Health Cluster bulletin

Bulletin No 10 24-31 March 2009 Highlights: Cholera outbreak situation update • About 92,482 cases and 4095 deaths, CFR 3.7% From August 2008 to 23 March 2009, cholera outbreaks were reported in 56 out of 62 dis- and I-CFR 1.8% tricts. On 24 March 2009 a new district, Umzingwane (Matabeleland North), reported a case, bringing the total number of affected districts to 57. (The case was imported from • Sustained decline of the outbreak .) A total of 92 482 cases of cholera and 4095 deaths was reported as of 28 March 2009, with a decrease in the crude case fatality ratio (CFR) from 4.4% to 3.7%, with 61.5% • Cholera hotspots still in of deaths occurring at community level. The total number of districts reporting increased Harare and from an average of 51% in weeks 10-12 (1 to 21 March 2009) to 63.8% in week 13 (22-28 cities; Kadoma district March 2009). new hotspot Cholera in Zimbabwe 17 Aug 08 to 28 Mar 09 There has been a sustained • Update on Malaria 10,000 decline in the number of 8,000 Cases Deaths cholera cases and deaths re- 6,000 ported in the last 8 weeks, 4,000 with a corresponding 17% Number 2,000 reduction in cases and 16% 0 reduction in deaths observed

w1 w2 w3 w4 w5 w6 w7 w8 w9 in week 13 compared to w36 w37 w38 w39 w40 w41 w42 w43 w44 w45 w46 w47 w48 w49 w50 w51 w52 w10 w11 w12 w13 weeks week 12 everywhere except Harare. There are, however, Cholera in , Zimbabwe 17 Aug are a number of areas that Inside this issue: 08 to 28 Mar 09 remain cholera ‘hotspots’. Cases Deaths These include Harare prov- Cholera situation 1 2,500 2,000 ince, Chitungwiza and Masho- Update on C4 2 1,500 naland West. cholera response 1,000 activities Number 500 During epidemiological week 0 13 (22-28 March) within Ha- Assessments and 3 rare city (Harare province), meetings w1 w2 w3 w4 w5 w6 w7 w8 w9 w35 w36 w37 w38 w39 w40 w41 w42 w43 w44 w45 w46 w47 weeksw48 w49 w50 w51 w52 w10 w11 w12 w13 the high-density suburbs of Malaria situational 4 Mbare, Budiriro, Glen update Areas in Harare city affected by cholera 21-28 Mar 09 view, Highfield, Wa- Note on maternal terfalls, Glen Norah MBARE health BUDIRIRO GLEN VIEW and Kuwadzana were HIGHFIELD Who, what, where, 4 WA TERFA LLS the seven most af- GLEN NORAH KUWADZA NA fected areas (see DZIVARASEKWA M UFAKOSE EPWORTH graph below and map HA TCLIFFE BORROWDALE on page two), with OTHER HA TFIELD Mbare accounting for WARREN PARK M ABVUKU TAFARA suburb KAM BUZUM A more than 30% of the HOPLEY FA R M AM ALIND RD cases from Harare. WESTGATE USHEWOKUNZE SOUTHERTON SNAKE PARK RUGARE M T PLEASANT GLEN NARA COLBRO NORTH ARCADIA

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New IEC materials including funeral guidelines, social New Cholera Cases in Harare City, 22 - 28 March 2009 mobilization guidelines and participatory health ac- tion toolkits were disseminated. Among the key Hatcliffe workshop recommendations were the revitalization of the village health worker programme and the strengthening of coordination and information shar-

Borrowdale ing. "Trainers of trainers" are expected to carry out cascade training at district and ward levels in the next few weeks.

