Creation date: 19 October 2018 Sources: Ministries of Health and WHO

Bulletin: Cholera and AWD Outbreaks in Eastern and Southern AfricaRegional Update for 2018 - as of 19 October 2018

Highlights10 out of the 21 countries in Eastern and Southern Africa Region (ESAR) have reported more than 34,965 cholera / AWD cases and 420 deaths (Case Fatality Rate, 1.2%), since the beginning of 2018. These countries include; Angola, Kenya, Malawi, Mozambique, Rwanda,Somalia, Tanzania, Uganda, Zambia and Zimbabwe. Zimbabwe accounts for 26.9 % (9,395) of the total case load reported this year, followed by Somalia at 17.5% (6,132).

Out of the 10 countries with reported cholera/ AWD outbreaks this year in ESAR, 5 (Zimbabwe, Tanzania, Somalia, Kenya and Uganda) have ongoing cholera outbreaks. During the week under review, Zimbabwe reported the highest number of new cases (386 cases). Of the five countries with active transmission, Tanzania has recorded the highest CFR (at 1.9%) in 2018.

Zimbabwe: The weekly case incidence has been on a downward trend in the past 3 weeks (week 39 to week 41), with an average of 41.5% weekly decline . During week 41 (week ending 14 October 2018), 386 new cases were reported compared to 1,000 cases including 6 deaths (CFR, 0.6%) reported in week 40 (week ending 7 October 2018). These new cases emerged from two provinces: Harare (only from Harare: 348 cases, and Chitungwiza: 6 cases), and Manicaland (only from Buhera: 32 cases). Cumulatively, a total of 9,395 cases including 58 deaths have been reported in 2018. Majority of these cases (98%, 9,218) and deaths (93%. 54) have been reported since the beginning of the new wave of the outbreak on 5 September 2018.

Tanzania: A decline in the epidemic trend has been noted. During week 41, 35 new cases including 1 death (CFR, 2.9%) were reported compared to 98 cases including 3 deaths (CFR, 3.1%) reported in week 40. These new cases are from 4 regions; Ngorongoro district in Arusha region (11 cases), Songwe DC in Songwe region (9 cases including 1 death), Simanjiro district in Manyara region (9 cases), and from Moshi DC in Kilimanjaro region (6 cases). Songwe and Kilimanjaro are new regions where cholera cases have been reported during the week under review. Cumulatively a total of 32,862 cases including 548 deaths have been reported in Tanzania mainland, as from August 2015. Of these, a total of 4,231 cases and 82 deaths have been reported since the beginning of 2018.

Somalia: During week 40, 23 new cases including 1 death (CFR, 4.3%) were reported compared to 29 cases reported in week 39 (week ending 30 September 2018). All new cases emerged from Banadir region. Cumulatively a total of 6,537 cases including 43 deaths have been reported since the beginning of the outbreak in December 2017. Of these, a total of 6,132 cases and 42 deaths have been reported in 2018.

Kenya : 7 new cases were reported from Isiolo County during week 41. Last case was reported in Turkana County on 18 September 2018, while Embu County reported 3 cases during week 40. Cumulatively a total of 26,591 cases including 421 deaths have been reported, as from October 2016. Of these, a total of 5,781 cases and 78 deaths have been reported since the beginning of 2018.

Uganda : A new outbreak was confirmed during week 41. 4 cases which were reported emerged from Kampala (2 cases) and Hoima/Kikuube districts (2 cases). Risk factors linked to this new outbreak include; population movement, poor sanitation and inadequate access to clean water

19

354,231

7

5,781

863

784

3

4,127

23

6,132

950

386

9,395

42,699 0 / 78

1 / 82

0 / 15

0 / 27

1 / 42

0 / 3

0/ 60

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 40 or 41) / 2018 Cumulative deaths

Status of the OutbreakNo data

Countries with no ongoing outbreaks Countries with ongoing outbreaks

Legend

No outbreak reported in 2018

10Countries

34,965 Cases

420 deaths

1.2% CFR

0 /58

Country Priorities and Response Interventions

Mozambique : Current preparedness and prevention interventions include;

• To prevent cross-border transmission of the cholera outbreak from neighbouring countries, the following actions have been implemented: (a) national multi-sector preparedness and response team has been reactivated to assess the risk of the outbreak and review the response plan. (b) Social and behavior change communication activities are being implemented in Manica province which borders Zimbabwe• Partners (WHO, UNICEF and MSF) have supported Ministry of health in the development of contingency plan for cholera preparedness and response • UNICEF in collaboration with MoH is planning the distribution of water purification solution (CERTEZA ®), targeting cholera hotspots in all provinces • UNICEF and WHO are supporting replenishment and prepositioning of AWD kits and water purification solutions• UNICEF developed radio spots on cholera prevention

