Epidemiological Bulletin Number 85 Week 45 (week ending 14 November 2010) Foreword This bulletin provides a weekly overview of the outbreaks and other important public health events occurring in Zimbabwe. It includes disaggregated data to inform and improve the continuing public health response by the various partners. 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 bulletin is published weekly. Note that the epidemiological week runs from Monday to Sunday. This edition covers week 45 (week ending 14 November 2010). The C4 team welcomes feedback. Data provided by individual agencies is welcome but will be verified with MOHCW structures before publication. Acknowledgements We are very grateful to MoHCW District Medical Officers, District and Provincial Surveillance Officers, Provincial Medical Directors, Directors of City Health departments, Environmental Heath Officers, and MoHCW's National Health Information Unit, 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 Highlights of the week ending November 2010: No new cholera cases reported 203 suspect measles cases reported Further Decline in Influenza A H1N1(2009)cases reported Figures The case definitions can be found in appendix 1 and detailed data by district are shown in appendix 2. See also summary tables (annex 1), maps (annex 2) and graphs (annex 3). Source: Ministry of Health and Child Welfare Rapid Disease Notification System 1 Cholera 18 out of the 62 districts in the country have been affected by the cholera outbreak that started on 4 February, 2010 compared to 54 districts last year at the same time. 790 cumulative cholera cases consisting of 688 suspect cases, 102 laboratory confirmed cases and 21 deaths were reported by the 24th October 2010 to the World Health Organization (WHO) through the Ministry of Health and Child Welfare's (MoHCW) National Health Information Unit. The crude case fatality rate since the outbreak started stands at 2.7% which is 1.6% lower than that of last year. By week 45 2009, 98 522 cumulative cases and 4 282 deaths had been reported since August 2008, with the crude case fatality rate of 4.3%. Week 45 (8 -14 November 2010) No new cholera cases were reported. The last cholera cases were reported in week 42. Hence the cholera outbreaks that started in week five are now over because there have been no reports for three weeks. Geographical distribution of cases The cases reported so far came from the following districts: Beitbridge, Bindura, Buhera, Chegutu, Chivi, Chimanimani, Chipinge, Chiredzi, Harare, Hurungwe, Kadoma, Masvingo, Makonde, Mt. Darwin, Mutare, Mwenezi, Plumtree and UMP. Urban/Rural distribution of cases 72% of the cases currently reported are from rural areas. In comparison, during the corresponding week in 2009, 67 % of the cases were from rural areas. Assessments & response Surveillance continued in all districts. Case management training for epidemic diarrhoeal disease is being conducted. Measles National Overview (September 2009 to 14 November 2010) 12 918 suspected cases and 631 deaths of measles were reported in all the districts of Zimbabwe. 691 confimed Measles IgM cases were reported in 61 districts. Bulilima is the only district that has not reported at least one confirmed measles case. However this could probably be due to figures of this new district being lumped together into the Mangwe district. 53 districts have reported confirmed measles outbreaks. The attack rate of suspected cases is 106 cases per 100 000 population. IgM Positive Cases by Age Group Source: Ministry of Health and Child Welfare Rapid Disease Notification System 2 109 (16%) of the positive IgM cases were below 9 months, 52 (8%) in the 9 – 12 months age group, 129 (19%) were in the 1-5 years age group, 266 (39 %) were in the 5 -14 years age group and 131 (19%) in the above 14 years age group and 4 cases(0.6%) had no agegroup. Hence 529 (77%) of the positive cases were above the routine immunisation age (9 -12 months). See table 3 for detailed distribution of the IgM positive cases by agegroup and and attack rates by district. Vaccination Status 6821 (53%) of the cases were not vaccinated, 4519 (35%) had unknown vaccination status and 1578 (12%) were vaccinated. Comparison of Measles Situation for the periods before and after the measles national immunisation days September 2009 to 4 July 2010 (before NIDs) 10 946 suspected cases were reported of which 602 were confirmed cases. 53 districts reported confirmed measles outbreaks. The attack rate of suspected cases was 90.1 per 100 000 .The attack rate of confirmed cases was 5 per 100 000. 