Cablegate: Zimbabwe Cholera Usaid Dart Health and Wash Assessment

DE RUEHSB #1137/01 3590924
O 240924Z DEC 08




E.O. 12958: N/A

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1. The current cholera outbreak inZimbabwe began in August 2008.
The outbreak resuled from a lack of access to clean water and
non-unctional sanitation systems, largely due to the crrent
regime's lack of maintenance, allowing forthe rapid spread of
cholera through the country nd across borders, creating a regional
crisis. Cholera has been a symptom of the breakdown in the ntional
health and water and sanitation systems ad signals a growing public
health crisis in the ountry. The lack of access to emergency
obstetrical care increases concerns for maternal mortality, and in
combination with the rise in communicable diseases, lack of
vaccination, and lack of safe water leaves the country at risk to
additional disease outbreaks. The current cholera crisis is
compounded by a dire country-wide food security situation, raising
serious malnutrition concerns. The U.N. World Food program has
estimated that 5.5 million Zimbabweans will require food assistance
in the first quarter of 2009. The cholera outbreak is occurring in
a context of hyperinflation, a lack of progress towards a unity
government, and what the U.N. Secretary General has termed a
profound multi-sectoral crisis, encompassing food, agriculture,
education, health, water, sanitation, and HIV/AIDS.

2. The response to the cholera outbreak has been hampered by
challenges in coordinating the response between partners, and the
lack of: 1) an overall strategy to guide partners; 2) timely and
quality data; and 3) the use of the data to implement rapid health
and water, sanitation, and hygiene (WASH) activities. The outbreak
has been exacerbated by a lack of resources, particularly human
resources to address case management, and the absence of a strong
strategy for community-based activities for hygiene, health
education, and case identification and treatment.

3. The objectives of the humanitarian response are to decrease
transmission and to limit mortality. The health and WASH clusters
in Zimbabwe are beginning to coordinate efforts to ensure timely
response to outbreaks and assess areas at risk to reduce
transmission. The U.N World Health Organization (WHO) is planning
to set up a cholera command and control center, which will
technically advise implementing partners in the areas of disease
surveillance, case management, infection control and WASH, social
mobilization, logistics, and communications. The response to
cholera should be viewed in the context of a declining health
system. Unless the lack of general primary health care is
addressed, outbreaks of similar significance will continue to affect
the country and the region. In the absence of a response by the
current regime to the crisis, donors should initiate short-term
efforts to save lives and reduce the spread of cholera and promote
basic primary health care. End Summary.


4. An outbreak of cholera that began on August 20 in the
Chitungwiza suburb of Harare has now spread to affect 9 out of 10
provinces in Zimbabwe and resulted in 20,896 suspected cases and
1,123 deaths as of December 18, according to WHO. The case fatality
rate (CFR), which should be under 1 percent, has been unacceptably
high with an average of 5.4 percent reported to date. In some
areas, the CFR has reached as high as 30 percent, according to WHO.
Deaths in the community, as opposed to deaths at a medical facility,
account for between 20 to 50 percent of total deaths, suggesting
late arrival to cholera treatment centers (CTCs) or lack of access
to immediate and appropriate health care.

5. More than 50 percent of the cases have been reported from urban
and peri-urban Harare, and along the borders of Mozambique and South

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Africa in Mudzi and Beitbridge districts respectively. The age
distribution shows a typical trend, with the most affected between
20 to 30 years old with an equal sex distribution. The trends in
the highly-affected regions are following a natural decline, but
peaks in cases are still reported throughout the country. The
largest recent outbreak has been reported in Chegutu district, where
there was a rapid rise in cases with approximately 275 admissions
from December 8 to 12 to the CTC, with 85 deaths and a CFR of 30.9

