MACHINGA DISTRICT COUNCIL(HEALTH SECTOR)

PRESENTATION ON THE 2015/16 CHOLERA OUTBREAK

PRESENTED TO: WHO TEAM27TH JUNE 2016.

Outline• Background.• The 2015/16 Cholera outbreak.• Major response activities• Strengths• Achievements• Challenges• Lessons learnt• Way forward/Suggestions for the future.

1.0 Background

1.1 District Profile• Location: Southern Region of Malawi-South East

Health Zone• The district has about 896 villages and

15Traditional Authority Areas.• Total population: 608,172 of which 30,409 are

under 1 and 103 391 are under 5 years.• 78% access to safe water sources: (33% samples

contaminated)• 64% access to basic sanitation- 24% access to

improved sanitation.

1.0 Background

• One of the economic activities in the district is fishing.

• one in larger scale in Lake Chilwa and Chiuta, and on a small scale in Lake Namalamba.

• Fishing in Lake Chilwa entails staying right in Lake on floating homes called “Zimbowera”.

• The Lake is used both as a source domestic water supply and a toilet.

• The Lake is inland drainage -no outlet ,hence highly contaminated, and a cholera hot spot .

• The fishermen are the at risk population.

Picture-Chimbowera

Picture-Chimbowera

1.0 Background.

1.3 Categories of Cholera & their risk factors.• Two categories of cholera are experienced: the wet

season and the dry season cholera.• Wet season cholera: Similar to that experienced in

most parts of Malawi -due to rainfall related factors e.g. water contamination etc

• Dry season cholera: Unique to Lake Chilwa-due to dwindling of water volume in the Lake leading to high concentration of micro organisms.

• Dry season cholera has in the past, naturally died on its own by: the onset of rainfall and increase in water volumes or complete drying up of the Lake.

1.0 Background 1.4 Cholera Trend from 1998

1998/99

1999/2000

2000/01

2001/02

2002/03

2003/04

2004/05

2005/06

2006/07

2007/08

2007/08

2009/10

2010/11

2011/12

2012/13

2013/14

2014/150

200

400

600

800

1000

1200

1400

1600

1800

2000

113

353

612

46

1893

222 222

0

229

0 0

638

35 0128

0 0

Cholera Cases

Cholera Cases

2.0 The 2015/16 Cholera outbreak.

2.1 Onset and Investigation findings:• The outbreak was confirmed on the 17th of December

2016- 3 samples.• First cases occurred and were concentrated on a group

of “Zimbowera” called Sekwele.• The area was a liquor and commercial sex business hub

right in the Lake.• The outbreak was triggered by congestion and

unhygienic behaviors especially intensified faecal defecation.

• Also observed intensified urination and disposal of used condoms into the Lake.

2.0 The 2015/16 Cholera outbreak

2.2 Cases so far.• The cumulative number of cases is 798 with17 official

deaths 21 Probable cholera deaths giving a CFR of 2%.

• Over 90% of the affected are the fishermen followed by their relatives/guardians.

• The health Facilities that have reported most cases are those near the entry points into the Lake.

• The most affected health facilities are: Mposa, Namanja and Nayuchi .

• Accessibility issues: Referral of patients from the “Zimbowera” has also been a big challenge.

2.2 Cholera Trend.

0

20

40

60

80

100

120

140

160

10

106

150

110

2919

4 1024

34

61

2335

16 14 10 9 5 419 21 25 20 17 15

4 2 3

NUMBER OF CASES PER EPIDEMIC WEEK

Machinga Cases/Week

WEEK OF 2015-2016

NUM

BER

OF

CASE

S

2.0 Cholera Trend.2.2 Cases so far

• The outbreak reached the peak the first week of January.

• Since then the cases dropped from the peak of over 50 cases to 10 or less per week

• The outbreak has however persisted up to May

• The explanation is that this is a dry season cholera intensified by the drought experienced this year

• The drought has also led to an influx of fishermen into the Lake for fishing as an alternative to agriculture negatively affected by drought.

2.0 The 2015/16 Cholera outbreak.Cases by health facilities

1%

4%3%

2%1%

25%

1%

34%

15%

2%1%0.1%

4%

7%

0%

Chamba Disp Chikweo HC

Gawanani HC Kawinga HC

Machinga District Hospital Machinga HC

Mbonechera Disp Mpiri HC

Mposa HC Namandanje HC

Namanja HC Nainunje HC

Nayuchi HC Ngowke HC

Nsanama HC Ntaja HC

Nyambi HC Mkwepere Disp

Mlomba Disp Mangamba

Ntholowa Mbanila

Nampeya HC

2.0 The 2015/16 Cholera outbreakcases-health facilities (March 16- 609 cases)

Chamba Disp

Chikweo HC

Kawinga HC

Machinga District Hospital

Mpiri HC

Mposa HC

Namandanje HC

Namanja HC

Nayuchi HC

Nsanama HC

Ntaja HC

Nyambi HC

Ntholowa

Mbanila

0 50 100 150 200 250

5

32

21

9

6

109

4

197

71

12

7

1

28

54

1

0

1

1

0

8

0

10

2

0

0

0

1

3

Number of DeathsNumber of Cases

2.0 The 2015/16 Cholera outbreak.Cases by Health Facility

• The Health Facilities that reported most cases are those near entry points into the Lake.• These are Mposa, Mbanila, Namanja

and Nayuchi.• Overtime and of late most cases have

been reporting to Mposa because of drying up of Lake Chilwa on the Namanja & Nayuchi side.

