Sources: Ministries of Health and WHO Creation date: 18th May 2018

Bulletin: Cholera and AWD Outbreaks in Eastern and Southern AfricaRegional Update for 2018 - as of 18 May 2018HighlightsMore than 17,479 cholera / AWD cases and 268 deaths (Case Fatality Rate, 1.5%) have been reported in 10 of 21 countries of Eastern and Southern Africa Region (ESAR) since the beginning of 2018. These countries include; Angola, Kenya, Malawi, Mozambique, Rwanda, Somalia, Tanzania, Uganda, Zambia and Zimbabwe. Zambia accounts for 23.4% of the total case load reported this year followed by Kenya at 22.5%.

Currently, 7 out of the 21 countries in ESAR are reporting active transmission of cholera / AWD (Kenya, Tanzania, Angola, Uganda, Somalia, Zambia and Zimbambwe). During the week under review, Kenya reported the highest number of new cases (302 cases), followed by Somalia (296 cases). Apart from Somalia, all countries with active transmission have recorded CFR above 1% in 2018, with Zimbabwe (CFR, 4.2%) and Uganda (CFR, 2.1%) recording the highest CFR.

Kenya: An increase in the epidemic trend has been noted. During week 19 (week ending 13 May 2018), 302 new cases were reported compared to 58 cases reported in week 18 (week ending 6 May 2018). These new cases emerged from the following counties; Garissa (202), Nairobi (29), Isiolo (24), Elgeyo Marakwet (17), Turkana (14), Kiambu (8), West Pokot (7) and Meru (1). Cumulatively a total of 24,741 cases including 414 deaths have been reported, as from December 2014. Of these, a total of 3,931 cases and 71 deaths have been reported since the beginning of 2018.

Somalia: An increase in the epidemic trend has been noted. During week 18, 296 new cases including 4 deaths (CFR, 1.4%) were reported compared to 212 cases including 2 deaths (CFR, 0.9%) reported in week 17 (week ending 29th April 2018). New cases emerged from Banadir (132 cases and 2 deaths), Lower Jubba (127 cases and 2 deaths) and Lower Shabelle (37) regions. Cumulatively a total of 2,967 cases including 17 deaths have been reported, as from December 2017.

Tanzania: A decline in the epidemic trend has been noted. During week 19, 44 new cases were reported compared to 89 cases including 3 deaths (CFR, 3.4%) reported in week 18. New cases emerged from Longido District Arusha region (33) and Songwe region (11). Cumulatively a total of 30,468 cases including 502 deaths have been reported, as from August 2015. Of these, a total of 1,837 cases and 36 deaths have been reported since the beginning of 2018.

Uganda: A decline in the epidemic trend has been noted. During week 17, 42 new cases were reported compared to 110 cases including 2 deaths (CFR, 1.8%) reported in week 16 (week ending 22 April 2018). These new cases are concentrated in the following districts Kagadi (19), Amudat (12), Hoima (9) and Kyegegwa (2). Cumulatively a total of 2,376 cases including 49 deaths have been reported since the outbreak started in February 2018.

Zambia: The country has been reporting an average 2 cases per day, mainly from Chelston sub-district of Lusaka district. During epidemiological week 19, the country reported 16 cholera cases and no deaths. Cumulatively a total of 5,905 cases including 115 deaths have been reported since the outbreak started on 6 October 2017. Lusaka district accounts for 92% (4,768) of the cumulative reported cholera cases countrywide.

Zimbabwe: Sporadic cases continue to be reported, mainly from Chitungwiza and Stoneridge (an informal settlement in Harare right next to Chitungwiza). Both places have extremely erratic access to tap water (from Harare city) and largely depend on well water. During week 19, 9 new cases were reported compared to 4 cases reported in week 18. Cumulatively, 167 cases including 7 deaths have been reported, as from January 2018, when the outbreak started.

Angola: 7 new cases were reported in week 19 compared to 6 cases reported in week 18. These new cases are concentrated in Uige district. Cumulatively, 944 cases including 15 deaths have been reported, as from 15 December 2017. Of these, 839 cases and 9 deaths have been reported since the beginning of 2018.

