*4.1.3. Magnitude of the 2008/2009 outbreak and response efforts*

This outbreak, described as the worst the country has ever experienced, resulted in 98,592 cases and 4288 deaths with all provinces, and 60 of the 63 districts in the country affected. The outbreak toll could have been reduced were it not for the lack of resilience in the health system and the adverse macroeconomic and political climate.

notification system (RDNS), the Front line SMS® was adopted for reporting from initial 1200 cell phones procured under the Global Fund using the DHIS 2.1. This system started in 2012 and improved reporting of the weekly disease surveillance system (WDSS) from about 40% to above 90% by 2015, and has maintained timeliness and completeness of the weekly reporting

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The initiative to strengthen Rapid Response Teams (RRTs) started during the cholera outbreak of 2008/2009. Tools for guiding RRTs were developed which included the Guidelines for Rapid Response Teams and training of RRTs at all levels. In 2011 a Compendium for Rapid Response Teams was developed to guide the work of these teams. Cascade training of RRTs was carried out since then and in 2016, following the Harare typhoid outbreak, another training of RRTs from 20 priority districts was carried out, mainly focusing on case management and surveillance. The IDSR technical guidelines and training manuals were revised in 2011 and used for training of health workers at all identified outbreak response levels. However

A number of disease specific guidelines were developed in 2009 and these include guidelines for cholera, typhoid, anthrax and rabies. These were distributed to all health facilities as resource materials for reference and guidance should they meet any of the conditions in their

The UN established the Office of the Coordination of Humanitarian Affairs (OCHA), in 2008 and the cluster system was formed. The main clusters that were formed were the Health Cluster, with WHO as cluster lead, the WASH Cluster, under UNICEF, the Food Cluster (FAO), Education (UNICEF) and Protection (UNHCR and IOM). As Ministry of Health structures were not functional at the time, the Health Cluster established the Cholera Command and Control Centre (C4), which became the response organ and nerve center for the cholera response at the WHO offices located at Parirenyatwa Hospital grounds. Technical experts including clinicians, epidemiologists, water and sanitation specialists, health promotion officers, data managers and administration staff were engaged to work in the C4. A Health Cluster Coordinator post was established and filled. The WHO mobilized experts through global outbreak alert and response network (GOARN), and these experts were from United States, Centers for Disease Control (CDC), International Centre for Diarrheal Disease Research, Bangladesh (ICDDRB), Burnet Institute Australia and SMI Sweden among others. Surveillance centers were strategically established throughout the country, and toll free lines

Cluster Coordination System was established and continued until 2012. The Health Cluster was abolished in 2012, and the Interagency Coordination Committee on Health (IACCH) was re-established, and this coordination system is chaired by the Ministry of Health and Child Care (MOHCC). The C4 brought in the concept of the Public Health Emergency Operations Center (PHEOC) and a room within the MOHCC headquarters was set aside for the purpose. Community health workers who had almost disappeared in the system were resuscitated following strong recommendations from the C4 and the finding that a significant proportion of the 2008/2009 cholera cases and deaths had been in the community. The Village Health Worker (VHW) training curriculum was reviewed, and the training resuscitated. Through

at above 95% from 2015 to 2018 (MOHCC WDSS Reports, 2015–2018).

because of inadequate funding not all identified health workers were trained.

were set up for surveillance and real time data transmission to C4.

areas of work.

The 2008/2009 cholera outbreak came amid repeated calls by all sectors that Harare City Council urgently resolves the dilapidated water and sanitation infrastructure. The outbreak came at a time when the country was experiencing its worst economic downturn when most health institutions were closed down due to unavailability of health workers. Health service delivery was left to non-governmental organizations (NGO). The outbreak response was marred by sluggish response due to several reasons among which were weak health systems and leadership.

Apart from the human resources, the resources required to implement a rapid response where not available at the initial stages of the outbreak because of economic challenges. The harsh economic climate characterized by hyperinflation meant that the common people did not have sufficient funds to get them to the health facility as well as procure the sugar and salt for preparing the oral rehydration solution [20].

## **4.2. The period: 2010–to date**

#### *4.2.1. Building resilience*

The situation gradually improved with the various interventions by the government and donor community realizing that there would be no good implementation of donor supported programs without public sector human resources for health. This led to various schemes to support retention of key health personnel at implementation levels including the creation of human resource retention schemes as part of the Global Fund and the Health Development Fund (then the Health Transition Fund). These schemes improved the availability of medicines and supplies for health including human resources which improved the country's responsiveness to emergencies.

