1. 1 Overview of the Cholera Outbreak 2 February 2009 Dr. Frew Benson, Cluster Manager: Communicable Diseases

2. 2 Outline Introduction Background Current status in the Region Current status in South Africa Current status in Mpumalanga and Limpopo Factors contributing to the spread Response to the outbreak Challenges Recommendations Conclusion

3. 3 Introduction Cholera has been prevalent worldwide and in Sub-saharan Africa since the early 19 th Century Cholera is caused by the bacteria Vibrio cholerae. Outbreaks in Africa caused by El Tor biotype of Vibrio cholerae serogroup 01 Spread through faecal-oral route. Contaminated water is the main source of infection Presents with a sudden onset of diarrhoea with or without vomiting – incubation period few hours to 5 days South Africa had its first outbreak in 1973 Biggest outbreak was in August 2000 to July 2001 when 106,389 cases and 232 deaths were recorded. KZN and Limpopo saw most cases (97,059 and 793 respectively) In 2003, around 3 901 cases in KZN, EC, Mpumalanga

4. 4 Background to Current outbreak Zimbabwe faced outbreak of cholera since Mid August 2008 On 15 Nov 2008 received a report of cholera in Beitbridge, Zimbabwe & fear of possible spillover into neighbouring Vhembe district, Limpopo 18 Nov ’08 Limpopo Provincial DoH reported increase in acute diarrhoea cases – including 1 death ? Cholera 19 Nov ’08 NICD confirmed Vibrio cholerae isolated in 5 out of 11 stool samples tested in Polokwane NHLS From this date Vhemde district the epicentre of the outbreak. Spread South along N1, from Mid December Capricorn and Sekhukhune also affected By this time Gauteng was also affected and all other provinces with 1-2 cases

5. 5 Current Status in the Region Country Reported Cases Reported Deaths CFRTime Period Angola*64381.24% 01 Oct 08 19 Jan 09 Botswana600.00% 01 Nov 08 23 Jan 09 Malawi682263.81% 15 Nov 08 18 Jan 09 Mozambique3,333461.38% 01 Oct 08 20 Jan 09 Namibia5858.62% 22 Oct 08 10 Jan 09 South Africa4,859 340.78% 15 Nov 08 20 Jan 09 Swaziland**2,53200.00% 22 Dec 08 11 Jan 09 Zambia***2,267281.25% 19 Sep 08 21 Jan 09 Zimbabwe48,6232,7555.7% 15 Aug 08 21 Jan 09

6. 6 Current Status in South Africa ProvinceCasesDeathsCFROccurrence Mpumalanga4165300.72% 21/11/08 to 31/01/ 09 Limpopo3680200.54% 15/11/08 to 31/01/09 Gauteng23431.28% 19/11/08 to 31/01/09 Western Cape900.00% 19/11/08 to 23/01/09 North West700.00% 15/11/08 to 24/01/09 Kwa-Zulu Natal2 150.00% 19/11/08 & 04/01/09 Eastern Cape100.00% 11/12/08 Free State100.00% 18/12/08 Northern Cape100.00% 12/12/08 Total8100510.63%

7. 7 Map: Limpopo VHEMBE MOPANI SEKHUKHUNE

8. 8 Current status in Limpopo

9. 9 Current Status in Limpopo

10. 10 Current Status in Limpopo

11. 11 Current Status in Mpumalanga

12. 12 Current Status in Mpumalanga

13. 13 Current Status in Mpumalanga

14. 14 Factors contributing to the spread of Cholera Migration of possibly infected people from affected countries and areas. Easy travel within the country makes it possible for the efficient movement of possibly infected people – Christmas period Inadequate safe water and sanitation coverage in certain areas. The rainy season exacerbates the bad sanitation situation in some areas Cases seen at facilities account for about 10% of people infected - the remainder usually asymptomatic or have mild symptoms and remain in the communities. This category of cases remain potentially infectious to others