2.0 The 2015/16 Cholera outbreak.(By March 16th )

RISK FACTOR NO of CASES %

Use of contaminated water from Lake Chilwa

548 89.9

Contaminated food 36 5.9%Guardian 9 1.4%Contact with cholera case 16 2.6%Total 609 100%

2.0 Cases by Risk Factor• The main risk factor is

consumption of contaminated water from the Lake.

• Other risk factors are contaminated food , guardian or contact with a cholera case.

3.0 Major response activities done

• Establishment of treatment centers and provision additional staff for case management.

• Distribution of Chlorine and Water guard to fishermen and the community

• Information Education and Communication to fishermen and the community members

• Door to door sensitization• Stakeholder and inter district meetings. • Daily data collection and reporting to

Epidemiology Unit

3.0 Major response activities

• Awareness campaigns through video shows, road shows

• Planning meetings with local leaders, political leaders and Village Health Committees.

• An appeal to fishermen and commercial sex workers to move out of the Lake.

• Distribution of water pump filters for water treatment ( MSF, Water Aid , Ministry of Water)

• The Oral Cholera Vaccination Campaign.

3.0 Major response activities

• Supervision• Mobilization of supplies• Establishment of ORT corners (12)• Surveillance trips into Lake Chilwa • Coordination meetings at the Zone Office

3.0 Major response activities

• Top up allowances for staff to motivate them (MSF, WVI, Njira Project)

• Allocation of an ambulance to improve referrals.

• Supervision of burial of cholera dead bodies.• Consultation meetings with local leaders, BVCs• Formation of Fishermen Committees• Training of the committees on cholera

prevention and case management.

4.0 Achievements.• Stakeholder coordination and

teamwork.• Quick detection , reporting

and investigation.• Quick mobilization of

resources (Human, drugs and supplies, vehicles from local , national and international partners and stakeholders).

4.0 Achievements• Implementation of various response

activities• Improved case mgt , adoption of

prevention measures i.e. water treatment• Cholera arrested and confined in the

Lake-Did not spread to the upland.• Reduction in deaths and cases.• The OCV-Improved immunity of the at

risk people.

5.0 Challenges• Heavy workload & inadequate

staff• Inequitable resource allocation-

Other interventions were highly funded while others had no resources.

• Not all resources pouring into the district made known by DHO for monitoring and technical input- transparency issues.

• Reactive and not proactive approach- no outbreak no resources from stakeholders

5.0 Challenges• Drought- leading to lowering of water levels,

congestion of fishermen and high concentration of cholera vibrios.

• Drought- poor harvests leading to an influx into the Lake for fishing.

• Resources not available for some district pressing needs eg i.e. daily surveillance communication, fuel for supervision , motivation for over worked health workers. etc.

• New lifestyles/Entertainment, commercial sex work etc leading to intensification of unhygienic behaviors in the “zimbowera”.eg at Sekwele area.

5.0 Challenges• Difficult accessibility of the affected area and

population.• Lack of structures and inadequate participation

among fishermen or the affected population• Lack of support from stakeholders when there

is no cholera.• Nature of the Lake brings challenges for daily

fishing from the mainland.• Absence of practical and long term technology

for fecal disposal and safe water supply.

5.0 Challenges• Misappropriation of water pump

filters by some fishermen• Negative feedback- Inadequate

appreciation of efforts by local staff- frustration instead of motivation.

• Other equally important activities requiring health workers time- Nets distribution, Child Health Days.

• Impatience/expectations (The role of underlying and difficult factors affecting the outbreak such as the drought (drought) not appreciated or understood by stakeholders)

5.0 Challenges• Prolonged outbreak leading to

fatigue, loss of interest among stakeholders to support and attend stakeholder meetings.

• HSAs demanding holiday or exchange with pay for failure to go for their entitled annual leave.

• Demand for incentives and no financial capacity by DHO to provide them because of inadequate financial capacity.

6.0 Lessons learnt

• Cholera requires proactive approach- Prevention has to be maintained even when there are no cases or expect crisis management.

• Good collaboration and stakeholder involvement eases response to the outbreak.

• Involvement of local leadership, structures beneficiaries is vital.

• The technical capacity of the DHO need to be put to use or respected for resources being entirely channeled through partners to benefit the district or properly accounted for.

7.0 Lessons learnt• Carefully planned incentives can

enhance health workers motivation. Good to be realistic on when and when not incentives can be provided.

• For cholera interventions to be workable there is need for consideration of the local situation and realities on the ground ( the drought)

8.0 Way forward/Suggestions.

• Discussion at national level on the feasibility of fishing from outside the Lake.• Strengthening structures and constant

involvement of fishermen in cholera issues.• Proactive and not reactive approach on

resources- Allocate resources for prevention.• Strengthening of interventions that have

worked e.g. the OCV.

8.0 Way forward/Suggestions.

• Transparency on all resources channeled through DHO or partners.

• Provide incentives where due.• Realistic expectations and fair

judgment to motivate staff.• Efficient and equitable allocation of

resources to interventions.

8.0 Way forward/Suggestions.

• Routine implementation of cholera prevention and control activities in Lake Chilwa• Suggestions, advice &

positive feedback when there is an outbreak.• Flexibility on resources to

address district felt needs.

THE END

THE END