Zimbabwe Health Cluster bulletin Bulletin No 11 1-15 April 2009 Highlights: Cholera outbreak situation update • About 96, 473 cases and 4,204 deaths, CFR 4.4% Following a 9 week decline trend in cholera cases, an upsurge was reported during epidemi- • Sustained decline of ological week 15. Batch reporting in three districts may have contributed to this slight in- the outbreak crease. • Cholera hotspots in The cumulative number of Mashonaland west, Cholera in Zimbabwe reported cholera cases was Harare and Chitungwiza 17 Aug 08 to 11th April 09 96, 473 and 4204 deaths with 10,000 cities cumulative Case Fatality Rate 8,000 Cases Deaths (CFR) as of 4.4 as of 15 April. During week 15, a 17% de- 6,000 crease in cases and 5% in- 4,000 crease in deaths was re- Number ported. The crude CFR is 2.7% 2,000 compared to 2.9% of week 14 0 while the I-CFR is 1.8% com- pared to 2.7% of week 14. The w2 w4 w6 w8 w36 w38 w40 w42 w44 w46 w48 w50 w52 w10 w12 w14 CFR has been steadily de- weeks clined although the proportion of deaths in health facilities has increased compared to Cholera in Zimbabw e from 16 Nov 08 to 11th A pril 09 those reported in the commu- W eekly c rude and institutional c ase-fatality ratios 10 nity. CFR 9 This is probably an indication Inside this issue: 8 iCFR 7 of more people accessing 6 treatment and/or the increas- Cholera situation 1 5 ing role of other co- 4 morbidities presenting along- ORPs in cholera 2 3 management percent side cholera. In order to bet- 2 ter analyse the co-morbidities, Update on meetings 3 1 0 it has been suggested that Cholera Treatment Centre Update on C4 4 w48 w50 w52 w2 w4 w6 w8 w10 w12 w14 (CTC) staff will be reoriented Epidemiological weeks cholera response to collect detailed notes on co-morbidities; Harare and Donor response 6 Cholera in Zimbabwe Week 15 from 29th March Chitungwiza will act as senti- nel sites for analysis. It is ex- to 11th April 09 Suspected cases reported by pected that this information province (N=1,169) will be used to inform policy Mashonaland West 455 within the Ministry of Health Manicaland 312 and Child Welfare (MoHCW). Harare 165 Mashonaland Central 158 The percentage of daily re- Mashonaland East 41 ports received from the dis- Masvingo 24 tricts increased from 50% in Midlands 10 week 14 to 64.6% in week 15. Matabeleland North 4 During week 13, the percent- Matabeleland South 0 age of daily reports received 0 Bulawayo was 60%. The decrease in com- pleteness of reporting was attributed to communication challenges and power cuts. Mashonaland west province (see graph above) accounts for the majority of cases (23%), Harare (19%), Manicaland (14%) and Masvingo (12%). 80% of cases reported during the week are from 6 districts; Makonde (300 cases from Chinhoyi), Chipinge, Bindura, Harare, Chitungwiza and Nyanga. Zimbabwe Health Cluster bulletin Chipinge back reported 237 cases on 6 April after 6 • the majority of cases were from Rimuka and Ka- days of not reporting, similarly, Bindura reported 90 doma prison, where attack rates of 9% and 7% cases on 6 April after 4 days of not reporting. In Ma- respectively were reported. Within Kadoma city, konde, the increase in cases comes against a back- the highest case loads (above 90 cases, reported drop of a water shortage in the urban area between 14 November and 4 April) were (Chinhoyi) . Kwerete, Chapendeka, Marandu, Zengwe and Almost 80% of the cases reported during week 15 Parirenyatwa. These areas are characterized by were from 6 districts of Makonde, Chipinge, Bindura, overcrowding, water shortages and poor sanita- Harare, Chitungwiza and Nyanga. The same five tion. districts; Makonde, Bindura, Harare, Chitungwiza and • About 89 deaths occurred within health facilities Nyanga, as well as Kadoma and Binga accounted for and 38 at community level. The CFR was higher 81% of all cases during week 14 (see the graphs from among those 6o years and above (13%) and lowest weeks 14 and 15). among those in the 10-20 years age group (0.4%). Among those in the age group 0-10 years, the CFR Cases was 2.8%. Makonde 340 • Actions taken include treatment at CTCs in Lions’ Chipinge 237 club, New CTC and the prison. Case management Bindura 115 was carried out in collaboration with MSF Holland Harare 86 and celebration health. GAA-Merlin set up Oral Chit ungwiza 79 Rehydration Points (ORPs) and staffed them. Nyanga 45 About 52% of all cases were treated at Lions’ 0 50 100 150 200 250 300 350 400 club, 23% at New CTC and 25% at ORPs. Commu- Number of cases nity health promotion was carried out by church youth groups, drama groups, community health