Source: Ministry of Health and Child Welfare Rapid Disease Notification System 1 Cholera in Zimbabwe: Epidemiological Bulletin Number 16 Week 13 (22-28 March 2009) Foreword This is the 16th epidemiological bulletin to be issued since the onset of a countrywide Zimbabwe cholera epidemic first reported in August 2008. Bulletins are to be published weekly to coincide with the end of an epidemiological week (Sunday to Saturday). Daily cumulative caseload updates are posted on the WHO website,http://www.who.int/hac/crises/zwe/en/index.html and http://www.who.int/hac/crises/zmb/sitreps/cholera_daily_updates/en/index.html as well as on the OCHA website http://ochaonline.un.org/zimbabwe The bulletin provides a weekly overview of the epidemic in Zimbabwe, including province by province data, to inform and improve the continuing public health response. 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 WHO Team welcomes feedback and data provided by individual agencies. Given the scope of this epidemic, errors and omissions are inevitable: we will be grateful for any information that helps to rectify these. Acknowledgements We are very grateful to MoHCW District Medical Officers, Provincial Surveillance Officers, Provincial Medical Directors, Environmental Heath Officers, and MoHCW's department of surveillance, 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 has recognized and thanked the efforts made by NGOs assisting in the response and providing support to MoHCW cholera treatment centres (MoHCW – 16/12/2008). This document would not have been possible without the contributions of the WHO data management team, who are part of the C4 Cholera Command and Control Centre. 1. Figures Please send any comments and feedback to the Cholera Control and Command Centre Email: [email protected]. Toll free number for alert by district and province is 08089001 or 08089002 or 08089000 Mobile number for alerts is 0912 104 257
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Source: Ministry of Health and Child Welfare Rapid Disease Notification System 1
Cholera in Zimbabwe: Epidemiological Bulletin Number 16
Week 13 (22-28 March 2009)
Foreword This is the 16th epidemiological bulletin to be issued since the onset of a countrywide Zimbabwe cholera epidemic first reported in August 2008. Bulletins are to be published weekly to coincide with the end of an epidemiological week (Sunday to Saturday). Daily cumulative caseload updates are posted on the WHO website,http://www.who.int/hac/crises/zwe/en/index.html and http://www.who.int/hac/crises/zmb/sitreps/cholera_daily_updates/en/index.html
as well as on the OCHA website http://ochaonline.un.org/zimbabwe
The bulletin provides a weekly overview of the epidemic in Zimbabwe, including province by province data, to inform and improve the continuing public health response. 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 WHO Team welcomes feedback and data provided by individual agencies. Given the scope of this epidemic, errors and omissions are inevitable: we will be grateful for any information that helps to rectify these.
Acknowledgements
We are very grateful to MoHCW District Medical Officers, Provincial Surveillance Officers, Provincial Medical Directors, Environmental Heath Officers, and MoHCW's department of surveillance, 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 has recognized and thanked the efforts made by NGOs assisting in the response and providing support to MoHCW cholera treatment centres (MoHCW – 16/12/2008).
This document would not have been possible without the contributions of the WHO data management team, who are part of the C4 Cholera Command and Control Centre.
1. Figures
Please send any comments and feedback to the Cholera Control and Command Centre
Toll free number for alert by district and province is 08089001 or 08089002 or 08089000
Mobile number for alerts is 0912 104 257
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 2
See also summary tables (annex 1), maps (annex 2) and graphs (annex 3) The case definition can be found in appendix 1 and detail data by district are gathered in appendix 2 Since August 2008
• 57 districts (out of 62) have been affected. One additional district reported an imported case.
• 93,482 suspected cholera cases and 4,095 deaths were reported until 28 March 2009 to the World Health Organization (WHO) through the Ministry of Health and Child Welfare's (MoHCW) surveillance Department.
• The weekly Crude Case Fatality Ratio (CFR) dropped from 4.2% to 3.7% although 61.6% of all deaths were reported to have occurred at community level.
