Weekly Epidemiological Bulletin

Number 165 Epidemiological week 21 (week ending 27 May 2012)

Highlights: Week 21 (21 – 27 May 2012) diagnosis was found positive on 5 May 2012. Of  3 cholera cases reported in District the three isolates of specimens sent to the  Late reporting of 46 typhoid cases by Mash West National Microbiological Reference Laboratory  6310 malaria cases and 2 deaths reported (NMRL) for quality control and sero typing, one was confirmed for Vibrio cholerae Inaba.

Contents Three cholera cases were reported from A. General context Chiredzi. As of 27 May 2012, a total of 19 cases B. Epidemic prone diseases have been reported of which 8 were laboratory C. Events of public health importance in the region confirmed to be positive. D. Completeness and timeliness of the national data E.Acknowledgments Response activities: F.Annexes 1. Classification of events that may constitute a  An initial rapid assessment done by Public Health Emergency of International Action Contre la Faim (ACF) and Save Concern the Children in conjunction with Health Executive 2. Standard case definitions (DHE) team 3. Alert/action epidemic thresholds  Setting up of a Cholera Treatment

Centre (CTC) A. General Context  Deployment of EHTs and nurses to the CTC by Chiredzi DHE team Typhoid outbreak in is still on-going  Support and supervision by the since 10 October, 2011. The disease has spread provincial RRT to other provinces. However the weekly number  Provision of of cases has declined. o Drugs and other medical supplies (supplied by WHO) A cholera outbreak has been reported in o Laboratory reagents, Chiredzi district. o Airtime and fuel  Health promotion activities Malaria outbreaks have been reported in the  Daily coordination meetings following districts: Mudzi, Seke, Hurungwe,  Water quality monitoring Makonde, Zvimba, Mt Darwinand and seasonal increases in the number of cases Challenge: have been reported in many other districts.  Establishing source of infection No reports of influenza A and measles outbreaks countrywide. Typhoid outbreak

B. Epidemic prone diseases Since 10 October 2011, Harare City has been experiencing an outbreak of Typhoid Fever. The Cholera outbreak disease eventually spread to City, Mashonaland Central Province ( A cholera outbreak has been reported in district), Mashonaland West Province (Zvimba Chiredzi district. The index case was a 45 years and districts) and old male from Njiga Kraal. He had the (Chirumanzu district). As of 27 May 2012, a following symptoms: abdominal pains, total of 4725 cases have been reported. The diarrhoea and vomiting on 3 May 2012 and distribution of the cumulative cases is as shown presented at Old Boli clinic on the same day. in Table 1 below. Stool sample collected from him for laboratory

This weekly Epidemiological Bulletin is published jointly by the Ministry of Health and Child Welfare, Zimbabwe and the World Health Organization. 1 For correspondence: Email: [email protected] and [email protected] or call: +263772104257 or +263772277893

Zimbabwe Weekly Epidemiological Bulletin

Table 1: Distribution of typhoid cases by Response activities place of treatment, Zimbabwe, 10 October 2011-27 May 2012  Coordination meetings with the thematic committees involving Harare Place of 10 Oct-31 1 Jan-6 May Total City Health authorities and Partners Treatment Dec 2011 2012 (WHO, UNICEF, CDC, NGOs) every 2 n=1197 (%) n= 3484 (%) n=4681 (%) Zvimba 118 (9.86) 253 (7.15) 371 (7.85) weeks  Social mobilization activities Bindura 0 69 (1.95) 69 (1.46)  Case management, and investigation Chirumhanzu 0 1 (0.03) 1 (0.02)  Active contact tracing Chitungwiza 0 2 (0.06) 2 (0.04)  Water quality monitoring Chegutu 0 16 (0.45) 16 (0.34)  Bucket chlorination at water points Harare 1079 (90.14) 3187 (90.13) 4266 (90.29) Harare Central 0 8 (0.23) 8 (0.17) Figure 2: Map of the distribution of typhoid Hospitals cases by place of residence, Harare City, 10 Oct 2011- 27 May 2012

From 26 October 2011 to date, 68 samples were laboratory confirmed to be S. typhi of which 63 were from Harare and 4 from Bindura.

This week, no cases were reported from Harare. In the previous week no cases were reported countrywide. The epidemic curve is shown in Figure 1.

The map (Figure 2) shows the distribution of cumulative cases by place of residence in Harare City since the beginning of the outbreak to date.