volunteers and staff at static health centres. Districts reporting highest case loads (29th March-4th April 2009) Harare, Matabeleland North and Masvingo reported fewer cases in week 15 than in week 14 while Mata- beleland South and Bulawayo reported no cases during Harare City 223 Chitungwiz 17 4 week 15. Makonde 15 0 Nyanga 99 Recommendations Bindura 94 Kadoma 57 • Although the epidemic appears to be coming to an Hurungwe 33 Chegutu/ N 27 end, there are hotspots that still need to be moni- Binga 26 tored closely. These include: Harare city, Chitung- 0 50 100 150 200 250 wiza, Makonde, Bindura and Kadoma. These are No of cases mainly the densely populated urban areas. Contin- ued efforts need to be exerted to increase the avail- This implies that there is a need for targeted inter- ability of safe water and improve sanitation in these ventions in these districts that continue to report areas. new cases and deaths. • Continued laboratory confirmation needs to be car- ried out especially in districts which are now report- The new cases reported in Bindura during week 14 ing fewer cases in order to verify that the outbreak (1-17 April) were mainly from the prison. Actions is actually tapering off in these areas. taken include the set up of two CTCs and the provi- • In districts where no case has been reported for sion of water treatment chemicals by MSF (as part of more than two weeks, materials, equipment and the WASH cluster) to the city which was suffering drugs from closed or closing CTCs should be central- shortages due to lack of chemicals. The upsurge in ized. cases from Binga (week 14) were mainly from Sina- • Vigilance is still required by the public health struc- koma, Siansundu, Pashu and Binga centre. tures so as to pick any resurgence. The rumours veri- An epidemiological report from Kadoma district (14 fication procedure should still be included into the Nov 08-4 April 09) indicates that; daily cholera reporting system, at least until the epidemic has been declared over at national level. • The cumulative number of reported cholera cases was 4482 and deaths, 127 (by 4 April). Oral Rehydration Points in cholera management The most affected age groups were those be- tween 20-30 years, with more males than fe- by GAA-Merlin males affected in groups above 20 years. This is consistent with the higher case burden re- GAA-Merlin have been involved in the set up and opera- ported from Kadoma prison and the Patchway tion of ORPS (27 January to present). So far, GAA- mine area in Rimuka which are male domi- Merlin have set up 63 ORPs in Harare (19), Chitungwiza nated. (3), Gokwe North (9), Gokwe south (4), Kadoma (21) Page 2 Zimbabwe Health Cluster bulletin and Makonde (7). According to the data, between 3 and 29 years old were more likely to present at the ORP for treatment within 24 hours than other age groups (see graph below). Chigupa Oral Rehydration Point, Gokwe South It has been suggested that children below the age of 2 Photo credit: GAA Merlin may not be taken to the OPRs within 24 hours due to the fact that currently, non cholera diarrhea is on the The treatment plans are based on the case definition increase because of the rains. In addition, children be- of three or more episodes of loose stool (whitish wa- low the age of 2 form a smaller proportion of affected tery diarrhea) in the past 24 hours. Patients are screened according to their level of dehydration, with age groups. those who are not dehydrated in plan A. Those who This analysis maybe limited by the fact that; are moderately dehydrated are treated using plan B, ORPs open different lengths of time and ORPs are run and the severely dehydrated with plan C. Patients un- by nurse aids (in Urban areas) or community volunteers der plans A and B are provided with are provided rehy- (in rural areas); making the diagnosis open to the possi- dration therapy using Oral Rehydration Salts (ORS). bility of misdiagnosis and reporting errors. The analysis For Plan C patients in Harare and Chitungwiza GAA- Merlin have facilitated transfers by providing ambu- is however, consistent with the national level data. lances. In other areas of operation, local solutions have been found by communities and GAA-Merlin. In Meetings Most areas ORPs are located close to CTCs/CTUs. A joint health-WASH meeting was held on 15 April and By the end of epidemiological week 14, a cumulative the following were the main highlights; total of 6, 160 patients had been treated at ORPs in Harare, Chitungwiza, Gokwe North and South, Kadoma • A World Bank scoping mission visited Zimbabwe to and Makonde.