Intra action review of the cholera outbreak response in Kadoma city, Zimbabwe, 2024

Abstract

Background

An Intra-Action Review (IAR) is a real-time evaluation conducted during an emergency response to identify good practices, challenges and inform corrective actions. It allows for timely learning and course correction during ongoing outbreaks. In 2024, Kadoma City experienced a cholera outbreak that resulted in 1799 cases managed at the Cholera Treatment Center (CTC), 2535 suspected cases seen at Oral Rehydration Points (ORPs), and 31 deaths. As part of the response, an IAR was conducted, led by Kadoma City Council, to evaluate coordination, identify challenges, and document best practices to improve the current response and strengthen preparedness for future outbreaks.

Methods

The IAR employed a qualitative and participatory approach following WHO methodology to assess cholera outbreak response activities in Kadoma City. The IAR reviewed response activities from January 4 to April 30, 2024, and was conducted in-person on May 2, 2024, using a working group format. The working groups covered eight response pillars aligned to the five core functions of the Incident Management System (IMS). Out of 83 participants invited, 77 (92.8%) attended and these included representatives from Kadoma City Council, Ministry of Health and Child Care (MoHCC) and partner organizations such as Africa Center for Disease Control and Prevention (Africa CDC), WHO and Médecins Sans Frontières (MSF). Data were collected using standardized IAR note-taking templates covering all eight response pillars and analyzed thematically to identify best practices, challenges, and recommendations.

Results

The IAR was attended by seventy-seven (77) participants. Several best practices that enhanced the cholera outbreak response were identified. These included the use of the IMS to provide structured coordination, marking the first activation of all five core IMS functions for a cholera outbreak response in Kadoma. Daily analysis of surveillance data which supported informed decision-making. The use of community health workers (CHWs) in community event-based surveillance (CEBS), enabling early case detection. Additionally, incorporating cholera survivors into risk communication and community engagement (RCCE) activities improved public awareness and increased acceptability of outbreak interventions. Key challenges noted included the absence of a dedicated physical Public Health Emergency Operations Center (PHEOC); transport constraints affecting movement of supplies, patients, and surveillance teams; human resource fatigue; shortages of infection prevention and control (IPC) resources and limited laboratory surveillance capacity due to shortages of rapid diagnostic test kits and inadequate capability to conduct culture-based identification of microorganisms. Also, inadequate consideration of people with disabilities in RCCE strategies was noted.

Conclusion

The structured response approach in Kadoma improved coordination, data use, and community-level case detection. However, challenges such as absence of a PHEOC, transport constrains, limited laboratory capacity, and supplies highlighted the need for stronger emergency preparedness and inclusive response systems.

Introduction

Cholera, a waterborne disease caused by Vibrio cholerae, continues to cause significant morbidity and mortality in Africa, despite its elimination from most developed countries over a century ago [1, 2]. Historically, cholera received limited attention as a public health priority disease until the 2010 outbreak in Haiti, which shifted global focus and triggered stronger surveillance efforts worldwide [1, 3]. Over the past two decades, more than 2.6 million cases and 60,000 deaths have been reported globally, with sub-Saharan Africa bearing a disproportionate burden [4]. Between 2010 and 2019, the region accounted for approximately 24% of all the cases globally [1]. In 2024 alone, cholera outbreaks in the WHO African region affected 14 countries, with severe impacts in the Democratic Republic of Congo, Ethiopia, and Nigeria [5]. As of 31 July 2024, 112,301 cases and 1,900 deaths had been reported, with a case fatality ratio (CFR) of 1.7% [5]. Comoros, The Democratic Republic of the Congo (DRC), Ethiopia, Zambia, and Zimbabwe, accounted for over 83% of these cases.

