epidemiological bulletin number 78€¦ · the c4 team welcomes feedback. ... (imc) included: •...

Source: Ministry of Health and Child Welfare Rapid Disease Notification System 1

Highlights of the week ending 26 September 2010:

2 new cholera cases reported from Chipinge 11 Measles cases and 46 deaths reported from Chiweshe, Mazowe 54 Measles Case reported from Mbire

Epidemiological Bulletin Number 78 Week 38 (week ending 26 September 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 38 (week ending 26 September 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

Please send any comments and feedback to the Cholera Control and Command Centre

Email: [email protected].

Toll free number for alert 08 08 9000

Mobile number for alerts is 0772 104 257


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). 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. 773 cumulative cholera cases consisting of 673 suspect cases, 100 laboratory confirmed cases and 20 deaths were reported by 26 September 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 2.6% which is 1.7% lower than that of last year. By week 38 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 38 (20 -26 September 2010) 2 new cholera cases were reported from Chipinge of which 1 case was confirmed. The last case to be reported occurred in section 5 of Chipinge on the 20th of September. 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, Nyanga and 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, 33% cases came from urban areas and 67 % from rural areas. Assessments & response Surveillance continued in all districts. MOH, MdM, World vision, ACF are collaborating in controlling cholera in Chipinge. The following activities have been implemented: 1. Sensitization session done within the community 2. Distribution of aqua tabs done 3. Provision of motor cycles The challenges being met :

1. Fuel for EHTs 2. Food for patients


Measles Global Overview (September 2009 to 26 September 2010) 11 841 suspected cases and 631 deaths of measles were reported in all the districts of Zimbabwe. 670 confimed Measles IgM cases were reported in 61 districts. Mbire is the only district that has not reported at least one confirmed measles cases. 53 districts have reported confirmed measles outbreaks. The attack rate of suspected cases is 98 cases per 100 000 population. IgM Positive Cases by Age Group 105 (15.7%) of the positive IgM cases were below 9 months, 48 (7.2%) in the 9–12 months age group, 125 (18.7%) were in the 1-5 years age group, 264(39.4 %) were in the 5 -14 years age group and 125 (18. 7%) in the above 14 Years age group and 3 cases(0.4%) had no agegroup. Hence 514 (76.7%) 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 7163 (61%) of the cases were not vaccinated, 2830 (24%) had unknown vaccination status and 1848 (15%) were vaccinated. Comparison of Measles Situation for the period before and after vaccination September 2009 to 4 July 2010 10 900 suspected cases were reported of which 602 were confirmed cases. 53 districts reported confirmed measles outbreaks. The attack rate of suspected cases is 90.1 per 100 000 .The attack rate of confirmed cases ranges from 5 per 100 000. 517 deaths were reported from 21 districts. 5 July to 26 September 2010 941 suspected cases were reported of which 68 were confirmed cases. 10 districts reported confirmed measles outbreaks namely Bikita, Binga, Chipinge Gweru, Insiza, Kariba, Makonde, Mazowe, Seke and Zvishavane. They were no confirmed outbreaks in the last 30 days. The attack rate of suspected cases is 8 per 100 000. The attack rate of confirmed cases is 0.4 per 100 000. Attack rates were calculated using the same populations used in the previous period. 114 deaths were reported. Week 38 (20 -26 September 2010) Week 38 (20 -26 September 2010) 65 suspected cases of measles and 61 deaths were reported this week through the Weekly Disease Surveillance System (WDSS).


The suspected cases were from the following areas: Chiweshe 11 cases and ,Mbire 54 cases,46 of the deaths were from Chiweshe and 15 of the deaths were from Mbire. Comparison of weekly measles indicators for the periods September 2009 to 4 July and 5 July-26 September 2010 Some notable changes in key measles weekly indicators are as follows:

1. Suspected weekly cases declined from 248 to 78.4, 2. Confirmed weekly cases from 14 to 6 cases 3. Weekly deaths also dropped from 12 to 10

Assessments & response

Integrated EPI disese surveillance and case finding continued. Districts are encouraged to continue to search for suspected measles cases and meet the detection rate of 2 suspected cases per 100 000 population per year. If we assume even distribution of cases, 5 suspected cases per week are expected to be reported.

