An outbreak of cholera at the end of 1999 and early January 2000 has affected many of the countries in the southern Africa region. More than two thousand people have been affected and 113 deaths reported. In response to this and the threat of further cholera outbreaks, the Federation has devised a 6 month reduction and prevention strategy to mitigate the impact of the disease in the worst hit countries. The emphasis is on intensive health education and sanitation activities at the village level, including dissemination of public health messages, community training in first aid (focus on diarrhoea diseases), the construction of water points in target villages, participatory construction of village family latrines, hand pump maintenance and community-based management of water points.
Cholera is an endemic disease in southern Africa, particularly affecting Mozambique, Malawi, Zambia and Zimbabwe in recent years. The disease is prevalent from the beginning of the rainy season in October (starting in Mozambique) through to the end of the rains around April. In 1998 and 1999, the number of reported cases was 13,255 and recorded deaths in the four countries identified above totaled over 480.
Cholera becomes common with the onset of the rains, being spread mostly through the water supply and poor sanitation. The absence of safe water, unavailability and use of latrines and inadequate hygiene spreads the disease. The micro-organism that causes cholera transmission usually takes place through the faecal-oral route. Infection is acquired after ingestion of a high number of vibrio cholerae present in water or food. In some areas in the region vibrio cholerae is found in the water that is drunk by the inhabitants. They do not get affected in anyway but people visiting, who do not take precautions to boil the drinking water, can easily contract the disease.
After the peace process in Mozambique, trade and commerce between different neighbouring countries increased significantly, contributing greatly to the movement of people and the present problem of cross border disease transfer. The region as a whole is more vulnerable since national boundaries now represent little obstacle to the spread of cholera. Cholera has again broken out in the southern Africa region in 2000. Zimbabwe reported 955 cases and 51 deaths. Mozambique has recorded 591 cases and 15 deaths. In Malawi, 723 cases have been reported with 19 deaths. Lesotho also reported cholera cases and 28 deaths. The situation in Zambia is a cause for concern because of the influx of refugees from the Congo and the risk that this represents for transmitting the disease across borders.
The Response so far
The various government Ministries of Health in the affected countries have responded by isolating and treating the patients. Their actions have been appropriate in the major urban cities but remain very weak at rural community levels where the major root causes of the problem are lack of access to health education, poor drinking water and sanitation.
In the case of the outbreak of cholera in Zimbabwe, Malawi and Mozambique, the Governments' health budgets are already over spent and cannot meet other health demands, such as the HIV/AIDS pandemic. The resources available to fight the spread of cholera are therefore limited. Cholera treatment camps and health personnel are handling the situation at the urban areas and within certain villages but preventative measures are unable to receive the priority they deserve. The Governments have therefore asked their National Societies for assistance with preventative measures such as health education, sanitation and safe water supply, especially at rural community level, as well as with some supplies such as ORS and tents.
Red Cross/Red Crescent Action
CHF 100,000 has been allocated from the Federation's Disaster Relief Emergency Fund (DREF) to provide National Socieities with the means to immediately respond in the most affected areas, and to initiate the implementation of the planned activities. Because the disease is endemic, the Red Cross Societies' ongoing health programmes play an important role by building in components of health education and water and sanitation as a measure to try to reduce the risk of the disease.
However, extra emergency actions have been or need to be taken by the Zimbabwe, Mozambique and Malawi Red Cross Societies, in consultation with their Governments, and the Federation Regional Delegation in Harare. These include:
- the Regional Delegation sending chlorine tablets to disinfect water supplies to Malawi, Mozambique, Zambia and Zimbabwe Red Cross;
- conducting house to house public education campaign (Mozambique and Zimbabwe RC) and other information dissemination campaigns including use of drama groups (Malawi, Mozambique, Zambia and Zimbabwe);
- distributing ORS (Oral Rehydration Salts) and education about their use (Zimbabwe and Mozambique);
- establishing sentinel and rehydration centres (Mozambique);
- building community and family latrines (Malawi, Mozambique, Zambia and Zimbabwe); and
- establishing safe water points either through digging and protection of wells and drilling boreholes (Malawi, Mozambique, Zambia and Zimbabwe).
The National Societies have worked closely
with other agencies in the past during serious outbreaks, for
example, with MSF in Mozambique.
All plans and activities have been closely coordinated with the authorities, particularly the Ministries of Health in the separate countries, since they see the National Societies as having a clear auxiliary role in assisting in addressing any cholera outbreak.
The Intended Operation
Assessment of Needs
The Zimbabwe Red Cross has made an assessment in Mashonaland West Province and proposed a plan of action for an intervention, that has already started.
Mozambique Red Cross presented a plan of action to respond to the cholera outbreak in the country.
The Malawi Red Cross received a request from their Government for ORS and tents to accommodate cholera cases. The Federation is consulting about further needs.
The assessment for the region is based on experience and the knowledge gained in the past about cholera spreading among vulnerable communities in the region.
Chlorine tablets were distributed in the initial stages of the cholera outbreak in Zimbabwe, Mozambique and Malawi but the need has increased as the rainy season progresses.
