Cholera is a gastrointestinal disease caused by the microorganism called Vibrio cholerae. V cholerae is a slightly curved, gram negative rod shaped and single polar flagellum microbe. The microorganism grows in the small intestines and produces an exotoxin (cholera toxin) that will cause the cells in the body to secrete water and electrolytes (especially potassium). The end result of this occurring will be “rice water stool” being excreted by the host. An individual can lose as much as 12 to 20 litres of fluid in just one day and this can result in shock, collapsing or even death due to the electrolyte lost as well. The loss of fluids causes vital organs to shut down due to blood becoming very thick. Spells of vomiting can also occur hence greater loss of fluids is not only due to the diarrhoea. The bacteria thrives in aquatic environments and forms biofilms on aquatic plants to insure its survival (G Tortora, 2010). There are different serogroup strains of cholera. In the 1800s serogroup O:1 caused a pandemic and is known as the classical strain. It was only in the 1900s that they discovered that there were other strains of cholera, for example, serogroup O:139. There are also non-epidemic strains such as non-O:/O:139 that are less frequently associated with large-scale cholera outbreaks. These strains usually cause sepsis and wound infections especially in people who compromised immune systems or suffering from liver disease. (Tortora G, 2013)Cholera causes large epidemics in more than fifty countries. The main mode of treatment of patients is replacing the fluids lost due to the diarrhoea in patients alongside antibiotics to decrease the period of diarrhoea. Antibiotics are advised for patients with moderate to severe dehydration. (J Harris, 2012)The world had experienced seven cholera pandemics within the last 190 years which has resulted in many lives being claimed by this disease. The contributing factors being the inability to access safe drinking water. Africa has shown to be the most affected continent and an example is the outbreak that occurred in Zimbabwe in 2008. The epidemic originated in Chitungwiza and gradually spread to the rest of the country affected 58 out of the 62 districts in the 10 provinces. The overall case fatality rate was 5.3% and more than two thirds of the deaths reported where from regions with no treatment facilities. There was a sense of urgency when it came to dealing with this outbreak because of the 634 cases reported daily 35 deaths occurred. Cholera treatment centres (CTC) where set up across the country to help manage the situation. The International Centre for Diarrhoeal Diseases Research, Bangladesh (icddr,b) where asked by the World Health Organization’s (WHO) Global Outbreak Alert and Response Network (GOARN) to assist with the situation in Zimbabwe. A six-member team of cholera experts where sent to support the Ministry of Health and Child Welfare (MoHCW) to manage the outbreak. It was observed that after there was an overuse of intravenous fluids and lack of monitoring of patients which contributed to the epidemic meaning individuals would continue to be unwell. The CTCs did not follow the stipulated antibiotic administration protocol thus contributing to the outbreak. Laboratory support was limited and rectal swab results showed that V. cholerae O1 of either Ogawa or Inaba serotype and that there was a 100% sensitivity to azithromycin and ciprofloxacin. Water sources in Zimbabwe where highly contaminated. Zimbabwe is endemic to cholera outbreaks since 1992. The disease was kept under control as small outbreak occurred between January-April did not attract much attention despite the deteriorating health system in Zimbabwe. Physicians and nurses where leaving the country due to the economic situation which resulted in poor health service during the epidemic (S Ahmed, 2011).A study revealed that the 2008-2009 outbreak was due to human rights abuse. The lack of clean water, good health care, aid and information. 98,585 cases where reported with more than 4,000 deaths recorded during this period. A second wave of infection that lasted through June 2011 was reported and this occurred after presidential elections (A Cuneo, 2017).Smaller outbreaks have occurred over the years. In 2010 and 2011, 1022 and 1140 cases respectively where recorded and dealt with within time due to the response capacity from the 2008/2009 outbreak. From the 22nd of January to the 24th of March 2018, 111 cases were reported with 4 deaths recorded with a CFR of 3.6%. Below is a table showing the outbreak trends in Zimbabwe since 2008 (A Chimusoro, 2018).In September 2018 another cholera outbreak occurred. Though it was swiftly dealt with this outbreak could have been avoided. The conditions that resulted in the 2008 outbreak