Chiweshe , Mazowe and Mbire Outbreaks.

• Extensive measles outbreaks have been reported from Mbire and Mazowe districts of Mashonaland province from the 28th of July to date.

• The health workers received received information about children being buried at night in affected villages and started investigations after that.

• The areas affected by the outbreak are hard to reach areas with known religious objectors of the Johane Marange apostolic church. It has been very difficult for health workers to access this community.

• Hostilities between this community and health officials have been reported. • The current wave of the outbreak has been traced to recent church gatherings in the

areas where several children were reported to have died and were buried secretly • A total of 102 community deaths out of a total of suspected 162 cases have been

reported from the two districts among vaccination objectors (Mainly Johane Marange Apostolic Sect whose children were denied vaccination during the June NIDs).

• Information from the two districts indicates that the affected people mostly children belong to the religious objectors (Johannes Marange), were never vaccinated before and they did not receive vaccinations during the June NIDs.

• The information on cases and deaths should be interpreted cautiously as it was provided by Village health workers, village heads and neighbours (Possibilities of both over and under reporting cannot be ruled out).

• It should be noted that no blood samples were sent from Mbire and Mazowe as the outbreak in the districts was discovered after reported community deaths by some community members.

• Breakdown of cases by age group was not possible at the time of writing this report and this will be done once the line list has been secured.

Action taken to date

The districts have conducted relevant investigations and findings were as follows:


Community meetings held with local leadership to map the best way forward involved the following:

• Chiefs • Councillors, • Police Officers • Women’s Affairs Representatives • Assistant District Administrators • The Health teams

Support provided by the Health teams and local partners (IMC) included:

• Vaccine Supplies to clinics • Local health teams put on high alert for case identification. The teams were advised to

continue with advocacy and social mobilization. • Rapid Response Teams put in place to visit affected wards for active search and gather

information on number of people and ages affected ,when affected and number of people who died

• Compilation of line listing of cases where possible is being maintained

Case management

-Only two cases managed to filter to the health care system in Mazowe. No specimens could be obtained since the families requested prompt treatment to avoid detection by other members of the church.

-10 of the children affected in Mbire were hospitalised at Mushumbi RHC and all of them recovered.

Response Vaccinations conducted

With assistance from Social welfare officer, CPU and the local council, 28 children were vaccinated in Mushumbi(Mbire) area after having been granted permission by the church heads(J. Marange)

Achievements

• All districts have active EPR teams in place • Community based surveillance is active utilizing the current trained VHWs. • Measles surveillance and data collection is underway despite resistance • Involvement of CPU, traditional and political leaders during active surveillance and

response • Strengthened supervision • Oracle fluid kits have been distributed to provinces with ongoing outbreaks so that they

can collect both blood and oracle fluids.


Annex 1: Summary Tables

Table 1: Cumulative Cholera cases and deaths reported by district as of week 38, 2010

