Feature on cholera outbreak

The Mavalane Cholera Treatment Centre is a collection of tents and improvised shelter in the grounds of one of the main hospitals in the Mozambican capital, Maputo. It is in the front line of the government's atempts to tackle a new outbreak of the highly contagious disease. Mavalane's intensive care ward consists of tents with makeshift cane roofing, held up by logs stuck into the sandy earth. Hundreds of people lie on wooden bed bases, tightly packed next to each other. The beds have a hole in the middle and a bucket underneath, a necessity for the weakened patients suffering from relentless diarrhoea. Drips to rehydrate them, and cardboard boxes with their records hang from wiring connected to the roof. The pediatric ward in Mavalane is small and overcrowded, and does not even have makeshift beds - the sick children lie on straw mats with their drips. A new extension for accommodating the latest influx of patients is under canvas, and on some days the heat in these wards reaches 40 degrees centigrade. Last year there was a cumulative total of around 3,500 cholera cases countrywide. In the latest outbreak, the number of cases in the last two and a half months alone has already reached 4,700. Some 340 patients were in the cholera centre when IRIN visited on 5 February. Despite the large number, it is an improvement on the 734 cases of the week before. The director of the centre, Dr Cremilde Moambe Anli, said dealing with this epidemic was the biggest challenge she had faced since beginning her medical career four years ago. Her team of 17 nurses, 24 auxiliary nurses and three doctors could not adequately care for the hundreds of sick people. "We can cope with the heat, we even cope with the cleaning - for example when the patients do not manage to use the bucket properly - but the problem is monitoring the drips in the way that we should. There are not enough of us." Yet, despite the pressures, when patients come in early enough, most survive. If the early symptoms of chronic diarrhoea are ignored, the patient will die of dehydration. Dr Anli said a boy, aged about five years, had died yesterday. "He was so weak from dehydration when he was bought to the centre that he could not stand up." The current cholera outbreak started just before Christmas. It has now affected Maputo City and five of the country's 10 provinces - Maputo, Gaza, Sofala, Zambezia and Nampula. Officially 26 people had died by 26 January. Maputo City has had the largest number of cases, peaking so far at over 700. Around 300 of the cases were children aged under seven, according to the UN Children's Fund (UNICEF). "Prevention activities are key to stemming the epidemic from getting further out of control," UNICEF water and sanitation officer, Domingos Chiconela, told IRIN. "Communities should focus on preventive measures, such as washing their hands with soap or ash after using latrines and before eating, and safe elimination of faeces." He stressed that it was crucial that the communities must "identify the problem areas in their hygiene practices, and come up with solutions, and then UNICEF can support them. It has to be a participatory approach." The Ministry of Health, UN organisations and NGOs have been working together for years in an attempt to prevent cholera outbreaks, and to encourage communities to adopt safe hygiene practices. They have mounted door-to-door hygiene promotional campaigns, street theatre, media campaigns and public debates. UN agencies and NGOs have also supported the provision of clean water, latrine construction and safe garbage disposal. But it is a mammoth challenge in one of the world's poorest countries, where most people still live in dismal conditions. Despite the efforts, official figures show that 74 percent of the rural population do not have access to clean water, and 71 percent are not using an improved latrine. The situation is a bit better in urban areas, but 60 percent of the population still do not have access to clean water, while and 64 percent do not have the use of improved latrines. Maputo city, the worst-hit province in the current outbreak, has a severe problem of garbage collection. It is a common sight to see swarms of flies around large overflowing garbage containers right next to street vendors, and to see litter lining the streets, which also suffer from poor drainage. The municipal authorities tried in vain last month to ban the selling of food prepared in the informal markets that have sprung up haphazardly in the city. Police swooped on vendors, confiscated their food, and caused an uproar. "Many of those selling the food are widows and single parents, and they depend on selling the food for their livelihood," said Bernard Luis Chauze, the head of one such market in the heart of Maputo. An elderly Rebecca Tembe cooks and sells rice and meat dishes in her makeshift stall in one of the crowded markets. She earns about three million meticais profit a month (about US $125) to support her unemployed daughter, her son-in-law and two grandchildren who all live with her. "Cholera is not new for us. I know how to prevent it. We must wash our hands and keep the place clean." Chauze has mobilised all the market vendors to clean the market each Monday and Saturday. Now a brigade from the municipality and the Ministry of Health visits the markets regularly to check on hygiene. If the vendors follow basic hygiene regulations, they are allowed to sell again. But it is still too early to say the situation in under control. "UNICEF has been supporting government institutions in pre-positioning emergency supplies, including cholera prevention and response equipment and consumables, such as water bladders, chlorine, cleaning tools and hygiene education materials. These are now going to be used in the affected areas, and UNICEF provides logistical support for their rapid delivery," Michael Klaus, UNICEF information officer, told IRIN. The cholera epidemic usually peaks in February, when Mozambique often suffers floods and heavy rains. Doctor Anli at the Mavalane centre told IRIN she was worried that the worst was yet to come. "I just pray it does not rain too heavily."