During week 13 (22-28 March 2009)
• 1,368 new suspected cases were reported (average 195/day) compared to 1,646 cases during week 12 (17% decrease).
• 51 new deaths (average 7/day) were also reported compared to 69 reported during week 12 (16% decrease).
• The institutional CFR (i-CFR) decreased from 2.1% to 1.6% (see interpretation section).
• One new district (Umzingwane in Matabeleland South) reported one case (a driver on transit from Harare) on 23rd March 2009. However, no other cases have been reported from this district subsequent to this.
At provincial level
• Less cases were reported during week 13 compared to week 12 in all provinces except Harare (which is having a real increase in cases) and Midlands where batch reporting on 25th March may have contributed to the increase.
• The highest (weekly) case loads were observed in Harare (504) and Mashonaland West (415). These two provinces contributed 67% of the week’s case reports.
• The highest weekly attack rates in cases per 100,000 inhabitants were observed in Mashonaland West (32), and Harare (27).
At district level
• 14 districts had an increased number of reported cases this week. However batch back reporting can not be ruled out in Gokwe North, Chipinge, Buhera and Hurungwe.
• The highest weekly attack rate was recorded in Kadoma (98/100,000 inhabitants). .
• 8 districts had a crude CFR above >5% although all of them had a low caseload except Mt Darwin, where 12 community deaths and 17 cases were reported.
• In Rushinga, no new cases were reported although 7 deaths were reported to have occurred in the community.
2. Reporting (annex 1)
• The percentage of daily reports received from the districts increased from 51% to 68%.
• Reporting was good in the two provinces with the highest case load (Harare and Mashonaland West).
• However, batch reporting might still have occurred in several districts this week as shown below
Province District Possible
batch reporting Date of report
Date of prior last report
Midlands Gokwe North 96 cases 25th March 20
th Mach
Mashonaland Central Rushinga 7 community deaths 24th March 19
th March
Buhera 51 Cases 27th March 25
th March Manicaland
Chipinge 61 cases 26th March 24
th March
MashWest Hurungwe 21 Cases 23rd March 20
th March
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 3
3. Data interpretation This week again, the cholera trend has decreased at national level. Back batch reporting still occurred this week suggesting that the true incidence of cases in week 13 might even be lower than suggested by the reported data. Overall completeness and timeliness also improved compared to the previous week. However, the most affected districts, Harare and Kadoma reflected an actual high case load since their reports have been timely. The epidemic seems to be under control almost everywhere, except in Harare city, Chitungwiza, and Kadoma where a real resurgence has been noticeable.
4. Response An evaluation mission was carried out by the C4 in Mashonaland West Province/Kadoma district on 26th and 27th March. The team established that the resurgence in Kadoma was attributable to a case load from Kadoma Prison which became affected on 17th March 2009. An increase of cases had also been noted in the provincial headquarters after the town had gone for some 4-5 days without water. Need for further support was seen in case management, data management, laboratory surveillance and logistics support including supply chain improvement.
5. Recommendations
Although the epidemic appears to be coming to an end, certain hotspots still exist and there is still need for continued vigilance especially in such areas. These include Harare and Kadoma. In districts where no case was reported for more than two weeks,centralization of material, equipments and drugs from closing or closed CTC/CTUs should be done to allow their reconditioning and restocking for further redeployment where needed. In addition, where CTCs are closing, clinics should be provided with an emergency stock of ORS and Ringers lactate to allow them to cope with new case influx until new CTCs can be opened., In addition, areas where CTC have closed, public health structures such as the rumours verification procedure should be included into the daily cholera reporting system, at least until the epidemic has been declared over at national level.
