $500,000 USAID WHO Health $787,659

World Vision Australia, World Vision Zimbabwe Health and WASH $11,483, 040 Canada and USA