Kuwadzana Warren Park Logistics Arcadia Kambuzuma Rugare Mb ar e The Logistics Cluster was instituted to support the Mufakose Southerton

Hatfield cholera response. Cluster members include UNICEF, Budiriro Epworth Highfield WFP and WHO, which work with nongovernmental Glen View Cases partners and the MoHCW to ensure the coordinated Glen Norah 1 - 10 Waterfalls 11 - 20 21 - 29 and prompt delivery of requested items. The cluster 30 - 50 > 50 is currently using five inter-cluster warehouses as No Cases hubs for warehousing and distribution in different areas in Zimbabwe. While responding to the cholera Chitungwiza continues to report a high number of cases outbreak, C4 logistic launched an national wide each week (see graph below). emergency preparedness assessment to prepare for next rainy season threat.

Cholera in Chitungwiza, Zimbabwe The C4 logistics working group is providing the fol- 17 Aug 08 to 28 Mar 09 lowing support in partnership with WFP (for transpor- 300 tation:

Cases Deaths 1. PUSH: Emergency Delivery of Cholera standardized 200 kits to Health Districts (Cholera commodities sent to Binga few hours after alert given) 100 Number 2. Supply of cholera commodities to CTC/CTU and 0 district upon request.

w1 w2 w3 w4 w5 w6 w7 w8 w9 3. Emergency Preparedness positioning of Provincial w35 w36 w37 w38 w39 w40 w41 w42 w43 w44 w45 w46 w47 w48 w49 w50 w51 w52 w10 w11 w12 w13 Weeks cholera kits (IDD). Kits have already been pre- positioned in Mashonaland East, Central, and West.

In Chitungwiza, the most affected wards were A, D and 4. Procurement of provincial C4 roll out equipment. M. Other affected areas were Rimuka, Patchway, ZPS In addition, three prison and Mayflower in Kadoma district, Mashonaland vehicles purchased West. for the C4 were com- missioned by Dr Cus- Many provinces continue to face a number of challenges todia Mandhlate, in surveillance and daily reporting. These include: non- WHO representa- tive to Zimbabwe on functional radios, unreliable phones and erratic supplies 25 March. of electricity. Dr Custodia, WHO representative The Environmental Update on Cholera Command and Coordination Centre for Zimbabwe commissioning a Health working group vehicle for the C4. (C4) activities has trained focal Photo credit: W. Julias, WHO points in all provinces Social mobilization and health promotion: The joint Health/WASH Cluster working group organized and car- and districts this month. The working group has final- ried out national health promotion training workshops in ized infection control guidelines for CTCs. Harare on 19-20 March and on 26-27 March for The Case Management working group, comprising provincial health promotion focal points and partners. officials from MoHCW, WHO, the International Centre The purpose of these workshops was to orient focal points for Diarrhoeal Disease Research, Bangladesh and and partners on a harmonized health promotion message Harare hospital have finalized cholera treatment and to set up structures to support epidemic prepared- flow charts and are revising current cholera response ness at community level. Page 2 Zimbabwe Health Cluster bulletin guidelines in order to ensure harmonized responses at level are needed. national level. • There is a need to advocate with the city authorities regarding the management of water and sewerage. Assessments Lack of safe water and untreated human waste are major risk factors for cholera; moreover, urban ar- Cholera Command and Control Centre (C4) multi- eas have been worst-hit by the current outbreak. disciplinary teams comprising health promotion ex- • Vulnerable population groups including transients perts, microbiologists, epidemiologists, data managers (people with no fixed abode), people with mental and logisticians conducted assessments of CTCS in illnesses, prisoners and people living in homes (Sakubva, Nyanyadzi and Chako- (orphanages and homes for the elderly) need to be hwa), Harare (Beatrice Road Infectious Diseases Hospi- considered by provinces and cholera response teams tal-BRIDH and Budiriro), and Chitungwiza and Kadoma when planning response efforts. (Mashonaland West). Following the visits, the teams • Latrine coverage remains a big challenge in rural areas. In discussions with health centre/CTC staff made a number of recommendations: and the C4 team, it was suggested that the provision of slabs and tools might be a way to rapidly increase • Provinces and their partners supporting CTCs need coverage. to ensure that samples are sent to the National Microbiology Reference Laboratory for testing Meetings (confirmation and typing at the beginning of the outbreak, sensitivity monitoring during the out- Consolidated Appeal Process (CAP break and confirmation of the end of the out- In response to a recent Inter-Agency Standing Committee break). recommendation, the Health Cluster has begun review- ing the 2009 Consolidated Appeal for Zimbabwe. The purpose of the review is to revise the response plan and existing projects based on the current humanitarian and socio-political environment. The plan is expected to de- part from strictly humanitarian activities to include re- covery or development programmes as well. The review will be based on up-to-date assessment reports from partners, together with the Ministry of Health and Child Welfare's (MoHCW) 100-day plan to revitalise the coun- C4 monitoring team at New urban CTC, Kadoma try's health system. Some of the new priorities include: retaining health workers; responding to the ongoing ma- Photo credit Dr. I. Sirajul, ICDDR, B laria epidemic; strengthening the health system; and revitalizing the village health team programme in order • Cross-border coordination remains vital in the pre- to strengthen surveillance and response to outbreaks at vention and management of outbreaks, particu- community level. The next Health Cluster meeting is larly in the case of Manicaland which shares a long planned for 28 April 2009. border with Mozambique, where cholera is en- demic. Efforts should be made to initiate coordina- Joint health/WASH cluster meeting tion or use existing coordination mechanisms to A joint Health and WASH Cluster meeting took place on 1 establish outbreak preparedness measures. April. One of the recommendations from that meeting • Comprehensive province preparedness plans need was that the Health Cluster should carry out an evalua- to be prepared in order to better manage eventual tion of its response to the cholera outbreak. The WASH future outbreaks. cluster is organizing an evaluation of its own response. • The national surveillance system, which is essen- Another key recommendation was that all partners tial to ensure the timely detection and manage- should follow set national guidelines (this was not the ment of outbreaks, needs to be strengthened. The case during the current cholera outbreak response). critical gap is in the area of communication. Concerns were raised regarding the lack of knowledge • Health promotion needs more support. The use of and limited use of oral rehydration salts (ORS) at com- community health workers and volunteers may be munity level; many patients who presented at cholera a feasible way to bridge human resource limita- treatment centres (CTCs) had not started rehydration at tions. Information, Education and Communication home, and this contributed to high mortality rates at (IEC) materials need to be replenished in many community level. It was also clear from interviews with areas. Messages targeting specific behaviour — for patients in CTCs that many lacked a clear understanding example, the use of easily-contaminated water of how to mix the salt and sugar solution. The social mo- pots and other wide-mouthed water containers — bilization working group is responsible for ensuring that may need to be incorporated in current messages. clear messages on the use of ORS and the appropriate • Consumables for water testing at district and ward mixing of salt and sugar solutions are shared with the public. Page 3 Zimbabwe Health Cluster bulletin Update on Malaria

