Sewage Problems cause Cholera Outbreak in Zimbabwe

Médecins sans Frontières (MSF) is treating people affected by the recent cholera outbreak in the Zimbabwean town of Chitungwiza. The first cases were reported at the beginning of September. At the start, there were between eight and ten patients admitted per day. Today (16 September) the number is under five.

Chitungwiza, a new city of 1.1 million inhabitants and built as a place to live for people who could not find space in Harare in the 1980s, has had insufficient funding for maintenance of its public services. Since before the end of last year the majority of the city's inhabitants have repeatedly faced periods in which they had to do without running water. Apart from causing a lack of access to safe drinking water this also resulted in blocked sewage pipes which eventually burst. Chitungwiza can be considered as one example for the degradation of basic infrastructure in Zimbabwe over the last five years.

In the last three months running water was cut to a number of suburbs forcing people to dig unprotected wells, in order to have water. As people were also unable to flush their toilets, they had to resort to defecating in surrounding fields, because the city by-laws do not allow alternatives such as pit latrines to be built. This mixture of unprotected wells and burst sewer pipes has created an almost "ideal" breeding environment for cholera.

Cholera is water-borne, thrives in unsanitary conditions and is endemic in the rural areas of Zimbabwe during the rainy season from November to March, but it is very rarely seen in urban settings and the dry season. The upcoming rains are therefore expected to only worsen the situation, as excess water effectively "flushes" the standing sewage into unprotected wells.

The first cases of cholera were reported at the beginning of September in Chitungwiza hospital, where MSF normally refers HIV/AIDS patients for tertiary care. The Ministry of Health has since announced that there have been "nine deaths in Chitungwiza" attributed to the disease. The vast majority of patients come from one street in the city, made up of approximately 100 houses, with three or more families living in each household. This could potentially mean that between two and five thousand people are at risk.

In response, the Ministry of Health in collaboration with MSF has set up two Cholera Treatment Centres (CTC); one is located in Chitungwiza Central Hospital, with the other located closer to the affected community as a more decentralized approach is taken. Both were averaging eight to ten new admissions per day, that number has now dropped to below five. In the meantime, an intervention to provide access to clean water has been initiated.

On average 200 people are being screened each day. High HIV rates and generally poor hygienic conditions cause many people to suffer from diarrhoea and seek treatment, which makes case identification difficult. MSF and the City Health Authorities are sharing technical expertise to ensure proper diagnosis. 

MSF are also engaged in other activities in this emergency, including sensitising the affected community to the crisis through our Outreach Teams, working to contain the epidemic and reduce the number of excess infections, ensure access to potable water and advocating for the long term needs of the community.

These are all extensive tasks and MSF has therefore lobbied other actors to engage, with Unicef now trucking water to the community and other NGOs distributing non-food relief items. This has allowed MSF to concentrate more on the medical aspects of the intervention with Environmental Health Teams linking in with the authorities to actively find patients by attending funerals and tracing links to existing cases. It is then hoped that people do not simply die quietly at home, unknowing or unable to access the CTC. MSF disinfection teams are also instrumental in reducing infection rates by chlorinating the households of existing patients, including the disinfection of kitchen utensils, to reduce the risk of family or other household members becoming infected.  

Since the onset of the outbreak the two CTCs have treated over 90 cases of suspected Cholera in the city. Treatment varies dependent on the severity of cases, but generally it is simple re-hydration through Oral Rehydration Salts and Ringer Lactate that will save the majority of lives.

Access to clean potable water in sufficient quantities and a solution to the city's sewage problems now must be found and must be found quickly before the rains start and the problem grows. It is this hunt for the medium and long-term solution that must occupy the authorities time between now and November. MSF is committed to assisting the community in need and will be involved in identifying solutions with all actors on the ground, not only to avert a greater public health crisis in the future, but also to aid in restoring the dignity of this at-risk suburb. 

MSF first started working in Zimbabwe in 2000 addressing nutritional needs. Soon after, in response to the HIV/AIDS crisis, MSF started to run HIV-focused projects. These programmes are being based in Epworth and Gweru, Bulawayo, Tsholotsho, Buhera and Beitbridge. MSF programmes, which are implemented within the Zimbabwean health structures, are ensuring medical care to more than 40.000 HIV-positive patients in Zimbabwe, out of whom more than 22.000 are receiving anti-retroviral (ARV) therapy. MSF-teams are also treating tuberculosis and malnutrition and are addressing emergency health needs, e.g. outbreaks of cholera in 2006 and 2008 and a diarrhoea outbreak in 2007. The most recent outbreak of cholera MSF reacted to happened in spring 2008 in Mashonaland, northeast of Harare.