Health Cluster Bulletin 11ver2 by xavieroman


									     Zimbabwe Health Cluster bulletin
                                                                  Bulletin No 11                                                   1-15 April 2009

• About 96, 473 cases and
                               Cholera outbreak situation update
  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
  cities                           10,000
                                                                                               cumulative Case Fatality Rate
                                    8,000          Cases Deaths                                (CFR) as of 4.4 as of 15 April.
                                                                                               During week 15, a 17% de-

                                                                                               crease in cases and 5% in-
                                    4,000                                                      crease in deaths was re-
                                                                                               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
                                                                                               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 April 09    those reported in the commu-
                                        W eekly c rude and institutional c ase-fatality ratios nity.
                                          9                 CFR
                                                            iCFR                                                                     This is probably an indication
Inside this issue:                        8
                                                                                                                                     of more people accessing
                                          6                                                                                          treatment and/or the increas-
Cholera situation     1                                                                                                              ing role of other co-

                                          4                                                                                          morbidities presenting along-
ORPs in cholera       2
                                          3                                                                                          side cholera. In order to bet-
management                                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-
                                                to 11th April 09 Suspected cases reported by
                                                                                                                                     nel sites for analysis. It is ex-
                                                                                                                                     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                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
                                                                                                                        was 2.8%.
       Makonde                                                                        340
                                                                                                                        Actions taken include treatment at CTCs in Lions’
                                                                                                                        club, New CTC and the prison. Case management
        Chipinge                                                   237

         Bindura                               115
                                                                                                                        was carried out in collaboration with MSF Holland
          Har are                    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-
                                                N um be r o f c a se s                                                  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
    Har ar e Cit y
    C h i t u ng wi z                                                                174
                                                                                                                  week 15.
       M a k on de
          N y a n ga                                         99
          B i nd ur a                                       94
          K a do m a                            57                                                                • Although the epidemic appears to be coming to an
                                                                                                                    end, there are hotspots that still need to be moni-
      H u r un gwe
     C h e g ut u / N              27
              B i n ga             26
                                                                                                                    tored closely. These include: Harare city, Chitung-
                         0                50               100            150               200            250
                                                                                                                    wiza, Makonde, Bindura and Kadoma. These are
                                                            N o o f c a se s
                                                                                                                    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
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. During week 14 itself, 387 patients were       assess the urban water situation for emergency fund-
seen at ORPs in the above named districts. The peaks        ing. This is part of the transitional WASH program for
in data collected at ORPS Harare, Kadoma and Chi-           emergency rehabilitation and risk reduction. Under
tungwiza are consistent with those in national level
                                                            the same program, UNICEF is assessing water and
data (see graph of aggregated data below).
                                                            sanitation needs in Chegutu and Kadoma
                                                          • The evaluation of the WASH cluster response to chol-
                                                            era is expected to begin in May.
                                                          • Increases in case loads in Mashonaland West have
                                                            been attributed to water shortages as a result of
                                                            power cuts. The power cuts are due to ongoing re-
                                                            pair of a transformer at the Kariba dam which sup-
                                                            plies power to areas in Mashonaland West including
                                                            Karoi and Chinhoyi. The WASH cluster is in negotia-
                                                            tions with Zimbabwe Electricity Supply Authority
There was no significant difference in distribution of      (ZESA) to provide electricity for some hours to facili-
treatment plans by age. Most of the patients were           tate pumping of water. Blanket distributions of Non
treated under plan A (55%), while 40% were plan B and       food Items (NFIs) which consist of aquatabs for water
5%, plan C. Patients aged 50 years and over accounted       purification, soap and hand washing facilities are
for the bigger proportion of Plan C patients. The me-       being carried out in Karoi.
dian age of all attendees was 26 years, with 25% of all
cases in the age group 20-29. This is consistent with     Dates to remember: WASH cluster meeting: 24 April
data from Kadoma district.
                                                                               Health cluster meeting: 27 April
                                                                                         Page 3
    Zimbabwe Health Cluster bulletin