Malaria transmission in Zimbabwe is generally unsta- This year the IRS programme was delayed due to a short- ble, with a few high transmission foci along the age of funds to cover allowances and pay for fuel, food northern and eastern borders. About 50% of the and transport for spray operators. Since then, the country’s population resides in the MoHCW has carried out IRS in 27 districts, mainly rural malaria-endemic ar- in partnership with Plan International, the eas, making attainment of univer- United States Agency for Aid in Develop- sal coverage of malaria control ment (USAID) and the UK Department for interventions eminently attainable International Development (DFID). and cost-effective. More than two (Another 18 districts have not been cov- million people suffer from this pre- ered by the current IRS programme. ventable disease annually. The Spraying as a control strategy is recom- most vulnerable groups are mended only in districts faced with a children under the age of five, ITN distribution at St Luke’s hospital, malaria epidemic, while an emphasis on pregnant women, the elderly and Matabeleland North Photo credit: D. Mtemeli, WHO case management is promoted in the people living with HIV and AIDS. other districts.) Malaria is the second leading cause The most vulnerable of outpatient attendance. Transmission groups are children Insecticide Treated Bed Nets (ITNs) occurs with varying intensity in 52 of below the age of 5 years, pregnant women, Coverage of ITNs remains quite low, even though Zimbabwe's 61 districts. During the peak the elderly and people they are generally promoted as a basic control malaria transmission season (mid Feb- living with HIV and strategy. The malaria control programme has AIDS. ruary to May), sporadic epidemics are appealed for and received additional funds reported in high-burden districts. to procure and distribute ITNs. The population affected varies from year to year depending on Case management the implementation of control The Global Fund to Fight AIDS, Tuberculo- measures (internal residue spray- sis and Malaria has donated funds to pro- ing, use of insecticide-treated cure Artemisin-based Combination Ther- nets, and personal protective apy (ACT) and train health workers on its measures). use. An initial batch of 1 600 000 treat- Surveillance: ment courses was received in November A tailor makes an ITN in Mashonaland 2007 and distributed to districts. About A significant increase in malaria Central Photo credit: D. Mtemeli, WHO 18% (294 721 )of the original ACT stock rates is anticipated during the cur- and 806 000 rapid diagnostic tests (RDTs) rent malaria season. Unfortunately, surveillance are stocked with the National Pharmaceutical Company mechanisms have been affected by overall difficul- of Zimbabwe (NatPharm). ties collecting and transmitting data from health fa- The ACTs and RDTs should be redistributed to where they cilities to central level. The irregular flow of data are needed (for example Harare and Bulawayo do not poses a risk of epidemics going unnoticed or being report many malaria cases, yet they have received large detected late. Zimbabwe is currently in the peak quantities of RDTs and ACTs that they are unlikely to period for transmission (mid-February to May); un- need). The supplies should be redistributed as soon as confirmed outbreaks have been reported in Nyanga, possible, as ACTs and RDTs have a short shelf life (current Mutoko, Mudzi and . Outbreak responses meas- supplies of ACTs and RDS are due to expire in July and ures include mop-up spraying of households, health September 2009 respectively). Moreover, recently- facilities and schools, and providing drugs. A team collected data on ACT consumption revealed that con- visited Kariba on 26 March to investigate the re- sumption rates ranged from 0% to 84%, with an average of ported cases and make recommendations for further 56% for the 26 districts visited. This means that many action. ACTs will go to waste if action is not taken promptly. Control interventions Emergency kits donated by WHO include some ACTs and Internal Residual Spraying (IRS) is the main vector RDTs that are due to expire in 2010. These are now being control intervention used in Zimbabwe. distributed to 32 malaria high-burden districts. Page 4 Zimbabwe Health Cluster bulletin