Country Priorities Response Interventions

Zimbabwe- Targeted hygiene kit distribution in all cholera affected areas

- Supporting and strengthening case follow up and case investigation teams in the epicenter

- Water point repairs/ rehabilitation and equipping with inline chlorinators in Harare

- Provision of supply consumables within the Government Analyst Laboratory for water quality testing

• More than 286,660 people reached with key health and hygiene messages in cholera affected areas (Harare, Chitungwiza, Buhera, Masvingo) through different communication channels, including door to door and media campaigns since the beginning of the outbreak. An additional 44,000 people were reached at public markets and bus terminuses in Harare and Mbare Musika

• 633 community health Volunteers, 222 school health masters and 72 church leaders were trained and are responsible for disseminating health and hygiene messages

• 10,683 families, 125 schools in the epicenter and 72 churches benefitted from hygiene kit distribution; comprising of soap for hand washing, point of use water treatment and IEC materials among others through support from UNICEF, Higher life Foundation, Oxfam, WHH, Mercy Corps, Christian Care, World Vision and ADRA

• 170,085 people reached with safe water through water trucking (private companies) and distribution of household water treatment chemicals by partners in the affected areas

• A total of 8 Emergency Strategic Advisory Group (ESAG) meetings held since beginning of outbreak. ESAG coordinated development of the WASH sector response plan and identified gaps for the next 6 months; with the current focus on targeted hygiene kit distribution, chlorination of water points at point of collection or using inline chlorinators in the affected suburbs

• WASH Provincial Focal Agencies (PFAs) in the other at risk provinces (Mashonaland Central, Mashonaland West, Mashonaland East, Matebeleland South and North) that are supporting surveillance and reporting activities on a weekly basis in their respective areas of operation

Somalia - Improve access to safe water, sanitation and health care for IDP's and refugees in the Banadir region (including Mogadishu) and Kismayo

• Chlorination of water sources has been conducted in the affected areas of Hanti-Wadaag, Bulo-Sheikh, Farjano, Allenley and Fanole

• 1,500 hygiene kits have been distributed in Kismayo

• Hygiene promotion is on-going in Kismayo districts; Farjano, Allanley, Gulwade and Shaqalaha

• WHO conducted on-job training for health workers in Banadir and Kismayo

Tanzania

• The District team in collaboration with Ngorongoro Conservation Authority (NCA) has continued to support community contact tracing and providing health education on Cholera prevention and control

• In Ngorongoro district, interpersonal communication with school children and 50 community members was conducted focusing on water treatment at household level. Following this engagement, 5,800 Aqua tablets were distributed to schools for water treatment at schools and 250 tablets were distributed to the villagers for household water treatment.

- For Ngorongoro district, the following are priority interventions; community based contact tracing, decontamination and regular provision of water supplies in cholera hot spot villages through water trucking

- Follow up closely with communities on construction of toilets in the affected areas and ensure adherance to by-laws

- Capacity building of medical personnel on proper handling of cholera cases

- Increase the number of various cadres of health personnel (from the community level to higher levels of the health system) in affected areas

Creation date: 19 October 2018 Sources: Ministries of Health and WHO

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

Pwani

DodomaSingida

Mbeya

Dar es Salam

Morogoro

Iringa

Kigoma

Mara

Tabora Tanga

Rukwa

Unguja

Nsanje

Chikwawa

Mwanza

Nampula

Cabinda

Zaire

- There are still gaps in the supply of water treatment chemicals, repairs of pump sets at treatment works and repair of water leakages to address non-revenue water for Harare City and other local authorities

- The lack of consumables within the Government Analyst Laboratory to process water samples has slowed down water quality testing for speedy remedial action.

Challenges: Zimbabwe

Challenges: Tanzania

Legend

Status of outbreak

Outbreak contained

Outbreak active

No outbreak reportedCholera / AWD Cases

XXNew cases

Cumulative cases 2018

Angola

South Africa

Tanzania

Burundi

Mozambique

Namibia

Botswana

Zimbabwe

Zambia

Malawi

Malawi

Rwanda

Rwanda

Katavi

Njombe

Lusaka

Luapula Northernprovince

KilimanjaroManyara

Lesotho

Swaziland

Ruvuma

CopperbeltCentral

Uige

EasternNorth-Western

SouthernWesternMashonaland West

Mashonaland Central

MashonalandEast

Cabo Delgado

Harare

Manicaland

MasvingoMatabeleland South

Midlands

Bulawayo

Arusha

- In Ngorongoro, settlements are sparsely located within the conservancy making it difficult to provide services like safe drinking water hence populations use the same water used by their animals/wild animals- Inadequate number of staff to support the response at all levels in WASH and Health - A major barrier to prompt care seeking from health facilities, is the community’s over-reliance on traditional medicines for all ailments as the 1st line of treatment.This barrier is currently being addressed through interpersonal communication targeting traditional healers to; raise their awareness about cholera, causes, prevention as well as emphasizing the need for referral of cholera patients to health facilities and advising against herbal treatments that might cause harm- Cultural practices/rituals that promote the transmission of cholera

