Zimbabwe Health Cluster Bulletin No 6 - 27 January 2009
Latest information on health partners and health needs in the current crisis in Zimbabwe:
- Cholera situation update
- Cholera Command Control Centre update
- Support from partners
- Health and WASH Cluster weekly meeting
- Rapid Assessment Cholera Knowledge, Awareness, Risk Perceptions, Related Behaviours and Contextual Barriers
- Report from ICDDR (Bangladesh) case Management experts field visits
Situation update and health assessment
As of 27 January, 57 702 suspected cases of cholera had been reported in all of Zimbabwe’s 10 provinces, with 3028 deaths, marking a case fatality rate (CFR) of 5.1%. The highest cumulative number of cases so far was reported in Harare/Beatrice Road Infectious Hospital (13 792 cases and 592 deaths - CFR 5.7%), followed by Beitbridge (4557 cases and 143 deaths - CFR 3.1%), Makonde (3813 cases and 143 deaths - CFR 3.8%), Chegutu (2514 and 142 deaths – 5.6%) and Mudzi (2371cases and 141 deaths - CFR 5.9%)
With the installation of toll free telephone lines in 12 districts, there has been an improvement in the number of districts reporting daily. On 27 January, 68.9 % of the affected districts reported. However, Hwedza, Makumbe in Mashonaland West, Chipinge in Manicaland and Masvingo continue to face reporting challenges due to communication problems, for which the Ministry of Health and Child Welfare (MoHCW) and health partners are trying to resolve.
The proportion of community deaths stays high at 61% of cumulative deaths. In Mutare city, Mutasa and Nyanga (Manicaland), Bindura (Mashonaland Central), Zaka (Masvingo) and Chirumhanzu (Midlands) all deaths recorded occurred in the community. This has been attributed to the lack of health staff at cholera treatment centres (CTCs) causing patients to return home without treatment, long distances to CTCs, lack of money to pay for transport, and religious reasons for not taking modern medicine.
Cholera Command and Control Centre (C4)
The C4 is continuing to improve the country's cholera surveillance system through implementation of an alert and response Standard Operating Procedures, in close collaboration with the Health and WASH clusters. Health partners are now participating actively in the process. Supplies have been sent to partners who reported on cases after investigation in a number of districts.
A senior WHO epidemiologist visited Masvingo province to assess the severely affected Bikita and Chiredzi districts where there was an upsurge last week. A plan to support the provincial team has been developed and will be supported trough the C4 resources. The C4 will roll out such support to all the provinces and some Districts.
The WHO/International Centre for Diarrhoeal Disease Research, of Bangladesh (ICDDR,B ) Assessment and Support of CTCs project has deployed experts in:
Makonde District of Mashonaland West Province
The WHO/ICDDR,B team visited Makonde District of Mashonaland West Province from 16-19 January, 2009. They visited Chaedza CTC, St Rupert’s Hospital and Nyampamila CTC to assess case management; dehydration status: the use of intravenous fluid, oral rehydration salt (ORS) solution and antibiotics. They also noted that there was overuse of intravenous rehydration fluids and underuse of ORS in the CTC and homes. The team observed that there was overuse of antibiotics and promptly offered bedside training. The team recommended that case management, training, and technical support at the field level be a continuous activity, preferably directly involving senior and experienced staff. All efforts should be made to address the non-medical challenges (human resources, food, fuel, staff allowances). Training activities and refresher courses should be done regularly. They called on discharged patients to be used as health promoters in their own communities.
Bulawayo and Binga
Another ICDDR/MOHCW team conducted an assessment on cholera case management in Bulawayo and Binga from 16-24 January, 2009. They visited Thorngroove CTC- Bulawayo, Health Clinics, Bulawayo, Sabah-Village, Siansundu Clinic, Siabua Clinic and Camprevisited, Chunga and Binga District Hospital to assess the current suspected cholera outbreaks in Bulawayo and Binga.
They aimed to build capacity of health professionals on the ground through sharing practical experiences following WHO guidelines on clinical management of diarrhoeal diseases, prevention and to strengthen the disease surveillance strategies and generate relevant recommendations based on field interventions and technical assistance.
They made the following recommendations; community mobilization for proper reporting of both deaths and cases, sentinel surveillance systems set to detect outbreaks, adaptive crisis management human resources, use of zinc, glucometer, stethescopes, social mobilization, and other hardware.
