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Remarks by Dr Henry Madzorera, the Minister of Health and Child Welfare at a press conference on the typhoid outbreak in the City of Harare
Henry Madzorera, Minister of Health and Child Welfare
February 01, 2012

Background

Typhoid is systemic bacterial disease that is characterised by insidious onset of sustained fever, headache, malaise, anorexia, a relative bradycardia, splenomegaly rose spots on the trunk, a non productive cough in the early stages of the illness and constipation of diarrhoea in adults. Many mild atypical infections occur, and the majority of persons in a typhoid endemic or epidemic area may assume a carrier status.

Typhoid used to be a very condition in Zimbabwe. The progressive deterioration of public health infrastructure, (water and sewerage reticulation), have seen such rare diseases like typhoid becoming more commonly encountered within our population. Salmonella Typhi has been isolated in sewerage, and the persistent blockages and sewerage spills have been implicated in the contamination of shallow wells to which urban dwellers resort to because of unreliable and erratic piped water supplies. An outbreak of typhoid occurred in Harare during the first week of February 2010 and affected mostly Mabvuku and Tafara, both of which had suffered chronic piped water supply shortages. Because of similar conditions prevailing elsewhere in Harare, this outbreak then spread to several other suburbs and ultimately in April of the same year.

The current outbreak was first reported in mid October 2011, and again in an area where there had been no water supplies for two weeks, forcing residents to unsafe water from shallow wells. This was in Dzivarasekwa. To date, no deaths and no serious complications have been reported. By the end of December 2011, more than 1 500 cases had been seen and treated, and for 2012 up to the week ending January 22, the ministry has received reports of a cumulative 350 suspected and 16 confirmed cases. An average 30 to 50 cases are reported on a daily basis.

Transmission of Typhoid

The mode of transmission is the faecal-oral route, through ingestion of bacteria in food or water contaminated with faeces or even the urine of infected persons. This happens in conditions of poor sanitation, and poor supply of clean water. In areas where sanitary facilities are well developed and maintained, there has been virtual elimination of typhoid. In this outbreak a number of factors have contributed propagation:

• Unavailability of piped water supplies in the affected suburbs, causing residents to resort to shallow wells; water deprivation at individual and household levels lower basic hygienic standards, because a critical amount of water per individual per day is required to ward off diarrhoeal diseases.
• Food preparation using contaminated and/or reduced amounts of water.
• Unregulated vending of foods, including fish taken out of sewerage contaminated waters, raw fruit, vegetables, poorly refrigerated foods especially chicken, fish, milk and other dairy products promote the efficient transmission of typhoid.

Managing Patients Infected with Typhoid

Following the 2010 typhoid outbreak, the ministry developed Case Management Guidelines and other job aides to assist health workers better manage this previously rare disease. Over 90 percent of patients can be managed at home on oral antibiotics, but close medical follow-up is essential for early detection of complications and possible failure to respond to therapy. This has been done in both outbreaks; supportive treatments, including ORS, intravenous hydration, and antipyretics, have been provided from clinics serving the affected areas. Some of the cases however required hospitalisation due to severity of the illness. A few patients required surgical intervention for intestinal perforation in the 2012 outbreak, but this complication has not been encountered in the current outbreak.

The Ministry of Health and Child Welfare Response to the Typhoid Outbreak

1. The Ministry of Health and Child Welfare receives reports of all notifiable and epidemic prone diseases through the Rapid Disease Notification System, compiles and distributes an electronic Weekly Disease Surveillance Bulletin. The City of Harare has been very consistent in providing updates on the typhoid outbreak to the ministry.

2. Coordination meetings have been convened since end 2011 to discuss immediate, medium and long term measures to address the preventable outbreaks of typhoid and other diarrhoeal diseases. Critical among these is the restoration of water supplies to all currently underserved areas in the City of Harare; with a view to eventually solve the problem of water inadequacy that is causing diarrhoeal diseases and typhoid to persist in the capital city.

3. Health care workers have been trained in typhoid case detection and management, Integrated Disease Surveillance and Response, and Rapid Response to Epidemics, in order to enable early detection and improved case management.

4. The Ministry has led a coordinated response involving the City of Harare's Health Department, local and international partners in the water sanitation and hygiene cluster as well as laboratory confirmation of cases of typhoid.

5. The ministry has strengthened the emergency response framework at national and sub-national levels through training and production of material on dealing with outbreaks.

Control Measures that have been put in place include the following:

• Intensive contact tracing and community messaging in the City of Harare. Other high risk areas have been put on high alert.
• Advocacy for the improvements in the water and sanitation coverage to the whole population, including interim measures such as boreholes to areas with reduced or no reticulation.
• Adequate community education of food preparation, food handling and storage, and improvements in the general individual, family and community hygiene.

This is my message to the people of Zimbabwe:

• Ensure thorough hand washing with soap and running water before food preparation and eating, after using the toilet, handling soiled diapers, bed linen, etc, and ensure good personal hygiene at all times. Use ash in the absence of soap for thorough hand washing.
• Maintain rigorous standards of cleanliness in food preparation and food handling, especially salads and other cold-served foods. It is advisable during this outbreak situation to eat only freshly cooked hot food.
• Make sure to properly refrigerate food where necessary.
• Remember to prepare salt and sugar solution or oral re-hydration salts for anyone with diarrhoea and start giving this while seeking health care.
• Manage refuse at personal, family and community levels, while my ministry collaborates with responsible authorities to come up with lasting solutions to the uncollected garbage heaps.
• Buy food from regulated premises, and if you are a food vendor or food handler, remember to protect your customers by ensuring food safety and that you yourself are free from infectious conditions like typhoid by getting examined.
• As with all deaths due to diarrhoeal disease, health workers must be notified immediately.

Next Steps

• My ministry is in the process of constituting the "National Emergency Operations Centre" to better coordinate the response to this and future outbreak. This will be housed in Kaguvi Building.
• The ministry is sensitising all Zimbabweans on the typhoid outbreak, including its potential to spread beyond Harare. The same poor water and sanitation in Harare prevail in most of our urban areas and other parts of the country. The high mobility of our people also makes it easy for diseases such as typhoid to move with them.
• We will continue population wide and Harare specific messaging and diarrhoeal diseases and other water-borne conditions currently affecting the country.
• We strongly urge treatment of ALL household water by boiling or chlorination with aqua-tablets at the point of use. Most boreholes have been noted to be contaminated with enteric coli forms, and reticulated water has also failed the quality tests in some instances.
• Hand washing at all critical times goes a long way in preventing diarrhoeal diseases and we will continue to promote it.
• There remains a critical need to deal with the underlying causes of these recurrent outbreaks of water borne diseases. To that end we urge government to ensure that resources to refurbish the water, sanitation and sewerage infrastructure are made available as a matter of urgency. This is the most cost effective with the menace of cholera, typhoid, and other diseases spread by the faecal oral route. The latter phrase is just civilised way of saying diseases caused by people eating faeces.
• The local authority must improve the management and collection of litter, a major contributor to contamination of the food being sold by the street vendors.

I would like to take this opportunity to sincerely thank all partners of the Ministry of Health and Child Welfare who continue to assist us measure up to the challenges currently besetting health delivery in the country; notably UNICEF, WHO, CDC, ICRC, MSF, and our very own local National Health Care Trust of Zimbabwe.

I sincerely pray and hope that we will get over this typhoid outbreak soon. Each of us has a role to play and a part to contribute in preventing typhoid and other diarrhoeal diseases. Together we will improve our own conditions of living.

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