Epidemiological Bulletin Number 34 Week 47 (week ending 22 November 2009)

Foreword

This bulletin provides a weekly overview of the outbreaks occurring in . 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 47 (week ending 22 November 2009).

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

Mobile number for alerts is 0912 104 257

Acknowledgements

We are very grateful to MoHCW District Medical Officers, District and Provincial Surveillance Officers, Provincial Medical Directors, 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.

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 1 Figures See also summary tables (annex 1), maps (annex 2) and graphs (annex 3). The case definitions can be found in appendix 1 and detailed data by district are shown in appendix 2

Since September 2009

9 out of the 62 districts in the country have been affected by the ongoing cholera outbreak. 146 cumulative cholera cases and 5 deaths were reported by 22nd November 2009 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 3.4%. By week 47 last year, 7186 cumulative cases and 282 deaths had been reported, with a crude case fatality rate of 3.9%.

The cases reported this year are 2.0 % of last year’s cases , whilst the deaths are 1.8% of last year’s deaths. This year’s case fatality rate is lower than last year’s by 0.5% .

Week 47 (16th November - 22nd November 2009)

29 cases were reported this week of which 26 cases were back reported from , 1 case from Kadoma and 2 cases from Gokwe North.

Geographical distribution of cases

The cases reported came from the following districts: , , Chipinge, Gokwe North, Gokwe South, , Kadoma, Makonde and Rushinga. The affected districts are in the following five provinces namely: Harare, Manicaland, Midlands, Mashonaland Central and Mashonaland West. 58 (39.7%) of the cumulative cases were reported by Manicaland, followed by Midlands with 57 cases (39.0%) and Mashonaland West which had 22 cases (15.1%). Mashonaland West province has the highest number of districts affected by cholera namely 3.

Urban/Rural distribution of cases

80.1 % of the cumulative cases were from rural areas and the rest, 19.9%, from urban areas compared to last year’s scenario of 84.9% cases from urban areas and 15.1% from rural areas in the corresponding week.

Assessments & response

A report from the Medical Officer indicated the following; • The index case did not have a history of travel, but collected water for household use from the river bed. The patient, who was part of the Johann Marange Apostolic sect, did not seek treatment after developing vomiting and diarrhoea. The case was not reported to the authorities. The second case and subsequent cases were linked to the first through burial gathering. • People 15 years and over (adults) were the most affected, with the oldest reported being 75 years old. • 13 villages in 3 wards (9, 35 and 35) were affected, with 9 being the worst hit. • Some of the risk factors for cholera in this community include;

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 2 • Attending a gathering especially funerals • Handling and Washing of bodies at funeral • Communal hand washing • Not using soap to wash hands • Use of water from unprotected source e.g. river beds • Use of wide mouthed water storage containers • low latrine coverage and use • Poor knowledge of cholera • Poor (or no) treatment seeking behaviour • Best practice has been the set up of Oral Rehydration Points (ORPs) set up in all affected communities. • Contact tracing, disinfection of affected households

Clinics are well stocked, with additional stocks available for CTU or ORPs in Gokwe District store through the support of Merlin and the C4. Blanket hygiene education and NFI distribution has been carried out in the district supported by the WASH cluster (UNICEF, OXFAM and CONCERN). Soap, aquatabs and ORS are therefore now available at the household level. The support of the Apostolic faith mission in Gokwe has been instrumental in getting the congregation to accept to use ORS and aquatabs. . Rumour investigations Reports of suspected cholera in Kanyemba border area, were investigated and found not to be valid. There is, however, an increase in the number of cases of diarrhoea reported in a ward in Guruve district that hosted an Apostolic gathering. Kanyemba may be vulnerable to cholera as the community depends on water from the Zambezi river for household use. An assortment of essential supplies such as ORS, water treatment tablets, buckets with lids, jik, washing soap, hand-gel, gloves and cotton wool are pre-positioned at Guruve Hospital. The District Medical Officer will arrange a meeting with Zambia and Mozambique counterparts to discuss and share information on cholera preparedness and response for the adjoining border districts. The meeting will be supported by IOM. IOM also plans to install temporary Blair latrine toilets at Kanyemba Border Post before the end of December.