C4 strengthens NatPham (MoHCW)
NatPham (MoHCW) medical procurement organization, which receives supplies for the cholera response, has been strengthened with logistical support, including information technology (IT) to improve supply management. Logistic focal points from UNICEF, WHO and the MoHCW met to strengthen collaboration to avoid duplication and improve supply management including forecasting, response to requests and distribution. The next step is to provide support in provinces and districts.
WHO Health Environmental engineer recommendations
A WHO environmental health engineer provided support through WHO and C4. His observations included: that shallow wells, boreholes, rivers and streams were sources of infection; and recommended treatment at source and the distribution of aquatabs at household level. His recommendations were in line with those of the Health and WASH clusters for an intervention package to households (education materials, water containers, Water purification tablets, soap and ORS.)
A rapid assessment on Cholera Knowledge, Awareness, Risk Perceptions, Related Behaviours and Contextual Barriers was carried out by Harare City Council and UNICEF. The objective was to collect information on the understanding of cholera sources of information, knowledge, myths and misconceptions, perceived risk, current hygiene practices that enhance/prevent risk of infection, contextual barriers (environmental, access etc),and attribution. The team made the following observations; cholera awareness is high in the City of Harare and the disease is perceived to be severe in Zimbabwe, about one third of respondents perceived themselves to be at personal risk of the disease.
There are misconceptions about transmission, mainly among the less educated, such as eating wild fruit and coughing and sneezing. Only half the respondents had used aqua tablets and this practice varied by area and non-availability and expense were cited as barriers to use. Poor water supply and poor sanitation are clearly perceived to be the main barriers to prevention in the City of Harare, personal risk perception is generally lower in respondents with less education and less exposure to affected persons.
They recommended that there be continued saturation of cholera information, education and communications (IEC) materials and activities that carry clear prevention messages that recognize the need to address varying levels of literacy through simple, user friendly methods of information dissemination. Widespread and free distribution of aqua tablets with clear instructions for use should be facilitated. Organizations involved in the cholera response should build capacity among teachers and Community-based Organizations (CBO) to enhance dissemination of cholera information. They should also maximize presence of existing community-based cadres and volunteers to disseminate information and distribute ORS and aqua tablets in Harare, as well as urging the local authorities to get safe water running in the City of Harare.
UNICEF Support to Partners: With support from UNICEF, 1114 youth volunteers, 30 HBC trainers, 60 OVC trainers were trained in cholera prevention and 13,877 people have been reached with interpersonal Communication on cholera prevention and early treatment in 40 districts. UNICEF provided medical supplies, tents (26), cholera beds (680), and personal protective equipments, water treatment chemicals to various NGOs, ZPS, districts and provinces.
International Federation of the Red Cross and Red Crescent (IFRC) and the Zimbabwe Red Cross Societies (ZRCS)
IFRC and ZRCS, through the Finnish, Norwegian, and Japanese Red Cross, have distributed the following non-food Items; laundry soap , water purification sachets, buckets, ORS and 2000 jerry cans. They also constructed latrines at CTCs and are providing safe water to Chikurubi Maximum Security Prison in Harare, which is connected to the Zimbabwe National Water Authority (ZINWA) system. To ensure safe water distribution by UNICEF and OXFAM in Chitungwiza, IFRC and ZRCS have installed an additional water treatment unit at Prince Edwards Water works with a capacity to produce 5 cubic metres of safe water per hour. In Gweru, they are complimenting the local authority with the daily production of 210 cubic metres of safe water.
ZRCS have trained health and hygiene promotion volunteers throughout Zimbabwe to work in Manicaland, Midlands, Mashonaland and Harare. They are reaching households in door-to-door campaigns with hygiene promotion IEC, demonstrations on water treatment and use of ORS. They are also supporting clinics and CTC cholera treatment kits.
OXFAM GB and Population Services International - Zimbabwe
IEC materials distribution through Dairibord Zimbabwe Limited (DZL) ice-cream vendors after training by public health and hygiene promoters. The materials focussed on hygiene awareness, cholera background, how cholera spread, preventing infection, cholera signs and symptoms, managing victims at home. In addition IEC materials on home-based water treatment, water contamination, water disinfection using boiling method and water purification tabs, safe storage and withdrawal were also distributed.
