Epidemiological Bulletin Number 59 Week 19 (week ending 16 May 2010) Foreword This bulletin provides a weekly overview of the outbreaks and other important public health events occurring in Zimbabwe. It includes disaggregated data to inform and improve the continuing public health response by the various partners. It also provides guidance to agencies on issues relating to data collection, analysis and interpretation, and suggests operational strategies on the basis of epidemiological patterns so far. The bulletin is published weekly. Note that the epidemiological week runs from Monday to Sunday. This edition covers week 19 (week ending 16 May 2010). The C4 team welcomes feedback. Data provided by individual agencies is welcome but will be verified with MOHCW structures before publication. Please send any comments and feedback to the Cholera Control and Command Centre Email: [email protected]. Toll free number for alert by district and province is 08089001 or 08089002 or 08 089000 Acknowledgements We are very grateful to MoHCW District Medical Officers, District and Provincial Surveillance Officers, Provincial Medical Directors, Directors of City Health departments, Environmental Heath Officers, and MoHCW's National Health Information Unit, who have helped to gather and share the bulk of the information presented here. Likewise, we acknowledge agencies, including members of the Health and WASH clusters, who have kindly shared their data with our team. MoHCW recognizes and thanks the efforts made by NGOs and other partners assisting in the response and providing support to MoHCW. Highlights of the week: • No cholera cases reported this week • Confirmed Measles Outbreaks reported in 50 districts • 6 Typhoid cases reported this week Source: Ministry of Health and Child Welfare Rapid Disease Notification System 1 Figures The case definitions can be found in appendix 1 and detailed data by district are shown in appendix 2. See also summary tables (annex 1), maps (annex 2) and graphs (annex 3). Cholera 15 out of the 62 districts in the country have been affected by the cholera outbreak that started on 4 February, 2010 compared to 54 districts last year at the same time. 477 cumulative suspected cholera cases, 68 laboratory confirmed cases and 15 deaths were reported by 16 May 2010 to the World Health Organization (WHO) through the Ministry of Health and Child Welfare's (MoHCW) National Health Information Unit. The crude case fatality rate since the outbreak started stands at 2.6% which is 1.8% lower than that of last year. By week 19, 2009, 98 234 cumulative cases and 4 277 deaths had been reported since August 2008, with a crude case fatality rate of 4.4%. Week 19 (10 - 16 May 2010) No cholera cases and deaths were reported this week. Geographical distribution of cases The cases reported so far came from the following districts: Beitbridge, Bindura, Buhera, Chegutu, Chivi, Chimanimani, Chiredzi, Harare, Hurungwe, Kadoma, Masvingo, Makonde, Mwenezi, Plumtree and UMP. Urban/Rural distribution of cases 62.7% of the cases currently reported are from rural areas. In comparison, during the corresponding week in 2009, 34.4% cases came from urban areas and 65.6 % from rural areas. Assessments & response Surveillance, case management and investigation of alerts continued in all the provinces. Measles 7 754 suspected cases and 517 deaths (of which 512 were community deaths) were reported since the beginning of the outbreak in September 2009. 1 401 blood specimens were received by the polio-measles laboratory and 508 cases have been confirmed to be Measles IgM positive. Vaccination Status of Measles Cases 5 317 (69%) cases were not vaccinated, 1 691(22%) had unknown vaccination status and 746 (10%) cases had been vaccinated at least once. Only 50 (9.9%) of the total positive cases had been vaccinated. See Table 7 for more details. IgM Positive Cases by Age Group 69 (13.6%) of the positive IgM cases were below 9 months, 41 (8.1%) in the 9 – 12 months age group, 102 (20.1%) were in the 1-5 years age group, 221 (43.5 %) were in the 5 -14 years age group and 75 (14.8%) in the above 14 Years age group. Hence 398 (78.3%) of the positive cases were above the routine immunisation age ( 9 months -12 months) Source: Ministry of Health and Child Welfare Rapid Disease Notification System 2 The district measles IgM positive attack rates ranged from 0.4 to 25.3 per 100 000 and the attack rate for all the affected districts is 4.2 per 100 000. The lowest attack rate was recorded in Chiredzi district and the highest was recorded in Bubi district. See table 3 for detailed distribution of the IgM positive cases by agegroup and and attack rates by district. Week 19 (10 - 16 May 2010) 21 specimens were received by the laboratory during the week. 12 of the specimens were IgM positive. The positive cases were from: Beitbridge -1, Harare-3, Kariba-1,Rushinga-2 and Zaka 5. 