Update on Cholera Command and Coordination Cen-                 of epidemics it is important to verify that cases being
tre (C4) activities                                             reported are in deed cholera. it is also necessary to
                                                                know whether patients are still sensitive to antibiot-
Case management:                                                ics in use as resistance to antibiotics sets in particu-
                                                                larly in protracted outbreaks such as this one.
• Training of health workers including doctors and
  nurses from Mashonaland West and the medical ser-         • Of the 40 stool samples taken, over 80% were posi-
  vices team from the uniformed forces (Military and            tive for cholera , all confirmed to be the type Vibrio
  police) was carried out by the case management                cholerae El tor Ogawa except two samples that were
  working group of the C4. A total of 53 participants           Vibrio cholerae El tor Inaba.
  attended the workshop. This is the final in a series
  of case management workshops carried out at pro-          • All samples tested were found to be sensitive to
  vincial level. The workshop was carried out in col-           common antibiotics, that is; tetracycline, ciproflox-
  laboration with the team from the International               acin, doxycycline, erythromycin and azithromycin.
  Centre for Diarrhoeal Diseases Research, Bangladesh           Further testing of samples will facilitate the inform-
  and other members of the C4 case management                   ing of policy regarding what drugs to use in the treat-
  team.                                                         ment of severe cholera cases. According to national
                                                                cholera guidelines, treatment of cholera is mainly
                                                                through rehydration, only severely dehydrated pa-
                                                                tients are given drugs. CTCs (through provinces) are
                                                                encouraged to send stool samples to the Central Mi-
                                                                crobiology Reference Laboratory to verify that the
                                                                cases are cholera. This is due to two reasons;
                                                                 • Due to the rainy season, there are non cholera
                                                                   cases reported especially among children below
                                                                   five years of age, and
                                                                 • the fact that when the outbreak is reaching its
                                                                   tail end it is necessary to verify whether all re-
                                                                   ported diarrhea cases are cholera or not.
C4 multidisciplinary team visit to Kadoma, New Urban CTC          Logistics
Photo credit: Dr Islam, ICDDR, B
                                                            A member of the logistics
                                                            team visited Marondera
• In light of the cholera cases being reported in pris-     (Mashonaland East) to;
  ons, the Director of Epidemiology and Disease Con-
  trol in the MoHCW met with the Director of Medical        • Assess logistical gaps
  services in prisons to discuss improvement of health            that can be met by
  services, particularly cholera response, in prisons. In         the C4,
  addition to training of prison medical staff, the C4 is
                                                            • Prepare the position-
  providing through provincial medical offices and the
                                                                  ing of the Provincial
  central prison medical services, emergency supplies
                                                                  cholera emergency
  for prisons. Non governmental organizations includ-
                                                                  response kits.
  ing Medicin du Monde (MDM), Médecin sans Frontière
  Holland and GAA-Merlin, are working with various          •   Organize PUSH imple-
  prisons to provide the following services; set up of      mentation at district level
  Oral Rehydration Points (ORPs), provision of food         with provincial authori-
  including supplementary foods like plumpynut, pro-                                      Members of the logistics team
                                                            ties. The PUSH is aimed at
                                                                                          preparing cholera materials for
  vision of drugs, IV fluids and other medical supplies     positioning emergency
                                                                                          distribution Photo Credit: P.
  for treatment of patients and water chlorination.         cholera supplies for treat-
                                                            ment of 200 patients at
                                                            district level.
• A team from the C4 (International Centre for Diar-        The findings were as follows;
  rhoeal Diseases Research, Bangladesh and National
  Microbiology Reference Laboratory) visited a number       • The province was informed about the C4 roll out
  of CTCs across the country including Seke south             and had meetings planned; they have a cholera co-
  (Chitungwiza), Beatrice Road Infectious Diseases            ordination mechanism in place. There were no ac-
  Hospital (BRIDH), Chinhoyi and Kadoma prison.               tive CTCs-the last was being closed as there had
  They met with case management teams at CTCs and             been no patients for two weeks. While the district
  also took stool samples for testing. Towards the end        had a working generator and an internet connec-
                                                              tion, it lacked printers, computers and stationery,
                                                              situation which the C4 equipment will solve. Proper
        Page 4
                                                                  Zimbabwe Health Cluster bulletin