clearly had not been rectified thoroughly (C Mavhunga, 2018). The first case reported was of a woman who tested positive for Vibrio cholerae serotype O1 Ogawa on September 5, 2018. The case fatality ratio was 0.8% with 98% of the cases occurring in the suburbs of Harare (Glen View and Budiriro). (WHO, 2018)The outbreak in 2018 clearly exposed the challenges that Zimbabwe was facing. Public gatherings had to be cancelled as a method of alleviating the outbreak rate as more that 5.00 had been infected. This outbreak brought to light the dilapidating infrastructure in the city. Clean water could not be availed by the city council resulting in boreholes being drilled as a source of clean water. However these very boreholes where contaminated with sewage water showing that the city was neglecting the availability of clean water as well as fixing sewer pipes. Politics played a role as opposing parties played the blame game as to why the city was falling apart (J Burke, 2018).Discussion C Fambira (2018) stated that, “The conditions that necessitate the spread of cholera and typhoid in Zimbabwe have not changed since the 2008 outbreak. They have worsened because there is no political will to tackle it” (Newsday, 2018). This statement was brought about as a result of the cholera outbreak in 2018. Though many lives were not taken unlike in 2008 this could still have been avoided.For nearly two decades the quality of drinking water in Harare has been questionable. City administrators fail to address the water problems in or push for the improvement of infrastructure. Former minister of Health, Dr David Parirenyatwa said that 95% of the boreholes in the city where contaminated. Thus highly increasing the risk of infection (Newsday, 2018). Zimbabwe continues to be a cholera hotspot due to the neglect imposed by city officials. Accessibility to clean water should be addressed by city officials but up to date some areas have no clean water available for consumption. Cyclone Idai struck Mozambique affecting part of Zimbabwe in the process in March 2019. The Global Vaccine Alliance with the support of UNICEF and WHO assisted in putting in place preventative measures against the risk of having a cholera outbreak. They did so by vaccinating all the residents from Chimanimani and Chipinge districts who were aged 12 and above with the cholera vaccine. This was because clean water sources were damaged by the cyclone (T Zivira, 2019).A Kone-Coulibaly (2010) and team carried out a case – control study. Their control group consisted of individuals above the age of 2 years of age who had not contracted cholera. The study group consisted of Harare residents above the age of 2 years who were suffering from acute watery diarrhoea and where either vomiting or not vomiting. The study looked at 11,203 cases which had a case fatality rate of 3.98%. The median age 28 years (Q1 = 20 and Q3 – 37.5) of age and 28.5 years (Q1 = 23 and Q3 – 38) for cases and controls respectively. The high case fatality rate could have been due to poor case management as well as lack of adequate staff in the treatment camps set up. The outbreak was due to lack of proper personal hygiene practices due to water supply shortages. The lack of sufficient knowledge about cholera was also a contributing factor to this outbreak as people had no knowledge of preventative measures against this disease. Another factor was living with an infected individual as this increased the chances of one contracting the communicable disease. For their study they concluded that clean water should be provided, people should be educated and health workers should be recruited who will prioritize cholera case management. Eating cold food (95% Confidence Interval (CI) of 1.53 – 11.70 and an Adjusted Odds Ratio (AOR) of 4.24) was found to not be a risk factor that contributed to the cholera outbreak. Independent protective factors where washing hands after using the toilet, drinking tap water and eating hot food always [95% CI (0.17 – 0.49) and AOR= 0.29] (A Kone-Coulibaly, 2010).This study brought fourth results and showed the gaps within the health system. These gaps where all brought forth by the poor economic situation in Zimbabwe. The lack of access to clean water being the main contributing factor that initiated this outbreak. The same can be said for the 2018 outbreak which was due to borehole water being contaminated. The shortfall with this study was the fact that their control group consisted of looking at individuals who where neighbours to a cholera case. The probability that these individuals where indeed not infected by the microorganism was high as they were in close proximity to infected individuals. If good hygiene practices were not practiced due to lack of education then this would result in healthy people