Cholera Outbreaks Bulletin for Eastern And

Bulletin: Cholera and AWD Outbreaks in Eastern and Southern Africa Regional Update for 2018 - as of 31 December 2018 Highlights

Cholera continues to represent a major public health concern in Eastern and Southern Africa Region (ESAR). From 10 37,565 443 1.2% Eritrea January to December 2018, approximately 37,565 cases and 443 cholera-related deaths were reported in the region with an average CFR of 1.2%. These cases emerged from 10 out of the 21 countries in Eastern and Southern Africa Countries Cases deaths CFR Region (ESAR).

In 2018, the cholera burden in ESAR was markedly heterogeneous, with Zimbabwe accounting for the highest case load at 28.8% (10,807 cases), followed by Somalia reporting 17.2% of cases (6,447 cases). During the same period; Kenya reported 15.4% (5, 782) of cases, Tanzania reported 4,688 cases, Zambia declared 4,127 cases, Uganda recorded 2,699 Somalia cases, Angola reported 1,262 cases, Mozambique declared 863 cholera cases, Malawi registered 785 cases, Rwanda 3 Ethiopia cases and recently Burundi declared 102 cases. South Sudan

Out of the 10 countries with reported cholera/ AWD outbreaks in 2018, 5 (Burundi, Zimbabwe, Angola, Somalia and 30 Tanzania) have ongoing cholera outbreaks. 6,447 Burundi: A new cholera outbreak emerging from Rumonge Health Province in Rumonge District was declared on 28 45 December 2018. This is attributed to heavy rains that have led to flooding in the coastal areas of Lake Tanganyika. The outbreak continues to evolve with a cumulative total of 102 cases including 1 death (CFR, 1%) notified by 31 December 2,699 Uganda 2018. 60 78 Somalia: 30 new cases of AWD/cholera were reported in week 52 (week ending 31 December 2018) compared to 26 Kenya cases reported in week 51 (Week ending 23 December 2018). Cumulatively a total of 6,852 cases including 45 deaths 3 Rwanda have been reported since December 2017 from 5 regions (Banadir, Lower Jubba, Middle Shabelle, Lower Shabelle and 1 19 Hiraan). The cholera outbreak has been contained in 4 regions, however active transmission is still ongoing in the Banadir Burundi 5,782 region where 30 new cases were reported in week 52. Children under five years bear the brunt of the cholera epidemic, representing 54.5% (3,512 cases) of the total case load reported in 2018 (Epidemiolgical week 1 to 52). 102 84 102 Tanzania Angola : Since the onset of the latest wave of cholera outbreak in September 2018, a total of 312 cases including 3 deaths (CFR, 1%) were reported by epidemiological week 52. During week 52, 20 new cases were reported from Uige province 13 compared to 10 cases reported in week 51. 4,688 Tanzania: A new district (Uvinza district in Kigoma region) reported 13 cases of Cholera in Week 52. Cumulatively a total of 20 33,319 cases including 550 deaths have been reported in the United Republic of Tanzania since August 2015. 4,127 1,262 28 Malawi Comoros Zimbabwe: The weekly case incidence has been on a downward trend in the past 3 weeks (week 50 to week 52). During week 52, 10 new cases were reported compared to 17 cases including 5 deaths (CFR, 29.4%) reported in week 51. These new cases emerged from Murehwa district in Mashonaland East (2 cases), Gokwe North district in Midlands (7 cases) and Angola Zambia 785 Mt. Darwin district in Mashonaland Central (1 case). Cumulatively, a total of 10,630 cases including 65 deaths have been 18 55 reported since the beginning of the new wave of the outbreak on 5 September 2018. Mozambique Urban - Rural Disaggregation of Cholera Cases 71 10 Zimbabwe 863 An analysis of cholera cases reported in 2018 from seven countries (Angola, Kenya, Mozambique, Malawi, Tanzania, Madagascar Uganda and Zimbabwe) reveals that overall, urban areas account for 57 % (15,214 cases) of the total caseload while rural 10,807 areas account for 43% (11,465 cases). Zimbabwe accounts for the highest number of cases (67.6%, 10,281) reported in Namibia Botswana 3 urban areas, followed by Uganda (15.2%, 2,307). However, it’s a contrasting scenario for Kenya, Malawi and Tanzania, Legend reporting higher cases in rural than urban areas, with Kenya reporting the highest number of cases (5,525, 48.2%) in rural areas Zimbabwe 10,281 533 New cholera cases (last 1 week: week Uganda 2307 392 Swaziland 52) 2018 Cumulative cases Angola 1262 0 Cholera Deaths Urban Rural Lesotho Mozambique 682 181 Number of new cholera deaths (Week 52) / 2018 Cumulative deaths South Africa Malawi 386 398 Status of the Outbreak No data No outbreak reported in 2018 Kenya 257 5525 Countries with no ongoing outbreaks Countries with ongoing outbreaks Tanzania 39 4436 Creation date: 31 December 2018 Sources: Ministries of Health and WHO Country Priorities and Response Interventions

