**5. Discussion**

The district had an average of two nurses manning each RHC. At any one time therefore one was likely to find just one trained nurse as a result of capacity building sessions and workshops being conducted from time to time on the various ministry programs, and at times the nurse aides were left on their own attending to patients. This was the case when the first cholera case presented to the health facility on the 3rd of May. Fortunately the nurse aide had attended to cholera patients during the 2008/2009 outbreak and quickly raised the alarm with

Chegutu cholera outbreak is one of the most recent cholera outbreaks the country faced. This outbreak had the potential to escalate into a massive outbreak because of the prevailing water and sanitation situation in the town, the easy link between the town and the capital, Harare City, which also had worse water and sanitation situation and being a link between the two major cities of the country, Harare and Bulawayo. However because of the built in resilience anchoring on health worker capacity, availability of extension workers, swiftness of response by RRTs and coordination of response through the Civil Protection Committee at district level and IACCH at national level, the outbreak was controlled in 20 days with 106 cases and 4 deaths reported. It should be noted that the four deaths were the alert which occurred before

On the 16th of January 2018, a report was made to the Chegutu District Medical Office of an increase in diarrhea cases at Chegutu Hospital in a male ward in which two cases had died. A follow up visit was made to the male ward and revealed that there were three male cases presenting with watery diarrhea and vomiting. Two deaths had occurred and a stool specimen had been collected from one of the deceased patients and sent to hospital laboratory for culture. The result was received on the 19th of January 2018 confirming *Vibrio cholerae*. The national office was immediately notified on the 19th of January 2018 who also notified WHO

Subsequent investigations revealed that all cases and deaths were associated with a funeral which had occurred in Pfupajena Township of Chegutu on the 8th of January 2018. A visit made to the given address revealed that the deceased (index case) had reported for treatment suffering from diarrhea and vomiting at a local private clinic before her death on the same day. The daughter to the index case also reported for treatment at Chegutu hospital on the 9th of January 2018 where she was admitted and discharged on the 11th. A stool specimen was

It was further established that there was a funeral which occurred on the 29th of December 2017 in the same neighborhood which was attended by two relatives from Zambia (Zambia was at the time experiencing a cholera outbreak). Among those who attended the funeral were members of a religious group who later visited the index case. It is highly possible that the source of infection could have been from those who came from Zambia who could have

On notification of the national office, the Minister of Health and Child Care immediately visited the area together with members of the National RRT to assess the situation and advise on

the district, resulting in the swift outbreak response that ensued.

*4.3.2. Chegutu cholera outbreak 2018*

56 Current Issues in Global Health

the outbreak was detected.

on the 22nd of January.

been healthy carriers.

collected and the results were negative.

Among the major issues we single out as having been strengthened over the years are the political commitment, multisectoral engagement, capacity to harness resources and coordinate actors, surveillance and RRT and, the health system capacity.

Political commitment is evidenced by the personal involvement of the Minister and other senior MOHCC staff, provincial and district health leadership. The role of political commitment in implementation of health programs is emphasized in literature and indeed effective institutionalization of cholera control measures has been reported in Mexico following the recognition of cholera as a national security problem [27]. The central role of high level political commitment in instituting rapid response measures and mobilization of resources is underscored [27]. Leadership at high level is a necessity for the response if properly managed, but in situations where it is not properly managed [28] it may lead to conflicts among workers in the field thereby delaying the implementation of activities and allowing the prolonged progression of the outbreak. Liberia offers a good example of proper coordination of response with high political leadership during the Ebola outbreak [29]. In the Zimbabwe cholera outbreak of 2008–2009, the failure by the political leadership to accept that a cholera outbreak was brewing led to delays in the response allowing uncontrolled continued infection and the resultant mortality. In years after 2008/2009 outbreak, political leadership has been prominent in all the outbreaks and their control within reasonable time can be explained.