6. The source of the outbreak was probably the contamination of the
main water supply in high density urban areas. The current cholera
crisis is characterized by widespread occurrence of cases with
periodic explosive outbreaks in high density urban and peri-urban
areas. The outbreak spread through population movement and
traditional funeral practices, including washing the body of the
deceased. The outbreaks observed in Chitungwiza and Chegutu
districts suggest a point source infection with a sudden spike in
caseload for 2 to 5 days, when most of the cases and deaths occur.
The high mortality rates reported during the early phase of the
outbreaks argues for strengthening the early warning and response
system. Some rural areas have not reported cholera cases, which may
be due to functioning WASH systems, a lack of detection or reporting
of cholera cases, or the absence of cholera in these rural areas to

7. WHO has suggested that up to 60,000 people may fall ill from
cholera over the next year. Cholera cases are expected to increase
due to the onset of the November to April rainy season and
population movement for the holiday season. This is compounded by
increasing food insecurity and malnutrition, continued decline of
the public health system, and deteriorating WASH infrastructure.
Vulnerable groups include mobile vulnerable populations, apostolic
sect members, who refuse treatment, and HIV/AIDS patients.


8. Beginning December 5, the USAID Disaster Assistance Response
Team (USAID/DART) health advisor and U.S. Centers for Disease
Control and Prevention (CDC) WASH advisor have conducted meetings
with Government of Zimbabwe (GOZ) Ministry of Health and Child
Welfare (MOHCW) officials, USAID/Zimbabwe and CDC staff, U.N.
agencies, and non-governmental organizations (NGOs). The health and
WASH advisors have participated in field assessments in the Harare
suburbs of Budiriro and Chitungwiza, as well as Chegutu, Mudzi,
Mazowe, and Mutoko districts.

9. The USAID/DART advisors examined the effectiveness of the
response to date in reducing spread of the outbreak, including
disease surveillance and early warning, access to safe water and
sanitation facilities, social mobilization for hygiene promotion and
health education, and limiting mortality through early detection,
proper treatment, and referral. The advisors also examined overall
coordination efforts to date.


10. Overall coordination within the health cluster has been lacking
due to the absence of a trained health cluster coordinator. This
has lead to difficulties in setting priorities and a strategic
direction for the response from the health and WASH clusters,
including an assessment of what has been done already, a needs
assessment, and a gap analysis ("who does what where"), in order to
inform response capacity. The USAID/DART and other donors have
reinforced the urgency of deploying a strong health cluster
coordinator and encouraged improved collaboration between the health

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and WASH clusters. In support of the MOHCW, WHO is planning to set
up a cholera command and control center to guide, coordinate,
monitor, and evaluate the cholera response. Donors have advocated
for a clear exit strategy for supporting the command and control

11. The WASH cluster has been better organized and more active,
although a number of limitations remain. The response of the
cluster has been somewhat slowed by the lack of clear data from the
health cluster on how the outbreak is spreading and where potential
new outbreaks may arise. The delays are due in part to the lack of
timely reporting of cases to the health cluster, as well as poor
communication between the clusters. Recent meetings between the two
clusters should alleviate some of the issues. On December 21, the
WASH cluster drafted a "who does what where" document, which the
USAID/DART is evaluating.

12. The USAID/DART has met with representatives from the U.K.'s
Department for International Development (DFID) and the European
Community Humanitarian Aid Office (ECHO) to ensure good coordination
from the donors so that gaps are filled and efforts are not
duplicated. There was general agreement that the leadership for the
response is critical, including increased leadership from the U.N.
Office for the Coordination of Humanitarian Affairs (OCHA). The
donors have requested a joint action plan with a gap analysis,
including resource needs for all partners.


13. The lack of rapid data collection, analysis, and dissemination
to the health and WASH clusters has seriously delayed a timely
response to the cholera outbreak. The slow collection of data is
due to a number of factors such as lack of logistical support,
communications, and human resources. In addition, there are
multiple flows of data from the district to central level and from
the MOHCW and NGOs. To address this WHO will implement direct
cholera reporting to the central level.

