Cholera and AWD Outbreaks Bulletin in Eastern and Southern Africa Region, as of 4 February 2019, 2 Issue
Highlights
7 out of the 21 countries in Eastern and Southern Africa Region (ESAR) have reported more than 941 cholera cases and 8 deaths with an average Case Fatality Rate of 0.9%, since the beginning of 2019. These countries include; Angola, Burundi, Kenya, Tanzania, Somalia, Uganda and Zimbabwe. Apart from Kenya, outbreaks from the rest of the countries spilled over from 2018. Kenya accounts for 60.8% (572) of the total cases reported this year, followed by Somalia at 21% (198). In 2019, highest Case Fatality Rate (CFR) has been recorded in Zimbabwe at 8.9%.
Of the 7 countries with reported cholera/ AWD outbreaks in ESAR since week 1 of 2019, 5 (Burundi, Kenya, Somalia, Uganda and Zimbabwe) have ongoing cholera outbreaks. During the week under review, Kenya reported the highest number of new cases (101 cases).
Kenya: Since the onset of the current outbreak on 2 January 2019, a total of 572 cases including 2 deaths (CFR, 0.3%) have been reported from three counties (Nairobi, Narok, Kajiado). 49.1% of these cumulative cases have emerged from Kajiado County (281 cases), 29% from Narok County (166 cases) and the remaining 21.9% from Nairobi County (125 cases). During week 5 (week ending 3 February 2019), 101 new cases were reported compared to 60 cases reported during week 4 (week ending 27 January 2019).
Somalia: 24 new cases of AWD/cholera were reported in week 3 (week ending 20 January 2019). This is a decline in the number of cases compared to the previous week (week 2) when 87 cases were reported. These cases emerged from across Somalia including Somaliland. Cumulatively a total of 7,050 cases including 45 deaths have been reported since December 2017. Of these, a total of 198 cases have been reported since the beginning of 2019.
Uganda: A decline in the epidemic trend has been noted in the last three weeks (week 2 to 4). For instance, during week 4, 5 new cases of AWD/cholera were reported compared to 8 cases reported in week 3.These new cases emerged from the overcrowded informal settlements of Sembabule zone and Katwe (Rubaga division) and Kisenyi (Central division) in Uganda’s capital, Kampala. Cumulatively, a total of 38 cases including 1 death have been reported since the onset of the latest wave of the cholera outbreak in December 2018. Lack of toilets and poor sanitation exacerbated by heavy rains are factors associated with the current outbreak.
Burundi: 10 new cases of cholera / AWD including 1 death (CFR, 10%) were reported during week 4 compared to 8 cases reported in week 3. New cases emerged from Bujumbura Mairie (8 cases) and Rumonge province (2 cases). Cumulatively a total of 169 cases including 2 deaths have been reported since the beginning of the outbreak in December 2018, with majority (69.2%, 45) of these cases emerging from Rumonge province. 38.5% (65 cases) of cumulative cholera / AWD cases and 50% of all reported cholera / AWD related deaths, have been reported since the beginning of 2019.
Zimbabwe: During week 5 (week ending 3 February 2019), 4 new cases were reported compared to 11 cases including 1 deaths (CFR,9.1%) reported in week 4. These new cases emerged from Murehwa and Mutoko districts in Mashonaland East province. Cumulatively, a total of 10,696 cases including 69 deaths have been reported since the beginning of the outbreak on 5 September 2018, with 93% (9,971) of these cases emerging from Harare and the remaining 7% emerging from 22 districts outside Harare. 0.4% (45 cases) of cumulative cholera / AWD cases and 5.8% (4 deaths) of all reported cholera / AWD related deaths, have been reported since the beginning of 2019.
Urban - Rural Disaggregation of Cholera Cases
An analysis of cholera cases reported since the beginning of 2019 from five countries (Angola, Kenya, Tanzania, Uganda and Zimbabwe) reveals that overall, rural areas account for 73.6 % (496 cases) of the total caseload while urban areas account for 26.4% (178 cases). Cases reported from rural areas are emerging from Kenya, Zimbabwe and Tanzania; while cases reported from urban areas are emerging from Uganda, Kenya and Angola. Kenya accounts for the highest number of cases reported in rural areas (90.1%, 447) and in urban areas (70.2%, 125).
