VZCZCXRO4417
OO RUEHBZ RUEHDU RUEHJO RUEHMR RUEHRN
DE RUEHSB #1137/01 3590924
ZNR UUUUU ZZH
O 240924Z DEC 08
FM AMEMBASSY HARARE
TO RUEHC/SECSTATE WASHDC IMMEDIATE 3852
RUEHSA/AMEMBASSY PRETORIA IMMEDIATE 5603
INFO RUEHGV/USMISSION GENEVA 1785
RUCNDT/USMISSION USUN NEW YORK 1965
RUEHRN/USMISSION UN ROME
RUEHBS/USEU BRUSSELS
RHEHAAA/NSC WASHDC
RUEKJCS/SECDEF WASHINGTON DC
RHMFISS/JOINT STAFF WASHINGTON DC
RUCNSAD/SOUTHERN AF DEVELOPMENT COMMUNITY COLLECTIVE
RUEHPH/CDC ATLANTA GA

UNCLAS SECTION 01 OF 06 HARARE 001137 
 
SIPDIS 
AIDAC 
 
AFR/SA FOR ELOKEN, LDOBBINS, BHIRSCH, JHARMON 
OFDA/W FOR KLUU, ACONVERY, LPOWERS, TDENYSENKO 
FFP/W FOR JBORNS, ASINK, LPETERSEN 
PRETORIA FOR HHALE, PDISKIN, SMCNIVEN 
GENEVA FOR NKYLOH 
ROME FOR USUN FODAG FOR RNEWBERG 
BRUSSELS FOR USAID PBROWN 
NEW YORK FOR DMERCADO 
NSC FOR CPRATT 
ATLANTA FOR THANDZEL 
 
E.O.  12958: N/A 
TAGS: EAID EAGR PREL PHUM ZI
SUBJECT:  ZIMBABWE CHOLERA USAID DART HEALTH AND WASH ASSESSMENT 
REPORT 
 
HARARE 00001137  001.2 OF 006 
 
 
------- 
SUMMAY 
------- 
 
¶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. 
 
------------------ 
SITUATION ANALYSIS 
------------------ 
 
¶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 
 
HARARE 00001137  002.2 OF 006 
 
 
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 
percent. 
 
¶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 
date. 
 
¶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. 
 
-------------------- 
USG RESPONSE TO DATE 
-------------------- 
 
¶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. 
 
------------------- 
CLUSTER COODINATION 
------------------- 
 
¶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 
 
HARARE 00001137  003.2 OF 006 
 
 
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 
center. 
 
¶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. 
 
------------------------------ 
SURVEILLENCE AND EARLY WARNING 
------------------------------ 
 
¶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. 
 
¶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. 
 
HARARE 00001137  004.2 OF 006 
 
 
 
-------------- 
WASH SITUATION 
-------------- 
 
¶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. 
 
------------- 
WASH RESPONSE 
------------- 
 
¶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 
necessary. 
 
 
HARARE 00001137  005.2 OF 006 
 
 
--------------- 
CASE MANAGEMENT 
--------------- 
 
¶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 
response. 
 
¶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 
assessment. 
 
------------------ 
SOCIAL MOBILZATION 
------------------ 
 
¶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. 
 
-------------- 
RECOMENDATIONS 
-------------- 
 
¶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 
caseloads. 
 
¶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. 
 
HARARE 00001137  006.2 OF 006 
 
 
 
¶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 
subsides. 
 
¶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.) 
 
DHANANI