19302

44

1,837

3,931

801

774

3

16

4,097

42

2,376

9167

296

2,654

0 / 71

0 / 36

0 / 9

0 / 22

4 / 16

0 / 3

0/ 49

0 / 55

South Sudan EthiopiaSomalia

Kenya

Uganda

Rwanda

Burundi

Tanzania

Angola Zambia

Malawi

Mozambique

ZimbabweBotswanaNamibia

South Africa

Lesotho

Swaziland

Madagascar

Eritrea

Comoros

New cholera cases (last 1 week)2018 Cumulative cases

Cholera DeathsNumber of new cholera deaths (Week 17, 18 or 19) / 2018 Cumulative deaths

Distribution of new cases: Week 17, 18 or 19, 2018No data

No new cases reported in Week 17, 18 or 19 1 to 500 cases > 500 cases

Legend

No outbreak reported in 2018

10Countries

In 2018;17,479 Cases

7839

268 deaths

1.5% CFR

0 / 7

Country Priorities and Response InterventionsCountry Priorities Response Interventions

Zimbabwe

Somalia

• 112,905 new beneficiaries reached with temporary water supply services through trucking, voucher and water source chlorination in Bay, Banadir, Middle Shabelle, Gedo, Sanaag, Sool, Mudug and Nugaal regions. • An additional 131,349 people accessed sustained water supply services through the construction and rehabilitation of water systems in Nugaal; Bakool, Bay and Sanaag regions• 19,908 people benefitted from adequate sanitation in Nuugal, Bakool, and Sanaag regions. • 6,939 school children got access to sanitation facilities in Nuugal, Bakool, and Sanaag regions• Hygiene kits and means for water disinfection were provided to about 185,000 people in emergency situation. These include 168,000 people affected by floods in the district of Belet Weyne, Hiraan region.• Hygiene promotion messages reached 109,313 people based in different IDP settlements

- Point of use water treatment- Rehabilitation of communal latrines - Continue to intensify hygiene promotion- Water treatment chemicals

• 1,200 Non-Food Items (NFI’s) kits i.e. soap, aquatabs and IEC were distributed to affected households in Stoneridge• Installation of inline chlorinators on 3 piped water schemes• Training of 55 health promotion volunteers resulting in door to door health and hygiene awareness campaign • Mass media campaigns in high risk areas• Water trucking (20,000L) to the Cholera Treatment Unit set up in the affected area• Repair of boreholes in Chitungwiza

- With an estimate 630,000 people affected by heavy rains and floods, more resources need to be mobilized in order to respond to emerging needs and prevent possible new outbreaks of infectious diseases including cholera- Support provision of emergency and sustained WASH serviced through different water supply option, appropriate sanitation and hygiene promotion activities at the community and institutional level- Provide people with hygiene kits enabling them to prevent cholera -Proper case tracing and management through early detection mechanisms, laboratory surveillance and timely referral to different CTCs/CTUs established- Continue oral cholera vaccinations campaigns in hotspot areas

Kenya

-Need for continuous capacity building in counties on IDSR, IPC and RRT-Ensure the availability of safe water (HWTS, HH water treatment and safe storage, and targeted investment in water supply) and safe human waste disposal (CLTS and ODF)-Strengthen cholera prevention (hand washing) and health promotion in high risk areas-For Nairobi County, key priority areas include: Strengthening coordination at the county level; engaging the unit committees, food vendors as well as the informal sector workers; sensitization of hospitality and other institutions; supporting rapid response teams and intensifying risk communication and public health education using the local FM radio stations

• The Ministry of Health with UNICEF continues to sensitize Health Care Workers in affected counties on case management and Infection Prevention and Control Measures• National MOH and UNICEF designed and printed IEC materials for cholera. The Materials were prepositions and distributed to the affected counties and those deemed to be at risk of Cholera outbreak.• The Ministry designed Radio spots which were aired in English and Kiswahili across the country• Cholera treatment centers have been set up in areas where cholera cases are reported• Hygiene promotion, health education activities are being carried out in the affected counties• Prepositioning and distribution of water treatment and storage commodities as well as medical supplies • The affected counties have enhanced surveillance activities, case finding and contact tracing with targeted provision of chemoprophylaxis for the members of affected families• UNICEF partnering with MOH and Kenya Red Cross to support effort to respond to outbreak