becoming infected. The risk becomes higher is there are children living close to or with infected individuals as they are susceptible to infection. Thus selection or observational bias was bound to occur as some individuals who were not ill ran the risk of becoming ill even though they were deemed as controls for the study. The advantages of case-control studies however where that results were obtained much faster allowing for the risk factor of an outbreak being identified. This type of study is also not expensive and rather simple (S Lewallen, 1998).Contrary to the decrease in case fatality ratio since 2008 it remains constant at about 2% which points towards the in-effectiveness of the current health systems (W Gwenzi, 2019).S Chigudu (2019) carried out interview based research arguing that cholera was mostly experienced in high density areas stating that the health problem was due to political-economic crisis. The economic crisis drove Zimbabweans to live a life of street hustling. The cholera outbreak allowed people to view the interconnections of the multiple urban crisis in Zimbabwe. The answers to Chigudu’s questions given in the article show a connection to the collapse of Zimbabwe’s infrastructure and public health. In one interview a gentleman who possessed the skills required to assist the city as a water, hygiene and sanitation specialist stated that they were unemployed as government was not employing people due to lack of adequate funds to sustain civil servant salaries.The challenge with interview based studies is that though one is getting information first hand individuals may supply incorrect information. For diseases like cholera this type of study allows researchers to see if the public health officers are relaying information to the general public or not. Capital also plays a part as a shortfall as the interviewer has to travel to gather information meaning the sample size is also limited.The advantages of this type of study however are that somewhat accurate results could be obtained from those on the ground when it came to this epidemic (S DeFranzo, 2014).ImplicationsThe public health response was implemented after the Ministry of Health and Child Care declared the cholera outbreak as an emergency. Committees where gathered and established at the national and district levels. WHO, offered support in terms of strengthening the surveillance and coordination international and national health experts as well as providing support for the laboratories in terms of improving diagnostic output. The government began to look at conducting vaccination campaigns. Cholera treatment centres were set up by Medecins Sans Frontieres who provided support by providing nurses to assist (WHO, 2018). Recommendations such as the use of effective and correct antimicrobial drugs were suggested by the icddr,b team. The development of certified laboratories as well as having a strong surveillance system and team. Training of individuals in order to have a good staff for the management of an outbreak. Creation of awareness programs that promote use of oral rehydration salt (ORS) solution by the community (S Ahmed, 2011).Organizations such as the Community Working Group on Health (CWGH) supported the cholera outbreaks by providing health literacy by sensitizing communities about the disease. They also aided with the installation of in-line chlorinators on boreholes so that communities had access to clean drinking water (I Rusike, 2017).ConclusionThe government continues not to learn from their mismanagement errors as cholera continues to take many lives. The life of one individual affects many especially if the breadwinner in a family is the one who passes on due to diseases like cholera which can be avoided. A disease that could be possibly eradicated still continues to thrive due to government neglect to fix sewer pipes.The mayor of Harare admitted that the water in Harare was not safe to consume due to the shortage of chemicals used to treat the water in order to make it safe for consumption. This brought to light the fact that people in Harare are not drinking safe water which contradicts the human rights of these citizens as it is a right to have clean water as stated under the Declaration of Rights, Chapter 4, Section 77. The government has introduced cholera vaccines in order to control the spread of the disease without even addressing the root causes of the disease origin. This clearly shows the gap in addressing public health matters. The Public Health Act (PHA) Amendment Bill has to be finalized in order for this disease to be dealt with swiftly as it addresses poor service delivery (I Rusike, 2017). Clearly the main aim of the government is to simply control the outbreak without addressing the causes and challenges of dealing with cholera.