Zimbabwe Cholera Fact Sheet
Cholera Overview
Seventh pandemic cholera was first reported in Zimbabwe in 1973. Since then, significant outbreaks have been reported in 1992-93, 1999, 2002, 2008-2009 (which was the most significant outbreak ever reported in Africa) and 2010-2011. In recent years, no major outbreak had been reported until cholera resurfaced in 2018 (Fig. 1).
Between 1998 and 2018, epidemiological surveillance reported 117,973 cases with 5,198 deaths (case fatality rate ≈ 4.4%)2.
Major outbreaks were reported in the following provinces: Mashonaland West, Mashonaland Central, Mashonaland East, Manicaland and Masvingo (Fig. 2 and Table I).
Cholera Distribution
Geographic distribution of cholera is markedly heterogeneous, with the five most affected provinces reporting 69.5% of the burden.
The northern and eastern provinces reported a combined 75% of all cholera cases between 1998-2018, with the highest proportion reported by Mashonaland West (22.5%), Harare (17.1%), and Manicaland (15.7%) Provinces (Fig. 2 and Table I). The most affected districts tended to be located along the northern and eastern border with Zambia and Mozambique as well as along main routes to Harare.
The southern and western part of the country has been generally less affected and reported only 25% of the total number of cases during the period 1998-2018.
Harare seems to play a role in amplifying cholera outbreaks. During years when Harare urban district was affected, a increased number of cases were reported (>10-fold) and a greater number of districts were affected.
Cholera in Zimbabwe displays a seasonal pattern and an apparent correlation with the rainy season (November to April/May) (Fig. 3).
Outbreaks tended to start between week 45 (November) and week 51 (late-December) (Fig. 3).
Strategic Recommendations
In cholera hotspots, preparedness and response plans should be developed and implemented including: (1) strengthening early detection and rapid response including community based surveillance and cross-border alerts; (2) establishing multisectoral and cross-border coordination mechanisms; (3) building capacity on outbreak management; (4) targeted pre-positioning of supplies and (5) developing risk communication, social mobilization and community engagement plans as well as harmonizing approaches and messaging.
Enhanced access to healthcare and early rehydration (e.g., community oral rehydration points) in remote areas, should be prioritized to prevent cholera-related deaths (Table II – hotspot types T1 - T4).
Sustainable Water, Sanitation and Hygiene and social mobilisation activities should be implemented in 21 high-priority hotspot districts regularly affected with significant outbreak duration (Table II – Types T1 and T2). If implemented in combination with preventive measures, oral cholera vaccine campaigns will reduce the likelihood of cholera epidemics in cholera foci and among high-risk populations.
The type T1 and T2 hotspots accounted for 36.1% of the disease burden2. Those 13 districts host approximately 2.5 million people (18% of the total estimated population). An identification of transmission foci at a finer geographical scale is necessary to better target at-risk populations.
 Cholera Factsheet_Zimbabwe_2018_Draft Final.pdf | [ ] | 447 kB |
Zambia Cholera Fact Sheet
Cholera Overview
Seventh pandemic cholera was first reported in Zambia in 1977. Since 1990, large-scale outbreaks have occurred in 1990-93, 1999-2001, 2004, 2006, 2009, 2010 and 2018. The overall yearly trend shows a decrease in case numbers over time (Fig. 1).
Between 1999 and 2017, epidemiological surveillance reported 61,157 cases with 1,832 fatalities (case fatality rate (CFR) ≈ 3%)1. The majority of outbreaks were reported in the provinces of Lusaka, Luapula, Copperbelt, Northern, Central and Southern2.
The country has been affected by cross-border outbreaks primarily along the borders with the Democratic Republic of the Congo (DRC), the United Republic of Tanzania and Zimbabwe (Fig. 2).
Cholera Distribution
From 1999 to 2018 (up to week 22 of 2018), most cholera cases (74%) were reported by Lusaka Province, which includes the capital Lusaka. On average, outbreaks lasted for four months.2
Luapula, Copperbelt and Northern Provinces,
located at the border with DRC and around Lakes Mweru and Tanganyika, reported 18% of all cholera cases. On average, outbreaks lasted approximately two months in Copperbelt Province and up to four months in Luapula Province. Additionally, Northern Province was the most regularly affected, with ten outbreaks over the near 20-year period (Fig. 2 and Table I)2.