With the support of partners, health commodities called the primary care packages were deployed to the health facilities at a regular basis using an approach called the Zimbabwe Informed Push System (ZIP). This improved the availability of medicines and as soon as the situation stabilized, the National Pharmaceutical Company (Natpharm) was capacitated to resume its role as the national supplier of pharmaceuticals and the distribution of medicines reverted back to the pull system. The pull system is whereby the distribution of medicines by Natpharm is on a quarterly basis in response to orders placed by health facilities. The implementation of the pull system followed an intermediary assisted pull system where the district pharmacists made quarterly visits to health facilities and assisted them in placing orders to Natpharm based on the stock levels.

The health information and surveillance system also improved quite significantly with the introduction of the District Health Information Software (DHIS) version 1.4, and then latter version 2.1. For reporting of outbreaks and other public health events under the rapid disease notification system (RDNS), the Front line SMS® was adopted for reporting from initial 1200 cell phones procured under the Global Fund using the DHIS 2.1. This system started in 2012 and improved reporting of the weekly disease surveillance system (WDSS) from about 40% to above 90% by 2015, and has maintained timeliness and completeness of the weekly reporting at above 95% from 2015 to 2018 (MOHCC WDSS Reports, 2015–2018).

*4.1.3. Magnitude of the 2008/2009 outbreak and response efforts*

system and the adverse macroeconomic and political climate.

for preparing the oral rehydration solution [20].

**4.2. The period: 2010–to date**

responsiveness to emergencies.

Natpharm based on the stock levels.

*4.2.1. Building resilience*

52 Current Issues in Global Health

This outbreak, described as the worst the country has ever experienced, resulted in 98,592 cases and 4288 deaths with all provinces, and 60 of the 63 districts in the country affected. The outbreak toll could have been reduced were it not for the lack of resilience in the health

The 2008/2009 cholera outbreak came amid repeated calls by all sectors that Harare City Council urgently resolves the dilapidated water and sanitation infrastructure. The outbreak came at a time when the country was experiencing its worst economic downturn when most health institutions were closed down due to unavailability of health workers. Health service delivery was left to non-governmental organizations (NGO). The outbreak response was marred by sluggish response due to several reasons among which were weak health systems and leadership.

Apart from the human resources, the resources required to implement a rapid response where not available at the initial stages of the outbreak because of economic challenges. The harsh economic climate characterized by hyperinflation meant that the common people did not have sufficient funds to get them to the health facility as well as procure the sugar and salt

The situation gradually improved with the various interventions by the government and donor community realizing that there would be no good implementation of donor supported programs without public sector human resources for health. This led to various schemes to support retention of key health personnel at implementation levels including the creation of human resource retention schemes as part of the Global Fund and the Health Development Fund (then the Health Transition Fund). These schemes improved the availability of medicines and supplies for health including human resources which improved the country's

With the support of partners, health commodities called the primary care packages were deployed to the health facilities at a regular basis using an approach called the Zimbabwe Informed Push System (ZIP). This improved the availability of medicines and as soon as the situation stabilized, the National Pharmaceutical Company (Natpharm) was capacitated to resume its role as the national supplier of pharmaceuticals and the distribution of medicines reverted back to the pull system. The pull system is whereby the distribution of medicines by Natpharm is on a quarterly basis in response to orders placed by health facilities. The implementation of the pull system followed an intermediary assisted pull system where the district pharmacists made quarterly visits to health facilities and assisted them in placing orders to

The health information and surveillance system also improved quite significantly with the introduction of the District Health Information Software (DHIS) version 1.4, and then latter version 2.1. For reporting of outbreaks and other public health events under the rapid disease The initiative to strengthen Rapid Response Teams (RRTs) started during the cholera outbreak of 2008/2009. Tools for guiding RRTs were developed which included the Guidelines for Rapid Response Teams and training of RRTs at all levels. In 2011 a Compendium for Rapid Response Teams was developed to guide the work of these teams. Cascade training of RRTs was carried out since then and in 2016, following the Harare typhoid outbreak, another training of RRTs from 20 priority districts was carried out, mainly focusing on case management and surveillance. The IDSR technical guidelines and training manuals were revised in 2011 and used for training of health workers at all identified outbreak response levels. However because of inadequate funding not all identified health workers were trained.