517 deaths were reported from 21 districts. 5 July to 14 November 2010 (after NIDs) 1 972 suspected cases were reported of which 79 were confirmed cases and 114 deaths were reported. 12 districts reported confirmed measles outbreaks namely Bikita, Binga, Chipinge Gweru, Insiza, Kariba, Kwekwe, Lupane, Makonde, Mazowe, Seke and Zvishavane. 10 confirmed measles cases were reported in the last 30 days from: Buhera 4, Chegutu 14, Chikomba 8,Hwedza 10, Gokwe South 7, Gweru 8, Goromonzi 1,Harare 69,Kadoma 4, Kwekwe 9, Kariba 4, Marondera 5, Mutasa 15, Mutare 16, Mvuma 5, Mt Darwin 10, Seke 8, Shamva 2,UMP 2, Tsholotsho 2, and Zvimba 1 case. Hence there was one confirmed outbreak in the last 30 days in Gokwe South. The attack rate is 14.5 per 100 000 for suspected cases and is 0.6 per 100 000. Week 45 (8 -14 November 2010) 203 suspected cases and no deaths were reported this week through the Weekly Disease Surveillance System (WDSS). The suspected cases were from the following areas: Beitbridge 3, Gokwe North 23, Gokwe South 11, Gweru 3, Chegutu 12,Chivi Harare 64, 12,Hwange 3, Kadoma 6, Kariba 29, Kwekwe 7, Lupane 2, Makonde 21, Mt. Darwin 4, Mwenezi 66, Shamva 2 and Zaka 1. 8 confirmed measles IgM cases were reported in the last 30 days( 15 October-14 November 2010) from: Beitbridge 1, Chiredzi 1, Chivi 1, Gokwe South 2, Harare 1, Mbire 1, Zvimba 1 . There is no district that reported at least 3 confirmed measles , hence there was no ongoing confirmed outbreak in the country during week 45 . Source: Ministry of Health and Child Welfare Rapid Disease Notification System 3 Comparison of weekly measles indicators for the periods September 2009 to 4 July and 5 July -14 November 2010 Some notable changes in key measles weekly indicators are as follows: 1. Suspected weekly cases declined from 248 to 103. 2. Confirmed weekly cases declined from 14 to 5 cases 3. Weekly deaths also dropped from 12 to 6 Assessments & response Integrated EPI disese surveillance and case finding continued. Districts are encouraged to continue to search for suspected measles cases and meet the minimum detection rate of 2 suspected cases per 100 000 population per year. Hence at least 5 suspected cases per week are expected to be reported if the cases are uniformly distributed. The continual reporting of high numbers suspected of suspected measles cases and low numbers (4%) of confirmed measles IgM cases is attributed to strengthening of the measles surveillance system and cases of rubella (German Measles) being misdiagnosed as measles. From next week we will include comparison of confirmed measles IgM cases and confirmed rubella cases. Influenza A H1N1 (2009) A suspected outbreak of Influenza A H1N1( 2009) was declared in Tsholotsho on the 15th of October, after having noted increases in cases that presented with severe flu like symptoms. The outbreak was targeting mostly the children (especially school going age) and the under five.Thereafter outbreaks of confirmed Influenza A were reported in Bulilima on 22 October, in Mangwe on 26 October, in Masvingo and Harare on 27 October.First suspected cases of H1N1 reported in Lupane on 28 October. In addition suspected Influenza outbreak was also declared in Beitbridge. 21 600 suspected cases have been reported up to date. Week 45 (8 -14 November 2010) 3 071 suspect cases cases were reported by end of the week in retrospect from Binga and Lupane. No cases were reported of the current week. Geographical distribution of cases H1N1 cases have been reported from 9 Districts namely Binga, Beitbridge, Bulilima, Gwanda, Harare, Lupane, Mangwe, Masvingo and Tsholotsho. Source: Ministry of Health and Child Welfare Rapid Disease Notification System 4 Assessments & response Surveillance and case management continues in all affected districts. Assessments were done in Lupane and Binga after they had reported suspected H1N1 cases on the 28th and suspected cases on the 19th October in Binga. The Binga cases were reported on the 29th to the province. The findings of the assesments are as follows: Characterization of the Epidemic by Place, Person and Time Characterisation Lupane Binga Occurrence of First Cases 28th October 19th October Notification to next level 29th October 29th October Areas Affected Menyezwa School, Gwayi Simatelele, Resettlement Area, Daluka Sinasengwe,Zumanana Communal Area, Jibajiba ward, Kanyandavhu RHC, Jotsholo RHC and Fatima RHC. Most Affected Agegroup 5 -14 Years Uniformly Distributed across all age groups Response Matrix Response Lupane Binga Case