A suspected case of cholera from Sanyati fishing area reported in Kanyati rural clinic (, Mashonaland West) was found to be negative.

The full assessment reports are available on request.

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 3 Pandemic H1N1 (2009)

By week ending 22 November, 249 cumulative probable1 cases of Pandemic H1N1 (2009) had been reported in Zimbabwe, 41 of which were confirmed by PCR (Polymerase chain reaction) to be Pandemic H1N1 (2009).

Week 47 (16th November - 22nd November 2009) No new cases of both probable and confirmed Pandemic H1N1 (2009) cases were reported this week.

Geographical distribution of cases The following provinces have reported cases: Manicaland, Harare, Mashonaland East and Midlands. The affected 8 districts are: Harare Urban, , , Goromonzi, Seke, Mutasa, Nyanga and Chirumhanzu.

Assessments & response

Two laboratory medical scientists from the National Microbiology Reference Laboratory, NMRL and National Virology Laboratory were on attachment training at the National Institute of Communicable Diseases (NICD), South Africa from 16 to 20 November, to capacitate them in using real time PCR technology

WHO has procured a Real Time PCR machine, reagents and consumables for use in confirmatory testing for H1N1. This will enable laboratory surveillance of the virus which is of particular importance given recent evidence of mutation and increasing resistance to Tamiflu®.

Measles

The total number of reported suspected measles cases to date is 207 whilst the total number of measles IgM positive cases is now 57.

Week 47 (16th November – 22nd November 2009)

7 new cases were reported. Kuwadzana and Hatfield in Harare reported 1 case each whilst Marange, had 5 cases. All the cases were members of Apostolic Sects which do not accept immunisations. 6 of the 7 cases were not vaccinated. The vaccination status of 1 was not indicated. The ages of the patients ranged from 4years old to 13 years.

Geographical distribution of cases

To date 13 districts have reported measles outbreaks namely: Bubi, , Gokwe South, Harare, , Makoni, Makonde, Marondera, Mutare, Chegutu, Chipinge, Chirumhanzu, .

1 See definition of probable case in Appendix 1

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 4

Annex 1: Summary Tables

Table 1: Cumulative Cholera cases and deaths reported by district for the period week 37 to week47

Cases Cumulative Institutional Community Attack Rate Province District Reported Cases Deaths Deaths Per 100 000 this week

Harare Harare 0 6 0 0 0 0 1 0 0 1 Mashonaland Rushinga Central Bindura 0 1 0 0 1

Kadoma 1 3 0 0 0 Mashonaland Chegutu 0 2 0 2 1 West Makonde 0 17 1 0 9

Manicaland Chipinge 26 58 0 0 19 Gokwe 2 25 Midlands 57 0 2 North Gokwe 0 0 1 0 0 South Total 29 146 1 4 5

Table 2: Age and Sex breakdown of cumulative cholera linelisted cases for the period week 37 to week 47

30 Years and Under 5 Years 5-14 Years 15-29 Years over District Male Female Male Female Male Female Male Female Gokwe North 3 0 5 4 8 14 7 16 Chipinge 0 0 5 5 4 4 4 4 Harare 1 0 0 0 0 2 1 1 Kadoma 0 0 0 0 1 0 0 1 Rushinga 0 0 0 0 0 0 0 1 Bindura 0 0 0 1 0 0 0 0 Total 4 0 10 10 13 20 12 23

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 5

Table 3:Age and Sex Distribution of Cumulative Confirmed H1N1 Cases from July to 8 November 2009

30 Years and Under 5 Years 5-14 Years 15-29 Years over District Male Female Male Female Male Female Male Female Chikomba 0 0 3 0 4 3 0 0 Harare 0 1 2 0 0 0 0 0 Mutasa 0 0 3 2 0 0 0 0 Seke 0 1 8 4 1 1 0 0 Unspecified District 0 0 5 2 1 0 0 0 Total 0 2 21 8 6 4 0 0

Table 4:Age Distribution of Cumulative Measles Igm Positive Cases from January to 16 November 2009