A number of disease specific guidelines were developed in 2009 and these include guidelines for cholera, typhoid, anthrax and rabies. These were distributed to all health facilities as resource materials for reference and guidance should they meet any of the conditions in their areas of work.

The UN established the Office of the Coordination of Humanitarian Affairs (OCHA), in 2008 and the cluster system was formed. The main clusters that were formed were the Health Cluster, with WHO as cluster lead, the WASH Cluster, under UNICEF, the Food Cluster (FAO), Education (UNICEF) and Protection (UNHCR and IOM). As Ministry of Health structures were not functional at the time, the Health Cluster established the Cholera Command and Control Centre (C4), which became the response organ and nerve center for the cholera response at the WHO offices located at Parirenyatwa Hospital grounds. Technical experts including clinicians, epidemiologists, water and sanitation specialists, health promotion officers, data managers and administration staff were engaged to work in the C4. A Health Cluster Coordinator post was established and filled. The WHO mobilized experts through global outbreak alert and response network (GOARN), and these experts were from United States, Centers for Disease Control (CDC), International Centre for Diarrheal Disease Research, Bangladesh (ICDDRB), Burnet Institute Australia and SMI Sweden among others. Surveillance centers were strategically established throughout the country, and toll free lines were set up for surveillance and real time data transmission to C4.

Cluster Coordination System was established and continued until 2012. The Health Cluster was abolished in 2012, and the Interagency Coordination Committee on Health (IACCH) was re-established, and this coordination system is chaired by the Ministry of Health and Child Care (MOHCC). The C4 brought in the concept of the Public Health Emergency Operations Center (PHEOC) and a room within the MOHCC headquarters was set aside for the purpose.

Community health workers who had almost disappeared in the system were resuscitated following strong recommendations from the C4 and the finding that a significant proportion of the 2008/2009 cholera cases and deaths had been in the community. The Village Health Worker (VHW) training curriculum was reviewed, and the training resuscitated. Through the support of stakeholders, and using the updated IDSR technical guidelines of 2008, the training has been ongoing since then and the numbers have been increasing steadily, and this greatly improving community health surveillance, awareness and reporting of public health events. Village Health Workers were found very useful in the recent Chegutu cholera outbreak of 2018, supporting in health promotion and surveillance.

responding to the initial cases. The Secretary for Health and Child Welfare sent the Director Epidemiology and Disease Control and Provincial Medical Director (PMD) Masvingo on an urgent directive to plan swift action and ensure adequate control of the Chiredzi cholera outbreak. Following communications with the PMD, the National RRT comprising the Director Epidemiology and Disease Control, Deputy Director Environmental Health, Health Promotion and Laboratory Services, WHO, the Environmental Health Alliance (German Agro Action-GAA and Save the Children-SC), European Civil Protection and Humanitarian Aid Operations (ECHO) and the Masvingo Provincial Health Executive teamed up on a support visit to Chiredzi. The National RRT was joined by the PMD, Provincial Environmental Health Officer, Chiredzi District Health Executive (DHE), Save the Children and Action Against Hunger (ACF). Investigations conducted pointed to an adult female who fell ill on 27th April 2012 with diarrhea and vomiting, and subsequently died at home on the 28th of April, as the index case. This cholera suspect had sought treatment from a traditional healer. She was buried on the 1st of May in her village. The burial was not supervised because cholera had not been suspected. Thereafter cases started presenting at a local health facility, three of them

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The PMD dispatched the provincial RRT to support Chiredzi on 7 May. They investigated, provided supplies and supported the district RRT and the partners on the ground, who had already set up a cholera treatment center (CTC) at the health facility on May 5th. Thereafter there was regular communication between the local, district and provincial teams, and updates to the Provincial Administrator's office. The Chiredzi DHE mobilized one nurse from a mission hospital and three EHTs, one from each of surrounding health institutions, all motorized to boost the staff at health facility receiving cholera patients. The team received support from local partners which included ACF, Save the Children and Plan International. Together they conducted active surveillance, contact tracing, decontamination of infected patients' homes

and conducted participatory health and hygiene trainings for the affected villages.

provided relief. ORT was made available at community level through EHTs and VHWs.

in Chiredzi, Ogawa having dominated in the previous outbreaks.

