Zimbabwe Health Cluster bulletin

Bulletin No 13 01-15 May 2009 Highlights: Cholera outbreak situation update • 98, 234 cases and 4, By 16 May, the cumulative number of reported cholera cases was 98, 234 and 4, 277 deaths 277 deaths reported by (since August 2008). The trend continues to decline, with Harare and Midlands provinces 16 May reporting 78% of all cases during week 20. • Sustained decline of The cumulative crude cases case fatality stands at 4.4% and the weekly • Cholera hotspots re- ported in Midlands and crude case fatality rate Harare provinces (week 20) stands at 3%, with all deaths reported occurring at community level. The deaths oc- curred in Midlands (5 in Gokwe south) and Manica- land (1 in Mutare urban) provinces.

There was a 28% reduction in reported cases com- pared to week 19 (201 compared to 281.The highest (weekly) case loads were observed in Harare (95) and Midlands (61) provinces. Matabeleland North and Matabeleland South re- ported no cases for the sixth cumulative week. Bulawayo also continued to report zero Inside this issue: cases this week. There was a decline in reported cases in all districts except for Gokwe South district where Cholera situation up- 1 an increase was experienced (6 cases in week 19 to 61 cases this week), resulting in Mid- date lands province reporting the highest weekly caseload. Chitungwiza reported 50 new cases Update on social mobi- 2 and Harare City, 45, among the highest district case loads for six cumulative weeks. Other lization working group districts affected by cholera this week include; Makonde, Chipinge, Mwenedzi, Masvingo and activities Makoni. The average weekly reporting rate dropped from 85% in week 19 to 76% this week, with suboptimal reporting observed in Masvingo province. 86 cases reported in Mutare rural Stories from the field 4 were established as a case of batch reporting. Meetings and events 5 Response and recommendations • Concerted efforts are still required in the identified areas (hot spots) which continue to Donor response to 6 report high numbers of cases and deaths. There is a need to work with the leaders of the cholera Apostolic faith churches to find ways to prevent the spread of cholera in their communi- ties as many of the cases reported in the last few weeks have been due to religious gath- erings. As a major annual apostolic gathering of 100, 000 or more is planned during July in Manicaland, there is an urgent need to initiate a partnership with the community to find a way to prevent unnecessary morbidity and mortality. • Laboratory testing is ongoing in Gokwe and Kadoma to verify that reported cases are in- deed cholera. A test on stool samples collected by GAA-Merlin at an Oral Rehydration Point (ORP) recently indicated the possibility of a rotavirus outbreak. • Rotavirus is a winter virus that is transmitted by the faecal-oral route. It causes severe diarrhea, abdominal pain, vomiting and fever for 3-8 days (incubation of a few hours to 2 days). Globally, the virus causes up to 527,000 annual deaths among children below 5 years old, most among children between 6 and 24 months. By age 3, most have devel- oped antibodies that make repeat episodes less severe. Mothers and caregivers of chil- dren are being encouraged to practice proper hand washing as well as to ensure that children’s nappies are properly covered to prevent the spread of the virus to other chil- dren. Health education is ongoing at ORPs, more community education shall be carried out during the national immunization days. Zimbabwe Health Cluster bulletin

Update on activities of the joint health and those who can be persuaded to seek treatment are discouraged by high mortality rates in institutions. WASH social mobilization working group

On 19/20 (Harare) and 26/27 March (Bulawayo), na- tional health promotion trainer of trainers’ workshops A Participatory were carried out by the joint health-WASH social mo- Health and bilization working group of the cholera command and Hygiene Educa- control centre. The participants were health promo- tion session tion resource persons at national and provincial level . during the The aim of the workshops was to; Masvingo train- ing Photo • Orient health promotion resource persons on har- credit: N. monized a health promotion message and Ngwenya, WHO • Set up structures at community level to support epidemic preparedness and response The methods used included; • Poor health seeking behaviour among many mem- • Pre and post tests bers of the community also caused a delay in seek- • Presentations by resource persons and discussions ing treatment and resulted in deaths at both com- with participants munity and in health facilities (many institutional deaths are also attributed to delays in treatment • Group work and plenary seeking). Focus group discussions in some communi- The trainers were then expected to cascade the train- ties revealed that a loss of faith in the formal ing to district and ward level, based on work plans health services due to lack of human resources and drawn at the workshops. As of 29 May, a total of 8 even drugs discouraged people from going to health provinces had carried out cascade training to district facilities for treatment. level (see the table below for details). • In addition, lack of sugar due to the economic crisis Based on discussions at the workshops, the following prevented the making of salt sugar solution (SSS), and Oral Rehydration Salts (ORS) was only available Province No of districts covered within institutions. Deaths in health institutions have been attributed to; Manicaland 7 • Other underlying causes such as malaria, HIV/AIDS, Masvingo 7 diabetes, high blood pressure among others;

