BACKGROUND
On 05 May 2003 the Mpumalanga Communicable Disease Control Coordinator reported five confirmed cases of cholera to the National Department of Health. However, the extent of the outbreak was not known until a comprehensive report was request from the province and this was received on 08 May 2003.
CURRENT STATUS
Epidemiology
The first case was admitted at Tonga hospital on 26 April 2003. National Outbreak Response Team was never informed as soon as the case was diagnosed, nor the notification system at national level received any entry on the case. On 8 May 2003, the province reported 75 suspected cases that were seen at Tonga hospital, of which 19 tested positive for Vibrio cholerae, and the rest tested negative.
The affected area is within Nkomazi Municipal area, Ehlanzeni District, Tonga sub-district. Three deaths were reported of which the one confirmed death was a two year old baby, and the laboratory results for the other two are still pending, although one of them was diagnosed with malaria. By 16:00, 8 May 2003, the total number of 13 cases was still in Tonga Hospital. The index case returned from Mozambique where media has reported outbreaks of cholera.
On investigation, it was established that a stream (Nkomazi River) that flows through the affected area maybe the source of the outbreak because it was heavily contaminated with faecal coliforms. Moore Pads results are still pending since the Vibrio strains take time to culture.
INTERVENTIONS
Coordination
The province has Medical Joint Operating Committees (MJOC) at provincial, district and subdistrict level
The MJOCs consist of the Department of Health [Communicable Disease Control, Environmental Health, Health Promotion, Hospital Infection Control], Department of Water Affairs and Forestry, Local Government, Emergency Medical Services, National Health Laboratory Services, and South African Military Health Services
Outbreak response team meet twice a day for planning and coordination
Case Management
Cases are being managed in accordance to the national cholera guidelines on cholera control
Case are managed in a clinic within Block B, in Tonga, and at Tonga Hospital
Oral rehydration on outpatient basis and intravenous rehydration for severely dehydrated patients are case management strategies
Ambulatory services and transport for follow-up, investigation, emergencies, health promotion are available
Surveillance
An early warning system for formidable disease of outbreak potential has been set up
Active surveillance of contact and surveillance at clinics and outpatient department is ongoing
The NHLS in Shongwe and Nelspruit are used for confirmation of cases through microbiological tests
All cholera case are being line listed and reported according to the normal notification system
Health Education
Extensive health education within communities is ongoing
Pamphlets and posters have been distributed, community radio slots are being used in Radio Legwalagwala
Health messages on how to boil water, chlorination, personal and environmental hygiene, use of toilets for ablutions, hand washing and hygienic food handling techniques are being communicated to members of the community
Community Involvement
The mayor, local traditional leaders, community-base organisations, churches, local municipality and schools are involved in control measures
Water and Sanitation
The DWAF is providing water to the affected area, due to shortage of water in the affected and at-risk areas
About 20% of the affected household were estimated to be without proper sanitation facilities
Information boards were place at sources of unsafe water, e.g. canals
CHALLENGES
The restructuring in the province is a threat to epidemic preparedness and response capacity as the Communicable Disease Control Coordinators, Environmental Health Practitioners, Health Promotion Practitioners do not appear on the new organogram
The province has an Acting Consultant for Communicable Disease Control (Dr Bernice Harris) since the resignation of Dr Dave Durrheim
All the Communicable Disease Control Coordinators have been allocated other tasks other than infectious diseases control, which has a negative impact on rapid response and there is no dedicated transport for Communicable Disease Control Coordinators
There is only one official responsible of infectious diseases outbreaks at national level. The position of the Chief Medical Officer within Directorate: Communicable Disease Control is not funded. As a result the only one official within directorate cannot cope with coordinating multi[ple epidemics, preparedness and response, investigation, development, implementation, training, monitoring and evaluation of outbreak
The notification systems at all levels cannot function as early warning systems due to poor infrastructure, untrained information managers, and late and incomplete reporting. These cannot be used for non-notifiable condition like shigellosis, parasitic outbreaks, SARS, etc
Poor commitment at national level towards implementation of Integrated Disease Surveillance and Response [IDSR] which is the only solution or early warning system to detect epidemic potential infectious diseases as soon as they occur
Slow rolling out of water and sanitation provision by the Departments of Water Affairs and Forestry, and Provincial and Local Government, particularly for at risk communities
RECOMMENDATION
Recommended to the Minister:
Takes note of the current status of in Mpumalanga
Urgently convene a meeting on "Integrated Disease Surveillance and Response" for epidemic prone infectious diseases in South Africa
Consider an urgent meeting for sensitization of management by the WHO on implementation of IDSR, in order to be on the same level with other countries in the region
Consider the need recognize the impact of outbreaks and redress lack of personnel to manage outbreak at national and provincial level
Establishment of Southern African Development Community (SADC) Epidemic Preparedness and Response Network