The district laboratory was supported with consumables to conduct rapid diagnostic tests (RDT), culture and sensitivity tests. Laboratory support for this outbreak was very commendable with results of rapid test conducted as well as culture and sensitivity, and with good correlation between the RDT and culture results. *Vibrio cholerae,* serogroup O1, biotype El Tor, Inaba serotype, was isolated. This was the first time in many years that Inaba has been isolated

Supplies were said to be adequate; diarrhea kits and laboratory consumables were received from the C4 through Save the Children. Some of the supplies were received from ACF and Plan international. The district also had left over supplies from the past outbreaks. A CTC and two Cholera Treatment Units (CTUs) were set up in health facilities in the catchment area. Case management protocols were delivered to the CTC and were used to guide patient management and staff managing patients had received training in cholera, typhoid and dysentery case management. On discharge the patients received health education; IEC materials, aqua tablets, and soap. The staff seconded were initially doubling up the clinic duties and those at the CTC until they were

with a history of having attended this unsupervised burial.

*4.3.1.1. Response measures*

The 2008/2009 cholera outbreak in the country drew a lot of interest from the local and international scenes including journalists, scientists and human rights activists [17–22]. From the documentation on the various themes pertaining to this outbreak the country remains with a wealth of information to learn from and avoid similar situations from happening in the future.

## **4.3. Reaping the results of building resilience: Response to cholera in the aftermath**

It should be noted that during and following the 2008/2009 outbreak many positive steps were taken, including:


As a result of the devastation left by the 2008/2009 outbreak, the affected communities still remember the impact this deadly disease can inflict on them. As a result of this the cooperation of the community in the cholera outbreaks following the 2008/2009 outbreak has been exemplary. We describe some important outbreaks to show how the detection and response has been improved.

#### *4.3.1. Chiredzi cholera outbreak: May 2012*

Chiredzi was the only district which had an outbreak in 2012. This outbreak which, was controlled within one month, remained localized in Chiredzi and resulted in 22 cases and 1 community death. Although the control took longer than the country's target of control within two weeks, the country's efforts to control this outbreak were commendable and the time taken to control the outbreak was much shorter that the 2008/2009 outbreak which took more than six months.

On the 3rd of May 2012 a case of cholera was reported to a RHC in Chiredzi district in a 30 year old man from a village in the communal areas. Thereafter a number of cases were seen mostly from three neighboring villages. The local response was swift in detection, reporting and responding to the initial cases. The Secretary for Health and Child Welfare sent the Director Epidemiology and Disease Control and Provincial Medical Director (PMD) Masvingo on an urgent directive to plan swift action and ensure adequate control of the Chiredzi cholera outbreak. Following communications with the PMD, the National RRT comprising the Director Epidemiology and Disease Control, Deputy Director Environmental Health, Health Promotion and Laboratory Services, WHO, the Environmental Health Alliance (German Agro Action-GAA and Save the Children-SC), European Civil Protection and Humanitarian Aid Operations (ECHO) and the Masvingo Provincial Health Executive teamed up on a support visit to Chiredzi. The National RRT was joined by the PMD, Provincial Environmental Health Officer, Chiredzi District Health Executive (DHE), Save the Children and Action Against Hunger (ACF). Investigations conducted pointed to an adult female who fell ill on 27th April 2012 with diarrhea and vomiting, and subsequently died at home on the 28th of April, as the index case. This cholera suspect had sought treatment from a traditional healer. She was buried on the 1st of May in her village. The burial was not supervised because cholera had not been suspected. Thereafter cases started presenting at a local health facility, three of them with a history of having attended this unsupervised burial.

#### *4.3.1.1. Response measures*

the support of stakeholders, and using the updated IDSR technical guidelines of 2008, the training has been ongoing since then and the numbers have been increasing steadily, and this greatly improving community health surveillance, awareness and reporting of public health events. Village Health Workers were found very useful in the recent Chegutu cholera

The 2008/2009 cholera outbreak in the country drew a lot of interest from the local and international scenes including journalists, scientists and human rights activists [17–22]. From the documentation on the various themes pertaining to this outbreak the country remains with a wealth of information to learn from and avoid similar situations from happening in the future.

It should be noted that during and following the 2008/2009 outbreak many positive steps

• Mobilizing resources for supporting and retaining core health workers through the Global

• Pooling resources for maintaining core health at the primary level through the supply of primary care packages by a mechanism called Zimbabwe Informed Push System.

• Development of key guidelines and training materials for RRTs, IDSR and cholera, typhoid,

• Establishment of the cluster coordination systems and the C4 as a precursor to PHEOC.