District Suspected Cases reported this week

Confirmed Cases Reported this week

Suspected Cases

Confirmed Cases

Discarded Cases

Total Cases

Deaths Attack Rate/ 100000

Beitbridge 0 0 16 1 0 17 0 15.14

Bindura 0 0 0 2 0 2 0 1.30

Buhera 0 0 101 5 0 106 0 44.48

Chegutu 0 0 19 13 32 2 13.12

Chimanimani 0 0 52 10 0 62 51.16

Chipinge 1 1 10 7 0 17 2 5.53

Chiredzi 0 0 45 9 0 54 2 21.31

Chivi 0 0 11 2 0 13 0 7.71

Harare Urban

0 0 1 3 0 4 0 0.25

Hurungwe 0 0 165 6 171 5 55.16

Kadoma 0 0 136 24 0 160 5 62.55

Makonde 0 0 3 1 0 4 0 1.40

Mangwe 0 0 0 1 0 1 0 0.99

Masvingo 0 0 9 1 10 1 3.50

Mt. Darwin 0 0 7 4 0 11 1 5.08

Mutare 0 94 6 0 100 1 23.51

Mwenezi 0 0 0 5 0 5 0 3.66

Uzumba Maramba Pfungwe

0 0 4 0 0 4 1 3.54

Total 1 1 673 100 0 773 20 16.11


Table 2: Age and Sex breakdown of cumulative cholera linelisted cases as at week 38

District

Under 5 Years

5-14 Years

15-29 Years

30 Years and over

Mal

e

Fem

ale

Mal

e

Fem

ale

Mal

e

Fem

ale

Mal

e

Fem

ale

Buhera 0 0 0 1 18 3 8 1 Chiredzi 2 2 5 3 6 9 6 8 Chivi 0 0 0 1 0 1 2 4 Harare 00 0 0 0 0 0 2 0 Chimanimani 4 2 2 7 6 20 10 9 Chipinge 0 2 1 2 0 3 3 4 Masvingo 0 0 0 0 0 1 2 3 Mwenezi 0 0 0 0 0 1 2 1 Beitbridge 0 0 0 0 0 0 0 0 Kadoma 0 9 0 17 0 0 0 0 Mutare 2 2 1 2 45 14 24 15 Total 6 12 9 30 59 42 42 37

Table 3: Distribution of Measles IgM Positive by Agegroup and District of residence since September 2009 – 26 September 2010

