Source: Ministry of Health and Child Welfare Rapid Disease Notification System 1 Highlights of the week: • Cholera spreads into Plumtree and Chimanimani • Confirmed Measles outbreaks in 36 districts • Typhoid cases now 325 Epidemiological Bulletin Number 53 Week 13 (week ending 4 April 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 13 (week ending 4 April 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 by district and province is 08089001 or 08089002 or 08 089000 Mobile number for alerts is 0912 104 257
Transcript
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 1
Highlights of the week:
• Cholera spreads into Plumtree and Chimanimani
• Confirmed Measles outbreaks in 36 districts
• Typhoid cases now 325
Epidemiological Bulletin Number 53
Week 13 (week ending 4 April 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 13 (week ending 4 April 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
Toll free number for alert by district and province is 08089001 or 08089002 or 08 089000
Mobile number for alerts is 0912 104 257
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 2
Figures
See also summary tables (annex 1), maps (annex 2) and graphs (annex 3) for analysis of
collected information.. The case definitions can be found in appendix 1 and detailed data by
district are shown in appendix 2.
Cholera
14 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. 361 cumulative suspected cholera cases, 45 of which were confirmed and 10 deaths were reported by 4 April 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 2.8%. By week 13, 2009, 94 622 cumulative cases and 4 130 deaths had been reported since August 2008, with a crude case fatality rate of 4.4%. This year’s case fatality rate is lower than last year’s by 1.6%. Week 13 (29 March - 4 April 2010) 27 new suspected cases were reported, from the following districts: Buhera 10 cases, Chegutu 1 case, Chimanimani 2 cases, Hurungwe 14 cases and 2 confirmed cases from Chegutu and Plumtree.
Geographical distribution of cases The cases reported so far came from the following districts: Beitbridge, Bindura, Buhera, Chegutu, Chivi, Chimanimani, Chiredzi, Harare, Hurungwe, Kadoma, Masvingo, Makonde, Mwenezi and Plumtree. Urban/Rural distribution of cases 92.5 % of the cases currently reported are from rural areas. In comparison, during the corresponding week in 2009, 44.2% cases came from urban areas and 55.8 % from rural areas.
Assessments & response
Surveillance, case management and investigation of alerts continued in all the provinces. Plumtree A male adult of 36 yrs old was admitted on 31/03/2010 with a history of travel to Kadoma on the 27-28 March, arrived in Plumtree on 29 March. Onset of diarrhoea was on the 30th of March. Attended OI clinic on 31 March in the morning and was sent home only to be admitted at around 1600hrs with profuse vomiting and diarrhoea. He was discharged on 08 April.
Sample was sent to Mpilo Hospital Lab on the 31st and was confirmed positive on 07 April 2010. He stays with his wife and two relatives who up to now have not shown any signs and symptoms.
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 3