In the middle part of the country, Central Province accounted for 3% of the total cases and was affected seven times, mainly in the Lukanga swamp (Kapiri Moshi) and the neighboring city of Kabwe (Fig. 3 and Table I)2.
In the southern part of the country, Southern Province notified 2.5% of all cases and was affected five times. Heavily affected areas were located at the border with Zimbabwe and around the Kafue Flat swamp and Kariba Lake (Fig. 3 and Table I)2.
A marked seasonality was observed with outbreak onset at the end of the dry season (from September to October) and outbreak termination at the end of the rainy season (May). A greater number of cases was reported during the rainy season, especially in Lusaka2,4,5 (Fig. 3 and Table I).
Strategic Recommendations
High-risk areas along the borders were located in zones where cholera outbreaks spread between neighboring countries such as DRC, Tanzania and Zimbabwe (Table II). This highlights the role of the Zambian National Public Health Institute in implementing cross-border surveillance and coordinated response between countries in the sub-region.
In cholera hotspots, preparedness and response plans should be developed and implemented including: (1) strengthening early detection and rapid response including community-based surveillance and cross-border alerts; (2) establishing multisectoral and cross border coordination mechanisms; (3) building outbreak management capacity; (4) developing risk communication, social mobilization and community engagements plans with harmonized approaches and messaging (Table II – Type 1 to Type 4).
Sustainable water, sanitation, hygiene and social mobilization activities should be implemented in the 12 priority districts regularly affected by outbreaks of extended duration (Table II – Types 1 and 2). While preventive measures are implemented, oral cholera vaccine campaigns conducted in border hotspots may reduce the likelihood of large-scale cholera epidemics in Lusaka. The Type 1 and Type 2 hotspots accounted for 91% of the disease burden3. Identification of transmission foci at a finer geographical scale (ward, village) is necessary to best target at-risk populations.
| Cholera Factsheet_Zambia_2017_Draft Final.pdf | [ ] | 501 kB |
Angola Cholera Fact Sheet
Cholera Overview
Seventh pandemic cholera was first reported in Angola in the early 1970s. Since 1990, large-scale outbreaks were reported in 1990-1991, 2006-2008 and 2013. The overall yearly trend shows a significant decrease in case numbers since 2006 (Fig. 1).1
Between 2006 and 2018, epidemiological surveillance reported 112,545 cases with 4,279 fatalities (case fatality rate (CFR) ≈ 3.8%).
From 2006 to 2018, the province reporting the majority of suspected cases was Luanda (29%). After Luanda, Benguela Province reported 15.4% of all cholera cases.2
Angola has been affected by cross-border outbreaks, especially among communities located in northern provinces bordering Democratic Republic of the Congo (DRC) (Figs. 2 and 4).3
Cholera Distribution
Luanda Province reported 29% of all cases over the course of nine outbreaks, although most outbreaks in Luanda occurred between 2006 and 2013 (Fig. 2, Table I).2
In the southwest, the provinces of Benguela, Huíla and Cunene accounted for a combined 31.1% of all suspected cholera cases. The large majority of cases (99.4%) in these three provinces were reported between 2006 and 2013 (Fig. 2, Table I).2
In the north along the DRC border, the provinces of Uíge, Zaire, Cabinda, Malanje and Lunda Norte reported a combined 20.9% of all cholera suspected cases. All five provinces were repeatedly affected, especially Uíge Province, which reported nine outbreak events. Uíge, Zaire and Cabinda reported 99% of all cases from 2015 to 2018 (Fig. 2, Table I).2
Cholera case numbers in Angola tended to increase between October and December, which coincides with the onset of the rainy season (Fig. 3).2,4 Extended drought followed by onset of the rainy season likely played a role in the 2013 outbreak in the southern provinces; case numbers peaked in Huíla and Cunene with the onset of the rainy season in late-2013.2, 3
Strategic Recommendations
Cross-border cholera transmission from DRC likely plays a major role in cholera dynamics in Angola (Table II, Fig. 4). Since 2011, the majority of outbreaks in Angola have coincided with the spread of cholera into the southwestern provinces of DRC.3,5,6 This highlights the importance of cross-border surveillance and coordinated response between countries in the region. Cross-border collaboration with DRC should be strengthened, with regular data and information sharing, especially when cholera outbreaks spread into the western provinces of DRC.