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 4
Annex 1: Summary tables
Table 1. Cholera cases reported during week 13 and since August 2008 and attack rate (AR) per 100,000 inhabitants by province in Zimbabwe as of 28
th March 2009 *
Affected Number of cases AR per 100,000
Province Populations(a) WEEK13 Cumulative WEEK 13 Cumulative
Provinces with increasing trend (note the difference in scales)
Cholera in Harare province, Zimbabwe
17 Aug 08 to 28 Mar 09
0
500
1,000
1,500
2,000
2,500
w35
w36
w37
w38
w39
w40
w41
w42
w43
w44
w45
w46
w47
w48
w49
w50
w51
w52
w1
w2
w3
w4
w5
w6
w7
w8
w9
w10
w11
w12
w13
weeks
Num
ber
Cases
Deaths
Cholera in Midlands province, Zimbabwe
17 Aug 08 to 28 Mar 09
0
200
400
600
800
1,000
1,200
1,400
17-2
3 A
ug 0
8
24-3
0 A
ug 0
8
31 A
ug- 6 S
ep 0
8
7-1
3 S
ep 0
8
14-2
0 S
ep 0
8
21-2
7 S
ep 0
8
28 S
ep -4 O
ct 08
5-1
1 O
ct 08
12-1
8 O
ct 08
19-2
5 O
ct 08
26 O
ct-
1 N
ov 0
8
2-8
Nov 0
8
9-1
5 N
ov 0
8
16-2
2 N
ov 0
8
23-2
9 N
ov 0
8
30 N
ov-6
Dec 0
8
7-1
3 D
ec 0
8
14-2
0 D
ec 0
8
21-2
7 D
ec 0
8
28 D
ec 0
8-3
Jan
4-1
0 J
an 0
9
11-1
7 jan 0
9
18-2
4 J
an 0
9
25-3
1 J
an 0
9
01-0
7 F
eb 0
9
08-1
4 F
eb 0
9
15-2
1 F
eb 0
9
22-2
8 F
eb 0
9
01-0
7 M
ar
09
08-1
4 M
ar
09
15-2
1 M
ar
09
22-2
8 M
ar
09
Num
ber
Cases
Deaths
* Probable under reporting of cases and deaths during week 1 (28 Dec08-3Jan 09) during the holiday period
*
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 7
Districts of Harare province (note the difference in scales)
Cholera in Chitungwiza, Zimbabwe
17 Aug 08 to 28 Mar 09
0
50
100
150
200
250
300
24-3
0 A
ug 0
8
31 A
ug- 6 S
ep 0
8
7-1
3 S
ep 0
8
14-2
0 S
ep 0
8
21-2
7 S
ep 0
8
28 S
ep -4 O
ct 08
5-1
1 O
ct 08
12-1
8 O
ct 08
19-2
5 O
ct 08
26 O
ct-1 N
ov 0
8
2-8
Nov 0
8
9-1
5 N
ov 0
8
16-2
2 N
ov 0
8
23-2
9 N
ov 0
8
30 N
ov-6
Dec 0
8
7-1
3 D
ec 0
8
14-2
0 D
ec 0
8
21-2
7 D
ec 0
8
28 D
ec 0
8-3
Jan 0
9
4-1
0 J
an 0
9
11-1
7 jan 0
9
18-2
4 J
an 0
9
25-3
1 J
an 0
9
01-0
7 F
eb 0
9
08-1
4 F
eb 0
9
15-2
1 F
eb 0
9
22-2
8 F
eb 0
9
01-0
7 M
ar 09
08-1
4 M
ar 09
15-2
1 M
ar 09
22-2
8 M
ar 09
Num
ber
Cases
Deaths
Cholera in Harare City, Zimbabwe
17 Aug 08 to 28 Mar 09
0
500
1,000
