Weekly Regional Cholera Bulletin: 8 March 2023

0 | P a g e Weekly Regional Cholera Bulletin: 8 March 2023 Cholera in the WHO African Region Data reported: as of 7 March 2023 1 | P a g e Situation update Overview The cholera outbreaks in the WHO African Region continue to evolve, with 13 countries currently reporting cases. South Sudan is the latest country to confirm a new outbreak during the reporting week. Overall, incidence cholera cases and deaths in the region have been declining in the past five weeks. In week 9 (27 February – 5 March 2023), a total of 3835 suspected cases were reported from 13 countries, reflecting a 12.6% decrease compared to 4389 cases recorded in week 8. Similarly, deaths decreased from 89 in week 8 to 70 in week 9, a 21.3% decrease. Between 1 January and 7 March 2023, 35 324 suspected cholera cases were reported from 13 countries, with 747 deaths (case fatality ratio [CFR] = 2.1%). Malawi accounts for 61% (21 412) of all reported cases in 2023, followed by Mozambique with 14% (4979) and the Democratic Republic of the Congo with 11.8% (4154). Of the deaths reported in 2023, Malawi accounts for 84% (608), followed by Mozambique at 4.7% (35) and Kenya with 4.3% (32). Cumulatively from January 2022, 129 757 cases have been reported, including 3024 deaths (CFR = 2.3%) as of 8 March 2023 (refer to figure 1). Malawi accounts for 39.7% (51 568) of the total cases and 53% (1612) of all deaths reported, and together with Nigeria, Democratic Republic of the Congo, and Cameroon, contribute to 88% (113 809) of the overall case load and for 94% (2835) of cumulative deaths. Cameroon has had an outbreak since October 2021, while Malawi, Democratic Republic of the Congo and Nigeria reported cholera outbreaks in the first quarter of 2022. Kenya, Mozambique, and Ethiopia reported their outbreaks between August and October 2022, while Burundi, Zambia, United Republic of Tanzania, South Africa, Zimbabwe, and South Sudan reported cholera outbreaks between January Cholera in the WHO African Region Weekly Regional Cholera Bulletin: 8 March 2023 Data reported: as of 8 March 2023 Regional Cholera Update Cumulative Cases 129 757 Grade 3 CFR 2.3% Cumulative Deaths 3 024 2 | P a g e and March 2023. The Ministry of Health of South Sudan declared cholera outbreak in Malakal, Upper Nile State on 7 March 2023. The cholera outbreaks in the region are happening in the context of natural disasters such as cyclones (Mozambique, Malawi), flooding (Nigeria, Malawi), drought (Kenya and Ethiopia), conflict (Cameroon, Democratic Republic of the Congo, Nigeria, Ethiopia) and multiple disease outbreaks including mpox, wild polio, measles, COVID-19 pandemic, etc. Many countries have limited and strained resources, shortage of medical commodities including cholera kits and Oral Cholera Vaccine (OCV). Poor sanitation and unreliable water supplies with increased cross-border movements also serve as driving factors for the outbreak across the region. Figure 1: Distribution of cholera cases and deaths in WHO African Region, January 2022—March 2023 3 | P a g e Table 1: Cholera Cases and Deaths in WHO AFRO Region, October 2021 to 7 March 2023 Country Cumulative Cases Cumulative Deaths CFR (%) Total Cases in 2023 Data Start Date Last update Burundi 145 1 0.7 145 Jan 2023 3/04/2023 Cameroon 15 275 310 2.0 151 Oct 2021 2/26/2023 Democratic Republic of Congo 22 703 321 1.4 4 154 Jan 2022 2/26/2023 Ethiopia 1 597 38 2.4 782 Aug 2022 3/05/2023 Kenya 6 238 99 1.6 2 721 Oct 2022 3/06/2023 Malawi 51 568 1 612 3.1 21 412 Mar 2022 3/06/2023 Mozambique 7 517 41 0.6 4 979 Sep 2022 3/05/2023 Nigeria 24 292 612 2.5 529 Jan 2022 2/05/2023 Zambia 215 5 2.3 215 Jan 2023 3/05/2023 South Africa 6 1 16.7 6 Feb 