We also note the importance of multisectoral engagement in emergency response and in particular, these reported recent cholera outbreaks. Multisectoral engagement is observed in the name of the cluster system during the cholera outbreak of 2008/2009, the civil protection committees at various levels led by the ministry of local government and the IACCH, all for the purposes of streamlining and coordinating the response. The success of controlling the cholera outbreaks is built upon functional multisectoral engagement. The Global Task Force on Cholera Control's Ending Cholera—A Global roadmap to 2030, recognizes multisectoral engagement as one of the three key axis for cholera control [30]. The key cholera drivers are largely known and most of them are outside the health sector. The tools for prevention and control of cholera outbreaks are also known to work and anchor on improving access to clean water and improving sanitation, improving community awareness and hygiene practices including the hand washing [10–13]. The health sector is mainly responsible for responding to outbreaks in terms of case management and surveillance. The requirement of multisectoral engagement becomes more important realizing the limitations of the health sector in cholera prevention efforts.

country faced [3]. Furthermore, surveillance is a key requirement for epidemic detection and control. Zimbabwe has registered improvement in this area and has built capacity for real time reporting. This has enabled fast detection and response to outbreaks. Capacitation of health workers in IDSR has improved their interpretation and use of data at local level.

Responding to Cholera Outbreaks in Zimbabwe: Building Resilience over Time

http://dx.doi.org/10.5772/intechopen.79794

59

Emergencies and in particular outbreaks of infectious hazards remain a global concern. The IHR (2005) together with other guiding documents on specific themes on emergency preparedness and response remain available to guide countries in building capacities for emergency preparedness and response. The capacity of countries to mount adequate response to control emergencies depend on the resilience of their health systems build upon organizational, community and individual resilience and to a large extent dependent health systems

Zimbabwe having gone through a period of economic difficulties, faced one of its worst ever cholera outbreaks, which resulted in high rates of infection and deaths. This being said the country managed to use this event as a stepping stone which has resulted in the country building resilience to mount adequate response to outbreaks in the recent years. Understandably, resilience is not an all or none event but a process with levels of attributes, and Zimbabwe continues to work towards achieving all resilience attributes. Other countries can learn from

The authors would like to appreciate all who made this work possible, which include but not limited to the Ministry of Health and Child Care, WHO Country office staff, UNICEF, and

This work was conceived by Dr. Juliet Nabyonga-Orem when she was Officer in Charge of WHO Country Office in Zimbabwe having observed with appreciation the country's response

to the cholera outbreak which occurred in Chegutu district starting in January 2018.

institutional capacities as defined by the WHO health systems building blocks.

**6. Conclusion**

Zimbabwe's experience to build resilience.

**Notes/Thanks/Other declarations**

**Acknowledgements**

MSF offices in Zimbabwe.

**Conflict of interest**

None declared.

Over the years Zimbabwe has witnessed rapid response to, and reducing case fatality rates from, cholera. The investments made over the years to strengthen the health system partly explain this phenomenon given the fact that the cholera case fatality rate reflects the access to basic health care [31]. Availability of HRH, strengthened surveillance and improved availability of basic commodities have been realized over the years. The per capita expenditure on health increased from \$9 in 2009 to \$24 in 2015. Regarding retention of health workers, average in-post rate stands at 81% [32]. Indeed the Ebola viral diseases outbreak in West Africa brought to the fore the central role of strengthened health systems in responding to diseases outbreaks [3, 4, 33].

The presence of skilled rapid response teams, especially following the scale up of training following the 2008/2009 cholera outbreaks, as well as the recent training sessions in response to the typhoid outbreaks in Harare, has improved the capacity of health workers to manage epidemics. Health worker capacity for rapid detection and swift control of outbreaks is essential in emergency preparedness and response [34]. RRTs which are multidisciplinary teams ensure this takes place and where they are functional this has led to reduced mortality and shortened period for control [35]. The timing of activation of RRTs is also important for good outcome for delayed activation may also lead to increased mortality.

Correct information is necessary for the communities to take appropriate action to prevent infection or to get immediate assistance when they get infected [36, 37]. The sustained information dissemination through the district structures made the people**'s** perception of risk remain high and to quickly adopt responsible behaviors as advised. Majority of the population anywhere in Zimbabwe still remember and reminisce the events of 2008/2009 which left them devastated and hence are very responsive to behavior change communication messages. Lessons from the field show us that when inadequate information is given it may lead to information gaps allowing unorthodox sources to lead with misinformation resulting in panic or inappropriate actions [3]. On the other hand clear information dissemination on a regular basis from trusted sources has led to communities taking part in the response measures leading to rapid containment of epidemics as reported in Uganda during an EVD outbreak the country faced [3]. Furthermore, surveillance is a key requirement for epidemic detection and control. Zimbabwe has registered improvement in this area and has built capacity for real time reporting. This has enabled fast detection and response to outbreaks. Capacitation of health workers in IDSR has improved their interpretation and use of data at local level.