Measles Errata Bulletin 52 In last week’s bulletin the number of positive cases that had dates of last vaccination was stated as 301 instead of 36. 3 318 suspected cases and 200 deaths, of which 192 were community deaths were reported since the start of the outbreak in September 2009. 1216 blood specimens have been received by the polio-measles laboratory and 387 cases have been confirmed to be Measles IgM positive. 36 of the total positive cases had dates of last vaccination. The vaccination status of the remaining 351 cases was not indicated. 57(14.7%) of the positive IgM cases were in the below 9 months, 32 (8.3%) in the 9 – 12 months agegroup, 75 (19.4%) were in the 1-5 years agegroup, 173 (44.7 %) were in the 5 -14 years agegroup and 50 (12.9%) in the above 14 Years. Hence 330 (85.3%) of the positive cases were above the routine immunisation age ( 9 months -12 months) The district measles IgM positive attack rates ranged from 0.32 to 17.5 per 100 000 and the attack rate for all the affected districts is 3.5 per 100 000. The lowest attack rate was for Hurungwe and the highest was for Bubi. See table 3 for detailed distribution of the cases by agegroup and district and attack rates. Week 13 (29 March - 4 April 2010) 41 specimens were received by the laboratory during the week. 21 of the specimens were IgM positive. The positive cases were from Beitbridge -1 , Bulawayo 1, Chimanimani 1, Chitungwiza 1, Harare 1, Kadoma 1, Kariba 1, Makonde 3,Mangwe 2, Mutoko 1 and Seke 2 and Zvishavane 1. 5 of the positive cases had been vaccinated. See table 4 for detailed distribution. Geographical distribution of cases Since September 2009, 53 districts out of 62, have had at least 1 laboratory confirmed measles case namely: Beitbridge, Bindura, Bikita, Bubi, Buhera, Bulawayo, Centenary, Chegutu, Chikomba, Chimanimani, Chiredzi ,Chirumhanzu, Chipinge, , Chivi, Gokwe North, Gokwe South, Goromonzi, Guruve, Gweru, Gutu, Harare (including Chitungwiza) ,Hurungwe, Hwange, Hwedza, Insiza , Kadoma , Kwekwe, Lupane,Makoni, Makonde, Marondera, Mangwe, Masvingo, Mazowe, Mt. Darwin, Mutare, Mutasa, Murehwa, Mutoko, Mwenezi, Nyanga , Umzingwane, , Seke, Shurugwi, Umguza, UMP, Zaka, Zvimba and Zvishavane. 57 out of 62 districts have reported suspected measles cases. Confirmed laboratory Outbreaks The number of districts with confirmed measles laboratory outbreaks is still 36. The districts are shaded in table 3. Suspected Outbreaks The number of districts with suspected measles outbreaks is still 48.
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 4
Assessments & response Vaccination and surveillance continued in all affected Districts. Case Management protocols sent to all health facilities.
Anthrax
Since the beginning of the year 21 cases and 2 deaths of Anthrax were reported. The cases distribution is as follows: Chirumhanzu 2, Kadoma 3, Shurugwi 8 and Chikomba 1 and Mwenezi 2. All the deaths were from Chirumhanzu.
Week 13 (29 March - 4 April 2010) No cases were reported this week.
Assessments & response Surveillance continues in all districts.
Typhoid
As of 1 April a total of 325 cases and 6 suspected deaths had been reported since the start of the outbreak on 14 February, 2010. 6 samples (4 blood and 2 stool) were laboratory confirmed to be Salmonella typhi, the cause of typhoid fever. Geographical distribution of cases The cases were reported from mainly Harare surburbs and areas in the environs of Harare. 70% of the cases were from Mabvuku suburb. Map 3 shows the distribution of the cases by surburb.
