VZCZCXRO9122
OO RUEHBZ RUEHDU RUEHJO RUEHMR RUEHRN
DE RUEHSB #0046/01 0161551
ZNR UUUUU ZZH
O 161551Z JAN 09
FM AMEMBASSY HARARE
TO RUEHC/SECSTATE WASHDC IMMEDIATE 3942
RUEHSA/AMEMBASSY PRETORIA IMMEDIATE 5624
INFO RUCNSAD/SOUTHERN AF DEVELOPMENT COMMUNITY COLLECTIVE
RUEHGV/USMISSION GENEVA 1846
RUCNDT/USMISSION USUN NEW YORK 1975
RUEHRN/USMISSION UN ROME
RUEHBS/USEU BRUSSELS
RHEHAAA/NSC WASHDC
RUEKJCS/SECDEF WASHDC
RHMFISS/JOINT STAFF WASHDC

UNCLAS SECTION 01 OF 04 HARARE 000046 
 
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 
 
E.O.  12958: N/A 
TAGS: EAID TBIO EAGR PREL PHUM PGOV ZI
SUBJECT:  ZIMBABWE CHOLERA - USAID/DART HEALTH COORDINATION UPDATE 
 
REF: 08 HARARE 1137 
 
HARARE 00000046  001.2 OF 004 
 
 
------- 
SUMMARY 
------- 
 
¶1. The USAID Disaster Assistance Response Team (USAID/DART) has been 
working closely with the team from the UN World Health Organization 
(WHO) and humanitarian partners to improve coordination, set up the 
cholera command-and-control center, and implement cholera response 
activities at the field level.  The USAID/DART health specialist 
worked with WHO and the UN Children's Fund (UNICEF) headquarters 
office staff in early December (REFTEL) to ensure that the inputs 
and actions for the center were put in place and has been following 
the progress to date. 
 
¶2. The command-and-control center was meant to be a technical arm 
that would provide standards and guidelines, technical assistance, 
and capacity building to the health and water, sanitation, and 
hygiene (WASH) clusters to ensure sound implementation of activities 
by implementing partners.  The center provides support in areas 
including overall coordination and strategic guidance, cholera 
surveillance and early warning alerts, case management, social 
mobilization and behavior change, WASH and infection control, 
logistics and supply management, and media outreach.  Each area will 
be represented by an expert in the center who will work with 
partners on specific technical issues.  The center's structure will 
be decentralized to at least the provincial level. 
 
¶3. There have been significant improvements since the beginning of 
December in coordination, surveillance, case management, social 
mobilization, and logistics.  However, there are still challenges 
regarding a lack of human resources, logistics coordination, and 
community-level interventions.  The case fatality rate (CFR) for 
cholera is still high and the impact of the command-and-control 
center needs to be closely monitored.  The arrival of a six-person 
team from the International Center for Diarrheal Disease Research - 
Bangladesh (ICDDRB), improved partner coordination and rapid 
response, and the increased prioritization of social mobilization 
and behavior change at the community level should help to address 
the high CFR.  END SUMMARY. 
 
--------------------- 
EPIDEMIOLOGIC UPDATE 
--------------------- 
 
¶4. As of January 14, the cholera outbreak had caused 2,201 deaths, 
with nearly 42,000 cases reported, and a case fatality rate (CFR) of 
5.2 percent, according to the UN World Health Organization (WHO). 
Approximately 56 percent of the deaths have occurred outside of 
health facilities, likely indicating a continued lack of access to 
treatment or lack of prevention and mitigation measures in at least 
some affected areas. 
 
¶5. According to the most recent WHO epidemiological bulletin, 
covering the period from January 4 to January 10, the cholera 
outbreak remained uncontrolled.  The CFR increased to 5.9 percent 
for the week, similar to the weekly CFR from two weeks before, after 
falling dramatically during the previous week due to lack of 
reporting over the holiday period.  WHO reported an average of 39 
deaths and 656 new cases per day over the week covered.  During the 
week of January 4 to 10, Mashonaland West Province reported 
approximately one third of the new cholera cases for the country. 
 