Country Priorities Response Interventions • More than 950,000 people reached with key health and hygiene messages in cholera affected areas through different communication channels, including door to door and media campaigns including the 3 new affected districts of Mt Darwin, Mrehwa and Mberengwa - Continue holding weekly coordination meetings through the Emergency Strategic • Over 1106 Community health Volunteers trained and disseminating health and Hygiene education. A total of 81 community health Advisory Group (ESAG) clubs set up to spearhead hygiene education and 1068 School Health Masters (SHM) trained on critical WASH related information Zimbabwe to prevent cholera. • A cumulative 17,301 families have received kits, comprising of soap for handwashing, point of use water treatment and IEC - Intensify health and hygiene education throughout the country materials among others through support from various partners • Over 540,000 people reached with safe water through water trucking (private companies) and distribution of household water treatment chemicals by partners in the affected areas and borehole repairs - Provision of safe water through promotion of point of use water treatment methods • WASH Provincial Focal Agencies (PFAs) continue with supporting surveillance and reporting activities on a weekly basis in their respective areas of operation. • UNICEF supported prepositioning of WASH hygiene kits in all the 10 provinces

• A National cholera contingency plan has been developed with an estimated budget of USD 257,928 • UNICEF provided Cholera Kits and WASH supplies which have been distributed by the Burundi Red Cross in Rumonge as part Burundi : Current response interventions include; of the response • In partnership with a local NGO, UNICEF is currently supporting training for community leaders, media, health professionals to improve their capacity in community mobilization and cholera prevention

- Reinforce National, provincial and municipal coordination and information The following activities were conducted by Provincial Health Department in Uige: management mechanisms, including better coordination between different sectors of intervention • Cholera prevention and mobilization activities at markets, churches and schools in Uige’s affected municipalities by provincial health promotion staff, community development agents and environmental department staff Angola - Cholera prevention and mobilization activities at community level in Uige’s affected municipalities • Cholera prevention and mobilization activities with religious and traditional leaders in Uige municipality

- Training on cholera prevention and mobilization as well as case management for • Distribution of aqua tabs in affected neighborhoods health staff in the affected provinces • Broadcasting of radio spots and daily programme on cholera prevention and response in different national languages - WASH technical support throughout the country, with a special focus on Uige • Active search of severe diarrhea cases in the health facilities of the affected neighborhoods of UIge, Epidemiological team’s are conducting active case search in neighborhoods recently affected by severe diarrhea cases

- Follow up closely with communities on construction of toilets in the affected areas and ensure adherance to by-laws • In Uvinza district - Kigoma region, a CTC has been established at Buhungu Health Centre with adequate supplies provided by the regional medical office Tanzania - Capacity building of medical personnel on proper handling of cholera cases For both Uvinza district and Songwe region; - Increase the number of various cadres of health personnel (from the community level to higher levels of the health system) in affected areas • Health education on cholera prevention and control is on-going, including promoting personal hygiene and use of latrines

- Delivery of clean and safe water in areas affected by cholera • Active case search at community level with household distribution of aqua tabs for house hold water treatment

• A Cholera preparedness and response plan for the period 2018 / 2019 has been updated Mozambique : Current preparedness and prevention interventions include; • Cholera surveillance has been intensified and updates are shared with partners and media

• Prepositioning of cholera response commodities in hotspots districts is ongoing • UNICEF has supported the distribution of 180,000 bottles of water purification solution nationwide targeting 90,000 families living in high risk areas Annex 1: Distribution of Cholera / AWD outbreaks in Southern Africa and Challenges in Response - as from 1 of January 2018