Uganda

- Additional water sources required to improve on current 8 litres per person per day to 20 litres per person per day - Construction of communal and household latrines required- Training of health workers in case management and Village Health Teams (VHTs) in community based surveillance

• Uganda police has started sensitizing people on cholera at border points with Kenya targeting traders, boda - boda riders• Orientation of school teachers and health workers about cholera outbreak is ongoing• UNICEF is partnering with Amudat district to strengthen inter personal communication in addition to printing of IEC materials; and dissemination of messages through radio• Cholera Treatment Centre (CTC) has been established at Amudat hospital. Government of Uganda has provided initial medical supplies to support case management. • UNICEF Zonal office is supporting Amudat district to conduct WASH assessment including quantification of key WASH supplies

Country Priorities and Response Interventions

- Training and continuous mentorship of CTC staff- Strengthening lab confirmation and epi-linkage of all cases- Co-ordinated GPS tracing of cases and ensure safe water availability at patient’s homes- Maintenance of residual chlorine level of 0.5mg/L in all supplied water- Continued engagement and sensitization of communities on hygiene practice and prevention of cholera

Country Priorities Response Interventions

Zambia

Angola

Mozambique- Sustain hygiene promotion- Laboratory surveillance- Mapping and identification of cholera hotspots

• Disease surveillance and laboratory surveillance is on-going. From January to March a total of 40 Multimedia Mobile Unit Sessions were conducted in the priority districts of Memba, Erati, Nacaroa and Nacala Velha, and reached a total of 48,100 people with key messages on prevention and treatment of cholera as well as on key hygiene and wash good practices. All interventions were followed by debates with the community members, local community leaders, local authorities and health professionals• In Cabo Delgado province, a total of 24,407 people have been reached out through house-to-house distribution of 7,821 bottles of Certeza, point-of-use water treatment products, and delivery of hygiene messages by Red Cross Mozambique in Pemba, Chiure, Meluco and Ancuabe districts since March, 2018. In addition, a total of 328 community workshops on the prevention and control of cholera were held and 11,669 people from those districts participated in the workshops during the same period

Tanzania- Follow up closely with communities on construction of toilets in the affected areas and ensure by-laws are adhered to - Capacity building of medical personnel on proper handling of cholera cases when under their supervision - Increase the number of health personnel

- District wide water chlorination especially in Urban/Peri Urban Lilongwe- Sinking of Waterwells in Rural Lilongwe- Promote construction and use of community latrines through CLTS - Extending Coverage of OCV in rural Lilongwe district- Continue with promoting good hygiene practices- Continue advocating with government and WASH cluster to increase safe water coverage in the hotspots- Water trucking in some Lilongwe rural and peri urban hotspot areas- Social accountability for WASH: Demanding duty bearers to provide safe water and sanitation facilities Raising awareness and knowledge regarding community case management and early reporting to avert community deaths- Rehabilitation of boreholes and drilling of new boreholes- Water quality surveillance

Malawi

• Community education and awareness raising regarding the prevention and control of Cholera through villages and Schools meeting and local media outlets is ongoing in all cholera hotspots areas• Public health law enforcements has been strengthened through environmental health officers (EHOs) with temporary closure of the food vending restaurants not abiding with the regulations • Training and mentorship of health workers in case management, infection prevention and control is ongoing mainly done by the RRT that visits the outbreak areas

- Provide Point of Use water treatment products

- Enhance sustainable water distribution

• Water trucking to refill central supply and collection points• Establishment, staffing and supplying commodities to CTCs for case management• Procurement of cholera supplies including chlorine and pharmaceutical commodities• Water quality testing in water tanks and at domestic level• WHO facilitated procurement of the Oral Cholera Vaccine (OCV). During round one of the OCV campaign which ran from 10th to 20th January 2018, 1,317,925 people were vaccinated, with a coverage of 109%. This included 1,407 inmates at Lusaka Central Prison were vaccinated• Behaviour change communication/hygiene promotion