2023 3/04/2023 United Republic of Tanzania 49 3 6.1 49 Feb 2023 3/04/2023 Zimbabwe 2 0 0.0 2 Feb 2023 2/25/2023 South Sudan 179 1 0.6 179 Feb 2023 3/07/2023 TOTAL 129 757 3 024 2.3 35 324 Page | 4 Figure 2: Epicurve of cholera cases and deaths in WHO African Region, 1 January 2022 – 7 March 2023 Figure 3: Epi Curve of cholera cases by country in the WHO African Region, 1 January 2023 – 5 March 2023 Overall, cases have been declining since week 6 3 major contributors in 2023 are Malawi (61%), Mozambique (14%) and Democratic Republic of the Congo (11.8%) Page | 5 Figure 4: Sub-regional trends of cholera cases and deaths, 2023 Page | 6 Country Specific updates Malawi declared a cholera outbreak on 3 March 2022, transmission rates spiked in the aftermath of the 2022 festive season, where cholera spread to new areas, particularly the capital Lilongwe. Overall, Malawi has reported 51 568 cumulative cases with 1612 deaths (CFR = 3.1%) from all its 29 districts as of 6 March 2023. A total of 21 412 cases have been reported since 1 January 2023, with 608 deaths (CFR = 2.8%). Lilongwe, Mangochi, and Blantyre districts have reported the highest number of cases. Although a modest decline in the number of cases has been recorded over the last four weeks, this is not uniform across the country. A total of four districts recorded an increase in new cases in the last week compared to the preceding week. The outbreak remains largely concentrated in the central and southern parts of the country, with the high-burden districts of Lilongwe, Blantyre, Salima, Mangochi, and Balaka constituting 71.4% of cases reported in the past week. Twenty-four out of the 29 districts have reported new cases in the past week. The ongoing rainy season and flooding in parts of the country continues to challenge response efforts. New deaths have decreased by 31% in the past week compared to the preceding week. However, eight districts including the capital Lilongwe reported an increase in deaths. This increase has been identified and reported from communities. Limited capacities for optimal clinical care in peripheral facilities has been noted as the outbreak spreads to peri-urban and rural areas, consequently contributing to this recent increase. Ongoing Public Health Actions ▪ A High-level Ministerial meeting on cholera is ongoing in Malawi this on 9–10 March 2023 ▪ OCV application was submitted, and country team is currently in a meeting with International Coordinating Group (ICG) for further clarifications ▪ 100% of response staff briefed on Preventing and Responding to Sexual Exploitation, Abuse and Harassment. ▪ Oriented 45 health assistants and 56 community health volunteers on Risk Communication and Community Engagement (RCCE) ▪ Completed construction of 7 Cholera Treatment Centres (CTCs) and Cholera Treatment Units (CTUs) with a total bed a capacity of 214 Challenges/Gaps ▪ Provision of food for patients on admission. ▪ Challenges with waste management ▪ Overstretched capacity of health system. ▪ Limited capacities for optimal clinical care in peripheral facilities ▪ Awaiting ICG approval on OCV request Malawi Cumulative Cases 51 568 Grade 3 CFR 3.1% Cumulative Deaths 1 612 Page | 7 Figure 5: Map of Malawi showing distribution of cholera cases and deaths, January 2022 to March 2023 Figure 6: Epi Curve for cholera outbreak in Malawi, 3 March 2022 – 5 March 2023 Page | 8 Figure 7: Staff of one of the cholera treatment centers in Malawi Page | 9 The cholera outbreak in Nigeria has been ongoing since January 2022. Cumulative cases as of 5 February 2023 were 24 292 with 612 (CFR = 2.5%). A total of 33 states and the Federal Capital territory and 271 Local Government Areas (LGAs) reported cases. Six