PLAN International has donated another 30 000 ACTs Who is doing what where: Partnerships for health and 30 000 RDTs to support seven districts. German Agro Association (GAA)/Merlin have supported Just over 50% of health workers have been trained in case management, provision of medical supplies and case management using ACTs. More funds are needed training of community health workers in Harare Urban, to complete the health worker training programme. Kadoma, (Mashonaland West) Gokwe North and Update on ACT/RDT supplies South (Midlands). GAA-Merlin are supporting 45 ORPs (19 in Harare and Chitungwiza, 17 in Kadoma, 7 in Gokwe • The National Malaria Control Programme (NMCP) North and 2 in Gokwe South). GAA-Merlin are also facili- has ordered 600 000 additional treatments. tating approximately 50 transfers per week of cholera • WHO has submitted a proposal patients to CTCs in Harare. through the CERF for additional ACTs to cover any gaps when the current GOAL is providing training, hygiene promo- stock expires. tion, support and supervision and water & • Zimbabwe has received 10 200 (6x4) sanitation support to 21 CTCs and commu- treatment blisters from the Namib- nities in Hurungwe, Makoni and Nyanga. ian Government that are due to ex- GOAL has distributed 11 000 household pire in May 2010. They are stocked cholera prevention kits consisting of a at Natpharm awaiting distribution. bucket with lid and tap, 30 water purifica- • The NMCP is awaiting current con- tion tablets, three ORS sachets, a bar of sumption data in order to initiate the soap, and IEC materials. GOAL's support to procurement of ACTS and RDTS for primary health care programmes in Makoni year 2 (close to 2.2 million treat- includes: support and supervision of rural ments). health facilities; distribution of long- Programme Management Staff taking care of a patient at lasting insecticide-treated Nets through Hatcliff CTC Photo credit: GAA-Merlin ante-natal clinics; and water and sanita- Two recently-advertised posts for the tion support for health facilities. GOAL NMCP (data manager and assistant monitoring & will also provide a buffer stock of emergency essential evaluation officer) have not been filled due to finan- medicines. cial shortfalls at the MoHCW. MSF Belgium has provided logistical support, medical Maternal health supplies, surveillance and on-the-job training and super- vision of health workers at CTCs; IEC materials and hy- Recent rapid assessments of health facilities have re- vealed the urgent need to rehabilitate maternal giene promotion; set up of ORPs and water and sanita- health programmes. In at least two assessments, tion support in 12 districts and two provinces. women patients cited the lack of equipment, including MSF has carried out these activities at the following basic protective gear for midwives and lack of water, locations: Mushandike, city, Bondolfi, Nyajena, as barriers to accessing services. Service users who Nyikavanhu, Musvovi , Ngundu, Benzi, Mbandamabwe, avoid the system, particularly those with difficult Nyahombe, Razi, Berejena, Ruware, Chizivirizvi, pregnancies, face referral difficulties as a result. As Chilonga, Chambuta, Mussiso, Fube, Bota, Mulelesi, Bo- part of initial efforts to improve maternal health ser- terere, Munyikwa, Dewure 1, Dewure 2, Mukasi, Chi- vices, UNICEF has procured and distributed emergency kuku, , Gangare, Odzi, , Chitasa, Village obstetric and neonatal kits to 56 districts. The equip- 6, Mupamaonde, Nyika (); BBH, ment includes sphygmomanometers, midwifery kits, Gunura, Chabata, Mutiusinazita, Chapanduka, Mutepfe, obstetric kits, resuscitation kits, urine strips and um- Zangama, Muzokomba, , Bangure, Betera, Mu- bilical tapes. Maternal health remains an area of danda, Nyashanu, Chiweshe, Chimbudzi, Buhera, Mu- critical need. rambinda, Nyanyadzi, Gudyanga, Chakohwa, Mutam- In response to this UNICEF has procured and distrib- bara, Elim, Avila, Sakubva, MIDH, Mufusire (Manicaland uted emergency obstetric and neonatal kits to 56 dis- province). tricts. The equipment includes sphygmomanometers, midwifery kits, obstetric kits, resuscitation kits, urine strips and umbilical tapes. Maternal health remains an This summary of who is doing what where is a work in progress. area of need. Page 5 Zimbabwe Health Cluster bulletin