1,500
2,000
2,500
24-3
0 A
ug 0
8
31 A
ug- 6 S
ep 0
8
7-1
3 S
ep 0
8
14-2
0 S
ep 0
8
21-2
7 S
ep 0
8
28 S
ep -4 O
ct 08
5-1
1 O
ct 08
12-1
8 O
ct 08
19-2
5 O
ct 08
26 O
ct-
1 N
ov 0
8
2-8
Nov 0
8
9-1
5 N
ov 0
8
16-2
2 N
ov 0
8
23-2
9 N
ov 0
8
30 N
ov-6
Dec 0
8
7-1
3 D
ec 0
8
14-2
0 D
ec 0
8
21-2
7 D
ec 0
8
28 D
ec 0
8-3
Jan 0
9
4-1
0 J
an 0
9
11-1
7 jan 0
9
18-2
4 J
an 0
9
25-3
1 J
an 0
9
01-0
7 F
eb 0
9
08-1
4 F
eb 0
9
15-2
1 F
eb 0
9
22-2
8 F
eb 0
9
01-0
7 M
ar 09
08-1
4 M
ar 09
15-2
1 M
ar 09
22-2
8 M
ar 09
Num
ber
Cases
Deaths
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 8
Provinces with decreasing trend (note the difference in scales)
Cholera in Mashonaland West province, Zimbabwe
17 Aug 08 to 28 Mar 09
0
500
1,000
1,500
2,000
2,500
3,000
3,500
24-3
0 A
ug 0
8
31 A
ug- 6 S
ep 0
8
7-1
3 S
ep 0
8
14-2
0 S
ep 0
8
21-2
7 S
ep 0
8
28 S
ep -4 O
ct 08
5-1
1 O
ct 08
12-1
8 O
ct 08
19-2
5 O
ct 08
26 O
ct-1 N
ov 0
8
2-8
Nov 0
8
9-1
5 N
ov 0
8
16-2
2 N
ov 0
8
23-2
9 N
ov 0
8
30 N
ov-6
Dec 0
8
7-1
3 D
ec 0
8
14-2
0 D
ec 0
8
21-2
7 D
ec 0
8
28 D
ec 0
8-3
Jan 0
9
4-1
0 J
an 0
9
11-1
7 jan 0
9
18-2
4 J
an 0
9
25-3
1 J
an 0
9
01-0
7 F
eb 0
9
08-1
4 F
eb 0
9
15-2
1 F
eb 0
9
22-2
8 F
eb 0
9
01-0
7 M
ar
09
08-1
4 M
ar
09
15-2
1 M
ar
09
22-2
8 M
ar
09
Num
ber
Cases
Deaths
Cholera in Manicaland province, Zimbabwe
17 Aug 08 to 28 Mar 09
0
500
1,000
1,500
2,000
24-30 Aug 08
31 Aug- 6 Sep 08
7-13 Sep 08
14-20 Sep 08
21-27 Sep 08
28 Sep -4 Oct 08
5-11 Oct 08
12-18 Oct 08
19-25 Oct 08
26 Oct-1 Nov 08
2-8 Nov 08
9-15 Nov 08
16-22 Nov 08
23-29 Nov 08
30 Nov-6 Dec 08
7-13 D
ec 08
14-20 D
ec 08
21-27 D
ec 08
28 D
ec 08-3 Jan 09
4-10 Jan 09
11-17 jan 09
18-24 Jan 09
25-31 Jan 09
01-07 Feb 09
08-14 Feb 09
15-21 Feb 09
22-28 Feb 09
01-07 M
ar 09
08-14 M
ar 09
15-21 M
ar 09
22-28 M
ar 09
Num
ber
Cases Deaths
Cholera in Mashonaland East province, Zimbabwe
17 Aug 08 to 28 Mar 09
0
200
400
600
24-30 Aug 08
31 Aug- 6 Sep 08
7-13 Sep 08
14-20 Sep 08
21-27 Sep 08
28 Sep -4 Oct 08
5-11 Oct 08
12-18 Oct 08
19-25 Oct 08
26 Oct-1 Nov 08
2-8 Nov 08
9-15 Nov 08
16-22 Nov 08
23-29 Nov 08
30 Nov-6 Dec 08
7-13 Dec 08
14-20 Dec 08
21-27 Dec 08
28 Dec 08-3 Jan 09