states namely Borno (12 465 cases), Yobe (1888 cases), Katsina (1639 cases), Gombe (1407 cases), Taraba (1153 cases) and Kano (1131 cases) account for 83% of all cases. Between 1 January and 5 February 2023 cumulative cases were 529, with 21 deaths (CFR = 4%), across 11 states and 23 LGAs reporting cases. Overall, trend of cases is on the decline. Figure 8: Weekly trend of cholera cases and deaths in Nigeria, week 1 to 52, 2022 Figure 9: Map of Nigeria showing affected states Nigeria Cumulative Cases 24 292 Grade 3 CFR 2.5% Cumulative Deaths 612 Page | 10 Figure 10: Weekly trend of cholera cases and deaths in Nigeria, week 1-5, 2023 Public Health Actions ▪ Ongoing review of draft of National cholera case management guideline ▪ Ongoing sensitisation of communities Challenges ▪ Inadequate health facility infrastructure ▪ Inadequate trained personnel in states for case management Page | 11 The cholera outbreak in Democratic Republic of the Congo started in January 2022. As of 26 February 2023, the country had reported 22 703 cases cumulatively, with 321 deaths (CFR = 1.4%) across 30 districts in 9 provinces. The outbreak in Nord Kivu was declared on 14 December 2022, associated with an influx of refugees in internal displaced persons (IDP) camps in Nord Kivu due to conflict with non- states armed groups. As of 26 February 2023, 5273 cases with 20 deaths (6 community) were reported. Approximately 88% (4646) of the cases were reported from the Nyiragongo health zone, while Kasirimbi reported 12% (627). In 2023, 4154 cases have been reported, with 19 deaths. Over the past 4 weeks, there has been a downward trend in number of cases. OCV campaign was carried out in IDP sites in Nord Kivu, and 355 074 people (97.5%) were vaccinated. Figure 11: Comparison of affected areas for Cholera in DRC 2022 and 2023 Democratic Republic of the Congo Cumulative Cases 22 703 Grade 3 CFR 1.4% Cumulative Deaths 321 Page | 12 Figure 12: Epicurve of cholera cases and deaths in Nyiragongo and Karisimbi Health Zones of Democratic Republic of the Congo, Epi week 1 2022 to Epi week 7, 2023 Page | 13 Cameroon declared a cholera outbreak in October 2021. Cumulatively, as of 26 February 2023 Cameroon has reported 15 275 cases with 310 deaths and nine deaths in 2023 (CFR = 2.0%). The outbreak affected 55 Health Districts in eight regions. Two regions have active transmission ongoing (Centre and Littoral). Figure 13: Epicurve of cholera cases in Cameroon from October 2021 to 26 February 2023 Public Health Actions ▪ WASH interventions ongoing in Ebebda et Monatélé districts ▪ Ongoing community sensitization Challenges/Gaps ▪ Access to safe water and toilet facilities a major challenge across communities Cameroon Cumulative Cases 15 275 Grade 3 CFR 2.0% Cumulative Deaths 310 Page | 14 The first case of cholera in Kenya was reported on 8 October 2022, following a wedding in Kiambu County. Cumulatively, 6238 confirmed cases and 99 deaths (CFR 1.6%) have been reported as of 6 March 2023. Cholera has been reported in 17 of 47 counties, with 8 counties reporting active transmission. Garissa and Tana River Counties have the highest attack rates. Garissa hosts IDPs and refugee population in Dadaab camps. Three of the most affected counties share a border with Somalia, and one with Ethiopia. Kenya has reported 2721 cases in 2023, with 32 deaths. The cholera outbreak in Kenya is occurring in the context of severe drought, especially in the most affected counties. Oral Cholera Vaccine campaign with 2.2M doses targeting four most affected counties was conducted between 11–20 February 2023, with vaccination c coverage reported as 99.1% Figure 14: Epicurve of Cholera outbreak in Kenya from 8 October 2022 to 6 March 2023 