Starting last October, Zambia experienced the worst cholera outbreak (mass infection) in its history. The further spread of infection was stopped by two JICA health project teams working in the area. What were the efforts that overcame the rapid increase in the number of patients and were highly evaluated by the Zambian government?
3D illustration of cholera bacteria (Adobe Stock)
Outbreak just before the rainy season Further outbreak threatened to spread
The first confirmed case of cholera was announced in Lusaka, the capital of Zambia, on October 15, 2023. Three days later, the Zambian government declared an outbreak. Cholera* is transmitted by ingesting water or food contaminated with the cholera bacteria and often occurs in densely populated areas where access to safe water is difficult. Lusaka is home to a number of poor neighbourhoods (so-called slums) called compounds, and this outbreak also originated from these compounds.
The rainy season (December-April) was approaching in Zambia. When the rainy season arrived, the compound would be flooded and the water source would be contaminated with waste from unpumped toilets, further worsening the sanitation situation.
- A bacterial intestinal infection whose main symptom is diarrhea. Severe cases can lead to dehydration and death, but the mortality rate is less than 1% if the disease is treated early and appropriately. The disease is still endemic in Africa and parts of Asia, and according to the WHO, 1.3 to 4 million people worldwide are infected each year, with 20,000 to 140,000 deaths.
Compounds where many poor people live do not have water and sewage systems, and when it rains, the water quickly overflows and sanitary conditions deteriorate.
From the very beginning, we knew that the number of patients would increase rapidly,” said Masataro Norizuki, a specialist working on a project to strengthen the administrative capacity of five hospitals in Lusaka County starting in 2021. We knew from the beginning that the number of patients would increase rapidly,” said Masataro Norizuki, a specialist working on a project to strengthen the operational management capacity of five hospitals in Lusaka County starting in 2021.
From the early stages of the outbreak, Hougetsu experts began to prepare for a rapid increase in the number of patients, and began instructing nurses at the five hospitals involved in the project on treatment procedures, infection control measures, and patient guidance lines. They then traveled to the communities to set up points to provide oral rehydration solution.
Cholera treatment requires prompt replenishment of fluids and salt lost due to diarrhea, but in compounds where many poor people live, there is a strong stigma against medical treatment, such as “going to a hospital will kill you,” and many people do not go to hospitals even if they have diarrhea or other symptoms. In addition, there are areas where access to hospitals is poor, so the establishment of these oral rehydration solution distribution points is a very important initiative.
Oral rehydration solution delivery points located in compounds with poor access to hospitals
A hastily opened treatment center breaks up the chaos.
As the rainy season began, the number of patients increased dramatically, as feared by legal experts. At its highest, the number of new patients per week averaged 461 patients/day (from a WHO report). As a result, there were not enough beds in existing hospital facilities, patients had to sleep on the floor, and the quality of medical care continued to deteriorate. With the medical field in dire straits, the Zambian government decided on January 2, 2024 to establish a 600-bed cholera treatment center at the National Heroes Stadium, an athletic stadium in Lusaka. Two days later, Zambia’s Minister of Health visited the stadium to inspect the facility and declared it open that day.
On January 3, the day after the decision was made to open the stadium, we went throughout the stadium and began mapping out the acceptance system, examining the zoning for infection control and even the garbage collection points, including room sizes and whether they had windows or not. The next day we had a visit from the Minister of Health, so we explained and made decisions as we went. However, as soon as it opened, patients began pouring in, and it lost its order as a treatment center. We expanded the number of beds to 1,000, and together with Zambian doctors and nurses, we were desperately trying to improve the on-site environment to restore order with a strong desire to ‘somehow break out of this situation'” (Hougetsu expert).
President of Zambia (third from right) and Specialist Hozuki (front row, second from left) visit the National Heroes Stadium on February 4, 2024 to comfort hospitalized patients. Specialist Hozuki is a specialist in infectious diseases and was involved in the response to the new type of coronavirus infection in Japan. He says his experience has been useful in Zambia.
