A REPORT BY HIS WORSHIP SOLOMON MGUNI

The MAYOR OF BULAWAYO

ON COVID -19

IN THE CITY OF BULAWAYO

THURSDAY, 18 JUNE 2020

i. Situational Report on COVID-19

COVID-19 SITUATION UPDATE / HIGHLIGHTS

• Global cumulative total of 8 061 550 confirmed (119 759) and 440 290 deaths (5 494) Source: WHO SitRep 149, as of 1000hrs CEST 17 June 2020
• Africa CDC Reporting 260 233 confirmed 7 019 deaths and 118 992 recoveries Source: A/CDC Dashboard, accessed https://africacdc.org/covid-19/ 17 June 2020
• Nationally a cumulative of 401 confirmed cases (10), 63 recoveries and 4 deaths (0) Source: Zimbabwe MoHCC Update issued 17 June 2020
• In Bulawayo 26 cases (2), 10 recoveries and 1 death (0) Source: City of Bulawayo: Health Services Department 18 June 2020

GASTROINTESTINAL DISEASE SITUATION UPDATE / HIGHLIGHTS

• At least 726 suspected cases of Gastrointestinal Disease have been seen and evaluated at Luveve Clinic this week and at least 37 seen at their homes as at 18th June 2020 at 0800hrs.
• At least 15 were transferred to Mpilo Central Hospital from Luveve Area (including the clinic) on the 16th June with the hospital reporting at least 59 people being admitted and 5 having died (4 children and 1 adult) as of 16 June 2020
• Investigations on community deaths ongoing, with at least 3 having been reported.
• Symptoms being reported include watery diarrhoea, bloody diarrhoea, fever, vomiting and abdominal cramps & pain.
• Two stool samples were initially sent to Mpilo Laboratory for testing and the stool was clear of Shigella and Salmonella sp. Two more stool specimen that had been collected and were sent to the 24 hour diagnostic laboratory did not yield growth of any organism by Tuesday 16th June 2020.
• At least 21 stool specimens have been submitted at the CIMAS laboratories and 15 more at Mpilo with results being awaited
• Investigations for aetiology (fluids, faeces, fingers, flies, fields and food) are ongoing.
• At least 4 treatment stations (children screening; adult screening; treatment; and resuscitation) set up, with mobilisation of mobile ablution facilities in progress
• Therapeutic consumables including antibiotics, oral and intravenous fluids have been mobilised with support of National Pharmaceutical Company (NatPharm)
• The City of Bulawayo has activated a Rapid Response team comprising of Community Nurses, Environmental Health Practitioners, Health Promotion Officers), complimented by a doctor, at least 7 nurses, and community health workers to conduct door to door searches of diarrhoea patients
• The Inter-departmental investigations (health and engineering services) are ongoing with water samples from taps, storage containers and unprotected wells being collected and sent to different laboratories for testing
• The City continues with engagement of local leadership and community structures
• Council has also waivered of the water shedding in the affected area
• Risk communication and community engagement, waiver of user fees for cases fitting the case GIT disease case definition, distribution of oral rehydration salts, placing neighbouring health facilities on high alert are among other interventions are in place.

CORONA VIRUS DISEASE OF 2019 CASE AND LABORATORY HIGHLIGHTS

The city at 08:00hrs on 18th June 2020 had a total of 26 cases of COVID-19 spread throughout the city, in at least 10 suburbs and the two quarantine centres; and has followed up at least 1 356 contacts. At least 662 (48.8.6%) of the contacts had been cleared having completed 21 days either without symptoms or/and testing negative by antigen tests where indicated.

There is still need to re-emphasize implementation of preventive measures such as cough etiquette, hand hygiene, routine temperature checks, wearing a mask in public and social distancing; to break the chain of transmission.

Of the first 12 cases (diagnosed in April 2020), though the index case had been diagnosed posthumously, 10 had recovered and only one of the cases was yet to receive results to confirm recovery. Eleven of these cases were due to local transmission. None of the cases needed hospital admission for medical treatment. Of these cases the 668 contacts were traced, followed up and eventually cleared.