Figure 1: Harare and Bindura Typhoid Epidemic Curve, 10 October 2011 – 27 May 2012 Anthrax

120 No cases of anthrax have been reported this week. The cumulative figure for anthrax is 17.

100

80 Malaria

60 This week, a total of 6310 cases and 2 deaths 40 were reported as compared with 7541 cases and Typhoid Cases Typhoid 9 deaths (CFR= 0.08%) in the previous week. 20 The 10 most affected districts are shown in 0 Table 3. Since the beginning of 2012, a total of

197 080 cases and 151 deaths (CFR= 0.08%)

2011/09/25 2011/10/02 2011/10/09 2011/10/16 2011/10/23 2011/10/30 2011/11/06 2011/11/13 2011/11/20 2011/11/27 2011/12/04 2011/12/11 2011/12/18 2011/12/25 2012/01/01 2012/01/08 2012/01/15 2012/01/22 2012/01/29 2012/02/05 2012/02/12 2012/02/19 2012/02/26 2012/03/04 2012/03/11 2012/03/18 2012/03/25 2012/04/01 2012/04/08 2012/04/15 2012/04/22 2012/04/29 2012/05/06 2011/09/18 has been reported.

Date of Symptom Onset

This weekly Epidemiological Bulletin is published jointly by the Ministry of Health and Child Welfare, Zimbabwe and the World Health Organization. 2 For correspondence: Email: [email protected] and [email protected] or call: +263772104257 or +263772277893

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Table 3: The top 10 malaria affected districts in week 21, Zimbabwe, 2012

C. Completeness and timeliness of the District Frequency National data n=7541(%) o Mt Darwin 836(19.9) National data reported in week n 21  Completeness increased from 79% to Hurungwe 681(16.2) 81% 660(15.7)  Timeliness decreased from 85% to 78% Chimanimani 505(12.0) 292(6.9) D. Events of public health importance within 292(6.9) SADC 270(6.4) Zaka 266(6.3) No new events reported. Binga 210(5.0) Mbire 197(4.7) E. Acknowledgements

Response Activities: All health workers, operating at different levels of the health system, providing information are  Outbreak verification assessment greatly acknowledged. In addition, special conducted by MOHCW with support thanks to Health and WASH cluster members from GOAL in for sharing their data with our team.

 Health promotion campaigns MOHCW is grateful to all Partners including  Challenges: late submission of statistics UN family and NGOs for their support. by the village health workers to Clinics Information on events of public health

importance occurring within SADC is

consolidated from the WHO daily summary of Figure 3: Comparison of national malaria cases health events. 2012 vs. 2011 and epidemic threshold

2011 threshold 2012

20000

15000

10000 Cases 5000

0 1 4 7 101316192225283134374043464952 Week Number

This weekly Epidemiological Bulletin is published jointly by the Ministry of Health and Child Welfare, Zimbabwe and the World Health Organization. 3 For correspondence: Email: [email protected] and [email protected] or call: +263772104257 or +263772277893

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Annex 1: Classification of Events that may constitute a Public Health Emergency of International Concern

There are three groups of events if detected by the national surveillance system should trigger the use of the IHR (2005) Decision Instrument to be notified as they may constitute Public Health Emergencies of International Concern. These are:

1. A case of unusual or unexpected diseases which may have serious public health impact: smallpox, poliomyelitis due to wild-type poliovirus, human influenza caused by a new subtype and SARS.

2. Any event of potential international public health concern including events of unknown causes or sources and those involving other events or diseases:  environmental health emergencies (natural events, chemical and radio-nuclear events, technological incidents, complex emergencies and deliberate events)  Food borne diseases  Zoonotic diseases or other infectious diseases.

3. Any of following diseases that have demonstrated the ability to cause serious public health impact and spread rapidly and internationally: Cholera, pneumonic plague, yellow fever, viral haemorrhagic fevers, West Nile Fever, other diseases that are of special national or regional concern e.g. dengue, RVF and meningococcal disease.

This weekly Epidemiological Bulletin is published jointly by the Ministry of Health and Child Welfare, Zimbabwe and the World Health Organization. 4 For correspondence: Email: [email protected] and [email protected] or call: +263772104257 or +263772277893

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Annex 2: Standard Case Definitions

Diseases Standard Case Definitions Cholera Suspected case  In an area where there is no cholera outbreak, any person aged five years or more, presenting with severe dehydration or death from acute watery diarrhoea  In an area where there is a cholera outbreak, any person aged two years or more presenting with acute watery diarrhoea, with or without vomiting

Confirmed case A suspected case in which Vibrio cholerae sero-groups O1 or O139 has been isolated in the stool. Note  All suspected cases under the age of two years must be confirmed.  The inclusion of all ages in the case definition somewhat reduces specificity, that is, inclusion of more non-cholera childhood diarrhoea cases (mainly those below 5years). It 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. Malaria Suspected uncomplicated malaria Any person living in a malaria area or history of travelling in a malaria area within the last 6 weeks, presenting with fever, malaise, chills, and rigors, without signs of severe disease such as vital organ dysfunction

Confirmed uncomplicated malaria Is suspected uncomplicated malaria with laboratory diagnosis by malaria blood slide or RDT for malaria parasites

