Situational analysis and Community Management of Suspected Cholera Cases, Zimbabwe

Cholera should be suspected when: – a patient older than 5 years develops severe dehydration from acute watery diarrhoea (usually with vomiting); or – any patient above the age of 2 years has acute watery diarrhoea in an area where there is an outbreak of cholera

should be suspected when: – a patient has stools of decreased consistency and increased volume due to imbalance of secretion and absorption of water and salts in the intestine.

Double check on the case definitions. It’s important for communities to be able to distinguish between a simple case of diarrhoea and a potential cholera case. In an outbreak situation, the general practice would be to encourage communities to seek medical opinion for all diarrhoea cases while not being over-elaborate and overwhelm the strained health services with referral of none priority cases.

Current Cholera Situation in Zimbabwe

  • Current outbreak started in Glenview suburb of Harare. On 6 September 2018, a cholera outbreak was declared in Harare by the Ministry of Health, after confirmation of 11 cases for cholera on rapid diagnostic test kits and the clinical presentation of the disease.

What is the current situation?

The Epidemic curve is showing a trend of reduction of new cases presenting at treatment centres or being picked up in the affected communities. The death toll due to the cholera outbreak that has hit Harare and other parts of the country has increased to 28, with more than 3 700 people hospitalised.

Disease spread

The bulk of the cases have been in Harare’s Glenview and Budiriro suburbs which are seriously affected by lack of consistent clean water and proper sanitation systems. Dotted cases have been picked up in Masvingo and Bulawayo. Overally Outbreak Response managed to curb the spread to other cities or suburbs in greater Harare which should be commendable. The Health Promotion Unit has been doing a stella job on the ground in raising awareness in communities and getting the correct message out to the public as there is potential for negative messages going out to the people.

 

Why the Cholera problem?

Cholera is not a problem in developed countries, but it is a major public health problem for developing countries, where outbreaks occur seasonally and are associated with poverty and poor sanitation.

According to the WHO, provision of safe water and sanitation is critical to control the transmission of cholera and other waterborne diseases. Thus the focus in trying to halt the current epidemic should also involve permanent solutions to the provision of proper sanitation for residents of greater Harare at large and in areas of need across Zimbabwe.

How is Cholera Transmitted?

It is almost always transmitted by water or food that has been contaminated by human waste. One common route called faecal-oral route. This is where an individual gets faeces of an infected person on their hands through handshakes or exchange of inanimate objects like cell phones or money and goes on to handle food without washing their hands! This is why hand shaking is discouraged during such epidemics. Also carry hand sanitizers with you always if you can afford one.

Raw or undercooked food and raw fruits and vegetables can also transmit the bacterium! Once the bacterium gets into your stomach, it multiplies rapidly in the small intestine and produces a toxin which causes diarrhoea, massive dehydration, vomiting and eventual death if left untreated. This is why time is of essence when you suspect one may have Cholera. Immediately take them to the nearest medical facility near you while administering oral rehydration salts.

Risk for cholera incidence and recurrence – communities, particularly children exposed to gurgling streams of waste from burst and blocked sewage pipes. Allowing stagnant pools of sewage to collect in front of homes and children playing nearby. Children playing around mounds of piled uncollected refuse. Contaminated shallow wells and boreholes that have since tested positive for cholera.

Symptoms of Cholera.

The primary symptoms of cholera are profuse watery diarrhoea and vomiting. These symptoms usually start suddenly ½ a day to 5-days after ingestion of contaminated food or water. One may also experience pain in the abdomen, severe dehydration and/or lethargy (lack of energy).

Cholera Treatments

Rehydration therapy, meaning prompt restoration of lost fluids and salts through rehydration therapy is the primary goal of treatment. Antibiotic treatment, which reduces fluid requirements and duration of illness, may be indicated in severe cases of cholera.

 

How to protect yourself and others from contracting cholera

Ensure that you consume clean drinking water by boiling it or adding small quantities of sodium hypochlorite (Jik/Waterguard). Follow the safe treatment of water instructions on the container.

 

Avoid takeaway foods from undesignated and unlicensed operators. Wash all fruits under running clean water which you have boiled or treated as indicated above.

 

Always eat food whilst it is still hot and reheat thoroughly any left over food before eating it.

 

Do not defecate outside in bushes leaving your faeces exposed to flies, but use proper latrines. Where this option is not viable then dig a hole deep enough to defecate in and then sprinkle some charcoal and cover thoroughly with soil.

 

Home Management of patient with suspected cholera

Suspected cholera patients in remote areas will likely experience limited or delayed access to health services. To minimise cholera mortality in these settings, communities must be adequately prepared to efficiently/independently manage any suspected cholera cases through the following simple steps.

 

Step 1. Assess for dehydration.

