On September 11, Zimbabwe’s health minister declared a State of Emergency after an outbreak of cholera killed 21 people and sickened a total of 3,067, primarily in Harare, Zimbabwe’s capital city. Recent deaths include 2 schoolchildren and a headmaster in a poor suburb of Harare. On September 12, cholera cases were reported outside the capital, prompting the UN to call the situation “very dire.” On September 13, the WHO regional office for Africa (AFRO) announced it was working with the Ministry of Health to strengthen coordination for the response, including providing “cholera kits” containing oral rehydration solution and establishing a “cholera surge team” of international and national experts.

Zimbabwe’s newly appointed Minister of Health pointed to “poor water supply, blocked sewers, and a failure to collect waste” as factors responsible for the ongoing cholera outbreak as well as outbreaks of other waterborne diseases, such as typhoid. AFRO states that the epicenter of the outbreak, a dense suburb of Harare with a highly mobile population, is vulnerable to cholera due to inadequate supplies of safe, piped water, leading residents to utilize alternative water sources, such as wells and boreholes.  

While small outbreaks of cholera occur annually in Zimbabwe, this represents the largest cholera outbreak in the country since the devastating 2008-09 outbreak, which led to approximately 100,000 cases and 4,000 deaths nationwide, Africa’s largest cholera outbreak on record. The current outbreak poses an early test for Zimbabwe’s new government, which recently took office following elections in July. The elections were scheduled as a result of the ouster of longtime Prime Minister and President Robert Mugabe in November, after 37 years in power. The Ministry of Health has taken dramatic steps to contain the outbreak, including closing schools in affected areas and banning public gatherings. Below we explore Zimbabwe’s recent struggle with cholera and role these social distancing measures might play in responding to cholera.

Africa’s cholera crisis

Cholera is a waterborne illness caused by ingestion of food or water contaminated with the Vibrio cholerae bacterium, which is typically spread via the feces of an infected person. The WHO has called cholera “a disease of inequity” because it is commonly found in war-torn or poverty-stricken environments with limited access to clean drinking water and hygiene and sanitation services. Symptoms of cholera include diarrhea and vomiting, and it can lead to rapid loss of bodily fluids and death, if not properly treated by rehydration therapy.

Cholera, which has largely been eliminated from the developed world, remains a significant cause of morbidity and mortality in sub-Saharan Africa, among other places. Between 1970 and 2011, African countries reported more than 3 million suspected cholera cases to the WHO, representing 46% of global cases during that period. The case fatality for cholera in Africa is approximately 2% (compared to the global average of 1.8%), and it has held relatively steady in recent years as the global trend is in decline.

In August, African health ministers pledged to end cholera on the continent by 2030 by adopting a new WHO strategic framework. Approximately 3.5 million doses of oral cholera vaccine are being deployed in 2018 to African countries—including Nigeria, Malawi, and Zambia—as part of a massive vaccination campaign implemented by the WHO and funded by GAVI. According to AFRO, the government of Zimbabwe is currently assessing the benefits of conducting an oral cholera vaccination campaign in the country, and the WHO is deploying a vaccine expert to Harare.

Recent cholera outbreaks in Zimbabwe

The WHO notes that cholera outbreaks “have become more frequent” in Zimbabwe since the early 1990s. With the exception of large outbreaks in 1999, 2002, and 2008, however, prevention and preparedness activities have largely kept the disease under control. Zimbabwe reported its largest and deadliest cholera outbreak in 2008-09, with 98,424 cases and 4,276 deaths. This outbreak was exacerbated by “the near-collapse of the country’s water and sanitation infrastructure,” which dramatically reduced public access to clean water and sanitation facilities.

The decline of Zimbabwe's water infrastructure has been linked to a variety of factors, including nationalization of the country's water system in 2005 and severe inflation and economic collapse in 2008. In addition, Human Rights Watch reports that human rights abuses, corruption, and mismanagement at the local and national levels of government also played a role in generating the conditions conducive to cholera’s spread.