   stock management has been hampered by inaccurate         • Following the national trainer of trainers workshop
   data collection which is in turn affected by unreli-       for provincial health promotion focal points, the
   able electricity and communication. Radio communi-         social mobilization working group is working on
   cation is non functional mainly due to lack of mainte-     plans to cascade the training to districts and ward
   nance.                                                     level in collaboration with provincial medical
• Members of the Provincial C4 were briefed on the            teams and partners . The first six districts are ex-
  positioning of a Provincial Cholera Emergency Kit as        pected to begin training in the last week of April.
  part of the emergency preparedness. Recommenda-           • The social mobilization working group, working
  tions were made regarding necessary preparation for         through the Ministry of Health and Child Welfare,
  the transfer of the kits.                                   shall in the coming weeks meet with Members of
Recommendations                                               parliament to advocate for their support and com-
                                                              mitment in the cholera response for this outbreak
• Communication being the key of any emergency pre-           and in future health programmes. A package of
  paredness and response, it is necessary to re-              advocacy materials including situation updates on
  establish a reliable communication network between          health and WASH by province, is being prepared by
  provinces and districts. This may be initiated by as-       the working group.
  sessment of HF communication system between prov-
  ince and remotest districts and support to the repair     • In response to the recent re-opening of schools,
  or replacement of the non functional systems.               the working group developed and produced IEC
                                                              materials for school children. The working group is
• The C4 plan is procuring equipment including com-           liaising with the education working group in order
  puters and printers to support provincial medical of-       to ensure that school social mobilization strategies
  fices; this will solve the problem of lack of office        and materials are appropriate, widely available
  equipment reported in Mashonaland East .                    and reach all target groups.
• Stock management: The nationwide prepositioning of
  cholera kits requires centralization of stock
  monitoring and the establishment of a monthly
  reporting system. For this to work, a database and
  monitoring tools need to be introduced or re-
  introduced, training in stock management carried out
  and a focal point put in place.
• The repair of existing vehicles will go a long way in
  solving the transport challenges that exist in the
• In response to an upsurge in cases in Binga reported
  during week 14, the logistics team sent out emer-
  gency supplies for treatment of cholera, disinfectant
  and chlorine to Binga District Hospital as part of the
  PUSH strategy.                                             Mobilizing members of the Apostolic sect for cholera response
                                                             activities Photo credit: P. Garwood
• PUSH strategy: the PUSH is part of a strategy by the
  C4 to move emergency cholera supplies from the
                                                            • A national clean up campaign covering 42 districts
  centre (Harare) to provinces and districts where they
                                                              is being planned by the social mobilization group.
  can be easily accessed. The cluster had by 17 April
                                                              Details about the dates and activities to be carried
  delivered an emergency basic cholera kit for the
                                                              out are being finalized.
  treatment of 200 patients to the following districts;
  Bindura, Binga, Buhera, Centenary, Chegutu, Chi-          • The working group is also working on reviewing
  komba, Chimanimani, Chipinge, Guruwe, Goromonzi,            social mobilization strategies and materials in or-
  Kadoma, Makonde, Makoni, Marondera, Mazowe,                 der to ensure that all sections of the population
  Mount Darwin, Mureva, Mutare, Mutasa, Nyanga,               are reached with the cholera prevention message.
  Shamva, Seke, Rushinga, UMP and Wedza.
                                                            • Guidelines on the use of Oral Rehydration Salts
• In addition, cholera kits were distributed to all prov-     (ORS) and Salt and Sugar Solution (SSS) were re-
  inces (one each) except in Harare and Bulawayo,             cently agreed upon by members of the group.
  which shall receive kits in the coming weeks.               ORS will be distributed in health facilities or by
                                                              trained Village health workers until it is available
Joint health-WASH social mobilization working group
                                                              on a large enough scale for sustainable use at
• The joint health-WASH social mobilization working           household level. In the meantime, communities
  group issued an alert for travellers and tourists for       are encouraged to continue to make SSS solution
  the Easter season in all the major newspapers in Eng-       to treat diarrhea.
  lish, Shona and Ndebele.                                                                    Page 5
                                                                              Zimbabwe Health Cluster bulletin

• In response to a request by the WASH cluster, a draft exit strategy for cholera response volunteers has been
  agreed upon by members of the working group.
• The working group has recently merged with the community based management/development working group.
Members of the group include: Celebration health, GAA-Merlin, GOAL, Institute of Water and Sanitation develop-
ment, Ministry of Health and Child Welfare, Oxfam, PSI (Population Services International), UNICEF, WHO and
ZinRe. The organizations work in partnership with provincial and district health promotion focal points and com-
munity based organizations. They have partnerships with private sector organizations including EcoNet and City
Residents Associations.

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      
Tel: +263 4 253 724-30,             
Dr S.M. Midzi,
                                              More information on the Health Cluster may be accessed online at;
Director, Epidemiology & Disease Control

         Please send contributions for next edition by COB on each Wednesday to Ida-Marie Ameda at

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

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
Government of Greece         WHO                                  Health                               €250,000
Republic of Korea            WHO                                  Health                               $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

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