6. You are a district medical officer in charge of Harare Eastern District.

You have noticed an

unprecedented rise of diarrhoeal cases in your area. Using the prevent , protect and treat strategy
briefly discuss the strategies necessary to address the problem.

In Zimbabwe, with the repeat occurence of diarrhoeal outbreaks annually, it is important to firstly define
wether or not this unprecedented rise in diarrhoeal cases is an outbreak. The Centre of Disease Control
defines an outbreak as the occurence of more cases of a disease than would normally be expected in a
specific place or in a group of people over a given period of time. In terms of prevention , protection and
treatment, I would classify my approach into four levels- primary, secondary, tertiary and quatenary.

At the primary level, prevention would involve reducing number of patients that acquire the diarrhoeal
illness in the first place. This would involve public eduation on improving personal hygiene, especially at
household and preschool levels. Improvement in proper sewage management systems, access for the
community to running water and soap for washing hands especially at food stalls and areas of public
gatherings. Promotion of proper preparation of food and consumption well cooked and heated food.
Drinking water should be from a verified safe source or treated to achieve adequate sanitary standards
for the district. Avoidance of over crowding, and avoid close contact or sharing of untensils with
individuals already diagnosed with the diarrhoeal illness and early referral of these individual cases. If
vaccine is already available for diarrhoeal illness, at risk groups should be given vaccine at least, and if
possible the general public should be vaccinated as well.

At the secondary level, case definitions should be made clear, with particular guildelines written out for
Harare, with use of WHO guidelines in conjunction if available. Clear distinctions should be made
between a confirmed case,at risk group, probable case state, chronic carrier state and a suspected case.
For example according to WHO, a confirmed case of typhoid is a patient with persistent fever lasting 3 or
more days, with laboratory confirmed salmonella typhi organisms noted in blood, bone marrow and
bowel fluid. These guidelines should be distributed to all health staff and easily available at all health
facilities, in hard and soft copies,as well as online, to increase ease of accessibility. Training sessions
should be carried out for health staff to improve competencies in use and applicabilty of guidelines to
the existent setting and infrastructure. Involvement of private and public stakeholders, including
ministry of health, non governmental organizations, such as, UNICEF, in assisting finanicially, as well as in
implementing strategies to prevent spread to other districts and/or to promptly start interventions in
other districts as well. Routine screening of at risk groups, public and potential carriers like child care
givers and food handlers. Child policy at day care centers should have requirements for children before
accepting them into the gathering, for example proof of vaccination card. Adequated nutrition,
notification and isolation of new cases. Easing access to health facility, using interventions such as
mobile clincis , improvement in transport infrastructure and prompt response by health teams present
at health facilities of presenting cases. Use microbiology studies to identify, isolate causative organisms,
culture and note sensitivity to enable use of appropriate antibiotics. Adequately equipped health centre,
to provide high quality efficient supportive care.

At the tertiary level, aggressive rescuscitation to reduce life threatening sequalae secondary to the
diarrhoeal illness. For example, for a patient with typhoid, it is essential to investigate and correct any
clotting defect using vitamin K, plasma platelet infusion, and use of antibiotics that are effective and
supported by microbiologic evidence. Focused nursing care and multi disciplinary team approach to
providebest patient care. For quaternary level, this includes methods to mitigate and/or avod use of
unneccessary or excessive interventions in the health system. Thus re -assurance of health staff, and
employment of public health personnel and techniques to research and guide refinement of evidence
based approach to interventions directed towards the diarrhoeal illness. Referral to pre- existing data on
the diarrhoeal illness should be made and contextual applicability of interventions ot the district's
unqiue social,cultural,economic state should be noted and used as part of guidance of approach
strategies.

In conclusion, no one method can adequately address an unprecedented rise in disease cases in a
district, but rather a combination of evidence based approaches should be used in effectively addressing
the health query.