15. 15 South African – Response National 17 Nov 08 NORT deployed in Musina to support with investigations Several subsequent support visits to Limpopo, Gauteng and Mpumalanga 19 Nov 08 – Cabinet informed and mobilized Contact made with other partners e.g., WHO, UNICEF SAMS and NGOs A National Multi-Sectoral Cholera Outbreak Response Committee set up that meets weekly (date of first meeting 24/11/2008) Alert messages were sent out to all provinces (25 November 2008). National Cholera Guidelines were disseminated (18 and 25/11/2008) IEC material sent to some affected provinces (in December and January) National Cholera Plan of Action plan was develop and distributed to support development of provincial plans Supported Reactivation of Outbreak Response Teams and Joint Operations Committees in provinces that have reported outbreaks. Training carried out in some districts in Limpopo and Mpumalanga. Development of a National Sitrep that is disseminated regularly Weekly Teleconferences with Communicable Disease Control Coordinators Bilateral meetings with DWAF since 22/01 to identify high risk areas

16. 16 South African – Response Provincial and District In Limpopo Mpumalanga and Gauteng Outbreak Response Teams (ORTs) formed working sub-committees (coordination, logistics and supplies, case management and infection control, epidemiology and surveillance, environmental health and social mobilisation); Declaration of Vhembe as a disaster area by the provincial govt Stakeholder mobilisation to support health promotion activities at community level Strengthening of public education to local communities and travellers Rehydration centres and Treatment tents erected at facilities Additional supplies obtained - Dehydration fluids (Oral and IV) beds, linen, buckets and covers for tent floors Additional health professionals mobilised Contact made with other partners

17. 17 Challenges - Water and Sanitation Contaminated Water Sources include: river water, streams, bore holes, wells etc. with faecal contamination through sewerage plant inefficiencies and spills Contaminated water containers due to improper handling and water storage Formal Water Supply problems Problems of chlorination Interrupted water supplies Sub-optimal maintenance of the system Over-stretched water system Poor water handling in households Raw water supply to communities through taps Poor sanitation coverage

18. 18 Challenges – Health System Regional Cross-border cholera epidemic out of control – initial high number of imported cases from Zimbabwe Institutions challenged with preexisting burden of disease Infrastructure challenges – insufficient beds Insufficient Health Promotion and IEC material Insufficient medical supplies in some provinces Inadequate human resources – national, provincial and institutions

19. 19 Recommendations National DOH Continued coordination with partners and mobilization of resources Strengthen health promotion and IEC support to provinces Strengthen capacity to provide technical support to provinces Coordination with DWAF, DPLG and SALGA to identify high risk areas Conduct EPR Audit of provinces Provincial DOH Development and implementation of provincial plans of action focusing especially on high risk areas Health Promotion to be strengthened in all provinces – focus on high risk areas Provinces to maintain high level of alert and ensure dissemination of guidelines to all institutions (District managers, hospital CEOs and clinical managers to be mobilised) Ensure sufficient stock levels of supplies – provinces at risk can plan according to different scenarios Strengthening joint regional outbreak response

20. 20 Recommendations District and Local Level Implement short term measures to address the need for safe water Environmental risk assessments and monitoring – strengthen role of EHPs Coordination with DWAF, DPLG to address water and sanitation challenges in short, medium and long term Aggressive implementation of Health Promotion in high risk areas Ensure sufficient stock levels of supplies – provinces at risk can plan according to different scenarios Strengthening joint outbreak response DWAF and DPLG Coordination with Local Authorities to address water and sanitation challenges in short, medium and long term Coordination with Health and Local Authorities to identify high risk areas

21. 21 Conclusion The outbreak of Cholera, which are occurring in 8 countries in the region, as well as provinces such as Mpumalanga, Limpopo and Gauteng in South Africa has the potential to spread as the risk factors such as insufficient safe water and sanitation exists in all provinces in the country.