Of the recently identified 14 cases of COVID-19, all are stable in isolation. One client had been readmitted for management, including Oxygen support for a few days but is now stable and out of hospital. Five of the new cases were returnees diagnosed at the quarantine centres and have been moved into isolation. At least 668 contacts of these cases had been followed up by 08:00 hrs of 18th June 2020.

At least a cumulative of 1 703 specimens have been sent to the laboratory for RT-PCR and Xpress Xpert testing for SARS-CoV-2 and this week turnaround time for RT-PCR results increased with some results taking more than 5 days to come out, compared to the less than 48 hours the previous week.

In the public sector the NUST ACTG/NTBRL RT-PCR platform is now complimented by the Xpress Xpert tests. The Gene Xpert platform, usually used for the Tuberculosis control programme is being capacitated. Xpress Xpert SARS-CoV-2 related software has been installed on the machines at Mpilo, United Bulawayo and Thorngrove Hospitals. At least a cumulative of 132 (8) samples have been tested for the SARS-CoV-2 RNA at Thorngrove Hospital after hours or/and weekends, when the machine is not being used for TB samples, and this is also expected to start at the Population Services International Bambanani Clinic and the hospital at Lookout Masuku Barracks.

Though there has been limited availability and / or frequent stock outs of specimen collection swabs and / or viral transportation media (VTM) the laboratory network has expanded in the city. As part of home grown initiative, and in line with WHO updated recommendations, the NTBRL has been exploring the use of phosphate buffered saline as a sustainable solution.

In the Private Sector the Lancet laboratory continues to collect specimens and sends to their Harare counterpart for RT-PCR testing, and Mater Dei based Diagnostic Laboratory Services have built capacity to perform the same antigen tests. They have not reported any new cases in the city.

This week the various city health institutions/facilities continued participating and facilitating in a study that will see front line health workers being tested for COVID-19 using various different tests. This study is conducted as part of the Tackling Infectious Diseases for the Benefit of Africa (TIBA) and the local leading institutions are the National University of Science and Technology and Iam4byo against COVID-19. The study will generate local evidence to inform policy on COVID-19 management.

GASTROINTESTINAL DISEASE BACKGROUND / HIGHLIGHTS

Following the ongoing integration of both Indicator Based Surveillance (IBS) and Event Based Surveillance (EBS) activities, a possible diarrhoea outbreak was detected in Emakhandeni Division. Ad-hoc reports and rumours from residents and political leadership that there was a diarrhoea outbreak in Luveve suburb were received in Epidemiological week 20 i.e. before the number of diarrhoea cases reporting to Luveve clinic had surpassed the alert threshold. A rapid response team was dispatched to the community to investigate, verifying the reports and encouraging health seeking behaviour. A sharp rise in diarrhoea cases was subsequently observed through the Weekly Disease Surveillance System (WDSS) from week 21 at Luveve Clinic.

Preliminary Actions Taken

• Constructed a working case definition i.e. defining a diarrhoea case as passing ≥3 loose stools within 24 hours.
• Reviewed health facility records to identify diarrhoea cases (Luveve Clinic) beginning 17 May 2020 working backwards.
• Followed up diarrhoea cases identified from the health facility records to their homes.
• Conducted house-to-house survey to actively find more diarrhoea cases (Luveve Suburb).
• Line listed all diarrhoea cases identified.
• Collected stool specimen to identify aetiological agent.
• Identified alternative water sources used by communities in question.
• Searched for food, flies, fingers, faeces, fields as well as fluid sources of illness*
• Identified type of water storage used by households.
• Collected water samples from (both tap and stored) to establish the quality.
• Verified the number of sewer bursts reported in the last two months.
• Conducted risk communication and community engagement activities.

Preliminary Findings

By the 29th May 2020 a total of 47 gastrointestinal disease cases had been identified (53% females; 47% males) with median age 36 years (range 3-87 years) and 3 deaths.

The most common symptoms included watery diarrhoea, dysentery, fever, vomiting and abdominal pain.

Two stool samples were initially sent to the Mpilo lab for testing and the stool was clear of Shigella and Salmonella sp.

Two more stool specimen that were collected and had been sent to the 24 hour diagnostic laboratory did not yield growth of any organism by Tue 16 June 2020.

Some of the patients from Luveve admitted at Mpilo hospital were critical and diagnosed with Haemolytic-uremic syndrome (HUS).