0 2 4 6 8 10 12 0 100 200 300 400 500 600 To ta l d ea th s To ta l c as e s Epi week Sum of cases Sum of deaths Kenya Cumulative Cases 6 238 Grade 3 CFR 1.6% Cumulative Deaths 99 Page | 15 Figure 15: Spot map showing distribution of cholera cases and deaths by Sub County in Kenya, 28 February 2023 Public Health Actions ▪ Water quality monitoring ongoing in affected counties ▪ Blocked sewer lines in Nairobi County being unblocked ▪ 99.2% reactive OCV coverage in refugee camps of Garissa County, and sub-counties of Tana River, Nairobi and Wajir Challenges/Gaps ▪ Inadequate capacity for cholera case management in the 14 counties with gaps in prompt patient management ▪ Drought in affected counties with competing priorities Page | 16 Since 2017 cholera outbreaks have been reported in Mozambique every year during the hot and rainy season (January to April and October to December), mainly from Nampula, Cabo Delgado, Sofala and Tete provinces. During the month of February 2023, more than 232 000 people were affected by floods and Tropical Storm Freddy-induced rainfall and flooding across south central Mozambique. This continues to challenge cholera response efforts. Since mid-September 2022 when the first cholera case was reported to 5 March 2023, a cumulative of 7517 cases have been reported, with 41 deaths (CFR = 0.5%). The outbreak has been confirmed in 33 districts in 6 of 11 provinces (Nissa, Sofala, Tete, Gaza, Manica and Zambezia). Niassa,Tete and Sofala account for 93.5% (7026) of all cases. From 1 January 2023, the country has reported 4979 cases with 35 deaths. Figure 16: Epicurve of cholera outbreak in Mozambique, September 2022 to 5 March 2023 0 1 2 3 4 5 6 7 0 100 200 300 400 500 600 700 800 900 2022 W49 2022 W50 2022 W51 2022 W52 2023 W1 2023 W2 2023 W3 2023 W4 2023 W5 2023 W6 2023 W7 2023 W8 2023 W9 To ta l d e at h s To ta l c as e s Epi week Sum of cases Sum of deaths Mozambique Cumulative Cases 7 517 Grade 3 CFR 0.5% Cumulative Deaths 41 Page | 17 Figure 17: Districts reporting Cholera cases in Mozambique as of 26 February 2023 Public Health Actions ▪ WHO supported with 6 tents, cholera kits (central, periphery, community), IV cannulas, Cholera RDT Kit and other consumables. ▪ The first virtual scientific session on clinical practice was held in Tete with participation of all districts. ▪ WHO provided 32 484L of Ringer Lactate to MoH ▪ WHO deployed staff to support the response in Niassa (4), Sofala (2), Tete (2) province ▪ Additional request for 1 571 099 doses for 15 districts submitted on 24 February 2023 to ICG. Challenges/Gaps ▪ Shortage of staff to carry out the case management. ▪ Inadequate hygienists ▪ Shortage of Certeza, spray pumps, buckets and chlorine. ▪ Delay sharing of data from the lower to the next levels. Page | 18 Cholera outbreak has occurred in 14 Woredas of Oromia (10 woredas) and Somali (4 Woredas) regions of Ethiopia. The Index case was from Harana Buluk on 27 August 2022. Cholera outbreak has occurred in 14 Woredas in Oromia (10 and Somali (4 woredas) regions. Cumulatively, Ethiopia has reported 1597 cholera cases with 38 deaths (CFR = 2.4%). Since 1 January 2023, 782 cholera cases with 11 deaths have been reported. The Somalia region, which had reported to have controlled now has active transmission. OCV campaign in Oromia region vaccinated 76 226 (99.8%); Somali region’s coverage is 14 021 (43.9%) since 22 February 2023, and the National coverage is 83.32%. Figure 18: Epicurve of Cholera outbreak in Ethiopia from October 2022 to 5 March 2023 0 1 2 3 4 5 6 7 8 0 20 40 60 80 100 120 140 160 2 0 2 2 W 3 4 2 0 2 2 W 3 5 2 0 2 2 W 3 6 2 0 2 2 W 3 7 2 0 2 2 W 3 8 2 0 2 2 W 3 9 2 0 2 2 W 4 0 2 0 2 2 W 4 1 2 0 2 2 W 4 2 2 0 2 2 W 4 3 