Interventions by the Ministry of Health Include;

• Dissemination of educational and informative messages on the prevention of Cholera and Malaria in the Provincial Radio Broadcaster, 6 times per day• Mass integration of 60 new ADECOS, in the joint activities of Social Mobilization in the municipality of Uíge• 1,260 Tablets of Aquatab were distributed in the districts of Cacole (760 tablets) and Popular (500 tablets)

• CTCs operational in all affected sites were erected• Robust Community Cholera prevention activities, including pot-pot chlorination, enhancing access to clean potable water by sinking boreholes, community wide 1% chlorine stock solution distribution in all affected villages • Reactive OCV immunization in Karonga, Lilongwe, and preemptive OCV in Salima and Dowa• Dissemination of key health messages through media, public gatherings, road shows, community cinemas, and community dialogue• Branded multimedia campaign and social movement involving entertainment approaches and social mobilization -targeting behavior change at multiple levels• Rehabilitation of boreholes and drilling of new boreholes• Water Trucking• Water quality surveillance

Creation date: 18 May 2018 Sources: Ministries of Health and WHO

Annex 1: Distribution of Cholera and AWD Outbreaks in the Horn of Africa and Challenges in Response - as from 1st January 2018

Garissa

Mombasa

Sool

Banadir

Bari

Bay

Galgaduud

Gedo

Hiraan

Lower JubaLower Shabelle

Mudug

Nugaal

Sanaag

Togdheer

Awdal

Middle Shabelle

Central Equatoria

Eastern Equatoria

Jonglei

Unity

Lakes

WarrapUpper Nile

Murang’a

SomaliOromia

Amhara

South Sudan

EthiopiaSomalia

Kenya

Legend

Status of outbreakOutbreak containedOutbreak active

No outbreak reported

Cholera / AWD Cases

XXNew cases (last 1 week)

Cumulative cases 2018

No data

Afar

Tigray

Beneshangul Gumuz

Gambela

SNNPR

Uganda

Addis AbabaHareri

Dire Dawa

Bakool

Western Equatoria

Western Bahr el Ghazal

Northern Bahr el Ghazal

Siaya CFR: XX%: Calculated based on new deaths reported

975202

11

Tharaka Nithi

BusiaMeru

Turkana

West Pokot

77114

Tana River

252

415

259

161

Western Region

302,329

Murang’a

5127

TransNzoia69

Nairobi

Nakuru

143Isiolo

8924

1,036127

899132

398

Nairobi

4029

Machakos29

2581

5237

Karamoja

1246

Kenya: Challenges

Uganda: Challenges

-Weak coordination between MOH national level and counties on cholera response-Weak disease outbreak response capacity at the county level and shortage of cholera RDTs in some counties-Limited funding at county level for prompt response -Weak enforcement of the Public Health Act-Zero vaccination coverage against cholera in Kenya -Limited capacity of some county laboratories to carry out confirmatory tests and hence have to ship specimens to the National Public Health laboratory and KEMRI -Water supplies in rural areas and informal settlements exhibit low levels of functionality. Across Kenya almost one-quarter (23%) of the population lack access to a water supply system, and depend on open water sources (rivers, ponds, irrigation canals) for their drinking water e.g. in Turkana County, 34% of rural households depend on open water sources.-Nationally, 12% of the population practice open defecation (15% in rural areas, 3% in urban areas). In the ASAL counties the problem of open defecation is even more serious e.g. in Turkana County, 90% of the rural population practice open defecation. -Across Kenya only 30% of the population have access to basic sanitation. -Inadequate utilization of IEC materials and slow adaptation and sustaining of new behaviors.