The treatment for diarrhoea patients that reported to the health facility (Luveve and Mpilo) was Salt and Sugar Solution, Zinc sulphate, paracetamol and ciprofloxacin.

Azithromycin was made available delivery from National Pharmaceutical as of the 15th June 2020.

Affected Area (Map)

• The diarrhoea cases are clustered in Old Luveve, New Luveve and Gwabalanda.
• Initially most of the Luveve cases complaining of diarrhoea were not reporting to the health facility citing that they did not have money to pay for service fees at the clinic.Patients were advised to seek care immediately whilst issue of payments was going to be addressed using the Council’s pro poor policy or unfunded mandate framework as has always been the case in outbreak situations.After that campaign, the numbers of patients seeking services has increased.
• t was also observed that the affected cases were not administering the home made sugar and salt solution as they did not have sugar or salt at times.ORS at clinics was distributed to those affected.
• The number of sewer bursts in the area is still to be established with engineering services having engaged a contractor to commence dechoking.

Key messages disseminated

• The importance of washing hands with soap and running water
• Keeping of utensils clean and stored in clean places
• Boiling of water to ensure safety
• The importance of keeping water in a clean and covered container
• Hygienic dispensing of water from the storage containers
• Importance of early treatment seeking behaviour
• Importance of food hygiene in the homes

Other actions taken

STOOL SAMPLES FOR ANALYSIS AT CIMAS

• At least 21 samples were collected at Luveve Clinic on 15 June 2020. The samples were sent to Cimas Laboratory for culture and sensitivity test on 16th June 2020. A further 19 stool samples were collected on the 16th of June 2020. Efforts to have them tested at Lancet were not fruitful.

WATER QUALITY CONTROL

• At least 20 water samples would be sent to National University of Science and Technology (NUST) for bacteriological and chemical analysis on the 18th June 2020. The laboratory is able to identify presence of coliforms both faecal and non faecal it however cannot test for presence of Salmonella. The samples will be done for free under the NUST/Council MOU. Other water samples would be sent to an alternative laboratory and Council was engaging CIMAS on the issue.

FOLLOW UP ON COMMUNITY DEATHS WITH LUVEVE POLICE STATION

• The initial discrepancy between official death statistics obtained from health institutions and those obtained from the community prompted investigations on the source of the additional figures. Consultations conducted at Luveve Police Station revealed that there were three community deaths which were attended by the police in the suburb. The Rapid Response Team (RRT) will follow up on the deaths and establish symptoms displayed at time of death.

CLINIC ATTENDANCE

• At least 212 patients were attended at the clinic on the 15th of June 2020 after seconding staff to the clinic and door to door searches, 3 children were attended to at their homes, found too ill and transferred to the hospital. At least 21 stool specimens were collected for analysis.
• On the 16th June 2020, 218 were seen and of these 15 (including children less than 15 years) were transferred to Mpilo Hospital for further management. On the 17th June 2020 at least 202 were attended to.
• There was a report of a family that mistakenly consumed rat poison that looked like sugar.
• A line list was compiled and once complete and cleaned, data analysis will commence
• Case management protocols were made more visible, and more distributed.
• In human resource mobilisation Africa CDC was sending staff to support with surveillance, microbiology and health promotion.

BULAWAYO CITY COUNCIL COORDINATION ACTIVITIES

The Bulawayo City Council (BCC) has different thematic teams participating in the Epidemic response: Call Centre; Case Management; Coordination; Risk Communication & Community Engagement (RCCE), Disease Surveillance; Disinfection, Environmental Sanitation, Waste Management & Body Management; Logistics Supply Chain Management; Rapid Response Teams (RRTs); Suspected / Probable Patient location facilitation. BCC Health Services Department Epidemic Preparedness and Response Teams get daily updates through physical meetings (beginning 28th of January 2020) and complemented by electronic media platforms.

For management of the Gastrointestinal Disease Outbreak, BCC Health and Engineering Services Department combined efforts.

A call out roster for staff, enhanced by a WhatsApp chat group remained in place. The BCC call centre (backed by resources persons) can be contacted for information / services on numbers:

• 08084700 (Econet Numbers Only)
• 08004700 (TelOne Numbers Only)
• 263-2922 71290 (All Networks)
• 263-774 668 432 (WhatsApp Only)

Two numbers are available for direct calls to the rapid response teams (cell phones courtesy of the Bulawayo Entertainment Industry) i.e.