Mashonaland Central 8 • geographical access to CTCs • human resource challenges resulting in low staff to Mashonaland East 8 patient ratios (3:100 reported in Manicaland) result- ing in deaths especially at night Mashonaland West 8 • Lack of skills/training as cholera was a ‘new’ disease Matabeleland North 7 • limited treatment supplies, particularly antibiotics for treatment of patients with co-morbidities Matabeleland South 7 2. Aquatabs and other household water treatment Midlands 8 chemicals face continued resistance due to the smell and taste of the water. There is a need for Total: 8 provinces 60 districts continued education on the importance of water treatment and boiling of all drinking water. The pro- vision of aquatabs on the retail market was strongly lessons have been drawn for future outbreak re- advocated for. In addition, there is a request from sponses; districts for provision of aquatabs as part of the 1. Explanations for high case fatality rates emergency response stockpile for use at facility level. At community level: 3.Hygiene practices: During pre and post workshop • Religious beliefs among predominant apostolic faith tests among participants, there was limited percep- (in Manicaland and Midlands) played a big role in tion of the fact that hand washing is meant to kill the high number of community deaths. This is be- germs, rather than merely remove dirt. This should cause they generally discourage medical treatment be addressed in the review of information education and discussions with the community indicate that & communication materials on hand hygiene. Page 2 Zimbabwe Health Cluster bulletin

