Africhol in Mozambique
Since 2007, Mozambique has reported cholera cases almost every week to the World Health Organization (WHO), and major outbreaks occurred in 1992, 2002 and 2009, with up to 31,731 cases reported in 1992.
In collaboration with the National Institute of Health and with support from the Ministry of Health, Africhol is working with local teams in the city of Beira and the district of Mocuba to establish enhanced surveillance zones.
Cholera epidemiology in Mozambique
Since 1973, cholera has been endemic in Mozambique. During the years 1992, 1993, 1998, 1999 notified cholera cases from Mozambique represented one third of all African cases. In 1992 for example, 31,731 cases were reported, with an incidence of 211/100,000. From 2000 to 2009, reported cholera cases varied from a low of 2,226 in 2005 to a high of 24,375 in 2002. Cholera deaths varied from a high of 342 in 2002 to a low of 22 in 2007 (CFR 0.46% to 1.4 %).
The last cholera outbreak in Mozambique started in 2009 and caused 19,310 cases and 155 deaths. Cholera cases drastically decreased between November and December 2009, but heavy rains in the first quarter of 2010 resulted in a renewed cholera outbreak. According to reports from the Ministry of Health (MoH), between January and March 2010, five provinces cumulatively reported 3,188 cases and 44 deaths (CFR of 1.4%). The most affected province of Zambézia had a total of 1,295 cases and 19 deaths. Annual incidence was greater than 300 per 100,000 in 3 districts (Gurue, Cidade de Pemba, and Mecufi).
Although cholera occurs predominantly during the rainy season from December to April, since October 2007, cholera cases have been reported most weeks in the country. A 20-year summary of cases confirmed a relationship between increased cholera cases and rainfall as well as a relationship with increasing urbanization.
Routine national cholera surveillance
- Suspected case of cholera: a person at least 5 years of age with acute severe diarrhea, dehydration and vomiting. Additionally, in Mocuba, Beira, and Boane, the initial case of suspected cholera in a neighborhood must have severe diarrhea and dehydration and also have stool with a cholera appearance (rice water possibly with a distinct smell).
- Confirmed case of cholera: an individual case from whom a rectal swab is collected and who is positive on culture for cholera. All persons with clinical cholera (severe diarrhea, dehydration, and characteristic appearance of stool) from the same neighborhood as the confirmed case are then considered cholera cases and usually do not have further testing. Clinically appropriate illness is considered cholera for 2 months after the last confirmed case in Mocuba and 6 months in Beira.
- Cholera outbreak: an outbreak is declared following the identification of a single confirmed cholera case in a neighborhood. The subsequent cases of severe diarrhea are treated as suspect cholera. We will retain this definition for the current project and conduct outbreak investigations where possible.
Enhanced surveillance zones in Mozambique
Based on the Africhol criteria, the joint Africhol team chose Beira City and Mocuba District as surveillance zones.
Beira city is a coastal urban site with 454,000 people, highly endemic for cholera (273 reported cases per 100,000 per year in 2009), with history of high quality work on cholera and the presence of two laboratories in Beira City that can provide cholera testing. A restricted area of 100,000 to 150,000 residents will be defined, centered on the cholera treatment centers.
Mocuba district is a rural area with 344,822 inhabitants and a relatively high incidence of reported cholera cases (89.6 per 100,000 population during 2010). Mocuba district has high level of health care access for persons in the Quelimane city and an history of providing surveillance reports on suspected cholera cases to the National Surveillance System. Moreover, there is a straightforward access and transportation from Maputo to Quelimane.