2 0 2 2 W 4 4 2 0 2 2 W 4 5 2 0 2 2 W 4 6 2 0 2 2 W 4 7 2 0 2 2 W 4 8 2 0 2 2 W 4 9 2 0 2 2 W 5 0 2 0 2 2 W 5 1 2 0 2 2 W 5 2 2 0 2 3 W 1 2 0 2 3 W 2 2 0 2 3 W 3 2 0 2 3 W 4 2 0 2 3 W 5 2 0 2 3 W 6 2 0 2 3 W 7 2 0 2 3 W 8 2 0 2 3 W 9 To ta l d e at h s To ta l c as e s Epi week Sum of cases Sum of deaths Ethiopia Cumulative Cases 1 597 Grade 3 CFR 2.4% Cumulative Deaths 38 Page | 19 Zambia’s index case was confirmed in Vubwi district on 21 January 2023 and was linked to the Mozambique outbreak. Vubwi district continues to receive cases from Malawi and Mozambique seeking for care in Vubwi health facilities. Currently six districts are affected (Vubwi, Chipata, Chipangali, Lusangazi, Mwansabombwe and Nchelenge. Three of the four districts in Eastern province all share a border with Malawi, with Vubwi bordering Mozambique as well. Mwansabombwe and Nchelenge districts in Luapula province both border the Democratic Republic of the Congo, which has an active cholera outbreak. The fishing camps on Luapula river are characterized with poor WASH and are the epicenters for the current outbreak. Cumulatively, Zambia has reported 215 cases and 5 deaths (CFR = 2.3%) as of 05 March 2023. Figure 19: Reported cholera cases seen at health facilities in Zambia 21 January to 5 March 2023 Public Health Actions ▪ 6-months National Cholera Contingency Plan finalized ▪ Technical teams deployed to support response in the 5 districts. ▪ Enhanced WASH interventions ongoing Challenges/Gaps ▪ Inadequate multi-sectoral participation by key line ministries and partners ▪ Critical shortage of transportation for responders in all the 5 affected districts (Motor vehicles, motor bikes, boats for marine transport) Zambia Cumulative Cases 215 Grade 3 CFR 2.3% Cumulative Deaths 5 Page | 20 Burundi has reported cholera cases since 8 December 2022, and the outbreak was officially declared on 1 January 2023. Since then, the country has reported 145 cumulative cases, and 1 death (CFR 0.7%) across six health districts, some of which border South Kivu in DRC. Figure 20: Epicurve of Cholera outbreak in Burundi by date of notification as at 4 March 2023 0 0.2 0.4 0.6 0.8 1 1.2 0 5 10 15 20 25 30 2022 W32 2022 W37 2022 W50 2022 W52 2023 W1 2023 W2 2023 W3 2023 W4 2023 W5 2023 W6 2023 W7 2023 W8 2023 W9 2023 W10 To ta l d e at h s To ta l c as e s Epi week Sum of cases Sum of deaths Burundi Cumulative Cases 145 Grade 3 CFR 0.7% Cumulative Deaths 1 Page | 21 Figure 21: Distribution of cholera cases in Burundi, 6 March 2023 Public Health Actions ▪ Adapted training modules on case management and on Infection Prevention and Control ▪ Supplied drinking water & distributed aquatabs for households in 5 districts affected with the water trucking system ▪ Recruited additional staff for case management in cholera treatment centres and units ▪ Trained of 180 community health workers, 71 healthcare providers and 30 floor technicians on various aspects of cholera management and response Challenges/Gaps ▪ Inadequate provision of safe drinking water to communities in affected areas ▪ Poor access to sanitation facilities in affected health districts ▪ Low involvement of community leaders and community health workers in awareness- raising and monitoring Page | 22 Two cases of cholera were imported into South Africa (Gauteng province) by two travelers returning from Malawi on 30 January 2023. The third case was a close household contact of one of the returning travelers in same province (import related cholera case). Two additional cases were diagnosed in Gauteng province (one from the city of Johannesburg district, one in the city of Ekurhuleni district). These two cases are not linked the earlier cholera cases and had no information