14. Little analysis has been made of data trends to prioritize
areas for immediate response. Currently, only raw numbers are being
provided, inconsistently, to partners through OCHA. There has been
no operational platform to ensure that the cluster leads and
partners are notified immediately to deploy resources to respond to
the affected areas. Similarly there is little investigation into
high risk areas to look at water quality and provide health
promotion and health education activities. The cholera command and
control center will help ensure there is a timely response by the
health and WASH clusters. The WHO epidemiologist has compiled a
countrywide epidemiologic bulletin, which was released on December

15. Laboratory confirmation of cholera cases is being conducted
both at the National Reference Laboratory and at peripheral labs in
district hospitals. According to a microbiologist at the reference
lab, samples are collected and tested from each new site in which
cases are detected. Antibiotic tests have shown sensitivity to
ciprofloxacin, tetracycline, and erythromycin. The reference
laboratory has minimal amounts of basic supplies. CDC is compiling
a list of basic media and supplies needed by the lab in order to
ensure continued monitoring of the outbreak for changes in
antibiotic sensitivity. As part of the cholera command and control
center, WHO has proposed conducting an assessment of the central and
regional laboratories.

16. The breakdown of the national surveillance and early warning
system has resulted in only 30 percent of the information reported
in a timely and complete way. This also puts the country at risk
for other communicable diseases.

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17. In urban areas of Zimbabwe the lack of a reliable power supply
and shortages of chemicals for water treatment have resulted in
shutdowns of the municipal water supplies in Harare and other areas,
forcing people to use alternative, unsafe, water supplies. In
addition, the lack of municipal water affects urban sewer systems
with increased numbers of blockages in the lines due in part to
reduced flows. The intermittent flow of water has resulted in
ruptured pipes, which combined with overflowing sewers has likely
led to cross-contamination of drinking water supplies.

18. In some parts of the high-density suburbs surrounding Harare
there are numerous shallow hand-dug wells. Some of the wells are
lined and protected above ground, while others are completely
unprotected. The wells provide water for washing and bathing during
times when the tap water is not flowing. However, with prolonged
water shortages in recent months, residents often depend on the
wells for driking water. Many of the wells are prone to surfac
runoff or subsurface contamination, particularl with increased
rains in recent weeks. It is notclear how important a role the
wells have playedin the current cholera outbreak but the risk of
ontamination is evident.

19. In rural areas, smilar issues have occurred in smaller water
treament plants such as Mudzi Growth Point, where the water
treatment plant stopped supplying water due o a lack of aluminum
sulphate and chlorine as wel as power shortages. In communities
that rely on boreholes with hand pumps, the inability of the
community or local authorities to repair broken hand pumps has
forced families to use unsafe sources such as shallow unprotected
wells, scoop holes, and surface water. In Mudzi, Oxfam/Great
Britain estimated that half of the hand pumps have broken down,
leaving a large proportion of the population without access to a
safe water supply.


20. In Harare, the U.N. Children's Fund (UNICEF) is currently
supplying aluminum sulphate and chlorine for the main water
treatment plant in order to ensure continued water supply. The
International Committee of the Red Cross is supplying replacement
parts and tools for the water treatment plant and distribution
system as well as providing tools to unblock the sewer lines. This
should lead to a more reliable supply of water than in the past, at
least in the short term. However, due to the water rationing and
the many breaks in both the water and sewer lines, there is still
the risk of contamination of the distribution network and further
spread of cholera.

21. The other main WASH response in both urban and rural areas is
water tankering, either from municipal water treatment plants or
from mechanized boreholes, to an elevated bladder or tank. This has
allowed WASH implementing partners to provide bulk quantities of
potable water to cholera-affected communities in a short time span.
USAID's Office of U.S. Foreign Disaster Assistance (USAID/OFDA) does
not normally support water tankering as a solution, but given the
emergency situation, water tankering should continue for the
immediate future.

