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The outbreak of cholera in Zimbabwe has been ongoing for the past 5 weeks. However,
the weekly case incidence has been on a downward trend since week 39 (week starting
on 23 September 2018). Since our last report (Weekly Bulletin 39), there have been 1
968 new cases reported including five deaths. Bulawayo Province is the latest to report
cases with a total of 38 cases with one death since 25 September 2018.
As of 12 October 2018, a cumulative total of 9 116 cases with 54 deaths (case fatality
ratio 0.59%) have been reported from eight provinces across the country. Of the reported
cases, 228 are confirmed by culture. Harare (8 824 cases) and Chitungwiza (109 cases)
cities in Harare Province have reported the majority of the cases accounting for 98% of
the cumulative cases reported across the country. The most affected areas in Harare City
are from the densely populated urban suburbs of Glen View (4 036 cases), Budiriro (2
538 cases), Mbare (349 cases) and Glen Nora (287 cases). Other provinces reporting
cases outside of Harare include Manicaland Province (85), Bulawayo (38), Mashonaland
East province (35), Mashonaland Central province (11), Midlands Province (10),
Masvingo (2), Matabeleland South (1), and Mashonaland West (1).
There are equal proportion of males and females affected. Of the 8 836 cases for which
age is known, the majority (5 011; 57%) are in the age group 5 to 34 years; children
under 5 years represent 22% of cases. Of the 54 deaths reported, the majority have
occurred in Harare City (46) followed by Buhera in Manicaland (5). The majority of
deaths (33/46; 72%) in Harare City have occurred in a healthcare institution, with most
(30) reported from the Beatrice Road Infectious Diseases Hospital (BRIDH).
The pathogen detected among confirmed cases is Vibrio cholerae O1 serotype Ogawa.
Since confirmation on 6 September 2018, a multi-drug resistant strain has been
identified and is in circulation; however, antibiotics are only recommended for severe
cases. Contaminated water sources, including wells and boreholes, are suspected as the
source of the outbreak.

On 5 October, South Africa notified WHO of a confirmed diagnosis of cholera in a
returning traveler from Zimbabwe. The case -patient, a 50-year-old female who traveled
to Zimbabwe (Mashonaland) on 16 September 2018 and arrived back in South Africa
on 30 September 2018, commenced with diarrhoea on 29 September 2018 just after
leaving Harare for South Africa and was admitted to a Tshwane hospital on 1 October
2018 with profuse watery diarrhea and dehydration. A second case, husband of the first
case-patient has also been confirmed for cholera. The pathogen identified in both cases
is the same Vibrio cholerae O1 serotype Ogawa.

PUBLIC HEALTH ACTIONS
The National Emergency Operations Centre (EOC) which was activated continue to
support coordination of response activities led by the Ministry of Health and Child
Care with support from WHO, MSF, US CDC, and other partners.
Enhanced surveillance including active case finding is ongoing. The case definition in Harare City for a suspected case of cholera has been updated as “Any person in an outbreak
area presenting with acute watery diarrhoea, with or without vomiting”. Refresher trainings were conducted from 3 to 4 October 2018 for approximately 70 staff at BRIDH, Budiriro
and Glen View on the correct use of case definition.
WHO is providing technical oversight into case management and providing guidance on the interpretation of laboratory findings to guide the choice of antibiotics.
The 2009 Zimbabwe Cholera Control guidelines, adapted from WHO guidelines, are now in use, with Médicines sans Frontièrs (MSF) orientating health workers on these guidelines.
Cases are being treated at four treatment sites in and outside of Harare City. UNICEF has prepositioned seven tents at Glenview for the cholera treatment centers (CTCs) and Oxfam
is providing mobile toilets in three CTCs.

The first phase of a reactive mass oral cholera vaccination campaign targeting 422 722 people in the most affected suburbs of Harare (Glen View, Budiriro, Glen Norah, and Mbare)
commenced on 3 October 2018. At the end of phase I on11 October 2018, a total of 403 167 people (administrative coverage: 95.4%) were vaccinated across all four suburbs.
Administrative coverage according to suburbs are as follow: Mbare (118%), Glen Norah (110%), Glenview (91%), and Budiriro (75%). A second phase of the vaccination campaign
is expected to commence on 15 October targeting 170 000 people in Epworth and Seke districts and a third phase on 17 October 2018 targeting 200 000 people Chitungwiza district.
Water, sanitation and hygiene (WASH) activities include enforcement of regulations for food vendors, City of Harare fixing burst water pipes and increasing the water supply to
hotspots, and private sector players supporting installation of water tanks and water trucking.
WASH partners (UNICEF, Higher life Foundation, Oxfam, WHH, Mercy Corps, Christian Care, World Vision and ADRA) are also supporting distribution of hygiene kits to vulnerable
households.
Risk communication, social mobilization, and community engagement activities continue with approximately 350 000 posters and flyers produced and distributed to inform the
public on cholera prevention messages as well as the oral cholera vaccination campaign.

SITUATION INTERPRETATION
The daily number of cases reported is beginning to show a declining trend. With the launch of the mass reactive vaccination campaign, it is anticipated that the outbreak will be brought
under control. However, authorities will need to step up efforts to ensure that a high vaccination coverage is attained. While the OCV campaign may provide short-term remedy for
controlling the outbreak, the risk factors are still present. There is a need for implementing conventional cholera prevention and control strategies focus on ensuring access to clean water,
sanitation and hygiene, and strengthening surveillance and preparedness activities.
The reports of cross-border cases in South Africa underline the potential for infection to spread to neighbouring countries. Cross-border collaboration aimed at early detection and control
measures will need to be strengthened.

A patient receives a medication by intravenous inside a cholera treatment tent during a visit of Zimbabwe Minister of Health, at the cholera treatment centre of the Beatrice Infectious Diseases Hospital, in Harare, on September 11, 2018. – At least 18 people have died over the past week in the Zimbabwe capital Harare and scores fallen ill after a cholera and typhoid outbreak in some areas, authorities said on September 10, 2018. (Photo by Jekesai NJIKIZANA / AFP) (Photo credit should read JEKESAI NJIKIZANA/AFP/Getty Images)