4. The importance of village health workers in com- formed with the church to improve immunization munity preparedness and response was acknowl- coverage. Interviews with members of the sect in edged; there was a recommendation for the ur- other areas indicate that they have not been in- gent revitalization of the program in all areas. As cluded in other health activities and resent the fact MoHCW is currently updating the VHW training that they have only been approached during a crisis. module and overall program, the working group They also feel stigmatized by attitudes expressed has made suggestions for additional areas to be towards them. As such, it has been agreed that per- included in the training including but not limited suasion as a strategy for health promotion is the only to community outbreak response, the VHW kit and option as enforcement of the public health act (for harmonization of incentives. A number of partners outbreaks) drove away the very people that it was are interested in working towards the revitaliza- meant to be protecting in the past. tion of the program and proper coordination will 11. There is a need to agree on strategies for communi- go a long way in making it successful. cation with vulnerable and/or hard to reach groups. 5. Importance of synergistic partnerships and coordi- In Manicaland and Mashonaland Central, gold pan- nation in management of cholera. Some areas ners were identified as an at risk community because reported conflict between partners and the dis- many are illegal and are therefore hesitant to pre- trict MoHCW staff. There is a need for clear infor- sent for treatment. The other vulnerable groups mation on C4 roll out down to district level as identified were prisoners, the elderly, children below there seems to be a dearth of knowledge on how 2 years, people with no fixed abode and people with to use it as a platform for coordination. There is disabilities. It was agreed that for health promotion also a need to strengthen leadership among ‘one size does not fit all’. MoHCW to support coordination, with clear roles 12. In order to strengthen health promotion, the joint and responsibilities drawn out for both MoHCW and health-WASH social mobilization working group have partners to avoid conflict. agreed that a shared annual work plan be made un- 6.Lack of personal protective equipment (PPEs)-many der the leadership of the Ministry of Health and Child health facilities were forced to improvise in ways Welfare. As part of this strengthening process, the that could have endangered their health. This area national draft health promotion strategy is being re- needs to be addressed urgently. viewed by the group. It has been agreed that remit of the group should move beyond outbreak response; 7.Transport and Communication challenges: lack of the expertise of its various partners should be used transport (no vehicles, broken down vehicles/ to strengthen health promotion down to district motorcycles, lack of fuel) and poor communication level. (lack of radios, broken down radio systems, poor telephone coverage, erratic electricity supply) Update on working group activities were major challenges in surveillance, community • An advocacy kit for parliamentarians was finalized health promotion and overall coordination of the and shared with MoHCW. It was used for advocacy for outbreak. Addressing these challenges will go a increased financial support to health systems. long way in improving the health system. • Population Services International (PSI) is using road- 8. Oral Rehydration Points (ORPs) in the community shows for health promotion (for cholera) at various were useful in preventing the progression of chol- locations. Initially targeting the Harare-Bulawayo cor- era cases to a severe state or death. It was sug- ridor, the program has expanded to cover the rest of gested that effort should be made to set up ORPs Zimbabwe. Prior to each roadshow, an assessment of in all communities during outbreaks of diarrhoeal the target area/population is carried out (this in- diseases, particularly at the peak of the outbreak. cludes meetings with local leaders and communities) 9. Incentives/staff salaries: The question of incen- to assess risk perception. PSI engages artistes to dis- tives for health workers at CTCs arose at every seminate the message using skits, music and other workshop. There is need for clear communication edutainment methods. The emphasis of the messages in this area as many health workers expressed dis- shared is on hand washing, signs and symptoms of di- appointment, lack of morale and even an unwill- arrhoea-what to do, the benefit of the water treat- ingness to be involved in future outbreaks, if they ment products, demonstration of products. IEC mate- occur. rials are also distributed. 10. The Health promotion best practice was noted in • A national clean up campaign is being planned and Manicaland where a partnership between the pro- coordinated by Zimbabwe National Revival Initiative vincial health team and the John Marange Apos- (Zinri) for the month of August. A weeklong cleaning tolic church worked to prevent unnecessary mor- campaign shall be preceded by conference sessions bidity and mortality due to cholera through the intended to encourage and challenge communities to set up of a CTC in a predominantly apostolic area take charge of their health by finding sustainable and the inclusion of members of the community ways to maintain good sanitation. Already some dis- in health promotion initiatives there. This may tricts in Masvingo are organizing district level cam- have worked because a partnership had been paigns. Page 3 Zimbabwe Health Cluster bulletin Experiences during the Zimbabwe cholera household members knew how to prepare Salt Sugar So- lution (SSS) but during the outbreak lacked the sugar to outbreak By Dr P Musiwa, Health consultant, UNICEF make it. They are currently using water treatment tab- lets due to fear of another wave of cholera in the chol- This article is an anecdotal account of interviews era. The family was grateful for the NFI kits received so with individuals and households affected by cholera; far and requested for more of everything as their family an effort to explain their circumstances and views. is quite large. They also requested for cement to build Case 1: Hunger causes cholera latrines and above all FOOD. A family of 36 people living in Chemagora Village on 1 homestead with 6 households in the compound. Case 2: I looked into the eyes of a woman who had lost The family is dependent on illegal gold panning—it a son to cholera often takes up to 3 or 4 days for an individual to col- lect enough to make a ‘point’ whose value is One of the families I visited had five family members, USD$1.50. They also practice backyard farming. The lived in a clean, well fenced homestead, had a rubbish head of the household is a polygamist with 3 wives, pit and a smart Blair latrine. They demonstrated excel- they are all members of the Vadzidzi Apostolic Faith lent knowledge of cholera transmission and prevention Church. 12 family members were available for the measures and general hygiene . interview. However, they had lost a member to cholera. The main The homestead is overcrowded, with many huts and respondent to the interview was the mother of the de- plenty of children flitting about. There were no la- ceased. When it came to answering the question of any trines, no rubbish pit and no demarcations around cholera cases in the family, there was a chilly silence in the compound. The vegetable garden was very small the room, she looked me straight in the eye and gave me with limited yield. a pained yes. He had died in the previous month and had left 2 orphans. Cholera Situation He had been residing and working in Bindura and had 7 Household members were affected by cholera and contracted the cholera and died there. They were called one is deceased due to the illness. The index case to the funeral, but unfortunately she wasn't able to at- was a young, single gold panner at the nearby Mu- tend it because she lacked the bus fare. Her other 2 sons karadzi River. He was taken to the local health facil- were able to travel, but by the time they arrived their ity after 1 week where he died. By that time his brother had already been buried in accordance with pub- mother and other family members had already con- lic health protocol for burial of cholera victims. tracted cholera. The subsequent cases were taken to the clinic more promptly and Oral Rehydration Salts (ORS) solution was made and used since the family Case 3: I live with cholera in my backyard had received some sachets from the health facility. In Budiriro ward 4, there is a widow who lives with her View of Cholera 2 teenage sons. She has a 7 roomed house but only uses Most of the respondents believed that the underlying 2 of the rooms. The rest of the house she lets to 3 other cause of this cholera epidemic in their family is hun- tenants who live there with their families. On the day of ger. They indicated that the mealie meal that they the visit one of her sons was suffering from diarrhea. He buy is of inferior quality and has made them vulner- had been to the cholera treatment centre and informed able to diarrhoea. They agreed that poor sanitation that he did not have cholera but another diarrhea for may have a role in the spread of cholera, however, which he was being treated. Of note is that this boy had they strongly believe that if the food situation is had this diarrhea on and off for more than 6 weeks. As a solved, it would go a long way in combating the dis- clinician, I was curious to investigate the case. The lady ease as hunger forces them to eat whatever they lay then explained that her flushing toilet had not been their hands on and throwing away leftovers is not an working for up to 3 weeks because the sewer system was option. not working. The general view was that individual disease suscep- Apparently, quite a number of homesteads had been us- tibility upon exposure played a big role in contrac- ing the bush system (open defecation) for some time in tion of cholera-those who have ‘weak blood’ will Budiriro. She however said her biggest challenge was the catch the illness. situation in her backyard which she unfortunately could not control despite all her efforts and knowledge of chol- Cholera Education era/diarrhea issues. It depended on the local council Thy reported receiving some hygiene education when maintenance and service activities. they received Non Food Items (NFI) kits. However She was really upset and insisted that I go around to her still have no latrine because they do not have money backyard and see for myself (see the picture). to buy cement to construct a blair toilet. They prac- tice hand washing with water only due to lack of soap. They reported never trying to use ash. Some