Use Table 1 to determine whether the patient has: – Severe dehydration – Some dehydration – No signs of dehydration. This table must be used as a guide. Immediate notification and referral must be prioritised in a community setting

 

Table 1. Assessment of a cholera patient for dehydration
1. LOOK AT: CONDITION EYES TEARS MOUTH and TONGUE THIRST Well, alert Normal Present Moist Drinks normally, not thirsty *Restless, irritable* Sunken Absent Dry *Thirsty, drinks eagerly* *Lethargic or unconscious; floppy* Very sunken and dry Absent Very dry *Drinks poorly or not able to drink*
2. FEEL: SKIN PINCH Goes back quickly *Goes back slowly* *Goes back very slowly*
3. DECIDE: The patient has NO SIGNS OF DEHYDRATION If the patient has two or more signs, including at least one *sign*, there is SOME DEHYDRATION If the patient has two or more signs, including at least one *sign*, there is SEVERE DEHYDRATION

In adults and children older than 5 years, other *signs* for severe dehydration are *absent radial pulse* and *low blood pressure*. The skin pinch may be less useful in patients with marasmus (severe wasting) or kwashiorkor (severe malnutrition with oedema), or obese patients. Tears are a relevant sign only for infants and young children

Step 2. Rehydrate the patient, and monitor frequently. Then reassess hydration status.

 

FOR SEVERE DEHYDRATION: Refer the patient to hospital immediately for higher management.

 

FOR SOME DEHYDRATION: Administer ORS solution in the amount recommended on Table 2. – If the patient passes watery stools or wants more ORS solution than shown, give more. Monitor the patient frequently to ensure that ORS solution is taken satisfactorily and to detect patients with profuse ongoing diarrhoea who will require closer monitoring.

Table 2. Approximate amount of ORS solution to give in the first 4 hours
Age Less than 4 months 4-11 months 12-23 months 2-4 years 5-14 years 15 years or older
Weight Less than 5 kg 5 kg 5-7.9 kg 8-10.9 kg 11-15.9 kg 16-29.9 kg 30 kg or more
ORS solution in ml 200-400 400-600 600-800 800-1200 1200-2200 2200-4000

Use the patient’s age only when you do not know the weight. The approximate amount of ORS required (in ml) can also be calculated by multiplying the patient’s weight (in kg) times 75

Reassess the patient after 4 hours, using Table 1:

 

– If signs of severe dehydration have appeared (this is rare), rehydrate for severe dehydration, as above.

– If there is still some dehydration, repeat the procedures for some dehydration, and start to offer food and other fluids.

– If there are no signs of dehydration, go on to Step 3 to maintain hydration by replacing ongoing fluid losses.

FOR NO SIGNS OF DEHYDRATION: Patient can self-manage through ORS packets obtained from the clinic or homemade ORS solution. The patient should take the amount of ORS solution as per below

 

Guide: Cholera suspected patient ORS solution volume when no signs of dehydration are present
Age Amount of solution after each loose stool ORS packets needed
Less than 24 months 50 – 100 ml Enough for 500 ml/day
2 – 9 years 100 – 200 ml Enough for 1000 ml/day
10 years or more as much as Enough for 2000 ml/day

 

The suspected cholera patient must be transported to a health facility if any of the following signs develop:

– Increased number of watery stools

– Eating or drinking poorly

– Marked thirst

– Repeated Vomiting or if any signs (fever or blood in stool) indicating other problems develop

 

Step 3. Maintain hydration: replace ongoing fluid losses until diarrhoea stops. When a patient who has been rehydrated with ORS solution is reassessed, and has no signs of dehydration, continue to give ORS solution to maintain normal hydration. The aim is to replace stool losses as they occur with an equivalent amount of ORS solution. As a guide, give the patient:

Age Amount of solution after each loose stool
Less than 24 months 100 ml
2 – 9 years 200 ml
10 years or more as much as wanted

 

Step 4. Refer patient with severe dehydration to health services for further management.

Step 5. Feed the patient.

  • Resume feeding with a normal diet when vomiting has stopped.
  • Continue breast-feeding infants and young children.

What not to do when cholera is suspected!

Do not attempt to self-administer antibiotics of any kind at home without medical prescription as the bacterium is showing signs of resistance to some antibiotics!

Do not use herbs or any natural remedies at home. The use of natural remedies is highly dangerous as there is little evidence to support that they actually work or the side effects of such on a person.

Let professionals treat you, do not take medical advice from unqualified people.

Do not hide cases in homes as they are better off in safe skilled hands of trained people. Hiding ill people not only puts them in further danger of deteriorating health but puts all those around them at risk of contracting the disease as they are not trained to handle such cases. Cholera cases are quarantined not because we fear them but because we want to protect our dear beloved from also falling sick of the same disease.

Last but not least, do not spread medical information on Cholera on social media if you are not qualified to do so. Social media is such a powerful tool in such times and your false or unverified information may end up killing someone. Be responsible on Twitter, Facebook, Instagram and Facebook!

 

Conclusions

Preventive interventions such as breastfeeding and complimentary feeding among infants, improving food safety, water, sanitation and hygiene must be expanded and coverage of other appropriate medical interventions such as Vitamin A & Zinc supplementation accelerated to reduce cholera infections and deaths in Zimbabwe.

In the long term, a health systems and service delivery solution is needed to avoid a recurrence of such outbreaks. We thus call upon the government of Zimbabwe to fulfil its commitment to the Abuja Declaration to which it is a signatory of dating back to 2001. Member nations of the Africa Union, including Zimbabwe pledged to increase their health budget to at least 15% of their national annual budgets. Zimbabwe’s current budget for Health is at 7.7%! The right to health must be prioritised accordingly as reflected through appropriate budgetary allocation.

 

Andrew Manjonjo is a Health Promotion Practitioner, Health activist, Wellness Coach and Weight Trainer and writing in his personal capacity!

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