------------- 
COORDINATION 
------------- 
 
¶6. A trained health cluster coordinator has been deployed to 
coordinate the health implementing partners and the WASH cluster to 
ensure a link between the cholera command-and-control center, 
implementing partners, and the Ministry of Health and Child Welfare 
(MOHCW).  The center is jointly led by an international strategic 
 
HARARE 00000046  002.2 OF 004 
 
 
technical coordinator recruited by WHO, responsible for daily 
operations and technical support, and a WHO national staff member 
responsible for overall management of the center and resolving 
policy issues with the MOHCW.  The center is now located in WHO 
offices in Parirenyatwa national hospital, having moved from the 
main WHO offices on the outskirts of town.  The hospital is much 
closer to humanitarian organizations and government agencies.  A WHO 
senior staff member from Geneva will be arriving this week to 
monitor progress of the cholera command-and-control center. 
 
¶7. The health and WASH clusters are now holding a weekly joint 
meeting on the cholera response in the same building as the center, 
as well as separate technical working group meetings.  The January 
14 joint meeting was well attended, including representatives from 
the MOHCW and the Zimbabwe National Water Authority.  Health and 
WASH coordination has improved with the deployment of an experienced 
health cluster coordinator. 
 
¶8. The health and WASH clusters are helping to ensure field-level 
coordination of partners with provincial and district MOHCW staff. 
At the January 14 cholera response meeting, the cluster coordinators 
circulated a draft matrix of organizations that have volunteered to 
serve as district-level cholera response focal points.  The majority 
of the organizations have WASH-focused programming, but the 
coordinators requested that these staff also cover health issues due 
to the small number of health-focused organizations. 
 
-------------------- 
DISEASE SURVEILLANCE 
-------------------- 
 
¶9. The center was first staffed by WHO epidemiologists funded by 
USAID's Office of U.S. Foreign Disaster Assistance (USAID/OFDA), 
followed by epidemiologists recruited through the WHO Global 
Outbreak Alert and Response Network (GOARN).  The epidemiologists 
have significantly improved the data collection and alert system. 
The daily cholera updates now include information on daily case 
numbers and trends, newly affected areas, lags in reporting, and a 
cumulative chart of epidemiologic data.  The reports also include 
actions that have been taken and high priority areas requiring 
follow up due to high CFRs, community deaths reported, new cases 
reported, or a lack of recent reporting.  Working with the WHO data 
managers, the center produces a weekly epidemiological report with 
summary data and trend analysis.  Replacements for the current staff 
have already been identified through GOARN to ensure continuity in 
the center. 
 
¶10. In order to improve information gathering from the district 
level as well as from hard-to-reach areas, WHO has set up three toll 
free reporting numbers.  WHO has sent a technical team to the areas 
not covered by cell phone networks to set up a radio system.  The 
cholera command-and-control center has produced a joint assessment 
tool for data collection, combining the health and WASH cluster data 
entry forms.  The tool can also be used as a basis for standardized 
monitoring. 
 
¶11. Many of the cases and deaths continue to occur outside of health 
facilities, requiring additional work to improve community-level 
reporting and active case finding.  Cholera treatment center (CTC) 
staff often do not follow case definition guidelines, and patients 
may seek care for other illnesses at the CTC, often the only health 
services available.  In such cases, some of the reported cases and 
deaths may not be from cholera, but from other diseases including 
HIV/AIDS. 
 
--------------- 
CASE MANAGEMENT 
--------------- 
 
¶12. Difficulties with standardized case management at the CTCs 
remain.  Overuse of intravenous fluids and haphazard use of oral 
rehydration salts (ORS) can lead to supply shortages.  As much of 
the focus has been on CTCs, the community level has not received 
 
HARARE 00000046  003.2 OF 004 
 
 
enough attention, leading to an under-use of ORS and a lack of 
active case finding and referral of severe cases.  A six-member 
ICDDRB team is now working in the cholera command-and-control 
center.  The USAID/DART will monitor the team's impact following 
deployment to the provincial level.  The ICDDRB team leader will 
remain in the center to liaise with the implementing partners for 
strategic guidance. 
 
¶13. In a presentation at the January 14 cholera response meeting, 
the ICDDRB team noted increased staffing levels, staff training, and 
staff motivation as the key components in an effective cholera 
response.  The ICDDRB team also handed out CDs with cholera 
prevention training modules to all organizations participating in 
the meeting.  The CDs were shipped to Harare by USAID/OFDA.  Human 
resources remains a major issue, and a retention scheme for health 
workers funded by the UK Department for International Development 
(DFID) has recently started in Harare and will start in other 
provinces in the near future.  The European Commission is also 
providing support for health staff retention. 
 