2 of the positive cases had been vaccinated this month. See table 4 for detailed distribution. Geographical distribution of cases Since September 2009, 59 districts out of 62, have had at least 1 laboratory confirmed measles case namely: Beitbridge, Bindura, Bikita, Bubi, Buhera, Bulawayo, Centenary, Chegutu, Chikomba, Chimanimani, Chiredzi ,Chirumhanzu, Chipinge, Chivi, Gokwe North, Gokwe South, Goromonzi, Guruve,Gweru, Gutu, Harare (including Chitungwiza) ,Hurungwe, Hwange, Hwedza, Insiza, Kadoma , Kwekwe, Lupane,Makoni, Makonde, Marondera, Mangwe, Masvingo, Mazowe, Mt. Darwin, Mutare, Mutasa, Murehwa, Mutoko, Mwenezi, Nyanga, Umzingwane,Seke, Shurugwi, Umguza, UMP, Zaka, Zvimba and Zvishavane. All districts have reported suspected measles cases. Confirmed laboratory Outbreaks The number of districts with laboratory confirmed measles outbreaks have gone up by 3 to 50 from last week’s figure. The districts with confirmed outbreaks are shaded in table 3. Assessments & response Vaccination and surveillance continued in all affected Districts. Supervisors from provinces and districts were trained on microplanning for the joint Child Health and Immunisation Days. Orientation of health facilities staff on what to do during the campaign has started. Distribution of vaccines, IEC materials, data collection has commenced. Typhoid Since the typhoid outbreak started on 3 February 2010, 446 cases and 8 deaths were reported by 16 May, 2010. 43 samples were laboratory confirmed to be Salmonella typhi, the cause of typhoid fever from 44 samples tested. Week 19 (10 - 16 May 2010) Six cases of Typhoid were reported from Mabvuku in the week. Geographical distribution of cases The cases were reported from mainly Harare surburbs and areas in the environs of Harare namely Bhobho Farm, Caledonia, Chishawasha, Epworth, Gwebi College, Mount Hampden, Hunyani(Norton), Order Farm Ruwa, Zimre Park, Zengeza 3 and Zengeza 5. 282 cases (63%) of the cases were from Mabvuku and 83 cases (19 %) were from Tafara. Hence Mabvuku and Tafara account for 82% of the cases. Nyamaturi Street was the most affected contributing 21% of the cases.Map 3 shows the distribution of the cases by surburb. Source: Ministry of Health and Child Welfare Rapid Disease Notification System 3 Assessments & response Surveillance, health promotion and case management continued. EHTs that had been seconded to Mabvuku from other areas in Harare have returned to their stations. Malaria 18 out of the 62 rural districts in the country have reported some malaria outbreaks to date. In week 18 a total of 10 676 cases and 31 deaths were reported, with 1 423 (13%) and 2 deaths being amongst the under 5s. The highest number of cases were reported in Mashonaland East province (3 509 cases) and Mashonaland Central (2 501 cases). Geographical distribution of cases The outbreaks have been confined to the districts in rural provinces namely: Beitbridge, Bikita, Binga, Buhera, Bulilima, Chiredzi, Hurungwe, Hwedza, Kariba, Mazowe, Mbire, Mudzi, Murewa, Mutoko, Mwenezi and Gokwe South. See Map 4 for spatial distribution of the outbreaks. Assessments & response The outbreaks have been attributed to late and prolonged rains. The increase in number of cases seeking treatment at health facilities also followed the discontinuation of chloroquine holders services due to change of first line drug used to treat malaria. The newly introduced first line drug, Coartemether is a registered as a prescription only drug and can only be dispensed by nurses and doctors for the time being. The thresholds being used were calculated using health facility data only (excluding cases which were being treated by Community based Workers) were an underestimate of the true malaria burden and have thus been easily exceeded, as all those cases which were previously being seen by the VHW are all coming to the health facilities. Whilst the IRS coverages for the past spraying season were high (86% for both Room and population coverages) and over 500 000 LLINs have been distributed in these disticts the behaiour of the community members (sleeping outside sprayed structures, and not using LLINs cosnistently) in some areas and reduced population immunity because malaria seasons have been light in recent years could also explain some of the outbreaks. Case Management training has taken place and is continuing in all provinces. Coartemether and RDTs have been distributed to affected health facilities. In some districts temporary treatment camps have been set up in affected areas that are far from static health centres. In some cases larviciding is also being used to control the epidemics.