The World Health Organization Country Representative in Tanzania, Dr Rufaro Chatora, has just completed a multi-purpose mission which included observation, assessment and support of the cholera outbreak response in Zanzibar.  WHO has been concerned about the persistence of the outbreak in Zanzibar, and hence Dr Chatora’s mission also to strengthening the on-going interventions through high level advocacy so as to bring the outbreak into immediate control.

Zanzibar is a semi-autonomous part of the Untied Republic of Tanzania. It is located 25 to 50 kilometers off the coast of the mainland.  It consists of many small islands and two large ones: Unguja (the main island) and Pemba. The cholera outbreak on the Island started on 19 September 2015.  As at 19 April 2016, it had recorded 3,027 cumulative numbers of cases with 47 deaths accounting to 1.6% case fatality rate.    

During his mission, Dr Chatora had a meeting with the newly elected President of Zanzibar, Dr. Ali Mohamed Shein, in the company of the Island’s Minister of Health, Deputy Minister of Health, Principal Secretary; WHO Liaison Officer for Zanzibar, UNICEF Zanzibar Office Representative, WCO Tanzania National Professional Officers for Diseases Prevention and Control and Health Promotion. He acknowledged to the President the work already undertaken by the Island in managing the outbreak.  He also briefed the President and the Meeting on the Partners views regarding the persistence of the outbreak on the Island and listed priority actions needed to be taken in the coming weeks so as to bring the outbreak into control.

 The priority actions included:

1. Convening responsible Ministers under a multi-sectoral coordination to agree decisive actions covering allocation of human and financial resources, finalizing the Island’s Response Plan with clear roles and responsibilities for each sector critical to the response and repurposing of staff to fill gaps and strengthen the response.

2. Compliance with the Cholera Outbreak Response Guidelines particularly on case management and surveillance.  This requires building requisite capacities for case management, cases line listing and reporting informed by outbreak case definition, and strengthening of IPC measures. 

3. Availability of Safe Water to communities from piped water, deep wells and shallow wells.  There’s a need to ensure piped water is adequately chlorinated at point of source with the required free residual chlorine level at point of use.  Water distributed through bowsers should maintain the minimum required Free Residual Chlorine level, either through chlorination at source or by bulk chlorination at the filling stations. To ensure compliance with WHO standards, water should be periodically tested for FRC.  While chlorination of shallow wells is proved to be ineffective, households should be educated to boil or use water treatment tablets before using the water for drinking purposes.

4. Community engagement being one of the main areas to control cholera transmission, it is critical to ensure communities know what cholera is, how to prevent, and what one need to do if they develop related symptoms.  Done effectively community engage will stop community deaths, will stop late presentation for care, and will stop all the adverse behavioral challenges to the outbreak response. 

5. Proper hygiene and sanitation being key factors in the control of cholera, communities have to be constantly sensitized for constructing and using improved latrines. Personal hygiene, and specifically handwashing, is a message that needs to be consistently communicated. Enforcement of public health by-laws is also critical to prevent and control unhygienic street food vending practices.

The President shared his appreciation of the timeliness and appropriateness of the Dr Chatora’s mission. He acknowledged that the current outbreak is different.

Just during Epidemiological Week 14 April (4-10), Zanzibar reported 142 cases and 4 deaths with most cases coming from Unguja 116 cases and 2 deaths and Pemba had 26 cases and 2 deaths. 

The president called on all actors to urgently join the response efforts by among others supplementing available resources.  He then released Dr Chatora to proceed with mission.

Assessment of the cholera outbreak response resources

In his assessment of the outbreak response resources, Dr Chatora attended a meeting of partners chaired by Principle Secretary (PS).  The meeting addressed government initiatives which included a cholera awareness drive that achieved a distribution of 3000 0000 leaflets and Public Service Announcements aired on TV and Radio. Partners’ material, technical and financial supports were acknowledged. 

 Dr Chatora indicated a need for resourced functional multisectoral approach and structures.  He observed that there is need for specific interventions to deal with some unique cholera transmission chains.  Some of the needed interventions for these chains of transmission are safe water and latrines which can be supported by partners with appropriate resources. The Case Management staff at Cholera Treatment Centers (CTC) should receive the required level of training which include appropriate use of resources and adherence to Infection Prevention Control in CTC.

Support of the cholera outbreak response

During the mission Dr Chatora managed to hand over on behalf of the World Health Organization some commodities for use in the current response efforts.

The commodities were received by the Second Vice President and they included the following items:

1. 4 Packages   – Basic Modules

2. 2 Packages -  IV Sets Modules

3. 60 Cartons – Gloves (S/M/L Sizes) 

4. 80 Cartons – Ringer lactates

5. 10 Pcs – Water Buckets 121 Ltrs each

6. 40 Pcs – Water Buckets 13LTrs each

7. 10 Boxes/Pack of 1000 sachets – ORS 

8. 10 Cartons/Pack of 20,000 Tablets – Water Guards

In concluding his mission the following actions were assured:

1. WHO will deploy Epidemiologist, Case management and WASH experts immediately,

2. WHO to support training of additional health workers to run the CTCs and also follow up cases in the community.

3. WHO to provide financial support for the transport allowance for the deployed staff, including those from other sectors as necessary.

4. UNICEF and WHO to work together on the community cholera prevention component to strengthen Social Mobilization and targeting in distribution of water treatment tablets.

5. WHO to discuss with other Partners on further support with respect to commodities required for Water treatment and Case management as well as additional technical support for case management, surveillance, WASH, etc.

WHO and UNICEF to monitor closely implementation of the recommended actions and undertake joint reviews in two weeks’ time with the MoH.