In cholera hotspots (Type 1-4), preparedness and response plans should be developed and implemented including: (1) strengthening early detection and rapid response including community-based surveillance and cross-border alerts; (2) establishing multisectoral and cross-border coordination mechanisms; (3) building outbreak management capacity; (4) targeted pre-positioning of supplies and (5) developing risk communication, social mobilization and community engagement plans with harmonized approaches and messaging (Table II).
Sustainable water, sanitation, hygiene (WASH) and social mobilization activities should be implemented in five priority provinces regularly affected by outbreaks of extended duration, especially at-risk provinces along the border with DRC (Table II – Type 1-2 hotspots). Sustainable WASH and social mobilization activities should include hard-to-reach and remote populations. Prepositioning of supplies is critical for hotspots located far from Luanda. To reduce the CFR in rural areas where access to health facility is restricted, community surveillance including active case search, and early referral to healthcare should be strengthened through community cadres. Furthermore, oral rehydration points should be established, and oral rehydration solutions should be distributed. Identification of transmission foci at a finer scale (i.e., municipality) within the priority provinces is necessary to best target at-risk communities.
| Cholera Factsheet_Angola_2018_FINAL.pdf | [ ] | 421 kB |
Angola - Study in cholera hotspots in Angola: Review and propositions for actions to prevent cholera in the most affected areas (October 2018)
Cholera continues to represent a major public health concern in Angola. To guide cholera control and prevention strategies, the current assignment aims to better understand the cholera dynamics in Angola and identify cholera hotspots.
Angola is recovering from a 40-year war that resulted in significant social and economic disruptions, including limited access to potable water and adequate health and sanitation infrastructures, which has rendered the country vulnerable to epidemic-prone diseases such as cholera. Following an unexplained near ten-year lull in cholera outbreaks from 1997 to 2006, Angola experienced a large-scale cholera epidemic that started in the sprawling slums (musseques) of Luanda in early 2006 (67,257 suspected cases). Since 2006, cholera outbreaks have been reported nearly every year in the country (with the exception of 2015), albeit at gradually dwindling rates.
Over the course of the study, the regularly affected communities were located in northern provinces bordering the DRC, especially Uíge and Zaire, as well as certain provinces in the southwest, such as Cunene, Huíla, Benguela and Namibe. In this study, 11 provinces in Angola were identified as cholera hotspots. The northern province of Uíge was defined as a highest-priority Type 1 hotspot. The southwestern provinces of Benguela, Cunene and Huíla as well as the northwest province of Zaire were defined as high-priority Type 2 hotspots. Luanda Province was defined as a medium-priority Type 3 hotspot. The northern provinces of Cabinda, Lunda Norte, Malanje, and Kwanza Norte and the southern province of Namibe were defined as Type 4 hotspots. Overall, the Type 1 – 4 cholera hotspots accounted for 90.6% of the disease burden throughout the study period. Five provinces affected by outbreaks of extended duration (Type 1 and Type 2 hotspots) reported 39.4% of the total number of suspected cases.
Cholera risk factors leading to the 2006 outbreak in Luanda included severe disruptions in basic health and sanitation services, limited access to potable water, and rapid urbanization due to population displacement. Other cholera risk factors throughout the country included limited access to potable water and sanitation facilities. In 2015, 23% of rural populations and 63% of urban population had access to at least basic drinking water sources. Furthermore, 21% of rural populations and 62% of urban populations had access to at least basic sanitation. As a result, open defecation is also widespread, especially among rural populations (56% in 2015). Extended drought followed by onset of the rainy season likely played a role in the 2013 outbreak in the southern provinces (e.g., Cunene and Huíla). Due to widespread open defecation, heavy rains triggered contamination of the few drinking water sources with fecal matter.
Cross-border cholera transmission from the Democratic Republic of the Congo (DRC) likely played a major role in cholera dynamics in Angola. The two most recent epidemic episodes in Angola (2011-2013 and 2016-2018), occurred in parallel to cholera outbreaks in western DRC. Furthermore, the recent outbreaks in Zaire, Cabinda and Uíge have been epidemiologically linked to cholera outbreaks in western DRC.
Based on the study findings, long-term WASH investments in the Type 1 and Type 2 hotspots are recommended.
| Cholera epidemiology in Angola_UNICEF_2018_FINAL.pdf | [ ] | 1630 kB |
