Zimbabwe is experiencing an outbreak of cholera since mid October 2008. It started in Harare and by 18 November 2008, it spread to nine of the country's provinces with 6 072 suspected cholera cases and 294 deaths as at 18 November.

On 15 November 2008, we received reports of cholera in Beitbridge, Zimbabwe. On 17 November 2008, Limpopo Provincial Department of Health reported an increase in the number acute diarrhoea cases since 15 November with one death that occurred on 16 November 2008. On 19 November 2008, the National Institute of Communicable Diseases confirmed Vibrio cholerae isolated in five out of eleven stool samples tested.

As at 23 November 2008, Beitbridge Hospital reported an admission rate of 200 patients per day with a cumulative number of 1 876 patients and 63 deaths.

As at Monday, 24 November 2008, 187 cases of cholera were treated and three deaths reported in Limpopo province, one of whom is South African (died on 16 November 2008) and the other two Zimbabwean citizens who died on 18 and 20 November. The South African who died was in Zimbabwe prior to the development of symptoms.

Two truck drivers, one Zambian and the other Mozambican, who travelled through the Beitbridge area, were confirmed to be suffering from cholera and were treated at the Charlotte Maxeke Hospital (formerly the Johannesburg Hospital) and Addington Hospital in Durban.

Both have succumbed to their illness and died on 21 and 24 November 2008 respectively.

Apart from Limpopo, the other affected provinces in South Africa are Gauteng, with nine cases and six suspected cases, KwaZulu-Natal with one confirmed case, Mpumalanga with one suspected case, and Western Cape with one suspected case.

In response to the outbreak the Department of Health (DoH) has:

* Deployed the National Outbreak Response Team (NORT) and the Provincial Outbreak Response Team (PORT) in Musina on 17 November 2008, to respond to the outbreak.

* A Joint Operations Committee was set up and working subcommittees were formed on the same day in Musina.

* Cabinet was informed and discussed the matter on 19 November 2008.

* Three treatment tents erected and adequately staffed and stocked to deal with the outbreak in Musina Hospital.

* Additional supplies were obtained - Rehydration fluids (oral and intravenous) beds, linen, buckets and covers for tent floors.

* Risk assessment of the environment was done and environmental health practitioners were deployed.

* Additional health professionals (doctors, nurses, epidemiologist, public health specialists etc) were mobilised and deployed to Musina.

* Contact was made with World Health Organisation (WHO), United Nations Children's Fund (UNICEF) SA Military Health Service (SAMHS), South African Red Cross, non-governmental organisations (NGOs) and other stakeholders for support and assistance.

* Water monitoring was done at strategic points in the Limpopo River and at the sewerage treatment plant.

* Public health promotion activities at community level on acute diarrhoeal diseases and cholera was increased. Focus was placed on high-risk groups such as travellers entering and leaving South Africa, truck drivers and their assistants.

* Cholera alert and contingency plans for strengthening emergency preparedness response activities for control of diarrhoeal diseases sent out to all provinces. A national multi-sectoral committee was convened to: (a) discuss the status of the cholera outbreak and challenges in South Africa and Zimbabwe; (b) to discuss major initiatives to deal with the challenges and (c) to agree on what needs to be done to strengthen our response. The meeting involved the National Department of Health (NDOH), Departments of Foreign Affairs (DFA), Water Affairs and Forestry (DWAF) DWAF, Limpopo Province (LP), Department of Provincial and Local Government (DPLG), SA Military Health Service (SAMHS), World Health Organisation (WHO), United Nations Children's Fund (UNICEF), International Organisation of Migration (IOM), United Nations High Commissioner for Refugees (UNHCR), Médecins sans Frontières (MSF), Centre for Disease Control (CDC), United Nations Office for Co-ordination of Humanitarian Affairs (UNOCHA), and Save the Children United Kingdom(UK).

The national multi-sectoral committee shared information on the current status in South Africa and in Zimbabwe. There was consensus that much is being done in both countries by various stakeholders to address the outbreak and its consequences: structures are in place and functional; additional supplies are being provided; IEC material is being distributed; treatment centres have been established; potable water is being provided in some areas.

However, given the scale of the outbreak, the weakened health system in Zimbabwe and the extent of the cross border movement of people it was agreed that all aspects of our interventions needed to be scaled up and a renewed sense of urgency to deal with this outbreak was needed at all levels. Clearly, a major focus should be to assist the people of Zimbabwe to access clean water and to repair sanitation plants.