4-10 Jan 09
11-17 jan 09
18-24 Jan 09
25-31 Jan 09
01-07 Feb 09
08-14 Feb 09
15-21 Feb 09
22-28 Feb 09
01-07 Mar 09
08-14 Mar 09
15-21 Mar 09
22-28 Mar 09
Number
Cases
Deaths
Cholera in Mashonaland Central province, Zimbabwe
17 Aug 08 to 28 Mar 09
0
500
1,000
1,500
2,000
2,500
24-3
0 A
ug 0
8
31 A
ug- 6 S
ep 0
8
7-1
3 S
ep 0
8
14-2
0 S
ep 0
8
21-2
7 S
ep 0
8
28 S
ep -4 O
ct 08
5-1
1 O
ct 08
12-1
8 O
ct 08
19-2
5 O
ct 08
26 O
ct-1 N
ov 0
8
2-8
Nov 0
8
9-1
5 N
ov 0
8
16-2
2 N
ov 0
8
23-2
9 N
ov 0
8
30 N
ov-6
Dec 0
8
7-1
3 D
ec 0
8
14-2
0 D
ec 0
8
21-2
7 D
ec 0
8
28 D
ec 0
8-3
Jan 0
9
4-1
0 J
an 0
9
11-1
7 jan 0
9
18-2
4 J
an 0
9
25-3
1 J
an 0
9
01-0
7 F
eb 0
9
08-1
4 F
eb 0
9
15-2
1 F
eb 0
9
22-2
8 F
eb 0
9
01-0
7 M
ar 09
08-1
4 M
ar 09
15-2
1 M
ar 09
22-2
8 M
ar 09
Num
ber
Cases
Deaths
Cholera in Masvingo province, Zimbabwe
17 Aug 08 to 28 Mar 09
0
500
1,000
1,500
2,000
24-3
0 A
ug 0
8
31 A
ug- 6 S
ep 0
8
7-1
3 S
ep 0
8
14-2
0 S
ep 0
8
21-2
7 S
ep 0
8
28 S
ep -4 O
ct 08
5-1
1 O
ct 08
12-1
8 O
ct 08
19-2
5 O
ct 08
26 O
ct-
1 N
ov 0
8
2-8
Nov 0
8
9-1
5 N
ov 0
8
16-2
2 N
ov 0
8
23-2
9 N
ov 0
8
30 N
ov-6
Dec 0
8
7-1
3 D
ec 0
8
14-2
0 D
ec 0
8
21-2
7 D
ec 0
8
28 D
ec 0
8-3
Jan 0
9
4-1
0 J
an 0
9
11-1
7 jan 0
9
18-2
4 J
an 0
9
25-3
1 J
an 0
9
01-0
7 F
eb 0
9
08-1
4 F
eb 0
9
15-2
1 F
eb 0
9
22-2
8 F
eb 0
9
01-0
7 M
ar
09
08-1
4 M
ar
09
15-2
1 M
ar
09
22-2
8 M
ar
09
Num
ber
Cases
Deaths
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 9
Provinces with low caseload (note the difference in scales)
Cholera in Matabeleland North province, Zimbabwe
17 Aug 08 to 28 Mar 09
0
100
200
300
400
500
24-3
0 A
ug 0
8
31 A
ug- 6 S
ep 0
8
7-1
3 S
ep 0
8
14-2
0 S
ep 0
8
21-2
7 S
ep 0
8
28 S
ep -4 O
ct 08
5-1
1 O
ct 08
12-1
8 O
ct 08
19-2
5 O
ct 08
26 O
ct-1 N
ov 0
8
2-8
Nov 0
8
9-1
5 N
ov 0
8
16-2
2 N
ov 0
8
23-2
9 N
ov 0
8
30 N
ov-6
Dec 0
8
7-1
3 D
ec 0
8
14-2
0 D
ec 0
8
21-2
7 D
ec 0
8
28 D
ec 0
8-3
Jan 0
9
4-1
0 J
an 0
9
11-1
7 jan 0
9
18-2
4 J
an 0
9
25-3
1 J
an 0
9
01-0
7 F
eb 0
9
08-1
4 F
eb 0
9
15-2
1 F
eb 0
9
22-2
8 F
eb 0
9
01-0
7 M
ar
09
08-1
4 M
ar
09
15-2
1 M
ar
09
22-2
8 M
ar
09
Num
ber
Cases
Deaths
Cholera in Matabeleland South province, Zimbabwe