Cholera treatment center set up at the National Heroes Stadium in the capital city of Lusaka. The beds and infusion tables were built overnight by local carpenters, and handmade tags with medical records and severity of illness are hung from the infusion tables to support orderly on-site management.
Analyze critical data based on the trust you have built
In addition to this support for infection control, support for epidemiology, laboratory, and medical care also played an important role in this outbreak. Together with the National Institute of Public Health of Zambia, the nerve center for infectious disease control, Tadatsugu Imamura, an expert in the field, collected stool specimens from patients, set up a laboratory system, analyzed clinical data from the cholera treatment center, and analyzed geographic information on the spread of infection within Lusaka.
Expert Imamura has been working at the Zambia National Institute of Public Health since April 2023 on a project to strengthen the monitoring and testing system for infectious disease outbreaks. The laboratory system developed under this project was solely responsible for testing stool specimens for suspected cholera in Lusaka and rural health facilities during the outbreak.
Since the beginning of the project, we have been working with Zambian staff to create a manual and repeatedly train them to establish a systematic inspection system that would be useful in the event of a cholera outbreak. The outbreak occurred just as we were planning to begin full-scale operations at the end of 2023, and we were able to take advantage of the results.
Specialist Imamura (right) instructs local technicians on how to collect stool samples at a clinic.
Technicians at the National Institute of Public Health of Zambia performing a stool culture test.
Expert Imamura was also engaged in cooperation in Zambia as an infectious disease control advisor from 2020 to 2022. He says that it was because of the trust he had cultivated with Zambian officials that he was asked by the Zambian government to assist in the analysis of data on cholera infection status, which is very important for the country.
How are community-acquired infections spreading, what risk factors are present, whether resistant strains of bacteria that do not respond to antimicrobials are occurring, whether there are any problems with the quality of treatment for hospitalized patients, and where there are not enough doctors and nurses – these are just some of the questions that have been raised. By analyzing epidemiological and clinical data and sharing information based on test results with the Ministry of Health and medical facilities, we were able to implement timely and appropriate data-based measures.
Furthermore, in February 2024, a survey team of Japanese experts in infectious disease control consisting of the National Institute of Infectious Diseases, the National Center for Global Health, and JICA arrived in Zambia. While conducting the field survey, they observed and proposed improvements to oral rehydration solution provision points set up in communities. They also verified factors contributing to the spread of infection, digitized and analyzed clinical data, and provided support for improving the accuracy of inspections.
A team of experts making recommendations to the Lusaka Provincial Department of Health, including a proposal for improvement compiled from visits to oral rehydration solution points in each community.
These all-Japan efforts were highly appreciated by the Zambian government. The President also expressed his gratitude for the many relief supplies sent from Japan and the dedicated support activities of Japanese specialists and others, saying, “I felt the love for the people of Zambia.
To prevent the next outbreak from occurring
Zambia is now over the outbreak and has regained its composure. However, with approximately 23,000 infected and 740 deaths (as of May 12), this outbreak is the worst in Zambia’s history.
There have been frequent cholera outbreaks in Zambia. In the future, the major challenge will be to prevent the next outbreak from occurring.
JICA also sent a survey team to Zambia after the country suffered a cholera outbreak in 2018, recommending the need to strengthen hospital capacity in cholera-prone areas and to strengthen the surveillance system for infectious diseases. This led to the creation of two projects that were responsible for supporting the outbreak. And now, each project is in the process of examining the cholera response to prevent the next outbreak from occurring in order to further expand cooperation.
The global pandemic of new coronavirus infections is still fresh in everyone’s memory and has left us with many experiences and lessons to learn. Infectious diseases are a common challenge that transcends national borders, and we do not know when or where it will happen again. A problem with an infectious disease in one country is not a problem for others, and the entire world needs to strengthen prevention and preparedness in normal times and in response to crises when they occur.
Experts Chiho Kaneko (Lab Management) and Chiho Imamura (Surveillance), laboratory technicians who play a central role in the fight against infectious diseases in Zambia at the Reference Laboratory of the National Institute of Public Health, Zambia.
© Source JICA
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