A nine point action plan was adopted by the committee together with a decision that the National Outbreak Response Team (NORT) meet weekly (the next meeting was scheduled for 2 December 2008) and that organisations that are not regular members of the NORT will be invited to attend these meetings until this outbreak is fully resolved.

The following nine areas were suggested for further strengthening and action:

* Need to strengthen co-ordination at Joint Operations Committee (JOC) level at Musina (health sector appears to be working well with two meetings a day) and need to ensure that actions that are agreed upon are implemented.

* Need to revise and strengthen South Africa's strategy/plan to deal with cholera.

* Need to develop a more detailed implementation plan for Musina and Zimbabwe that outlines exactly what additional efforts are needed, including quantification of supplies needed.

* Need to strengthen information, education and communication (IEC) to ensure focus on good hygiene practices (but need to also ensure that water and sanitation services are adequate); with particular focus on high risk populations such as truck drivers, etc.

* Need to meet with the Department of Home Affairs (DHA)re: dealing with irregular immigrants; key issues include dealing with immigrants at the reception area, etc (need to ensure that we do not drive people with symptoms of cholera underground but that they are able to seek and receive treatment).

* All partners will work with the National Department of Health (DoH) and through the World Health Organisation (WHO) in providing assistance to the people of Zimbabwe.

* SA Military Health Service (SAMHS) to explore possible assistance (apart from membership of JOC in Musina which they are already members of).

* Need a sense of urgency: activate Operations Committees (JOCs) in all provinces - especially in high risk areas; JOCs to meet more regularly, every day if necessary with support from the Provincial Outbreak Response Teams (PORTS) and the NORT.

* Need to rapidly develop a plan to deal with cases of cholera in high density areas in South Africa, e.g., Johannesburg, including referrals to hospitals for serious cases; hospitals to be informed of need for admission for those with severe symptoms.

Travellers to and from the Beitbridge area, Zimbabwe are at risk and should engage in the following preventative activities:

* Water purification or ensuring a safe water supply by boiling or chlorination of domestic water using household bleach: Add one teaspoon full (five millilitre, or one capful if bottle has a screw cap) of household bleach to 20 to 25 litres of water. Thoroughly mix solution with the water and allow it to stand for at least thirty minutes (preferably overnight) before use.

* Sanitary disposal of human waste without contaminating water sources.

* Wash hands thoroughly with soap after using the toilet and before preparing or eating food.

* Food hygiene - avoid any potentially contaminated food especially raw or partially cooked fish and shellfish. Food of vegetable origin should be peeled or shelled. Boil or pasteurise all milk.

* Wash vegetables and fruit in treated water before use.

* Prepare and store food under proper hygienic conditions.

* Cook food thoroughly in treated water and eat it while still hot, or reheat it thoroughly before eating.

* Prevent contamination of food by contact with other contaminated raw food, contaminated surfaces or flies.

* Use clean cutlery when eating.

* Discourage the habit of several people eating simultaneously from a communal food container.

* Left over food should be reheated before eating.

* Encourage breast-feeding of infants.

Travellers in and from the Beitbridge area who suspect that they contracted Cholera should note that besides prevention, the best control measures are the early detection and effective treatment of the disease. Recognition of the "rice water stools" of a suspected Cholera case is very important. Cholera should be suspected when:

* Any person develops an sudden onset of three or more watery stools after being in an area where there is an outbreak of Cholera, or

* A person develops severe dehydration from acute watery diarrhoea (usually with vomiting).

In cases where cholera is suspected, drink more Oral Rehydration Solution - make this mixture by adding eight teaspoons of sugar and half teaspoon of salt to one litre of safe water and seek medical care immediately.

We are working closely with the WHO in trying to assist people in Zimbabwe cope with the outbreak. Within South Africa we are working closely with a range of stakeholders to ensure that we have a comprehensive and coherent strategy that will assist us to contain the spread of the disease and to respond quickly to patients who have contracted the disease.

This outbreak and its spread teaches us a number of lessons. Firstly we need to ensure that communities are provided with basic services like water and sanitation. Secondly, that communities need to be informed about communicable diseases, their symptoms and what can be done to treat these diseases. Thirdly, no community is an island - with movement of people and goods through the region and within our country all provinces and health facilities need to be on alert. Fourthly, we must treat anyone with a communicable disease, we cannot say this person is not local and therefore should not be treated. By treating those with symptoms of communicable diseases we will protect everyone in the community. We are therefore, with our partners doing everything we can to assist the affected communities but there is also a need for communities to need the simple messages that I have noted earlier.

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