Assessments & response 4373 Households have been given full NFI kits by Penya Trust. Week 13 ( 29 March – 4 April 2010) 60 cases were reported. All the cases were from Harare.
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 5
Annex 1: Summary Tables
Table 1: Cumulative Cholera cases and deaths reported by district for the period week 13, 2010
District Suspected Cases reported this week
Confirmed Cases Reported this week
Suspected Cases
Confirmed Cases
Discarded Cases
Total Cases
Deaths Attack Rate/100000
Bindura 0 0 0 2 0 2 0 1.3
Harare Urban 0 0
0 1 0
1 0 0.06
Mwenezi 0 0 0 5 0 5 0 3.66
Shamva 0 0 2 0 2 0 0 0
Makonde 0 0 3 1 0 4 0 1.4
Chegutu 1 1 9 4 13 1 5.33
Masvingo 0 0 9 1 10 1 3.5
Chivi 0 0 11 2 0 13 0 7.71
Beitbridge 0 0 16 1 0 17 0 15.14
Bulilima 0 1 0 1 0 1 0 0.99
Kadoma 0 0 65 11 0 76 1 29.71
Buhera 10 0 36 1 0 37 0 15.53
Chimanimani
2 0
2 0 0
2 1.65
Chiredzi 0 0 45 9 0 54 2 21.31
Hurungwe 14 0 165 6 171 5 55.16
Total 27 2 363 45 2 406 10 9.33
Table 2: Age and Sex breakdown of cumulative cholera linelisted cases for the period week 13 ,2010
Under 5 Years 5-14 Years 15-29 Years
30 Years and over
District
Male
Female
Male
Female
Male
Female
Male
Female
Chiredzi 2 2 5 3 6 9 6 8
Chivi 1 1 2 4
Harare
Masvingo 1 2 3
Mwenezi 1 2 1 Beitbridge Total 2 2 5 4 6 12
12 16
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 6
Table 3: Distribution of Measles IgM Positive by Agegroup and District of residence since September 2009-4 April, 2010
District < 9
months
9 months
-12 months
1-5 years
5-14 years
>14 years
TOTAL Attack
Rate Per 100 000
Beitbridge 0 0 0 1 0 1 0.89
Bikita 0 0 0 4 0 4 2.35
Bindura 0 2 2 0 0 4 2.1
Bubi 0 0 0 6 3 9 17.54
Buhera 0 1 3 2 0 6 2.54
Bulawayo 7 5 2 4 2 20 2.73
Centenary 0 0 0 1 0 1 0.86
Chegutu 1 0 2 6 0 9 3.69
Chikomba 1 0 0 1 0 2 1.54
Chimanimani 0 0 0 0 2 2 1.6
Chipinge 0 0 2 5 2 9 2.96
Chiredzi 1 0 0 0 0 1 0.4
Chirumanzu 0 0 0 3 0 3 3.93
Chitungwiza 1 0 0 4 1 6 1.73
Chivi 1 0 2 1 0 4 2.37
Gokwe North 0 0 0 2 0 2 0.86
Gokwe South 1 1 4 10 1 17 5.35
Goromonzi 1 1 1 5 0 8 4.79
Guruve 1 0 0 1 0 2 1
Gutu 0 0 2 1 0 3 12.03
Gweru 1 0 0 2 0 3 1.23
Harare 28 17 11 38 19 113 7.15
Hurungwe 0 1 0 0 0 1 0.32
Hwange 2 0 1 0 3 6 5.49
Hwedza 0 0 2 5 0 7 9.15
Insiza 0 0 0 2 0 2 2.16
Kadoma 1 0 1 4 0 6 2.37
Kariba 0 0 0 1 0 1 1.57
Kwekwe 1 0 2 4 0 7 2.58
Lupane 0 0 0 0 1 1 0.94
Makonde 0 0 2 3 1 6 4.77
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 7
District < 9
months
9 months
-12 months
1-5 years
5-14 years
>14 years
TOTAL Attack
Rate Per 100 000
Makoni 1 0 6 3 2 12 4.47
Mangwe 0 0 0 1 1 2 2.36
Marondera 2 0 2 6 1 11 9.88
Masvingo 1 1 0 2 0 4 1.9
Matobo 0 0 0 1 0 1 0.93
Mazowe 1 0 0 1 1 3 1.42
Mt Darwin 0 0 1 5 0 6 2.77
Mudzi 0 0 1 3 0 4 2.91
Murehwa 0 0 0 4 1 5 2.85
Mutare 1 0 2 4 1 8 1.9
Mutasa 0 0 3 4 0 7 3.88
Mutoko 0 0 2 2 1 5 2.85
Mwenezi 1 1 2 1 0 5 3.66
Nyanga 1 0 3 1 2 7 5.57
Seke 1 0 4 4 1 10 12.01
Shurugwi 0 0 1 1 0 2 2.09
Umguza 0 0 0 1 0 1 1.25
Umzingwane 0 1 0 0 0 1 0.5
Uzumba-Maramba-Pfungwe 0 1 2 0 2 5 5.45
Zaka 0 0 0 1 0 1 0.5
Zvimba 0 0 1 3 1 5 2.09
Zvishavane 0 0 6 9 1 16 14.47
TOTAL 57 32 75 173 50 387 3.49
Table 4: Distribution of Confirmed measles cases by agegroup by district reported in week 13, 29 March -4 April 2010.