Challenges: Zimbabwe 2 Burundi - Lack of WASH services for the ‘informal’ settlement in Mukaradzi, Mt Darwin Rwanda district with new cases - The artisanal miners who are the affected population are highly mobile and this is a risk factor to the spread of cholera Tanzania - High levels of insecurity and fear for attacks for humanitarian actors responding to the artisanal miners. Mara 1892 3 - Municipal Water Supply remains erratic in Harare Rwanda Arusha - illegal vending of foodstuffs at the shopping centers resurfaced 102 Western Province 102 Kilimanjaro 47 13 Manyara Rumonge 176 Cabinda 61 Kigoma Tabora 75 Tanga Dodoma Katavi Singida Unguja Uige 593 Dar es Salam 916 Iringa Zaire 20 Rukwa Pwani Challenges: Angola 1,108 Mbeya 88 Morogoro 56 - Successive outbreaks, inadequate funding, lack of Luanda Northern Njombe experienced partners within the country and skilled staff Luapula province at provincial and municipal levels, poor coverage of basic 93 361 services including WASH, informal settlements and rapid Ruvuma Karonga Zambia Cabo Delgado urbanization are factors that hinder cholera preparedness 213 interventions, mainly in terms of WASH and Communication 642 for Development Copperbelt North-Western EasternMalawi Rumphi 13 Angola Central Nampula 4,127 Lusaka 221 Nkhata Bay Western Mashonaland Southern Central 4 Mashonaland Mashonaland West 1 Malawi 248 East Likoma 13 108 Harare 50 10,133 Zimbabwe 2 Manicaland Challenges: Tanzania Midlands 46 Mozambique Kasungu 38 87 7 1 Bulawayo 145 Masvingo Dowa Matabeleland South 3 - There are limited staff to support in the response at all levels Namibia 8 1 Salima (case management at CTCs and prevention) Lilongwe 108 Botswana - The community’s 1st line of treatment for all ailments is traditional 386 Dedza medicine hence majority of cases arrive at the health facility very late 31 Legend - Cultural practices/rituals that promote the transmission of cholera 1 Swaziland Mwanza Blantyre Status of outbreak 2 Mulanje Chikwawa 4 Lesotho Outbreak active Outbreak contained Nsanje 6 No outbreak reported South Africa *Cases presented for Zambia refers to cumulative cases reported in 2018 from all the Cholera / AWD Cases affected districts New cases XX Cumulative cases 2018

Creation date: 31 December 2018 Sources: Ministries of Health and WHO Annex 2: Distribution of Cholera and AWD Outbreaks in the Horn of Africa and Challenges in Response - as from 1 of January 2018

Somalia: Challenges - Children under the age of 5 constituted 54.5% of all reported AWD cases and 40% of AWD related deaths during EPI week 1-52 in 2018. This accounts for 3,512 children under 5 being affected and 18 AWD/ cholera related deaths in that age group throughout 2018. (Source WHO). 10 deaths in the under 5 age group were recorded in the Banadir region (CFR 0.6) and 8 deaths were recorded in the Kismayo district of the Lower Jubba Tigray region (CFR 0.6)

- The most affected areas of the current cholera outbreak were the flood-prone areas of Middle Shabelle, Hiraan, Lower Jubba and Banadir, with the majority of cases reported Afar from the Kismayo district in Lower Jubba (32% of all reported cases; Cholera Attack Rate 0.97) and the Hodan district in Banadir (9%; Cholera Attack Rate 0.02). These two Amhara regions also have a high percentage of IDPs with limited access to water and sanitation, which makes these areas vulnerable to future outbreaks Beneshangul Gumuz Awdal Sanaag Bari - The case fatality rate (CFR) for Kismayo Dire Dawa is 0.7%. The overall CFR for Banadir Sool is 0.8%; Daynile (CFR 1.8%), Karaan Northern Upper Nile Hareri (2.0%) and Waberi (1.8%) are the the Bahr el Warrap Addis Ababa Togdheer Ghazal Unity Banadir districts with the highest case Nugaal fatality rates. The highest CFR throughout Oromia 2018, 16.7%, was recorded in the Western Bahr el Ghazal Jonglei Gambela Somali Mudug Kurtunwarey district of Lower Shabelle Lakes SNNPR Ethiopia South Sudan Central Somalia Western Equatoria Eastern Equatoria Galgaduud Equatoria Hiraan Bakool Turkana 252