17 Aug 08 to 28 Mar 09
0
100
200
300
400
500
600
700
800
900
1,000
1,100
1,200
1,300
24-3
0 A
ug 0
8
31 A
ug- 6 S
ep 0
8
7-1
3 S
ep 0
8
14-2
0 S
ep 0
8
21-2
7 S
ep 0
8
28 S
ep -4 O
ct 08
5-1
1 O
ct 08
12-1
8 O
ct 08
19-2
5 O
ct 08
26 O
ct-1 N
ov 0
8
2-8
Nov 0
8
9-1
5 N
ov 0
8
16-2
2 N
ov 0
8
23-2
9 N
ov 0
8
30 N
ov-6
Dec 0
8
7-1
3 D
ec 0
8
14-2
0 D
ec 0
8
21-2
7 D
ec 0
8
28 D
ec 0
8-3
Jan 0
9
4-1
0 J
an 0
9
11-1
7 jan 0
9
18-2
4 J
an 0
9
25-3
1 J
an 0
9
01-0
7 F
eb 0
9
08-1
4 F
eb 0
9
15-2
1 F
eb 0
9
22-2
8 F
eb 0
9
01-0
7 M
ar
09
08-1
4 M
ar
09
15-2
1 M
ar
09
22-2
8 M
ar
09
Num
ber
Cases
Deaths
Cholera in Bulawayo province, Zimbabwe
17 Aug 08 to 28 Mar 09
0
20
40
60
80
100
120
140
24-3
0 A
ug 0
8
31 A
ug- 6 S
ep 0
8
7-1
3 S
ep 0
8
14-2
0 S
ep 0
8
21-2
7 S
ep 0
8
28 S
ep -4 O
ct 08
5-1
1 O
ct 08
12-1
8 O
ct 08
19-2
5 O
ct 08
26 O
ct-
1 N
ov 0
8
2-8
Nov 0
8
9-1
5 N
ov 0
8
16-2
2 N
ov 0
8
23-2
9 N
ov 0
8
30 N
ov-6
Dec 0
8
7-1
3 D
ec 0
8
14-2
0 D
ec 0
8
21-2
7 D
ec 0
8
28 D
ec 0
8-3
Jan 0
9
4-1
0 J
an 0
9
11-1
7 jan 0
9
18-2
4 J
an 0
9
25-3
1 J
an 0
9
01-0
7 F
eb 0
9
08-1
4 F
eb 0
9
15-2
1 F
eb 0
9
22-2
8 F
eb 0
9
01-0
7 M
ar 09
08-1
4 M
ar 09
15-2
1 M
ar 09
22-2
8 M
ar 09
Num
ber
Cases
Deaths
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 10
6. Appendix 1: Case definition
The Zimbabwe cholera state definition states that
"in an area where there is a cholera epidemic, a patient aged 2 years or more develops acute watery diarrhoea, with or without vomiting".
‘’A confirmed cholera case is “when Vibrio cholerae is isolated from any patient with diarrhoea”.
This is adapted from the WHO case definition for cholera.
The inclusion of all ages in the case definition somewhat reduces specificity, that is, inclusion of more non-cholera childhood diarrhoea cases. It, however, does not impede meaningful interpretation of trends. Teams should monitor any shift in the age distribution of cases, which might indicate a changing proportion of non-cholera cases among patients seen.
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 11
7. Appendix 2: Cholera in Zimbabwe: Suspected cases, deaths, AR, CFR week 11 to 13, 2009