Age Groups

District Under Five Years 5-14 Years Above 15 years Total

Bubi 0 6 3 9

Bulawayo 3 0 0 3

Chegutu 2 3 0 5

Chipinge 1 4 1 6

Chirumhanzu 0 1 0 1

Harare 4 4 0 8

Gokwe South 0 1 0 1

Makonde 0 1 0 1

Makoni 1 0 0 1

Marondera 1 0 0 1

Mutare 1 4 0 5

Insiza 0 2 0 2

Kwekwe 1 0 0 1

Zvishavane 5 11 1 17

TOTAL 19 37 5 61

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 6 Annex 2: Maps

Map 1: Comparison of cumulative cholera cases by district as of week 47, 2008 and 2009

2009 2008

Map 2: Cumulative probable Influenza A H1N1(2009) cases by district, July-22 Nov 2009

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 7

Annex 3: Graphs

Graph 1:Ranking of District Cumulative Cholera Cases Reported by week37-47,2009

Chipinge

Gokwe North

Makonde

Harare Urban

Kadoma

Chegutu

Gokwe South

Rushinga

Bindura

0 10203040506070

Graph 2:Ranking of District Probable H1N1 Cases Reported by July to 22 November 2009

Last Epidemic Cases Present Epidemic Cases

9000 30

8000

25

7000

6000 20

5000

15

4000 2008 Cholera2008 Cases Cholera2009 Cases

3000 10

2000

5

1000

0 0 w34 w35 w36 w37 w38 w39 w40 w41 w42 w43 w44 w45 w46 w47 w48 w49 w50 w51 w52 w1 w2 w3 w4 w5 w6 w7 w8 w9 w10 w11 w12 w13 w14 w15 w16 w17 w18 w19 w20 w21 w22 w23 w24 w25 w26 w27 w28 w29 w30 w31

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 8 Graph 3:Ranking of District Probable H1N1 Cases Reported by July to 15 November 2009

Graph 3:Ranking of Provincial Measles Cases Reported from January to 15 November 2009

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 9 Appendix 1: Case Definitions

Cholera The Zimbabwe cholera state definition states that "In an area where there is a cholera epidemic, a patient aged 2 years or more develops acute watery diarrhoea, with or without vomiting". ‘’A confirmed cholera case is when Vibrio cholerae is isolated from any patient with diarrhoea”. This is adapted from the WHO case definition for cholera. The inclusion of all ages in the case definition somewhat reduces specificity, that is, inclusion of more non-cholera childhood diarrhoea cases. It, however, does not impede meaningful interpretation of trends. Teams should monitor any shift in the age distribution of cases, which might indicate a changing proportion of non-cholera cases among patients seen. Influenza A H1N1 Influenza A and B are two of the three types of influenza viruses associated with annual outbreaks and epidemics of influenza. Only influenza A virus can cause pandemics. The Zimbabwe IDSR technical guidelines define influenza case by a new sub type (including Avian flu Influenza A H5N1 and Swine flu Influenza A H1N1) as; ‘’Any person presenting with unexplained acute lower respiratory illness with fever (>38 ºC ) and cough, shortness of breath or difficulty breathing AND notion of exposures in the 7 days prior to symptom onset.’’

Probable case definition: Any person meeting the criteria for a suspected case AND positive laboratory confirmation of an influenza A infection but insufficient laboratory evidence for H1N1 infection.

Confirmed H1N1 case: A person meeting the criteria for a suspected or probable case AND a positive result conducted in a national, regional or international influenza laboratory whose H1N1 test results are accepted by WHO as confirmatory.

There may be difficulty in telling apart mild cases of pandemic influenza from the seasonal influenza.

Suspected measles: Any person with fever and maculopapular rash and cough OR Coryza (running nose) Or conjunctivitis ( Red eyes) OR clinician suspects measles.

Measles Outbreak Definition: A cluster of 5 or more suspected cases OR at least 3 measles IgM positive cases in a district /health facility in a month.

Lab confirmed: Suspected case of measles with positive serum IgM antibody, with no history of measles vaccination in the past 4 weeks.

Confirmed by epidemiologic linkage: Suspected case of measles not investigated serologically but has possibility of contact with a laboratory-confirmed case whose rash onset was within the preceding 30 days (same / adjacent districts with plausible transmission)

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 10