District Missing < 9 months

9 ‐12 months

1‐5 years

5‐14 years

>14 years

Total Cases

New Cases

Attack Rate per 100 000

BEITBRIDGE 0 0 0 2 2 2 6 0 5.3BIKITA 0 1 0 4 6 0 11 0 6.5

BINDURA 0 0 2 3 0 1 6 0 3.2BINGA 0 0 1 1 3 4 9 0 6.9BUBI 0 1 0 2 7 3 13 0 25.3

BUHERA 0 0 1 3 2 0 6 0 2.5BULAWAYO 1 6 6 2 5 2 22 0 3.0CENTENARY 0 0 0 0 2 1 3 0 2.9CHEGUTU 0 2 0 4 7 0 13 0 11.1

CHIKOMBA 0 1 1 2 3 1 8 0 3.3

CHIMANIMANI 0 0 0 1 1 2 4 0 3.1CHIPINGE 0 0 1 1 6 4 12 0 9.6CHIREDZI 0 3 2 1 2 1 9 0 3.0

CHIRUMANZU 0 0 0 1 5 1 7 0 2.8



9 ‐12 months

1‐5 years

5‐14 years

>14 years

Total Cases

New Cases


CHITUNGWIZA 0 11 0 0 5 6 22 0 28.8CHIVI 0 1 0 2 2 0 5 0 1.4

GOKWE NORTH 0 0 0 0 2 1 3 0 1.8GOKWE SOUTH 0 1 1 5 12 3 22 0 9.5

GOROMONZI 0 1 1 1 6 0 9 0 2.8GURUVE 0 1 0 0 1 0 2 0 1.2

GUTU 0 0 0 2 5 0 7 0 3.5GWANDA 0 0 1 0 0 2 3 0 1.4GWERU 0 3 0 1 3 2 9 0 6.4HARARE 2 35 17 13 44 42 153 0 62.8

HURUNGWE 0 2 1 2 4 0 9 0 0.6HWANGE 0 3 0 1 0 6 10 0 3.2HWEDZA 0 0 0 3 5 0 8 0 7.3INSIZA 0 1 0 1 7 0 9 0 11.8

KADOMA 0 1 0 1 5 0 7 0 7.5KARIBA 0 0 0 0 5 3 8 5 3.2

KWEKWE 0 2 0 3 6 1 12 0 18.8LUPANE 0 2 1 2 3 3 11 0 4.1

MAKONDE 0 1 1 3 5 2 12 0 11.2MAKONI 0 1 0 6 3 2 12 0 9.5

MANGWE 0 0 2 0 2 2 6 0 2.2

MARONDERA 0 3 0 2 6 1 12 0 14.2MASVINGO 0 1 1 0 2 1 5 0 4.5MATOBO 0 0 0 0 3 1 4 0 1.9MAZOWE 0 2 1 0 3 3 9 0 8.3

MBERENGWA 0 0 0 0 1 0 1 0 0.5

MT DARWIN 0 0 0 1 5 0 6 0 3.0MUDZI 0 0 0 2 7 0 9 0 4.2

MUREHWA 0 0 1 0 4 1 6 0 4.4MUTARE 0 1 0 2 4 1 8 0 4.6MUTASA 0 0 0 3 4 0 7 0 1.7



9 ‐12 months

1‐5 years

5‐14 years

>14 years

Total Cases

New Cases


MUTOKO 0 0 0 3 2 1 6 0 3.3MWENEZI 0 1 1 2 1 0 5 0 2.8

NKAYI 0 0 0 2 1 1 4 0 2.9NYANGA 0 2 0 3 1 2 8 0 6.6

RUSHINGA 0 0 0 1 2 0 3 0 2.4SEKE 0 7 0 6 7 3 23 0 31.6

SHAMVA 0 0 0 0 1 0 1 0 1.2SHURUGWI 0 0 0 2 1 1 4 0 3.8

TSHOLOTSHO 0 1 0 1 1 0 3 0 3.1UMGUZA 0 1 0 2 2 1 6 0 4.6

UMZINGWANE 0 1 1 0 1 0 3 0 2.7

UZUMBA‐MARAMBA‐PFUNGWE 0 0 1 3 3 4 11 0 9.7

ZAKA 0 3 1 3 1 1 9 0 13.5ZVIMBA 0 1 2 6 8 3 20 0 10.0

ZVISHAVANE 0 1 0 8 17 3 29 0 12.1TOTAL 3 105 48 125 264 125 670 5 5.5

Table 4: Distribution of Community and Institutional Measles Deaths attributed to Measles as of 26 September 2010

District Community Deaths

Institutional Deaths

Total Deaths

Bikita 11 0 11 Bindura 10 0 10 Buhera 92 4 96 Chegutu 2 0 2 Chimanimani 3 0 3 Chipinge 3 0 3 Gokwe North 18 1 19 Gokwe South 6 0 6 Goromonzi 46 0 46 Guruve 1 0 1 Hwange 2 0 2 Insiza 4 0 4 Kadoma 1 0 1


District Community Deaths

Institutional Deaths

Total Deaths

Makoni 24 5 29 Marondera 20 0 20 Mudzi 31 0 31 Mazowe 72 0 72 Mbire 32 0 32 Murehwa 50 0 50 Mutare 47 0 47 Mutoko 46 0 46 Mutasa 10 0 10 Nyanga 9 0 9 Seke 17 2 19 UMP 55 0 55 Insiza 7 0 7 Total 619 12 631

Table 5: Comparison of some Measles Indicators before vaccination plus four weeks and after

Indicator September to 4 July ( 44 weeks)

5 July –26 September(11 weeks)

Suspected Cases 10 946 941

Confirmed Cases 602 68

Deaths 517 114

Cumulative number of Districts that reported laboratory confirmed outbreaks

53 10

Ongoing outbreaks 0 0

Overall Attack Rate of suspected cases Confirmed cases

90 per 100 000 22 per 100 000


Table 6: Vaccination Status of Measles Cases by District September 2009 to 26 September 2010