In Zimbabwe, the plan of action, based on a successful project carried out in Mudzi District (1999) of Mashonaland East, forecasts the building of 200 family Blair latrines and the rehabilitation of 10 water points in two districts. This will be complemented by an intensive health education programme conducted by trained volunteers of the Zimbabwe Red Cross.
In Mozambique, with serious flooding in large parts of the country, plus in South Africa, over the last week, the cholera risk has been magnified significantly. Some of the urgent needs to address this problem are expected to be met through a separate appeal for assisting these particular flood victims. The Ministry of Health considers the National Society to be the main vehicle for conveying public health messages. The Red Cross health worker volunteer network of some 4,000 people are a key resource for public education and assistance is needed to provide the resources for a sustained campaign.
The Malawi Red Cross will assist government efforts with the provision of 3000 sachets of ORS, 10 tents and mobilisation of trained volunteers to conduct a dissemination programme.
Lesotho Red Cross will assist through their clinics providing health education and diarrhoea treatments.
Anticipated Later Needs
At this stage, the immediate needs in Mashonaland Province of Zimbabwe are known, as are the general requirements based on experience in Mozambique. A plan of action in Malawi largely depends upon the ability of the Federation to provide resources.
It can be reasonably expected that needs will continue to grow during the rest of the rainy season. Based on known and expected needs, this regional appeal will enable the Federation to respond immediately to the request sought from the Zimbabwe Red Cross; to support the Malawi, Mozambique and Lesotho Red Cross Societies to strengthen their responses to the developing situation in their countries; and to be ready to assist other National Societies to combat the disease should there be further outbreaks in the region.
Red Cross Objectives
The objective is to:
- prevent the spread of cholera through
public health education campaigns targeting over 200,000
- provide safe water to 20,000 vulnerable people through provision of 40 water points;
- improve sanitation for 4,000 vulnerable people by providing 500 latrines.
Emergency Phase: February - June 2000
In Zimbabwe, experienced personnel from the 1999 Mudzi Operation have been deployed so that the lessons of last year's project can be applied and integrated into the new project. Provision of 5000 sachets of ORS, 30,000 chlorine tablets, 10 water points and the construction of 200 family latrines is planned.
In Mozambique, the plan is to prioritise the deployment of Red Cross health workers as part of the public health campaign. Also, 5000 sachets of ORS, 60,000 chlorine tablets, 10 water points, and 100 family latrines will be provided.
Plans in Malawi include the provision of 30,000 chlorine tablets, 10 water points, and 100 family latrines. To provide the resources needed at a regional level to respond quickly when there is an outbreak of the disease, there is a need for two cholera kits, 5,000 sachets of ORS, 30,000 chlorine tablets, 250 jerry cans and funds to provide 100 family latrines and 10 water points.
Two regionally recruited personnel will be deployed for six months to assist in coordinating the operation and to give technical back up and support in the public health campaigns and the community based health initiatives.
Phase Two: July - September 2000
During this period, the operation will be concluded and an assessment made to learn lessons for the future. Any measures that can already be taken to strengthen preparedness for the coming rainy season will be taken.
Capacity of the National Society
Most of the Societies in the region already have experience in undertaking operations to address a cholera epidemic. Each of the four Societies that could expect to have the greatest problems in the coming months has a Coordinator of Health and staff engaged in Water and Sanitation activities. Regional resource personnel from other Societies can be deployed for extra Water and Sanitation technical back up and support. The technicians on the regional resource personnel data base received field training in 1999 in methods to combat the spread of cholera.
As has been the practice in the past,
assistance from the Federation will include an integrated institutional
development component to build Red Cross capacity to prevent the spread
of cholera and to strengthen coping skills in the community, partly through
the formation of Red Cross branches where possible. Red Cross branches
and volunteers will be involved in health education and community mobilisation
for the construction of latrines and waterpoints. Branch committees will
be made part of planning, implementation and monitoring of progress. This
will benefit the operation, as they have the local
knowledge, and at the same time this is a learning opportunity for the committees. This requires initial support to strengthen the branches. As the operation is regional and the needs are similar in different countries there will be an exchange of experiences and staff between the National Societies involved.
Present Capacity of the Federation in Southern Africa
The Regional Delegation in Harare will give technical back up and support. It has a Regional Health Delegate and a Regional Water and Sanitation Delegate, plus both a Health Officer and Water and Sanitation Officer. Furthermore, a data base of 25 Water and Sanitation technicians within the Region is maintained and used to deploy experienced personnel when they are needed.
In addition, limited stocks of chlorine tablets are available. These need to be built up, along with reserve cholera kits so that the Delegation is well placed to provide emergency assistance and logistical support. The Regional Delegation has a Finance and Administration Delegate and in February will have a Reporting Delegate to join the team. This will strengthen its accountability functions.
The success of the appeal will be evaluated at its conclusion to determine how best to plan for the next cholera season. Technical evaluations will be conducted for selected interventions (at least one), as has been the practice in the past, to encourage institutional learning.
Under Secretary General,
Disaster Response & Operations Coordination