HP Chabalala\
Emerging and Re-emerging Infectious Diseases
Communicable Disease Control
National Department of Health
Republic of South Africa
27 March - 01 April 2002
1. Background
2. Findings\Interventions
3. Monitoring and Support
4. Laboratory Service
5. Reporting and Surveillance
6. Constraints and Outbreak in Rapetse, Knobel
7. Recommendations
On 08 March 2002, the Limpopo Province reported the first of its cholera patients from villages outside Mokopane [formerly Potgietersrus], and these were Malepeketle, Mosesetjane and Weenen. Patients were admitted at Mokopane and Voortrekker Hospitals and Pholotsi Clinic. The causative agent was identified as Vibrio cholerae, Serotype Ogawa. This district was adversely affected during the previous epidemic before declared closed in July 2001. No fatalities were reported this time, and interventions included house-to-house health education, provision of bleach and purified water and bleach. A temporary rehydration centre [school] was established in the village. Zero reporting and surveillance of diarrhoeal cases played a major role in tracking the epidemic, and the microbial water quality testing helped in singling out water sources as reservoirs the vibrio. Appropriate case management techniques also contributed to zero fatalities in the province. Case management was reported to be according to the guidelines, except that a few cases were given antibiotics.
On 25 March, the Province notified the National Department of Health of the reported and clinically confirmed cases of cholera in Sekonye [Botlokwa]. A local Council Member reported to the Limpopo Health authorities that eight people had died of a mysterious diarrhoeal disease. A few days later, a 72 year old woman died, and was the only confirmed case to have died of cholera at Botlokwa Health Centre.
1.1 Moria and Other Church Gatherings
Annually, the Limpopo Province hosts the largest gathering in Africa, the Moria Easter Conference. Over 3 million Zion Christian Church members visit the two churches in Moria, Boyne. Overcrowding always increases the chances of cholera transmission. It is also the churches tradition to baptise newly converts in life streams. Sanitation also contributes in the spread of cholera if inadequately planned. A rapport had already been established between the Limpopo Department of Health and two churches. It is against this background that Mr Chabalala visited the Limpopo Province to offer support to the Outbreak Response Teams.
2.1 Coordinations
Provincial JOC
- There is a Provincial Joint Operating Committee [JOC], represented by the Provincial and District Health Departments, Water Affairs and Forestry, Public Works, Polokwane Municipality, South African National Defence Force.
- Final preparedness plans on Moria and other church gatherings throughout the province where discuss and finalised on Wednesday, 27 March 2002.
Moria-DOH Collaboration
- A pre-conference assessment on Moria water and sanitation facilities was conducted and a report with recommendation was submitted to the churches' elders for interventions. The two churches have Health Committees.
- The recommendations with regard to water and sanitation, including purifying the baptismal pond were implemented in collaboration between church elders and provincial authorities.
Sekonye Community-DOH Collaboration
- There is a good working relationship between the various stakeholders within the community, e.g. school headmasters, churches, chiefs and indunas, youth groups.
- Outbreak response activities have been going on in Sekonye, and teams were in place to implement intervention in funerals within the village.
2.2 Water and Sanitation
Moria
- Adequate water and sanitation facilities were provided before the beginning of the conference. There are water tanks at strategic positions within the church grounds. Toilet facilities in both churches were satisfactory.
Sekonye-Community
- The Sekonye community obtain its water both from boreholes and community cemented tanks supplying most of the taps. However, an observation was made and it was established that not all taps are working, although generally, water supply is not a problem. Toilet facilities in Sekonye are fairly good and are utilised.
- Water sources were sampled and tested for contamination, but all tests were negative of E. coli, faecal coliform and total coliform, and negative for cholera bacteria.
2.3 Health Education
Moria
- The most important health education messages were communicated to the church elders. A request was made that these messages should be broadcasted from the internal broadcasting stage. Posters and pamphlets were provided to Evelyn Lekganyane Clinic, which supports all church members.
- There is an onsite emergency clinic supported by volunteer doctors, paramedics and nurses, who are church members. The Elders informed the team that a permanent structure would be erected soon.
Sekonye Community
- There are teams of health promoters doing house-to-house health education on prevention and control of cholera. The knowledge of community members, young and old is satisfactory, however change in behaviour is doubtful since there had been no reduction in the number of new cases since 26 March. Poster and pamphlets for public awareness were provided to the public.
- Presentations were made by health educators at the various funerals on proper handling of food, use of toilets and hand washing. Drinking ritualistic and purificatory water was discouraged. Health seeking behaviour was encouraged, by advising community members to visit the clinic or rehydration centre as so as they show any signs and symptoms of cholera.
