Epidemiological Bulletin Number 30 Week 43 (week ending 25 October 2009) Foreword This is the 2nd combined epidemiological bulletin to be issued. Information on other epidemics that arise shall also be included in this bulletin. Bulletins are published weekly. Note that the epidemiological week runs from Sunday to Saturday. The bulletin provides a weekly overview of the outbreaks in Zimbabwe, including province by province data, to inform and improve the continuing public health response. 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 C4 team welcomes feedback and data provided by individual agencies 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 department of surveillance, 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 • 7 out of the 62 districts in the country have been affected by the ongoing cholera outbreak. • The cases reported came from the following districts: Bindura, Chipinge, Gokwe North, Harare, Kadoma, Makonde and Rushinga. • 95 cumulative cholera cases and 3 deaths were reported by 25 th October 2009 to the World Health Organization (WHO) through the Ministry of Health and Child Welfare's (MoHCW) surveillance Department. • The crude case fatality rate since the outbreak started stands at 3.2%. Week 43 (18 th – 25 th October 2009) • 23 cases were reported this week. 18 of the cases were reported from Gokwe North, 3 from Chipinge and 1 from Bindura and Rushinga each. • No death was reported. Provincial distribution of cases • Cholera has been reported in the following five provinces namely: Harare, Manicaland, Midlands, Mashonaland Central and and Mashonaland West. • 37 (38.9%) of the cumulative cases were reported by Midlands, 32 (33.7%) by Manicaland Province, followed by Mashonaland West which had 18 (18.9%) of the cases. • Mashonaland Central and Mashonaland West each had 2 districts affected by Cholera. District distribution of cases • The cases have been confined mostly in rural districts namely Gokwe North,Chipinge and Rushinga save for Chinhoyi Municipality Assessments & response Bindura Investigations have shown that the case was from Rushinga. International Medical Corps (IMC) have teamed up with the Rushinga District Health Executive to conduct Participatory Health and Hygiene Promotion (PHHP) training and Cholera Campaigns in the district. Gokwe North The Gokwe North District Health Team in conjunction with Oxfam GB have distributed NFIs kits to 1000 households, trained 45 volunteers in PHHP , cholera awareness campaigns in 2 schools and 3 sessions for the public, rehabilitated 2 boreholes. The Civil Protection Unit is working with the Police and Veterinary Department to cull pigs contaminating water sources in the affected areas. Source: Ministry of Health and Child Welfare Rapid Disease Notification System 2 Recommendations Wash and Health Cluster members to assist in transmitting Cholera linelists to District and Provincial Medical Offices. Influenza A H1N1 • By week ending 25 October, 208 cumulative probable1 cases of Influenza A H1N1 had been reported in Zimbabwe, five of which were confirmed by PCR (Polymerase chain reaction) to be Influenza A H1N1. WHO is working with the Ministry of Health & Child Welfare to strengthen laboratory surveillance for H1N1 by procurement of rapid test kits, equipment and reagents. WHO will support the sending of specimens for PCR testing to confirm H1N1. • The following provinces have reported cases: Manicaland, Harare, Mashonaland East and Midlands. The affected districts are: Harare Urban, Chivhu, Marondera, Ruwa, Seke, Mutasa, Nyanga and Chirumhanzu. • 5 new cases of probable H1N1 were reported in Nyanga and 6 cases from Chirumhanzu Measles The National Virology Laboratory, as of 26 October 2009, had recorded 35 Igm positive measles cases. All the 35 cases were not vaccinated during the June National Immunisation Days(NIDS). 27 of them were above 5 years and 3 below 9 months of age. Most were therefore outside the target age range for the NIDs. The remaining 5 children were within the age range but were not vaccinated during the NIDs. 32 of the 35 children belong to either Johane Marange or Johane Masowe sects that object to vaccinations Figure 1: Distribution of caregivers by religious faith whose children were not given OPV during 2009 IDs Bubi and Zvishavane Districts have responded to the outbreaks by vaccinating children in from 6 months to 14 years old in the affected villages. In Bubi they managed to include children from the Apostolic Sects. Other districts are encouraged to follow suit. 1 See definition of probable case in Appendix 1 Source: Ministry of Health and Child Welfare Rapid Disease Notification System 3 Annex 1: Summary Tables Table 1: Cumulative Cholera cases reported by district since September 2009 as of the 25 th October 2009 Week 42 Province District th 18 – 25 October 2009 Insitutional Community AR/ Cases death death 100,000 Harare Harare 5 0 0 0 2 0 0 1 Mashonaland Rushinga Central 1 0 0 0.7 Bindura 1 0 0 0 Mashonaland Kadoma West 17 1 0 9.2 Makonde 32 0 0 10 Manicaland Chipinge 37 0 2 8 Midlands Gokwe North 95 1 2 2 GRAND TOTAL Table 2: Age and Sex breakdown of Cholera linelisted cases District Under 5 5 -14 15-30 At least 30 % Years Years Years Years Females Gokwe 0 5 12 7 63 North Chipinge 0 12 6 8 51.9 Makonde 0 0 0 4 75 Harare 1 0 2 2 60 Bindura 0 0 1 0 100 Source: Ministry of Health and Child Welfare Rapid Disease Notification System 4 Table 3:Age and Sex Distribution of H1N1 Samples received by NMRL as at 19 September 2009 District Under 5 5-14 15-30 At % Females Yrs Yrs least 30 Years Mutare 0 3 0 0 33 Harare 1 2 0 0 66.7 Marondera 0 0 0 1 100 Inyanga 0 2 2 0 25 Mutoko 0 0 1 0 0 Chivhu 0 2 3 0 20 Sadza 1 2 4 2 44.4 Source: Ministry of Health and Child Welfare Rapid Disease Notification System 5 Annex 2: Maps Map 1: Cumulative cholera cases by district, Week 42 Map 2: Cumulative probable Influenza A H1N1 cases by district, Week 42 Source: Ministry of Health and Child Welfare Rapid Disease Notification System 6 Annex 3: Graphs Graph 2: Ranking of Provincial Cumulative Cholera Cases Reported by week 42 Midlands Manicaland Mashonaland West Province Harare City Mashonaland Central 0 5 10 15 20 25 30 35 40 Cholera Cases Source: Ministry of Health and Child Welfare Rapid Disease Notification System 7 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. Source: Ministry of Health and Child Welfare Rapid Disease Notification System 8 .