Global, national efforts must be urgently intensified to control Zimbabwe cholera outbreak

GENEVA -- Zimbabwe’s cholera outbreak, one of the world’s largest ever recorded, is far from being brought under control. An enhanced response is needed to urgently reverse an epidemic that has so far infected more than 60,000 people and killed more than 3,100 since August 2008.

“The World Health Organization and other international and local partners are supporting the Ministry of Health and Child Welfare’s (MoHCW) efforts to control the epidemic. But unless drastic action is taken by all players in this crisis, more Zimbabweans will succumb to the outbreak, and other countries in the southern African region will face the continued threat of spill over epidemics,” said Dr Eric Laroche, Assistant Director-General for WHO’s Health Action in Crises Cluster.

Urgent measures needed in Zimbabwe include:

* increasing awareness, particularly at grassroots level, regarding prevention and treatment measures. Most recorded deaths have occurred at home, which means that more effective messaging directed at all communities, particularly the remotest parts of the country, is crucial for the Zimbabwean public to be best prepared to act against the epidemic.
* making available more medicines, particularly oral rehydration salts (ORS) and chlorine tablets, at community level so health care workers, and ordinary people themselves, have the means to quickly treat cases of cholera that emerge. One of the greatest challenges is ensuring people can access health services. As this is not possible for many people, due to limited access to transport or money to pay for the trip to the health facility, stocks of simple yet life-saving supplies, such as ORS and chlorine tablets, must be provided to each community.
* mobilizing resources to pay thousands of Zimbabwean doctors, nurses and other health staff who have been unable to obtain salaries and have not had enough money for basic needs, such as buying a bus ticket to get to work. This vacuum in availability of national health staff is a prime factor in the increasing number of cholera sufferers dying.
* opening access to more nongovernmental organizations (NGOs) to respond to the cholera outbreak in more areas of the country. Currently, NGOs, such as Médecins Sans Frontières, are operating large numbers of cholera treatment centres and units in areas where other support, including government, is not available. Such activities must be promoted so to increase access to health care, particularly at district level.
* strengthening the multisectoral response being provided by all players - United Nations, NGOs, governments and donors - is vital. More effort is needed in multiple areas, including improved case management, water and sanitation, social mobilization, provision of financial resources to health providers operating in Zimbabwe, and increasing health staff in the field.

“We are dealing with an extraordinary public health crisis that requires from us all an extraordinary public health emergency response, and this must happen now before the outbreak causes more needless suffering and death,” Dr Laroche said. “Political differences need to be put aside, economic barriers overcome, health services in the country’s periphery strengthened and community awareness to respond enhanced to save many more people from dying due to a disease that can be readily prevented and treated.”

As of 29 January, 2009, that number had reached 60 401, with 3161 deaths, and showed no signs of abating. All 10 provinces, as well as neighbouring countries, have been affected. Although the Case Fatality Rate has decreased slightly, it is still above 5%, with about three times more deaths being recorded at community level rather than within health facilities. The acceptable level should be below 1%. Neighbouring South Africa has also reported 3000 cases, but the strength of its health care and water and sanitation systems have seen the case fatality rate remain below 1%.

WHO and its partners have worked efficiently with the MoHCW to date to respond to the outbreak, including by:

* establishing a Cholera Command and Control Centre in the capital, Harare, to coordinate and strengthen alert, response, case management, social mobilization and logistics activities.
* mobilizing an outbreak response team of more than 40 experts, including national and international disease control specialists from across WHO. This team has been working on technical coordination, early warning alerts, social mobilization activities, case management and training, outbreak logistics, laboratory support and critical response activities in the most affected provinces.
* deploying 10 experts from public health institutions and technical partners in the Global Outbreak Alert and Response Network (GOARN) to support technical coordination at the Cholera Command and Control Centre, and provide technical support to the MoHCW for outbreak response. These include the Burnet Institute in Australia; the London School of Hygiene and Tropical Medicine (LSHTM) and Health Protection Agency in the UK; the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B); US Centers for Disease Prevention and Control; and the National Board of Health and Welfare, Sweden.
* delivering medicines and other health equipment to health centres treating cholera patients.
* working with the donor community to raise badly needed resources for cholera response activities, as well as the overall strengthening of Zimbabwe’s health sector.

Dr David Heymann, WHO’s Assistant Director-General for Health Security and Environment Cluster, said despite these measures, the scale of the outbreak should serve as a catalyst for increased support from all parties involved in response efforts.

“The challenge is not just in Harare, but in remote, hard-to-access parts of the country where the effective implementation of control measures to contain Zimbabwe’s cholera epidemic is very difficult,” said Dr Heymann. “In addition to the issue of staff shortages, there is a need for increased awareness about how to treat cholera, filling the gaps in medical supplies, providing reliable logistics support and capacity to deliver supplies, and increasing access to health services and safe water supply in remote areas where nongovernmental organizations are not operating. Combined, these factors present a major challenge to bringing this outbreak quickly under control.”