Luanda

2

Western Province

Blantyre

221

213

4

386

108

796

642

3

4,127

361

593

3

1

4

6

2

13

88

13

1

56

31

61

163

111759

916

975

647

*Cases presented for Zambia refers to cumulative cases reported in 2018 from all the affected districts

93

11

3549105

3285

35

21

3810

108

Karonga

Nkhata Bay

Kasungu

SalimaLilongwe

Dowa

Mulanje

Likoma

Rumphi

Dedza

Creation date: 19 October 2018 Sources: Ministries of Health and WHO

Annex 2: Distribution of Cholera and AWD Outbreaks in the Horn of Africa and Challenges in Response - as from 1 of 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 SudanEthiopia

Somalia

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

1,577

Tharaka Nithi

BusiaMeru

Embu

Turkana

West Pokot

Tana River

252

591

161

Western Region

Murang’a

596

TransNzoia69

Nairobi

Nakuru

143Isiolo

1027

2,329

2,69923

85

Nairobi

129

Machakos52

3

261

294

Karamoja

46

558

118

5

Kilifi

South Western

132

Central

191

Elgon 1837

13122,199

2

Somalia: Challenges

- 54.7 % and 43.9% of cases and deaths reported respectively by affected districts are children under the age of five. From Epidemiological week 1 to week 38 in 2018, a total of 3,326 cases including 18 deaths (CFR, 0.5%) have been reported among children under the age of five (Source, WHO).

- Cholera endemic areas have been and are still being affected by floods. These areas include; South West, Jubbaland and Hirshabelle State. These areas also have a high concentration of refugees with limited access to water and sanitation making them vulnerable to outbreaks of cholera and other epidemic prone diarhoeas.

- Overall, case fatality rate for all Banadir districts is 0.8%. Daynile (2%) and Hamar Jaba (0.6%) districts of Banadir continues to record highest CFR as compared to other districts

Kirinyaga

** New wave of the cholera outbreak in Uganda emerged from Kampala (in central region) and Hoima and Kikuube districts (in Western region).

3153133

Tharaka Nithi

10

Kirinyaga

Kiambu

Kiambu

Annex 3: Epi Curves for Countries with Active Cholera Outbreaks Currently

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Zimbabwe

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Somalia

0100200300400500600700800900

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20182017

Tanzania

Country Week 37 Week 38 Week 39 Week 40 Week 41 2018 Cumulative Cumulative since the beginning of the outbreak

Beginning of

Outbreaks

Status of the outbreak

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

Cases Deaths CFR (%)

Zimbabwe 2528 11 2806 16 1275 3 1000 6 386 0 9,395 58 0.6 9,218 54 0.6 Sep-18 Active

Somalia 34 0 30 0 29 0 23 1 6,132 42 0.7 6,537 43 0.7 Dec-17 Active

Kenya 1 0 3 0 2 0 3 0 7 0 5,781 78 1.3 26,591 421 1.6 Dec-14 Active

Tanzania 118 0 150 6 96 3 98 3 35 1 4,231 82 1.9 32,862 548 1.7 Aug-15 Active

Zambia 0 0 0 0 0 0 4,127 55 1.3 5,935 114 1.9 Oct-17 Controlled

Uganda 0 0 0 0 0 0 0 0 4 0 2,699 60 2.2 4 0 2.2 Oct-18 Active

Angola 0 0 0 0 0 0 0 0 0 0 950 15 1.6 1046 21 2 Dec-17 Controlled

Mozambique 0 0 0 0 0 0 863 3 0.3 2,435 3 0.1 Aug-17 Controlled

Malawi 0 0 0 0 0 0 0 0 0 0 784 27 3.4 939 32 3.4 Nov-17 Controlled

Rwanda 3 0 0.0 3 0 0.0 Jan-18 Controlled

Namibia

Burundi

South Sudan

Madagascar

Comoros

Swaziland

Botswana

Eritrea

Lesotho

South Africa

TOTAL 34,965 420 1.2 85,570 1,296 1.5

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