• 263 - 784 150 042
• 263 - 784 149 828

The national lockdown is in effect indefinitely. Some sectors are now allowed to resume work on condition that their employees have temperature tests upon entering work premises; hand sanitizers upon entry to sanitize their hands; each employee to wear a face mask in appropriate form; and employees to practice social distancing in the work place.

This week the City Council was visited by high level officials from the Ministry of Health and Child Care led by Chief Directors Mr Sydney Makarawo (Curative Services) and Dr Robert Mudyiradima (Policy Planning Monitoring and Evaluation).

A subsequent meeting of the Ministry of Health and Child Care Stakeholders, chaired by the Acting Provincial Medical Director held at Ingutsheni Hospital on Tuesday 16th June 2020 observed that the resolution for Mpilo Hospital staff to cater for returnees at United college of Education (UCE) continues, while the United Bulawayo Hospital staff look after those at Bulawayo Polytechnic, Bulawayo City Council look after positive cases at Elangeni Institution and Ingutsheni Hospital staff be cross cutting and needed operationalisation issues to be looked at.

A meeting was called by the Provincial Minister of State on the 12th June 2020 at St Patrick’s Hotel. Bulawayo City Council (BCC) was represented the Director Engineering Services Engineer S Dube and the Assistant Director of Health Services Dr K Nyathi

The Health Services Department (HSD) had been on the alert for Typhoid and other epidemic prone diarrheal diseases since August 2018. The City water supply has been erratic due to drought. The city is experiencing water shedding. Illicit activities of water and sewer infrastructure damage are common. Water and sewer pipe bursts also have been occurring.

CASE MANAGEMENT

For COVID-19 a WHO case definition which includes all age groups is being used. The city has 26 confirmed cases of Covid-19 by 18th June 2020. Ten of the initial cases have now recovered, i.e. they have had at least 2 RT-PCR respiratory specimens testing negative. Five other cases have at least one negative RT-PCR and await the second repeat test result. Other than the index case, diagnosed posthumously the eleven diagnosed (active and former cases) were stable without symptoms and did not need admission for medical reasons. Of the 14 recently diagnosed cases, only one patient needed to be admitted for 4 nights with shortness of breath that had commenced in February 2020, because of a malignancy. He has no more need for oxygen and is recovering in isolation. Five other cases needed admission for isolation to Elangeni, and one has a gynaecological acute condition.

It remains emphasised that these low figures should not lull health care workers and the community into complacency because a surge in the number of cases remains possible.

The citywide health facilities have been trained to triage patients, elicit epidemiological and clinical history as well as expedite movements into and out of the clinic.

Bulawayo City Council continues offering to orient staff in the surveillance activities as well as the specimen collection, handling and transportation techniques.

Thorngrove Hospital is still undergoing renovations and these include a new ambulance wash bay, a disinfection septic tank, a wheel bath at the main entrance gate, extension of the drug store, servicing of internal service roads, creation of a new entrance and gate, as well as, a walkway leading to staff rest rooms. The children’s isolation ward has been refurbished as follows: external walls painting, roof painting, repairs of broken window panes, and removal of gutters, yet to be replaced. Two boreholes were drilled. Mechanical ventilation is being installed.

The City extrapolated the number of cases and remains alert to the fact that an upward surge of cases is still possible.

RISK COMMUNICATION and COMMUNITY ENGAGEMENT

Summary of the activities conducted

• COVID-19 Campaign with Nehemiah Project
• Gender based violence community dialogue at Mazwi Village
• Bulawayo Poly Technical College Sensitization Meeting for staff (Law Enforcement, Social Welfare and Bulawayo Poly Technical College Staff x 55)
• United College Education Sensitization meeting of staff (Law Enforcement, Social Welfare and United College of Education Staff x 24)
• SOS staff sensitization meeting (x15)

COVID-19 Campaigns

The City of Bulawayo Health Services Department in conjunction with the Nehemiah Project participated in a COVID-19 Campaign where officers monitored shops in Cowdray Park for adherence to basic hygiene standards. COVID-19 key messages were disseminated in high volume sites. Diarrhoea prevention messages were also disseminated.