----- 
WASH 
----- 
 
¶14. The WASH cluster will assign two staff members to the cholera 
command-and-control center to provide technical advice and response 
actions to outbreak alerts and to link the health and WASH 
activities more closely.  WHO WASH staff will monitor WASH and 
infection control activities at the CTCs.  The WASH cluster is 
examining WASH requirements at schools to prepare a response for 
potential outbreaks once the term resumes, currently delayed until 
January 27.  The WASH cluster will provide the education cluster 
with WASH guidelines.  The USAID/OFDA WASH Specialist will conduct a 
follow-up assessment in the coming weeks to provide additional 
details. 
 
---------------------------------------- 
SOCIAL MOBILIZATION AND BEHAVIOR CHANGE 
---------------------------------------- 
 
¶15. Social mobilization activities are one of the most important 
components of epidemic response.  The health and WASH clusters will 
coordinate efforts in hygiene promotion, health education, active 
case finding and reporting, home-based care and feeding practices, 
health care seeking behavior and the provision of supplies including 
ORS, aquatabs, water containers, soap, and information, education, 
and communication materials. 
 
¶16. The cholera command-and-control center social mobilization 
technical advisor has been working with partners to consolidate IEC 
materials, develop a strategy and assemble a package for community 
health workers and hygiene promoters, as well as map the 
availability of various community-based volunteers and health 
workers. 
 
¶17. The technical advisor is also working to provide guidance for 
hygiene promotion and infection control for large gatherings such as 
funerals.  A MOHCW representative noted that the ministry plans to 
train community volunteers to monitor large gatherings in the 
absence of environmental health technicians.  Approximately half of 
the environmental health technician positions countrywide are 
currently vacant. 
 
¶18. Before the arrival of the technical advisor, social mobilization 
activities focused primarily on mass media campaigns without a 
robust effort to develop a community-level component.  However, many 
questions concerning what behaviors are leading to increased 
transmission of cholera and a high CFR need to be further examined. 
The International Federation of Red Cross and Red Crescent Societies 
has mobilized resources that could improve the implementation of 
behavior change activities at the community level, including seven 
international emergency teams focusing on health, WASH, and social 
mobilization.  As a significant donor in the cholera response, 
 
HARARE 00000046  004.2 OF 004 
 
 
USAID/OFDA's main focus has been on community mobilization and 
behavior change, so progress by the cholera command-and-control 
center is welcome.  USAID/OFDA partners are focused on social 
mobilization but need additional technical guidance. 
 
---------- 
LOGISTICS 
---------- 
 
¶19. A WHO logistician to be based in the command-and-control center 
has arrived in Zimbabwe and will be working with partners and the 
National Pharmaceutical Company of Zimbabwe to ensure availability 
and access to supplies.  The logistician will monitor issues such as 
stock management, distribution, transport management, 
communications, and gaps in supply chain of medical supplies.  WHO 
recently signed an MOU with the UN World Food Program, the lead for 
the logistics cluster, to ensure transportation of cholera 
prevention supplies to the district level.  Logistics coordination 
continues to be an issue, which was exacerbated by a gap in the 
staffing of the logistics coordination position. 
 
---------- 
CONCLUSION 
---------- 
 
¶20. Although the cholera command-and-control center is functioning, 
there are still constraints in logistics coordination, human 
resources, and community-level interventions.  Donors such as DFID 
and European Community Humanitarian Aid Office, along with 
USAID/OFDA, should continue to coordinate efforts to ensure close 
cooperation between the health and WASH clusters and monitor 
continued operations of the center.  This includes helping the 
health and WASH clusters to better coordinate efforts, advocating 
for strong and clear leadership of the command-and-control center, 
and working to ensure that the ICDDRB team is allowed to effectively 
work at the provincial level.  Donors should also help to ensure 
that the social mobilization and behavior change response is 
technically sound and that there is an adequate gap analysis and 
provision of resources.  If required by partners, support may be 
necessary for further assessments or studies of data quality 
regarding reported cholera cases and deaths in health facilities and 
communities, as well as further investigation into key behaviors to 
prevent cholera transmission and reduce mortality. 
 
MCGEE