linking them to recent international travel to cholera affected countries. The sixth case is a Malawian national with no travel history. South Africa is therefore experiencing cholera from importation and possible local transmission, a situation that poses a risk of further spread within the country due to population movements, presence of unplanned human settlements and squatter camps, flooding in some parts of the country, areas with limited access to safe water and hygiene and sanitation facilities. Zero new cholera cases have been reported from South Africa during week 9 (week ending 4 March 2023). Figure 22: Epicurve of Cholera outbreak in South Africa, 28 January to 4 Mar 2023 Public Health Actions ▪ Mapping of high-risk points of entry and provinces for cholera importation done ▪ Cholera readiness assessment completed at national level and for eight of nine provinces Cholera contingency plans for 5 provinces completed, ▪ The National Department of health released three media statements to alert the public about the cholera threat. Challenges/Gaps ▪ Finalisation of national contingency plan ▪ Risk of importation remains high even with current community transmission ▪ Training needs across all response pillars ▪ Scale up of WASH & RCCE interventions South Africa Cumulative Cases 6 Grade 3 CFR 16.1 % Cumulative Deaths 1 Page | 23 Cholera was first reported on 22 January 2023 in Nyasa District Council in Ruvuma Region. The index case had participated in the burial of person who died in Mozambique, whose body entered Tanzania on 13 January 2022. Cumulatively, 49 cases and 3 deaths (CFR 6.1%) have been reported. Kigoma (bordering DRC) and Katavi regions have also reported cases. Figure 23: Epicurve of cholera cases in United Republic of Tanzania, 15 January to 4 March 2023 0 0.5 1 1.5 2 2.5 0 2 4 6 8 10 12 14 16 18 2023 W2 2023 W3 2023 W4 2023 W5 2023 W6 2023 W7 2023 W8 2023 W9 To ta l d e at h s To ta l c as e s Epi week Sum of cases Sum of deaths Public Health Actions ▪ Total of 106 800 Aqua tabs have been distributed to 534 households ▪ o Total of 534 households inspected: households with improved toilets, 337 (63.1%), without toilets, 34 (6.3%) and with durable and functional handwashing facilities, 123 (24%) ▪ Engagement with border district (Uvinza) to strengthen surveillance and risk communication ▪ Water quality check in all checked sources of water showed contamination by E.coli ▪ Partner engagement (Save the Children) in the areas of WASH, RCCE and Surveillance Challenges/Gaps ▪ Water quality testing ▪ Need to treat household water sources United Republic of Tanzania Cumulative Cases 49 Grade 3 CFR 6.1% Cumulative Deaths 3 Page | 24 Zimbabwe reported two cholera cases with zero deaths on 23 February 2023 in the city of Chegutu, Mashonaland West Province, about 100 km east of the capital Harare. Total number of suspected cases were 25. A total of 13 tests were done, of which two were positive (positivity rate = 15.3%). Two admissions were done at Chinengundu clinic cholera camp. It is still unclear what the source of the infection is, but there is a suspicion of a borehole being the source. The borehole is two metres away from the sewage pipeline. Public Health Actions ▪ CTC has been set up at Chinengundu ▪ Community engagement ongoing with health education in helth facilities Challenges/Gaps ▪ No stock of Lab consumables – stool collection jars Zimbabwe Cumulative Cases 2 Grade 3 CFR 0.0% Cumulative Deaths 0 Page | 25 The Ministry of Health of South Sudan declared cholera outbreak in Malakal, Upper Nile State on 7 March 2023. The MoH received an alert of suspected cholera outbreak on 25 February 2023 from the State Ministry of Health. On 22 February 