- Currently the district is experiencing challenges to conduct community based surveillance and active case finding- Inadequate human resources for health especially at the district level- High risk of cross border transmission of the cholera outbreak between Kenya and Uganda. For instance the index case had a history of visiting Kenya- Mobility of the population across border between the two countries - Sub-optimal coordination of the local leadership

- An estimated 630,000 people have been affected by heavy rains and floods, and this is a risk factor to new outbreaks of infectious diseases including cholera

Somalia Challenges

Kirinyaga

** Cases from Uganda emerged from Hoima, Kyegegwa and Kagadi districts (in Western region), and Amudat district in Karamoja3083133

Tharaka Nithi

10

Kirinyaga

Kiambu

Kiambu

Creation date: 18 May 2018 Sources: Ministries of Health and WHO

Annex 2: Distribution of Cholera / AWD outbreaks in Southern Africa and Challenges in Response - as from 1st of January 2018

Pwani

DodomaSingida

Mbeya

Dar es Salam

Morogoro

Iringa

Kigoma

Mara

Tabora Tanga

Rukwa

Unguja

Nsanje

Chikwawa

Mwanza

NampulaTete

Cabinda

Zaire

- Access to improved and safe water a major problem in most of the hotspots areas as well as low coverage of improved sanitation

Challenges: Tanzania

Challenges: Angola

Challenges:Zimbabwe

Legend

Status of outbreak

Outbreak contained

Outbreak active

No outbreak reportedCholera / AWD Cases

XXNew cases

Cumulative cases 2018

CFR: Calculated based on new cases and deaths reported

Angola

South Africa

Tanzania

Burundi

MozambiqueNamibia

Botswana

Zimbabwe

Zambia

Malawi

Malawi

Rwanda

Rwanda

Katavi

Njombe

Lusaka

Challenges: Zambia

Luapula Northernprovince

DodomaManyara

Lesotho

Swaziland

Ruvuma

CopperbeltCentral

Uige

EasternNorth-Western

SouthernWestern

Mashonaland West

Cabo Delgado

- Stoneridge is a 'peri-urban' surbub on the outskirts of Harare. The area is not serviced and rely mainly on shallow unprotected well. The area is also not connected to sewer network and uses pit latrines- St Mary's is the oldest surbub in Chitungwiza with delapidated sewer network. Residents disconnected the sewer and opted for septic tanks due to sewer bursts

- Inadequate water supply from Lusaka Water and Sewerage Company network-The quality of the supplied water is not optimum. 42% of sampled water have high levels of contamination with fecal coliforms- Due to inadequate water supply, people resorted to using alternative water sources including shallow wells that are contaminated by surface or ground run-off water-The general state of sanitation in affected areas is poor-The urban water supply infrastructure is old and prone to contamination as the infrastructure often runs through dirty contaminated ground water.-People in some sections of affected areas use pit latrines for human waste disposal, which are often shallow and prone to fecal matter wash off when it rains.

Harare

Challenges: Malawi

Arusha

- Poor sanitation of the environment- Inadequate supply of drinking water, both from the public Cistern Trucks- Insufficient water reservoirs to meet the demand for water- Inadequate means of transport to support response teams in the Field- Demotivation of Personnel (CTC Health workers, social mobilizers and data managers)

- Misconceptions and risky beliefs regarding cholera treatment and OCV in some parts of the affected communities- CTC staff demotivation owing to lack of incentives- Fatigue observed in health workers owing to long and sustained outbreak especially in Karonga and Lilongwe- Within Lilongwe City, in some cholera affected locations, piped water supply is intermittent, therefore people resort to unsafe dug wells- In the cholera hotspots in Lilongwe Rural, some people drink water from rivers and unsafe dug wells without treating or boiling it. - Suboptimal coordination at District level

25

Western Province

Blantyre

159

213

4

386

99

7788

642

3

45,688

123

132

361

270593

9

3

1

4

6

1

13

88

13

1

56

39

31

107

36

51

163

960

33190

*Cases presented for Zambia refer to cumulative cases since the beginning of the outbreak on 6th October 2017