Information on courses and training

The United Nations Population Fund (UNFPA) and International Rescue Committee (IRC) have invited individuals and partners to apply for the following training programmes;

1. Minimum initial service package (MISP) for Reproductive health and GBV in Humanitarian response. The course shall be held on 22-24 April 2009 in Harare (training code MGH) and 04-06 May in Bulawayo (training code MGB) 2. Gender Based Violence (GBV) prevention and response in humanitarian settings . The course shall be held in on 27-29 April in Harare (training code GBH) and on 07-09 May in Bulawayo (training code GBB) Applicants are asked to submit a detailed CV, a motivation letter no exceeding 500 words which shall include how you will utilize the train- ing or skills gained from the training in current programmes. The applicant should also submit a letter from their organization recommending their participation and confirming release for the entire duration of the course. Applications can be sent to The Representative, UNFPA, PO Box 4775, 5th Floor Takura house, 67-69 Kwame Nkurumah Avenue, Harare or my email to [email protected] copied to [email protected]. applicants are requested to indicate the training code on the envelope or in the subject of the email.

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, Director, Epidemiology & Disease Control More information on the Health Cluster may be accessed online at; 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 Republic of Korea WHO $99,405

SIDA IOM Health $628,000

OFDA IOM Health $500,000 USAID WHO Health $787,659

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