District 1-5 years 5-14 years >14 years Total
Beitbridge 0 1 0 1
Bulawayo 0 1 0 1
Chimanimani 0 0 1 1
Chitungwiza 0 1 0 1
Kadoma 1 2 0 3
Kariba 0 1 0 1
Makonde 1 1 1 3
Mangwe 0 1 1 2
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 8
Mutasa 1 2 0 3
Mutoko 1 0 0 1
Seke 2 0 0 2
Zvishavane 0 1 0 1
Total 6 11 3 20
Table 5: Distribution of Community and Institutional Measles Deaths attributed to
Measles as of 4 April 2010
District Community
Deaths Institutional
Deaths Total
Deaths Percentage
Bikita 9 0 9 4.62
Bindura 10 0 10 5.13
Buhera 36 2 38 19.49
Chegutu 2 0 2 1.03
Chimanimani 3 0 3 1.54
Chipinge 3 0 3 1.54
Gokwe North 18 1 19 9.74
Goromonzi 3 0 3 1.54
Insiza 4 0 4 2.05
Kadoma 1 0 1 0.51
Makoni 24 5 24 12.31
Marondera 1 0 1 0.51
Murehwa 13 0 13 6.67
Mutare 47 0 47 24.1
Mutoko 8 0 8 4.1
Mutasa 9 0 9 4.62
Nyanga 1 0 1 0.51
Total 192 8 200 100.01
Table 6: Some Key Measles Indicators as of 4 April 2010
Indicator Value
Suspected Cases 3 318
Blood Specimens received by Laboratory 1 216
Confirmed Cases 387
Deaths 200
Districts with laboratory confirmed outbreaks Affected
36
Overall Attack Rate of Lab Confirmed cases 3.5/100 000
Confirmed Cases that were vaccinated 36
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 9
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 10
Annex 2: Maps
Map 1: Comparison of cumulative cholera cases by district as of week 13, 2009 and 2010
2010 2009
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 11
Map 2: Comparison of Cumulative Measles IgM positive cases and Suspected Measles case by district
reported this year, as at 4 April, 2010
Confirmed Cases Suspected Measles Cases
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 12
Map 3: Distribution of Cumulative Typhoid Cases in Harare as of week 13, 2010
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 13
Annex 3: Graphs
Graph 1:Ranking of District Cumulative Cholera Cases Reported as at week 13, 2010
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Beitbridge
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Graph 2: Cumulative Cholera Cases by week for the years 2009 and 2010
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Source: Ministry of Health and Child Welfare Rapid Disease Notification System 14
Graph 3:Ranking of Confirmed Measles Igm Cases by District Reported from September 2009 to 4 April 2010
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Graph 4:Ranking of Suspected Measles Cases by District Reported from September 2009 to 4 April 2010
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Source: Ministry of Health and Child Welfare Rapid Disease Notification System 15
Graph 5:Distribution of Suspected Measles Cases by Week, as at week 13, 2010
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 16
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.
Influenza A H1N1
Influenza A and B are two of the three types of influenza viruses associated with annual outbreaks and epidemics of influenza. Only influenza A virus can cause pandemics.
The Zimbabwe IDSR technical guidelines define influenza case by a new sub type (including Avian flu Influenza A H5N1 and Swine flu Influenza A H1N1) as;
‘’Any person presenting with unexplained acute lower respiratory illness with fever (>38 ºC ) and cough, shortness of breath or difficulty breathing AND notion of exposures in the 7 days prior to symptom onset.’’ Probable case definition: Any person meeting the criteria for a suspected case AND positive laboratory confirmation of an influenza A infection but insufficient laboratory evidence for H1N1 infection. Confirmed H1N1 case: A person meeting the criteria for a suspected or probable case AND a positive result conducted in a national, regional or international influenza laboratory whose H1N1 test results are accepted by WHO as confirmatory.
There may be difficulty in telling apart mild cases of pandemic influenza from the seasonal influenza.
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)
Source: Ministry of Health and Child Welfare Rapid Disease Notification System 17
Typhoid Fever Any person with gradual onset of steadily increasing and then persistently high fever, chills, malaise, headache, sore throat, cough, and sometimes abdominal pain and constipation or diarrhoea.
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