Karonga

Nkhata Bay

Kasungu

SalimaLilongwe

Dowa

Mulanje

Likoma

Rumphi

Dedza

Annex 3: Epi Curves of Countries with Reported Outbreaks Since 2017

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2017 2018

Kenya

Annex 3: Epi Curves of Countries with Reported Outbreaks Since 2017

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Zimbabwe

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47W

k 48

Wk

1W

k 2

Wk

3W

k 4

Wk

5W

k 6

Wk

7W

k 8

Wk

9W

k 10

Wk

11W

k 12

Wk

13W

k 14

Wk

15W

k 16

Wk

17W

k 18

Wk

19

2017 2018

Angola

0

0.2

0.4

0.6

0.8

1

1.2

Wk

23W

k 24

Wk

25W

k 26

Wk

27W

k 28

Wk

29W

k 30

Wk

31W

k 32

Wk

33W

k 34

Wk

35W

k 36

Wk

37W

k 38

Wk

39W

k 40

Wk

41W

k 42

Wk

43W

k 44

Wk

45W

k 46

Wk

47W

k 48

Wk

49W

k 1

Wk

2W

k 3

Wk

4W

k 5

Wk

6W

k 7

Wk

8W

k 9

Wk

10W

k 11

Wk

12W

k 13

Wk

14W

k 15

Wk

16W

k 17

Wk

18

2017 2018

Rwanda

05

1015202530354045

Wk

23W

k 24

Wk

25W

k 26

Wk

27W

k 28

Wk

29W

k 30

Wk

31W

k 32

Wk

33W

k 34

Wk

35W

k 36

Wk

37W

k 38

Wk

39W

k 40

Wk

41W

k 42

Wk

43W

k 44

Wk

45W

k 46

Wk

47W

k 48

Wk

49W

k 1

Wk

2W

k 3

Wk

4W

k 5

Wk

6W

k 7

Wk

8W

k 9

Wk

10W

k 11

Wk

12W

k 13

Wk

14W

k 15

Wk

16W

k 17

Wk

18

2017 2018

Burundi

Country Week 14 Week 15 Week 16 Week 17 Week 18 Week 19 2018 Cumulative Cumulative since the beginning of the outbreak

Beginning of Outbreaks

Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases Deaths CFR (%)

Cases Deaths CFR (%)

Somalia 214 0 178 0 192 0 212 2 296 4 2,654 16 0.6 2,967 17 0.6 Dec-17

Kenya 24 0 63 0 87 0 24 0 58 0 302 0 3,931 71 1.8 24,741 414 1.7 Dec-14

Tanzania 5 0 148 1 115 5 12 0 89 3 44 0 1,837 36 2.0 30,468 502 1.6 Aug-15

Malawi 15 3 15 0 14 0 11 0 0 0 0 0 774 22 2.8 929 30 3.2 Nov-17

Mozambique 16 0 0 0 0 0 0 0 0 0 0 0 801 3 0.4 2,373 3 0.1 Aug-17

Angola 13 0 17 0 11 0 4 0 6 0 7 0 839 9 1.1 944 15 1.6 Dec-17

Zambia 168 3 184 3 16 0 4,097 55 1.3 5,905 115 1.9 Oct-17

Uganda 60 4 33 0 110 2 42 0 2,376 49 2.1 2,376 49 2.1 Feb-18

Zimbabwe 2 2 22 1 12 0 13 0 4 0 9 0 167 7 4.2 167 7 4.2 Jan-18

Rwanda 0 0 0 0 3 0 0.0 3 0 0.0 Jan-18

Namibia

Burundi

South Sudan

Madagascar

Comoros

Swaziland

Botswana

Eritrea

Lesotho

South Africa

TOTAL 17,479 268 1.5 70,873 1,152 1.6

For further information Contact:

Georges Tabbal Ida Marie Ameda Maureen Khambira WASH Emergencies Specialist UNICEF Eastern and Southern Africa Region

Health Emergencies Specialist UNICEF Eastern and Southern Africa Region

Information Management Specialist UNICEF Eastern and Southern Africa Region

Email: gtabbal@unicef.org Email: iameda@unicef.org Email: mkhambira@unicef.org

Annex 4: Weekly Reported Cholera / AWD Cases and Deaths for Countries in Eastern and Southern

Africa