Confirmed severe malaria A patient hospitalized with P. falciparum asexual parasitaemia as confirmed by laboratory tests with accompanying symptoms of severe disease (vital organ dysfunction) Typhoid Suspected case Any person with gradual onset of steadily increasing and then persistently high fever, chills, malaise, headache, sore throat, cough, and, sometimes, abdominal pain and constipation or diarrhoea

Confirmed case A suspected case confirmed by isolation of Salmonella typhi from blood, bone marrow, bowel fluid or stool

Diarrhoea Suspected case Passage of 3 or more loose or watery stools in the past 24 hours with  or without dehydration or  some dehydration and two or more of the following signs: restlessness, irritability, sunken eyes, thirsty, skin pinch goes back slowly, or  severe dehydration and two or more of the following signs: lethargy or unconsciousness; sunken eyes; not able to drink or drinking poorly; skin pinch goes back very slowly

Confirmed case Suspected case confirmed with stool culture for a known enteric pathogen. Note: Laboratory confirmation of specific agent causing outbreak is not routinely recommended for surveillance purposes.

This weekly Epidemiological Bulletin is published jointly by the Ministry of Health and Child Welfare, Zimbabwe and the World Health Organization. 5 For correspondence: Email: [email protected] and [email protected] or call: +263772104257 or +263772277893

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Annex 3: Alert/Action Epidemic Thresholds for selected epidemic prone diseases and other diseases of public health importance in Zimbabwe Disease or condition Alert Threshold Action Threshold Measles 5 suspected cases within a district in a 1 measles IgM confirmed case month Note: This also applies to closed settings like Refugee camps, schools, or health facilities Meningococcal meningitis 1 suspected case 1 confirmed case Plague 1 suspected case 1 confirmed case Rabies 1 case of a bite from 1 case of a bite from suspected rabid animal (Suspected rabid bites) suspected rabid animal Trypanosomiasis 1 suspected case  1 case in an area that is not endemic or  For endemic areas 3 cases per 100,000 Typhoid fever 1 case  5 suspected cases per 50,000 population or  20 suspected cases per District’s catchment area or  any 1 confirmed case by blood culture Viral Haemorrhagic Fever 1 suspected case 1 confirmed case Outbreak of unknown 3-5 cases or deaths with Any cluster of cases or deaths that had similar cause similar symptoms that symptoms over a short period of time and fail to don’t fit most case respond to treatment for the usual causes of the definitions symptoms Acute Flaccid paralysis 1 AFP case 1 confirmed case of polio (virus isolated). (AFP) / Polio Dysentery 5 cases or more per  A 2-fold increase in the number of cases reporting site per week compared to an expected number usually seen in previous season – specific time period  Any increase in number of deaths due to bloody diarrhoea Cholera 1 suspected case 1 confirmed case (where it has not been reported before) Diarrhoea under five Increasing number of Doubling of no of cases as compared to the same cases in a short time time period of a previous year. Malaria Increasing cases above  No of cases that exceed those in the 3rd the median quartile (the upper limit) of the expected number of cases or  No of cases that exceed the mean plus 1.5 x Standard Deviations (Mean + 1.5 SD). Neonatal Tetanus (NNT) 1 suspected case 1 confirmed case Human influenza caused by 1 suspected case 1 confirmed case a new Subtype Severe Acute Respiratory 1 suspected case 1 confirmed case Syndrome (SARS) Adverse Events Following 1 suspected case 1 confirmed case Immunisation (AEFI) Acute Viral Hepatitis 1 suspected case 1 confirmed case Anthrax 1 suspected case 1 confirmed case

This weekly Epidemiological Bulletin is published jointly by the Ministry of Health and Child Welfare, Zimbabwe and the World Health Organization. 6 For correspondence: Email: [email protected] and [email protected] or call: +263772104257 or +263772277893

Zimbabwe Weekly Epidemiological Bulletin

Notes An alert threshold suggests to health workers that further investigation is needed. Health workers respond to an alert threshold by:  Reporting the suspected problem to the next level  Reviewing data from the past  Requesting laboratory confirmation to see if the problem is one that fits a case definition  Being more alert to new data and the resulting trends in the disease or condition  Investigating the case or condition  Alerting the appropriate disease-specific programme manager and district epidemic response team to a potential problem.

An epidemic/action threshold triggers a definite response. Possible actions include communicating laboratory confirmation to affected health centres, implementing an emergency response, community awareness campaign, or improved infection control practices in the health care setting.

Reporting  T1 for notification of an infectious notifiable disease (used for up to five cases after which line lists must be filled)  Weekly Rapid Disease Notification Form  Reporting is to the next level (health facility to district to province to national level)

This weekly Epidemiological Bulletin is published jointly by the Ministry of Health and Child Welfare, Zimbabwe and the World Health Organization. 7 For correspondence: Email: [email protected] and [email protected] or call: +263772104257 or +263772277893