While the new, post-Mugabe government is under intense pressure to respond to the cholera outbreak, its commitment to doing so has been called into question by political rivals, civil society groups, and members of the public. The Zimbabwean Association of Doctors for Human Rights said it was deeply concerned that the government has not moved swiftly enough or allocated enough resources to tackle the outbreak. It has urged the government to appoint an inclusive task force comprising members of the government, civil society, and local residents to develop a comprehensive plan to contain the outbreak. A pro-democracy group, the Platform for Youth Development, believes politicians are “more worried about consolidating power” than devoting resources to fighting the outbreak.  

Anti-cholera measures: what works?

AFRO states that it is working with the Zimbabwe Ministry of Health to implement steps to contain the outbreak, including rapidly expanding access to clean drinking water, decontaminating unsafe water supplies, and establishing cholera treatment centers in affected communities. As part of its State of Emergency declaration, Zimbabwe officials implemented a ban on public gatherings in Harare, including a major political rally scheduled for Saturday. The control measures also closed illegal food vendors and suspended schools to reduce opportunities for disease transmission.

Despite these measures, the WHO does not specifically recommend the use of social distancing or other movement restrictions to contain cholera. For example,WHO guidance indicates that restrictions on travel and trade within different regions of a country should be avoided, “as they have been proven ineffective, costly, and counter-productive.”

Similarly, while the non-profit organization Oxfam acknowledges in its cholera outbreak guidelines that communal gathering places—such as marketplaces, weddings, and funerals—can play a role in spreading cholera, it does not recommend suspending or banning these gatherings altogether. According to Oxfam, exceptions to this guidance may include the closing of certain eateries or food vendors that have been identified as a source of cholera transmission. Additionally, temporarily closing or repurposing of schools to conduct public education interventions and risk messaging can promote social mobilization against cholera.

Local news sources reported that Zimbabwe officials have directed that cholera victims be buried locally in Harare as a way to prevent spread of the disease to other areas. Traditionally, bodies in Zimbabwe are buried in the deceased person’s home village, which can result in victims’ bodies being transported out of the city to a variety of rural areas. Some residents are reportedly defying this directive by burying bodies in unapproved locations. The corpses of cholera patients are highly infectious via contact with bodily fluids, and the US CDC observes that “localized [cholera] outbreaks have been associated with funeral gatherings.” UNICEF similarly notes in its funeral guidelines for cholera [download] that funerals “can contribute to the spread of the epidemic.” Neither the CDC nor UNICEF, however, recommend restrictions on burial locations, instead highlighting the need to promote safe handling practices for the deceased, including use of gloves, disinfection of the corpse, and frequent handwashing.

Conclusion

This is the country’s largest cholera outbreak in the past decade, and the rapid acceleration in cases raises the possibility of a repeat of the devastating 2008-09 cholera epidemic. The outbreak comes at a crucial moment in Zimbabwe’s political transition, representing an early test of the new government’s ability to provide public services in the post-Mugabe era. So far, the government has taken aggressive measures to contain the outbreak, including banning communal gatherings in Harare, suspending schools in affected areas, and prohibiting the burial of cholera victims outside city limits.

Guidance from international organizations and humanitarian agencies suggests that some of these social distancing measures may not be productive. Alongside the WHO and its international partners, the Zimbabwe government will need to pursue effective, evidence-supported response activities in order to quickly control the growing outbreak. These include providing life-saving rehydration therapy, disinfecting contaminated water supplies, promoting hygiene and handwashing, and implementing safe burial practices. Ultimately, improving infrastructure—including the healthcare, water, and sanitation systems—will be critical to preventing and mitigating future outbreaks and moving toward the goal of eliminating cholera from the continent.

Photo: A cholera treatment station, comprising beds for patients, disinfection supplies, and buckets for different types of waste, is set up as part of the response to Zimbabwe’s 2008-09 cholera outbreak. Photo courtesy of Flickr user Teseum.

Outbreak Observatory aims to collect information on challenges and solutions associated with outbreak response and share it broadly to allow others to learn from these experiences in order to improve global outbreak response capabilities.