Zimbabwe Cholera and health situation - 1 December 2008
WHO response and needs
Overall Health Situation
Zimbabwe’s overall health service has been steadily declining for the last five years. Once a system that neighbouring countries referred patients for special care to, the Zimbabwean health service today is wracked by critical shortages of essential drugs and skilled and experienced personnel.
Another challenge is there has been no comprehensive assessment of Zimbabwe’s health system since 2006, making it difficult to assess its true state. Also, its disease surveillance and early warning system, which depends on a weekly epidemiological system, has been compromised in terms of timeliness and completeness of data, which is only around 30%. Staffing and financial limitations are impacting on Zimbabwe’s ability to produce a national health profile.
Universal access to basic health services is compromised due to deteriorating infrastructure, staffing and financial resources. Reactivating primary health care services should keep being addressed as a matter of emergency.
Zimbabwean health facilities face a massive gap – estimated this year at 70% – in required medicines due to reduced local manufacturing capacity, which has been weakened by a lack of foreign currency. This is despite support received from different partners through UNICEF’s procurement systems.
A large cholera outbreak is affecting most regions of the country, with more than 11 700 cases and 473 deaths recorded between August and 30 November. This represents a case fatality rate (CFR) of 4.0% nationally, but reached 50% in some areas during the early stages of the outbreak. The CFR benchmark should be below 1%.
Cholera outbreaks in Zimbabwe have occurred annually since 1998, but previous epidemics never reached today’s proportions. The last large outbreak was in 1992 with 3000 cases recorded.
Areas recording high CFRs have been demonstrating weaknesses in case management and/or infection control practices. Potential causes of the high CFR that must be addressed are
- delays in people seeking treatment:
- poor accessibility to health facilities:
- gaps in case management: and
- inadequate infection control.
Cholera cases have also been reported either side of Zimbabwe’s border with South Africa, Botswana and Mozambique, demonstrating the subregional extent of the outbreak. In South Africa, the Ministry of Health has confirmed more than 160 cholera cases, including three deaths. Cases have also been reported in Johannesburg and Durban.
This cholera outbreak has strained Zimbabwe’s overburdened health care system and resulted in a nationwide shortage of medicines and other materials for treatment, aggravating the scarcity of health care providers and the poor access to overall care. The outbreak can spread quickly into areas without access to safe water and sanitation. Case fatality rates may rapidly escalate in populations without rapid access to simple treatments.
Cholera is easily preventable by ensuring access to safe water and appropriate hygiene, while deaths can be prevented with quick access to simple, standardized treatment regimens.
WHO Response Strategy
WHO and its Health Cluster partners are finalizing a "Cholera Response Operational Plan" to control the current outbreak. The response must be viewed as an emergency measure within the context of a severely deteriorated health care system and civil environment. The response should be multi-sectoral in support of the Zimbabwean Ministry of Health and partner agencies intervening in the field.
The objectives of the response are to:
1. Reduce the epidemic spread by:
- Ensuring access to safe water and sanitation conditions, particularly in health facilities;
- Reinforcing community mobilization;
- Ensuring safe isolation and infection control practices in health structures (including funerals);
- Strengthening Health Cluster coordination.
2. Decrease mortality by:
- Ensuring early case detection;
- Improving access to health care;
- Ensuring adequate care, including feeding support.
The response should cover needs in the domains of epidemiology, surveillance and response; water and sanitation; infection control; social mobilization; and logistics. This coordinated approach will involve close collaboration with public health authorities in Zimbabwe and neighbouring countries, as well as nongovernmental organizations and United Nations agencies including UNICEF. An Inter-Agency Rapid Assessment Team must be established to investigate and confirm outbreaks.
The emphasis must be on rapidly addressing the known risk factors for cholera transmission. Immediate priorities include:
- Standardized case reporting to understand their distribution, guide treatment priorities, and inform prevention messages;
- Ensuring access to safe water and sanitation;
- Standardized case management to reduce mortality;
- Producing treatment and prevention materials, as well as prevention messaging campaigns to mitigate the risk to populations.
WHO Response Operations to Date
WHO and its Health Cluster partners are monitoring and responding to the outbreaks reported in multiple areas (including Mutare, Chimanimani, Guruve, Concession, Chiredzi, Mwenzie, Kwekwe, Gutu, Chivi, Bikita, Zvimba) and supporting cholera treatment centres in 26 districts.
WHO’s close relationship with the Ministry of Health is providing added value for health sector players. WHO and the Ministry of Health are collaborating to provide the cholera case and mortality data by district that is used in the daily and weekly cholera situation updates issued by OCHA.
At the Health Cluster meeting on 25 November, several gaps were identified in the detection, assessment, organization of response, case management and surveillance and information management. In response, WHO has been airlifting emergency stocks of supplies from United Nations Humanitarian Resource Depot in Dubai and mobilizing additional drugs and supplies through WHO Country Office in South Africa.
WHO headquarters, in liaison with its African regional office and Harare-based Inter Country Support Team, is deploying a full outbreak investigation and response team, including logisticians, epidemiologists, social mobilization, communications officer and specialists in water and sanitation.
WHO, on behalf of the Health Cluster, produced a document titled Zimbabwe Health Situation: Let us show our Leadership and act NOW!, which was provided on 25 November to and endorsed by the Ministry of Health. The document called for an emergency response to the cholera outbreak. The Health Cluster is also finalizing its Cholera Operational Response Plan as well as the provincial distribution of agencies to lead cholera outbreak response.
Health Priorities and Needs
US$ 2 million in financial support is required to cover the cost of health response activities for the next three months, including providing:
- Cholera and diarrhoeal disease kits;
- Emergency health kits;
- Water purification equipment;
- 10 portable laboratory kits for diagnosis;
- Personnel (including for epidemiological control and Health Cluster coordination);
- Cholera treatment training.
For more information:
Dr Custodia Mandlhate, WHO Representative
Tel: +263 4 253730 ; Fax: +263 2 253724
Jukka Sailas, External Relations, Health Action in Crises
Tel: +41 22 791 4778 ; Fax: +41 22 791 4844
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