District Not Vaccinated Unknown Vaccinated TOTAL

Missing 95 2369 17 2481

Beitbridge 42 2 16 60 Bikita 31 2 3 36

Bindura 13 0 10 23 Binga 9 0 9 18 Bubi 31 0 4 35

Buhera 586 0 1 587

Bulawayo 64 0 39 103

Bulililamangwe 6 20 1 27 Bulilima 6 0 0 6

Centenary 7 0 1 8 Chegutu 24 0 6 30

Chikomba 46 7 13 66

Chimanimani 15 0 5 20 Chinhoyi 1 0 1 2

Chipinge 42 0 9 51 Chiredzi 17 0 0 17

Chirumanzu 9 6 5 20

Chitungwiza 413 3 61 477 Chivi 16 9 7 23

Gokwe 11 0 1 12

Gokwe north 276 66 26 368

Gokwe south 80 11 4 95

Goromonzi 105 6 18 129



Guruve 9 0 4 13 Gutu 14 1 0 15

Gwanda 9 16 12 37 Gweru 40 24 10 74 Harare 2204 60 901 3165

Hurungwe 22 3 22 47

Hwange 41 36 39 116 Hwedza 20 0 5 25 Insiza 17 2 54 73

Kadoma 80 6 14 100 Kariba 7 11 4 22

Kwekwe 55 30 31 116 Lupane 44 0 6 50

Makonde 73 4 45 122 Makoni 239 0 15 254 Mangwe 4 0 2 6

Marondera 91 4 18 113

Masvingo 64 4 10 78 Matobo 10 25 2 37

Mazowe 51 26 16 93

Mberengwa 4 24 0 28

Mbire 54 17 0 71

Mt darwin 16 0 12 28 Mudzi 58 14 9 81

Murehwa 22 0 6 28 Mutare 215 1 4 220



Mutasa 59 0 12 71 Mutoko 26 3 9 38

Mwenezi 11 0 3 14 Nkayi 25 0 9 34

Nyanga 49 0 11 60

Plumtree 3 0 0 3 Rushinga 7 0 3 10

Ruwa 3 0 0 3 Seke 1360 19 233 1612

Shamva 5 0 0 5

Shurugwi 16 2 13 31

Tsholotsho 18 0 13 31 Umguza 17 1 5 23

Ump 13 4 6 23

Umzingwane 4 1 1 6 Zaka 22 4 1 27

Zvimba 53 4 16 73

Zvishavane 64 0 7 71 Total 7098 2847 1840 11841


Annex 2: Maps Map 1: Comparison of cumulative cholera cases by district as of week 38 for the years 2009 and 2010

2010 2009


Map 2: Comparison of Cumulative Measles IgM positive cases and Suspected Measles case by district reported this year, as at 26 September 2010

Confirmed Cases Suspected Measles Cases


Annex 3: Graphs Graph 1:Ranking of District Cumulative Cholera Cases Reported as at week 38, 2010

Graph 2: Cumulative Cholera Cases by week for the years 2009 and 2010


Graph 3: Cholera Epidemic Curve Week 5 - Week 38, 2010

Graph 4:Ranking of Confirmed Measles Igm Cases by District Reported from September 2009 to 26 September 2010


Graph 5:Ranking of Suspected Measles Cases by District Reported from September 2009 to 26 September 2010

Graph 6: Measles Epicurve as at week 38, 2010


Appendix 1: Case Definitions Cholera 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. Suspected measles: Any person with fever and maculopapular rash and cough OR Coryza (running nose) OR conjunctivitis (Red eyes) OR clinician suspects measles. Measles Outbreak Definition: A suspected outbreak is where you have a cluster of at least 5 suspected measles cases in a facility or district within a month whilst a confirmed outbreak is where you have a cluster of at least 3 confirmed measles IgM positive cases. Lab confirmed: Suspected case of measles with positive serum IgM antibody, with no history of measles vaccination in the past 4 weeks. Confirmed by epidemiologic linkage: Suspected case of measles not investigated serologically but has possibility of contact with a laboratory-confirmed case whose rash onset was within the preceding 30 days (same / adjacent districts with plausible transmission)

epidemiological bulletin number 78€¦ · the c4 team welcomes feedback. ... (imc) included: •...

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