German Agro Action (GAA)
GAA and their implementing partner, Merlin, have received confirmation of an ECHO grant to establish Oral Rehydration Points (ORPs) and support to outbreak response capacity in Northern Zimbabwe, so we will soon begin scaling up.
GOAL has deployed two door-to-door hygiene promotion and distribution teams in Kariba Urban, Karoi Urban and Tengwe Area in Hurungwe District. They have reached over 15 000 households and are planning to conduct clean up campaigns and waste management activities in Dzivaresekwa and Hatcliffe in Harare. They are also working with ZINWA for drainage and sewage repair.
They are involved in the response in Kadoma district addressing the last increase in number of cases, working in collaboration with Health Authorities and partners.
While managing or supporting some CTCs, MSF Teams have continued to support investigation of alerts, and provide rapid responses in several districts. They are supporting where needed to set up care management units, providing supplies and training health workers. They have been working closely with the Health Cluster Coordinator and the C4 team.
Health and WASH Cluster
Update on Retention of Health workers Scheme
The weekly Health and WASH Cluster meeting discussed the Retention of Health Workers Scheme. MoHCW official, Ms Jane Mudyara, gave an update on the scheme, which has started being implemented in Harare.
Depending on available funds, the scheme aims to reach all health workers in all parts of the country. Global Fund (22 districts), European Union (16 districts) and UNFPA are providing support in staff retention. DFID was paying some staff under the scheme in Harare and will be moving to Municipalities, Mudzi and Beitbridge. UNICEF also came on board to support the retention packages. The allowances range from US$30 for the lowest paid to US$700 for the highest paid, and potentially food packages for health workers. As health workers are required in the actual response to reducing deaths in health institutions and communities, partners agreed for an immediate specific cholera allowance to keep staff at work. This cholera allowance will be replaced by the effective implementation of the retention scheme (above) as soon as possible (challenge to cover the all country so far).
Based on field assessment and missions the challenges have been summarized in the table below. The C4 and Health and WASH clusters would take appropriate strategic action to readjust the response accordingly.
Challenges related to the response to the cholera outbreaks in Zimbabwe
Support to community-based interventions including surveillance and alert, response, access to health care with adequate motivated health workers and supplies, social mobilization with community health workers, and NFI (water containers, water purification tablets, ORS, soap, leaflet…) and communication package to household, with a door to door strategy would help in reducing number of new cases and -deaths. The medium term should target a minimum rehabilitation of the water provision system.
The strengthening of Provincial and District teams would strengthen local capacities for improved coordination, alert and response and also case management monitoring.
Integrating Nutrition into the national cholera response
A meeting was held on 26 January at the MoHCW to update plans on integrating nutrition in the country response. It was attended by the National Nutrition Unit, Harare City Health, UNICEF, WHO, MSF-B and SCUK.
They discussed compilation of data of severely malnourished children and adults admitted to CTCs, treatment regimes of severe malnutrition upon admission at CTC. Breast feeding was also promoted during diarrhea and cholera both in the community and in CTCs. Food preparation at CTCs was also discussed.
IEC materials on infants and young children affected by diarrhea and cholera were developed; field tested and are awaiting finalization. Additional IEC materials on the prevention of dehydration in children with diarrhea as well as promotion of breastfeeding during a cholera attack in children are being incorporated into existing materials.
They recommended that all children and adults be screened for malnutrition on admission to CTCs to ensure appropriate rehydration of the severely malnourished. The meeting also suggested that food preparation at CTCs follow food safety guidelines and will work with health promotion in MoHCW to share information on food protocol according to the National Cholera Treatment Guidelines.
For more information, please contact:
Dr Custodia Mandlhate, WHO Representative to Zimbabwe
Tel: +263 4 253 724-30
Ms Zora Machekanyanga, Communications Officer, WHO Zimbabwe
Tel: +263 4 253 724-30 ext 38172
Dr Stephen Maphosa, Emergency and Humanitarian Action, WHO Zimbabwe
Tel: +263 4 253 724-30 ext 38158
Dr Michel Yao, Emergency and Humanitarian Action (EHA) Inter-Country Support Team
Tel: +263 4 253 724-30 ext 38210
Dr S. Midzi, Director, Epidemiology and Disease Control
Tel: +263 4 229032
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