Page 4 Zimbabwe Health Cluster bulletin

However one evening, in August 2008,, at the begin- ning of the outbreak when people were still unsure if there was cholera or not, the nurse had her supper prepared as usual. She waited for her husband to come home and they had supper as always. Later that evening she left for work (she was on night duty) complaining of a mild stomach upset. On arriving at work she started to have rice water stool. She notified her colleagues of her predicament when she felt it had become too uncontrollable for her too manage on her own. She was transferred to the just opened main CTC in Harare in the early morning hours. Her family was notified of this event and by that time her husband was had diarrhoea. The children and grandchildren were all well. They took Drying faecal matter covered by asbestos sheets in a back- their father to the clinic immediately. They both died yard, case 3. Photo credit: P. Musiwa, UNICEF later in the morning.

Case 4-Cholera is all about your immune susceptibil- Case 6-Remove the Budiriro CTC and cholera will go ity somewhere else During visits in Budiriro some statement constantly Some individuals, especially youth interviewed felt came up from the community members, such as very strongly about the the CTC in Budiriro. They had “Cholera is really God’s will” , not been directly affected by the disease but they “contracting cholera depends on the person’s blood” felt that their community had been exposed to the and risk of contracting cholera by having the cholera “Acquiring cholera is dependant only on one’s immune treatment centre in their community. susceptibility”. These community members acknowledged the prob- lems of inadequate water supply, no refuse collection Most of these people argued that despite all the hy- and burst sewer pipes within their community as ma- giene promotion, a lot of very smart people got chol- jor factors to the cholera outbreak and its persistence era whilst some people who are so filthy did not get in their community. However, they also felt that by the disease. They cited examples in their own commu- having the cholera treatment centre in Budiriro nity of households were cholera had attacked quite a (which is a referral hospital for Harare province), it number of family members yet it will be a household keeps their community at risk of cholera hence the ranked as one of the most sanitary and clean in the high number of cases reported in the area. They re- neighborhood. They remarked that some households ported that many patients were brought in they by considered prone due to poor hygiene standards and public transport, vomiting and passing diarrhea along evident filth had escaped the disease. Some even went the roads which the community members use in their on to support their ideas by noting that the “mad” day to day activities. They wanted the CTC moved as people on the streets who ate from the bins had not they strongly believed this would change matters in suffered or died yet they ate from the garbage it- self….Food for thought from these community mem- Budiriro. bers Meetings and events “Maybe if you are too smart/hygienic you may end up getting the disease because your immune system is not • The revised Zimbabwe Consolidated Appeals Proc- exposed to diseases and therefore it is weak……..” ess (CAP) shall be launched on 1 June 2009 at Miekles Hotel, Harare. The priorities have been revised to reflect changes in the current situation Case 5-Health workers can die because of their jobs for example under health, the need for support to In Glen View 1 a nurse, 58 years of age, and her hus- health system in terms of equipment, staff recruit- band aged 55 years, died of cholera. This nurse worked ment and retention. at one of the central hospitals in Harare. They lived in a 5 roomed house and did not have any lodgers in their • The joint health and WASH cluster meeting shall main house. They lived with their children, daughter- be held on 3 June at WHO conference room, Pari- in-law and 2 grand children. The homestead was al- ways kept immaculately clean with a functioning toilet renyatwa hospital at 9am. and a refuse bin. According to the respondents, They • National Immunisation Days shall be held on 8-12 boiled their drinking and thoroughly prepared their June 2009 food and kept all vegetables washed. Page 5 Zimbabwe Health Cluster bulletin

Update on Influenza A preparedness in Zimbabwe ness of health institutions and ports of entry

Although Africa has not reported any cases of Influ- • Over 21,000 stocks of tamiflu and 75 personal protec- enza A (H1N1), high HIV prevalence rates and winter tive equipment for investigation in Southern Africa (influenza season) could make it • Flyers and posters with alerts for the general public potential disaster as not much is known about the ae- and travelers. Short messages shall be sent to subscrib- tiology of the virus. ers by Econet, a telecommunication provider. Some of the mitigation measures in place in Zimbabwe • Assessments at ports of entry and infectious diseases include: hospitals (Wilkins, Harare and Thorngroove, Bulawayo) • Weekly taskforce meetings to coordinate prepared- More information can be made available on request

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 Email: [email protected] http://ocha.unog.ch/humanitarianreform/Default.aspx?tabid=75

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/USAID IOM, WHO Health $7, 305, 529

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