As a result of the devastation left by the 2008/2009 outbreak, the affected communities still remember the impact this deadly disease can inflict on them. As a result of this the cooperation of the community in the cholera outbreaks following the 2008/2009 outbreak has been exemplary. We describe some important outbreaks to show how the detection and response

Chiredzi was the only district which had an outbreak in 2012. This outbreak which, was controlled within one month, remained localized in Chiredzi and resulted in 22 cases and 1 community death. Although the control took longer than the country's target of control within two weeks, the country's efforts to control this outbreak were commendable and the time taken to control the outbreak was much shorter that the 2008/2009 outbreak which took

On the 3rd of May 2012 a case of cholera was reported to a RHC in Chiredzi district in a 30 year old man from a village in the communal areas. Thereafter a number of cases were seen mostly from three neighboring villages. The local response was swift in detection, reporting and

**4.3. Reaping the results of building resilience: Response to cholera in the aftermath**

outbreak of 2018, supporting in health promotion and surveillance.

Fund, Health Transition fund and other donors.

anthrax and rabies guidelines which are in use to date.

• Revitalization of the Village Health Worker program.

• Training of core health staff in updated IDSR and rapid response.

were taken, including:

54 Current Issues in Global Health

has been improved.

more than six months.

*4.3.1. Chiredzi cholera outbreak: May 2012*

The PMD dispatched the provincial RRT to support Chiredzi on 7 May. They investigated, provided supplies and supported the district RRT and the partners on the ground, who had already set up a cholera treatment center (CTC) at the health facility on May 5th. Thereafter there was regular communication between the local, district and provincial teams, and updates to the Provincial Administrator's office. The Chiredzi DHE mobilized one nurse from a mission hospital and three EHTs, one from each of surrounding health institutions, all motorized to boost the staff at health facility receiving cholera patients. The team received support from local partners which included ACF, Save the Children and Plan International. Together they conducted active surveillance, contact tracing, decontamination of infected patients' homes and conducted participatory health and hygiene trainings for the affected villages.

Supplies were said to be adequate; diarrhea kits and laboratory consumables were received from the C4 through Save the Children. Some of the supplies were received from ACF and Plan international. The district also had left over supplies from the past outbreaks. A CTC and two Cholera Treatment Units (CTUs) were set up in health facilities in the catchment area. Case management protocols were delivered to the CTC and were used to guide patient management and staff managing patients had received training in cholera, typhoid and dysentery case management. On discharge the patients received health education; IEC materials, aqua tablets, and soap. The staff seconded were initially doubling up the clinic duties and those at the CTC until they were provided relief. ORT was made available at community level through EHTs and VHWs.

The district laboratory was supported with consumables to conduct rapid diagnostic tests (RDT), culture and sensitivity tests. Laboratory support for this outbreak was very commendable with results of rapid test conducted as well as culture and sensitivity, and with good correlation between the RDT and culture results. *Vibrio cholerae,* serogroup O1, biotype El Tor, Inaba serotype, was isolated. This was the first time in many years that Inaba has been isolated in Chiredzi, Ogawa having dominated in the previous outbreaks.

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

the correct course of action in support of actions that had already started. Isolation of patients requiring hospitalization and appropriate rehydration, infection prevention and control in the hospital, safe and dignified burials, water quality monitoring and health promotion activi-

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A follow up visit by the Minister of Health and Child Care was on the 20th of January, teaming up with the local member of parliament and a minister colleague in the president's office, in the company of the WHO Officer In Charge, to provide further support to teams on the ground and assess the evolution of the outbreak. On the 20th of January, the National RRT together with the District RRT worked together with the Civil Protection Committee, chaired by the District Administrator and allocated tasks to teams on the following thematic areas: (i) Coordination, (ii) logistics, (iii) Case management and surveillance, (iv) Health and hygiene promotion (v) Water, Sanitation and hygiene. The teams became immediately operational with coordination meetings taking place twice a day at district level. Community members were trained to participate in contact tracing. A treatment camp was set up to receive patients for diagnosis and treatment. Food premises were inspected and those not meeting minimum health requirements closed. Water quality monitoring was carried out and samples taken for

At National level the IACCH started coordination meetings on a weekly basis with the National RRT having daily coordination meetings. A cholera preparedness and response plan was developed and used to guide the response. Gaps in the response were identified and

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 coordi-

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

filled by the donor community, UN, NGOs and the private sector.

nate actors, surveillance and RRT and, the health system capacity.

in all the outbreaks and their control within reasonable time can be explained.

ties were already ongoing.

testing.

**5. Discussion**