22. Due to the explosive nature of the outbreaks in some urban
areas, the combination of water tankering, distribution of aqua
tabs, water containers, and soap, and hygiene promotion are all

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23. Case management at the CTCs has been variable, from putting all
patients on intravenous fluids, to sending every individual home
with oral rehydration salts (ORS) and an assortment of antibiotics,
to providing no antibiotics. In some areas doxycycline has been
distributed for prophylaxis to communities where cholera cases have
been found. The MOHCW and WHO have standard cholera treatment
protocols, which were not observed to be posted for use by the
health staff. WHO intends to deploy staff from the International
Centre for Diarrheal Disease Research, Bangladesh, to help improve
case management.

24. The local health staff from the doctors to the community health
workers are quite motivated, however, there is no incentive due to
lack of salaries and high cost of transport and food. DFID and ECHO
are initiating a retention scheme for health care providers to
supplement the lack of salaries as an emergency stopgap, although
without a clear exit strategy. On the positive side, there are many
international NGOs with strong partners and community volunteers
already working in country that could be supported for the

25. Currently, there is not a clear picture of the level of medical
supplies in the country. Numerous NGO, U.N., and GOZ partners are
bringing in medical supplies to manage cholera, including a UNICEF
airlift reported on December 22. USAID/OFDA and other donors have
asked UNICEF and WHO to conduct a gap analysis and needs


26. The USAID/DART has prioritized the formation of a strong and
coordinated response at the community level. This includes hygiene
promotion and health education, including care seeking behavior,
home-based care and feeding practices, and active case finding and
early treatment at the community level with ORS. Many NGO partners
are interested in this component but there is little strategic
direction or standardized tools currently available. There are also
a variety of methods to get messages and ORS out to communities,
including development health programs, food aid, and HIV programs.
Such resources could be better coordinated for a more rapid and
robust community-level prevention and response program. The
activities would not only benefit the response to the current
outbreak, but also would build capacity for community-based
mechanisms to respond to other emergencies.


27. The health and WASH clusters need to improve coordination and
leadership, consider a joint needs assessment, and prioritize early
warning to alert both health and WASH implementing partners of new
outbreaks or potential hotspots on a timely basis. The clusters
should also develop a clear strategy for prevention efforts in areas
at high risk for cholera, responding to newly emerging areas with
increasing cases of cholera, and monitoring areas with high cholera

28. Newly emerging areas with increasing cases should be targeted
with hygiene promotion, the provision of safe water via tankering or
household level disinfection, distribution of water storage vessels
and soap, and health education and distribution of ORS. Measures
should also include active case finding and referral for care,
setting up a CTC, and a resources needs assessment.

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29. In high-risk communities such as urban and peri-urban areas,
hygiene promotion activities and an assessment of the quality and
reliability of drinking water sources should begin as soon as
possible and should not wait for an outbreak to occur. In addition,
health activities could include active case finding and a needs
assessment for additional resources for a local outbreak.

30. The health and WASH clusters should continue to monitor heavily
burdened areas such as Budiriro, Beitbridge, and Mudzi, and continue
to provide care at the CTCs as needed. WASH interventions should
continue at a minimum until no new cases are detected in the
community, and if resources are available until the outbreak

31. The health and WASH clusters should initiate a task force on
social mobilization to ensure an overall strategy on community
mobilization, better cluster coordination on health education and
hygiene promotion messages, analysis of existing community health
worker and hygiene promoter networks and to ensure that the use of
standardized information education and communication materials.

32. Providing interim support to the primary health care system
would help to prevent further outbreaks of communicable diseases,
maternal deaths, and to better monitor nutritional status of the
population. Any long term support to reviving the GOZ's collapsed
health care system should be contingent on government reform.
(Note: While the USAID/DART recognizes the need for a robust
response to save lives and alleviate suffering, close monitoring of
donor resources for the cholera crisis is important, given the
possibility that the current regime will attempt to use the donor
response to the cholera crisis for personal or political profit.
End Note.)


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