Key Messages

• COVID-19 symptoms
• COVID-19 prevention
• Bulawayo Toll free numbers
• Addressing myths and misconceptions on (COVID-19)

Areas Covered

Cowdray Park and CBD

Poly Technical College returnees (x 285)

Observations

• Children and adults loitering the streets
• Poor adherence to hygiene standards amongst vendors (using hands to pack maputi)
• Poor adherence to wearing of masks by the residents, particularly vendors

Achievements

• Key Messages disseminated
• Successful implementation of social distancing measures at bus termini

INTEGRATION OF SERVIVCES

Gender based violence community dialogue at Mazwi Village

A community dialogue was conducted in liaison with the Nehemiah Project which sought to assess challenges that women encounter with regards to gender based violence. Integration of services with COVID-19 information dissemination was conducted. In addition to this another campaign was conducted with

Menstrual Hygiene Campaign

A campaign on Menstrual Hygiene was conducted in conjunction with PLAN international and was integrated with COVID-19 key messages. Areas covered were: Pumula North, Old Pumula, Pumula East, St Peters Robert Sinyoka Mazwi and Mzilikazi.

Radio Programs

Recordings on COVID-19 and diarrhoea were flighted on, Skyz Metro, Star FM and Khulumani FM (Sponsored by, City of Bulawayo and PSZ)

Estimated Population reached

15 400

Total Mileage Covered

720km

Integration of COVID-19 and diarrhoea outbreak at Luveve suburb activities were as follows

Summary of the activities conducted

Health education and counselling sessions at the clinic on daily basis

Door to door health education sessions

WhatsApp messages to the residents through existing platforms of the residents

Key Messages

• COVID-19 symptoms and Prevention
• Promotion of early/positive treatment seeking behaviour and that services for ALL patients with diarrhoea are FREE
• Use of Salt Sugar Solution
• Use of Bulawayo Toll free numbers

Observations

• Late treatment seeking behaviour from the residents affecting disease progression, management and outcomes
• Some patients were too ill from the diarrhoea so much that they were not able to reach to the clinic, hence home treatment recommended

Achievements

• Key Messages disseminated
• Door to door education yielded good results
• Influx of patients seeking health services

CHALLENGES / RESOURCE GAPS IN RESPONDING

1. Limited ability to continue testing, with stock out of lab consumables
2. Inadequate human resources to cater for 2 outbreaks and maintain essential services
3. Need for more oxygen canisters, flow metres, delivers tubes an masks/nasal prongs
4. Late treatment seeking behaviour from some of the residents
5. Frequency of the diarrhoea deterring patients from seeking health services early
6. Water shortages deterring messages on hand washing as there was backlash experienced from the community
7. Illegal vending on the increase
8. Diarrhoea outbreak may not be limited to Luveve

RECOMMENDATIONS & PRIORITY FOLLOW UP ACTIONS

1. Expedite exploration of home grown solutions in developing standard Viral Transportation Media (VTMs)
2. Expedite secondment of 15 nurses and laboratory staff to BCC
3. Expediting infrastructure renovations
4. Health education and community engagement to continue, encouraging the residents on appropriate treatment seeking behaviour
5. More teams required for door to door home treatment
6. Engage partners for support of the diarrhoea outbreak
7. Public gathering to be discouraged. And Illegal activities to be stopped.
8. Investigation of diarrhoea cases in Cowdray Park to be scaled up.

LOGISTICS AND SUPPLY CHAIN MANAGEMENT

DIARRHOEA OUTBREAK

Tents, beds sent to Luveve Clinic. Some IV fluids, ORS and related consumables were sent to Luveve Clinic.

A vehicle for ferrying staff to work and a driver on standby is in use, and task sharing between both COVID-19 pandemic and Gastrointestinal Disease Outbreak Response activities.

Among commodities mobilised are:

• B/100 ORS sachets
• Zinc sulphate-ORS Co-packs
• Paracetamol 100mg dispersible tablets
• Paracetamol 500mg tablets
• Ciprofloxacin 500mg tablets
• Paediatric Azythromycin
• Dextrose 5%
• Ringer Lactate solution
• IV cannulas (each size)
• Adult fluid giving sets
• Paediatric fluid giving sets