2023, Medicines’ San Frontiers Spain (MSF Spain) in Malakal received alert of increasing cases of acute watery diarrhea and vomiting in children aged one year and below. Investigations were carried out and two out of nine samples tested positive for Vibrio cholerae on PCR at the Central Public Health Laboratory in Juba. Cumulatively, 179 cases including 1 death (CFR = 0.6%) have been reported as of 7 March 2023. Children aged 0–4 years are the most affected, accounting for 95% (170) of the cases. Of the 179 cases, 109 (61%) are from Malakal Town, while 70 (39%) are from Malakal Protection of Civilian Sites (POC). Add South Sudan map WHO ACTIVITIES Readiness: ▪ A High-level Emergency Ministerial meeting on Cholera epidemics and Climate-related public health emergencies take place this week 9-10 March 2023 in Malawi. The meeting will also include discussion on cross border engagements across neighbouring countries ▪ 19 countries prioritized for Cholera readiness under priority 1 and 2 countries (see blow table). ▪ WHO in the African Region has shared an alert memo to all priority 1 and 2 countries including recommended action for cholera readiness. ▪ Ongoing bi-weekly meetings with priorities 1 and 2 countries to share updates on the ongoing readiness activities. Response: ▪ Regional cholera strategic readiness and response plan finalized. ▪ Ongoing weekly meetings with all countries in response ▪ Strengthening cross-border collaborations on cholera surveillance ▪ Ongoing deployments to countries as requested by countries ▪ Technical inputs on training in case management and establishment of CTCs/CTUs ▪ Strengthening surveillance activities including community-based surveillance ▪ Intensified risk communication and community engagement using all media types as well as community influencers ▪ Conduct of mortality audits in some countries ▪ Technical support to countries on vaccination strategies for reactive OCV campaigns South Sudan Cumulative Cases 149 Grade 3 CFR 0.6% Cumulative Deaths 1 Page | 26 Table 2: Categorisation of countries at risk Category Description of category Member States Key Actions. Category One Member States with • High number of districts at high risk of cholera • Unaffected provinces /districts in countries with an active cholera outbreak • Countries at high risk of cross-border transmission • Countries with limited capacity in the cholera checklist • Zimbabwe, South Sudan, the United Republic of Tanzania, Niger and Togo • Unaffected provinces/districts in countries with an active cholera outbreak (Mozambique, Zambia, Kenya, Ethiopia, DRC and Burundi, Nigeria, South Africa, Cameron) • Countries with limited capacity using the cholera checklist assessment tool (Madagascar) Response actions if Outbreak is confirmed. Application of Minimum Operational Requirements +Recommended Readiness Interventions Category Two Member States with • moderate risk of importation of a cholera case from one or any of the above countries (category one) • few districts with a high risk of the cholera outbreak Uganda, Benin, Rwanda and Burkina Faso Response actions if Outbreak is confirmed. Application of Minimum Operational Requirements +Recommended Readiness Interventions Category three Member States with: • low risk of importation of a cholera case from one or any of the above countries (categories one and two) All the other countries in the Region Application of Minimum Operational Requirements +Recommended Readiness Interventions and Risk Monitoring Page | 27 For additional information, please contact Cholera Epi/Surveillance Team Lead: Dr LUKOYA Okot Charles e-mail: okotc@who.int or the Incident Manager Regional Cholera IMST: Dr RAMADAN Otim Patrick: ramadano@who.int