2.4 Case Management
Moria
- All diarrhoea and vomiting cases seen at the emergency clinic inside Moria were referred to Evelyn Lekganyane Clinic. Complicated and critical cases were referred from Evelyn Lekganyane to Mankweng Hospital. A few diarrhoea cases were seen at the centre inside Moria, however, health workers suspected food poisoning since church members do not have appropriate facilities to store food. These cases were referred to Evelyn Lekganyane for rehydration and later discharged. Case management posters, guidelines, pamphlets and public awareness posters were distributed at Evelyn Lekganyane Clinic.
Sekonye Community
- There is a rehydration centre in a local school in Sekonye. Case management at the centre in through oral rehydration and also intravenously. There is good response and support from community members.
- The use of antibiotics was only on a few cases during the beginning of the epidemic. Supplies for case management are still adequate, and both case management posters and guidelines were distributed in the clinics and health centre.
Both Moria and Sekonye reports all diarrhoeal cases and send the result to the Provincial Office, which forwards the statistics to Pretoria of r confirmation of cholera in the area. Zero reporting of all diarrhoeal cases was emphasised
Outbreak in Rapetse, Knobel
- On 30 March 2002, 7 cases of diarrhoea were reported from Knobel Hospital in Rapetse village.
- The index case is a female that cleaned and dressed the deceased person in Sekonye. The two villages are at least 100km apart form each other
- Antibiotics [Doxycycline, flagyl and bactrin] were use on five of the seven patients; however, clinicians were advised to emphasise rehydration, except in very severe cases.
- Human resource is still a problem in Knobel wards and, however, one team from Sekonye may be deployed to Knobel
- Two rectal swabs were taken on 30 March, but were difficult to extract the vibrio, and additional swabs were taken on 31 March 200. Cholera outbreak was then laboratory confirmed.
- Community structures were met, and a mass will be convened, where volunteers will be mobilised to assist in health education and monitoring.
- There was poor co-ordination and planning in is terms the roles and responsibilities of the official that visited Knobel.
- The hospital personnel were not fully involved, until late during the second day. There were limited human resources mainly due to Easter holidays.
Moria
- Security clearance though necessary, is time consuming, and limits observers from covering all the strategic points within the church and outside
Sekonye
- The source on infection is difficult to identify in Sekonye, but personal and environmental hygiene seem to be the major problem, especially in affected families.
- The impact of health education is still difficult to notice due to the constant flow of patients both to the rehydration centre Botlokwa Health Centre.
- Funerals and the Easter Holiday festivals posed a serious threat to the intervention, since the majority of that infection over the weekend attended the funerals of cholera victims. As a result, more cases should be expected.
- It was reported that there are squatters in a neighbouring village, with people outside South Africa, and the area does not have adequate water and sanitation facilities.
- There are already sporadic cases from the neighbouring villages, which is a good indication that the epidemic may spread fast
Other Gatherings
Moria
- Arrangement should be made with church elders aimed at minimising security clearance with the church security officers since it is time consuming. This cannot be difficult since there is a good working relationship between the church and provincial authorities.
- Planning should be done in consultation with the church volunteers, Evelyn Lekganyane Clinic, Provincial JOC and other relevant stake holders
- A communication system should be established between the two clinics, and other ailments should also be given priority as well, e.g. asthma and epilepsy
Knobel
- In responding to Knobel Outbreak, proper coordination should be in place, and roles and responsibilities of various role players should be clarified, especially within the health department
- A sub-district outbreak response team based at Knobel hospital may be ideal, however, human resources problems should first be addressed
- The Laboratory personnel should always be part of the outbreak response teams in order to facilitate proper sample collection and confirm diagnosis on time
Sekonye
- Interventions should be expanded to the neighbouring villages before the epidemic spreads, e.g. Ramatjowe, Mokomeng. Health education messages on personal and environmental hygiene should be intensified in Sekonye and the neighbouring villages
- The reported "squatter" area must be carefully investigated for any cases of cholera, since the residents are from outside the South African border
- NB: Water and food storage practices should be closely investigated in order to minimise contamination and recontamination of water containers within the households
- The use of antibiotics should be discouraged, except in severe diarrhoea cases, since this complicate case management strategies
Province
Acknowledgement
The National Department of Health would like to acknowledge the Limpopo Provincial Department of Health, the Teams and Health Personnel in Botlokwa, Evelyn Lekganyane, Zion City Moria and Knobel, for having contained the outbreak thus far.