Karamoja 1027 Gedo Bay Middle Shabelle 558 46 West Pokot Uganda Kenya Banadir 30 191 596 3,014 Western Region 183 Lower Shabelle Central Elgon TransNzoia 294 2,199 69 Isiolo Lower Juba Busia 143 131 261 Meru Legend Siaya 2,329 Tharaka Nithi Garissa CFR: XX%: Calculated based on new deaths reported South Western Nakuru Kirinyaga 161 Embu Murang’a 3 Status of outbreak 132 10 Kiambu 1,577 Nairobi 52 591 Machakos Outbreak active Outbreak contained Tana River No data No outbreak reported

Kilifi Cholera / AWD Cases Kiambu 85 5 New cases (last 1 week) 129 Mombasa 118 XX 3 Cumulative cases 2018 Nairobi 133 315 Murang’a Kirinyaga Tharaka Nithi Creation date: 31 December 2018 Sources: Ministries of Health and WHO Annex 3: Epi Curves for Countries with Active Cholera Outbreaks Currently

Zimbabwe Somalia 3000 1000 2500 900 800 2000 700 600 1500 500 1000 400 300 500 200 100 0 2 1 0 9 8 7 6 5 4 3 2 1 0 9 8 7 6 5 4 3 2 1 0 9 8 7 6 5 4 3 2 1 0 9 8 7 6 5 4 3 2 1 0 9 8 7 6 5 4 3 2 1 0 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2

1 2 3 4 5 6 7 8 9 5 5 5 4 4 4 4 4 4 4 4 4 4 3 3 3 3 3 3 3 3 3 3 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1

1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 5 5 5 k k k k k k k k k

k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k k W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W 2018 2018

Tanzania Angola 1000 1000 900 900 800 800 700 700 600 600 500 500 400 400 300 300 200 200 100 100 0 0 2 1 0 9 8 7 6 5 4 3 2 1 0 9 8 7 6 5 4 3 2 1 0 9 8 7 6 5 4 3 2 1 0 4 3 2 1 0 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 9 8 7 6 5 9 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 9

5 5 5 4 4 4 4 4 4 4 4 4 4 3 3 3 3 3 3 3 3 3 3 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 5 5 5 1 1 1 1 1 1 1 1 k k k k k k k k k

k k k k k k k k

** Burundi recorded 102 cases in 2018, all notified during epidemiological week 52 (week ending 30 December 2018) Annex 4: Weekly Reported Cholera / AWD Cases and Deaths for Countries in Eastern and Southern Africa

Country Week 48 Week 49 Week 50 Week 51 Week 52 2018 Cumulative Cumulative since the Beginning Status of the beginning of the outbreak of outbreak Outbreaks Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases Deaths CFR Cases Deaths CFR (%) (%) Zimbabwe 297 4 45 0 53 1 17 5 10 0 10,807 71 0.7 10,630 65 0.6 Sep-18 Active Somalia 32 0 32 0 36 1 26 0 30 0 6,447 45 0.7 6,852 45 0.7 Dec-17 Active Kenya 0 0 0 0 0 0 0 0 0 0 5,782 78 1.3 26,592 421 1.6 Dec-14 Controlled Tanzania 193 1 45 0 25 0 12 0 13 0 4,688 84 1.8 33,319 550 1.7 Aug-15 Active Zambia 0 0 0 0 0 0 0 0 0 0 4,127 55 1.3 5,935 114 1.9 Oct-17 Controlled Uganda 0 0 0 0 0 0 0 0 0 0 2,699 60 2.2 4 0 0.0 Oct-18 Controlled Angola 33 0 19 0 26 0 10 0 20 0 1262 18 1.4 312 3 1 Sep-18 Active Mozambique 0 0 0 0 0 0 0 0 0 0 863 3 0.3 2,435 3 0.1 Aug-17 Controlled Malawi 0 0 1 1 0 0 0 0 0 0 785 28 3.6 940 33 3.4 Nov-17 Controlled Burundi 0 0 0 0 0 0 0 0 102 1 102 1 1 102 1 1 Dec-18 Active Rwanda 0 0 0 0 0 0 0 0 0 0 3 0 0.0 3 0 0.0 Jan-18 Controlled Namibia Burundi South Sudan Madagascar Comoros Swaziland Botswana

Eritrea Lesotho South Africa

TOTAL 37,565 443 1.2 87,124 1,235 1.4

For further information Contact:

Georges Tabbal Ida Marie Ameda Maureen Khambira WASH Emergencies Specialist Health Emergencies Specialist Information Management Specialist UNICEF Eastern and Southern Africa Region UNICEF Eastern and Southern Africa Region UNICEF Eastern and Southern Africa Region Email: [email protected] Email: [email protected] Email: [email protected]