A Cholera Outbreak Linked to a Funeral in Chegutu, Zimbabwe, 2018

On January 16, 2018, Zimbabwe's Ministry of Health and Child Care was told of five adults admitted to Chegutu District Hospital, in Mashonaland West Province, with watery diarrhea and severe dehydration. Three died within hours. Vibrio cholerae O1, serotype Ogawa, was found in a stool sample from one of them, and an investigation began.

The district had reason for concern. In 2008–2009 Zimbabwe suffered one of the largest and deadliest cholera outbreaks in recent history — 98,585 cases and 4,287 deaths — and Chegutu's case fatality rate then topped 5%. Cholera had been rare since (93 cases and two deaths nationwide in 2012–2016), but Chegutu's growing population and aging water and sanitation systems raised the risk of another large outbreak.

A funeral at the center

Investigators traced the outbreak to a 79-year-old woman who died on January 8 after 2 days of watery diarrhea. She had visited a private clinic, but cholera wasn't suspected.

• Preparing the body: following local practice, water was flushed through her body to cleanse it for burial, and that water went into the municipal sewer untreated.
• Sharing food: a person who helped prepare the body and served traditional food at the multiday funeral reception at her home developed watery diarrhea 2 days after the funeral.
• Spread among mourners: six other attendees, including all three who later died, developed acute watery diarrhea within 6 days; two of those who died had helped with the burial.

Within 4 days of the funeral, the outbreak had spread to local residents with no link to it.

The 106 cholera cases with a known onset date, by funeral attendance. CDC figure.

Where did it come from? The woman hadn't traveled. But her home was less than half a mile from another funeral, on December 30, 2017, attended by two people who had come 292 miles (470 km) from Lusaka, Zambia, where cholera was spreading. Neither had diarrhea, and neither was tested for carrying the bacteria without symptoms. How the woman was infected remains unknown, but the funeral practices used to prepare her body and unsafe food handling at the funeral probably helped the outbreak spread.

Containing it

A rapid, coordinated response by the ministry and international partners — surveillance, health promotion, laboratory testing, training in case management, and emergency water, sanitation and hygiene (WASH) work — kept the outbreak to urban and peri-urban Chegutu. One suspected case turned up along the highway to Harare, 62 miles (100 km) away, but none in the capital.

As of April 5, 2018:

• 107 cases, 51 hospitalizations and 4 deaths (case fatality rate 3.8%); 9% of cases were in children under 5.
• The last case was reported on February 19.
• About 60% of cases were in three suburbs: Chegutu township (19), Pfupajena (31) and Kaguvi (13).
• Of 64 stool samples tested, 9 grew V. cholerae O1. Eight isolates showed reduced susceptibility to cotrimoxazole and two to tetracycline, but all were susceptible to ciprofloxacin, the first-line treatment for severe cholera under Zimbabwe's guidelines.

The lesson

During cholera epidemics, outbreaks have been tied to funerals — transporting, washing and preparing bodies, and contaminated shared meals — but outside epidemics this is rare. With more travel to and from countries with cholera outbreaks or ongoing transmission, cholera is an ever-present risk wherever water and sanitation are inadequate. The authors concluded that even where cholera has been absent, public messages about safe burial and safe food handling should be given at all times, alongside early detection.

Sources

• McAteer JB, Danda S, Nhende T, et al. "Notes from the Field: Outbreak of Vibrio cholerae Associated with Attending a Funeral — Chegutu District, Zimbabwe, 2018." Morbidity and Mortality Weekly Report 67(19), Centers for Disease Control and Prevention.