Zimbabwe has experienced recurring cholera outbreaks, most notably in 2008–09, 2010, 2018, and 2023 [6, 7]. The most recent outbreak began in Chegutu district in February 2023 and spread nationwide, reaching Kadoma City by early January 2024. In Kadoma the outbreak was declared officially over in July 2024, after seven months of response. During this period, Kadoma recorded a total of 1799 cholera cases at its cholera treatment center (CTC) located at Ngezi and 2535 suspected cases were attended to at five community-based oral rehydration points (ORPs). The city reported 31 fatalities, with an overall CFR of 0.72%. To improve outbreak response, Kadoma City health department used the Incident Management System (IMS), which centralized response coordination through five core functions- incident management, operations, finance & administration, planning, and logistics. Guided by an Incident Action Plan (IAP), the IMS provided a structured framework for managing the outbreak, defining specific activities for each response pillar and establishing key performance indicators to monitor response effectiveness.

Under the International Health Regulations (IHR) 2005, countries are required to develop core capacities for detecting, assessing, and responding to public health emergencies [8]. The IHR Monitoring and Evaluation Framework further emphasizes regular evaluation through annual reporting, joint external evaluations (JEEs), simulation exercises and After-Action Reviews (AARs) [9, 10]. To complement this, the World Health Organization (WHO) introduced Intra Action Reviews (IARs) to enable continuous assessment during active outbreaks, allowing for real-time response adjustments that strengthen resilience [9, 11]. In line with this, Kadoma City Council conducted an IAR in May 2024 as part of cholera outbreak response monitoring and evaluation. This study describes how Kadoma City Council conducted a structured real time evaluation of the cholera outbreak response, documenting the operationalization of the IMS at subnational level, with the aim of systematically identifying best practices, challenges, and their associated impacts, and developing evidence-based recommendations to strengthen the outbreak response.

Methods and materials

Study design

The intra-action review followed the WHO methodology and principles for conducting an IAR [11]. A qualitative and participatory approach was used to assess response activities carried out from January 4 to April 30, 2024. It was designed as a one-day event structured into plenary sessions and breakout working groups.

Study setting

The IAR was conducted in Kadoma City, located in Mashonaland West Province, Zimbabwe. The city has a history of recurring cholera outbreaks, with significant episodes recorded in 2008–09, 2010, 2018, 2023 and the most recent outbreak from January to July 2024. Response to the outbreak in 2024 was managed using an Incident Management System, with operational support from local and international partners, including UNICEF, International Medical Corps (IMC), WHO, Médecins Sans Frontières (MSF), Africa CDC, and the Zimbabwe Red Cross Society. The IAR was conducted in-person on May 2, 2024, at the Anglican Hall in Kadoma.

Study population and sample

The IAR involved a multidisciplinary team of stakeholders who were directly engaged in the cholera response. A total of 77 participants attended the IAR out of 83 individuals invited, yielding a response rate of 92.8%. Participants were purposively selected based on their involvement in cholera response activities, ensuring representation from different operational levels and response pillars. These participants included Kadoma City Cholera IMS core function pillar leads, representatives from the Ministry of Health and Child Care (Sanyati District Health Team), cholera survivors, community health workers, representatives of people with disabilities including those with sensory and physical impairments, community members, and private sector stakeholders. Additionally, experts from partner organizations such as the Africa CDC, MSF, World Vision, Zimbabwe Red Cross, and WHO were in attendance. A summary of the participant composition is presented in Table 1.

Table 1.

IAR participants composition, Kadoma city, 2024

Participant Group/Affiliation	Number of Participants
Kadoma City Council	21
Other local municipalities	19
Ministry of Health and Child Care (Sanyati District Health Team)	8
Office of the President and Cabinet	2
Private sector representatives	3
Community Health Workers	8
Cholera survivors	2
Representatives of partner organizations	7
Leaders of local community groups	7

Data collection

To conduct the IAR, Kadoma City established a coordinating team consisting of 12 members. These included the Cholera IMS core function pillar leads (8) and four representatives from partner organizations that supported the city’s outbreak response. The team was responsible for defining the objectives, scope, and methodology of the IAR, identifying relevant stakeholders, and engaging external lead facilitators, report writers, and notetakers.

As part of the preparatory phase, the team reviewed the line list data and constructed an epidemic curve to visualize the temporal distribution of cases, which was later referenced during the analysis of response activities. The IAR began with introductory presentations outlining the methodology, objectives, agenda, and an epidemiological overview of the cholera situation in Kadoma City. The IAR focused on five core functional areas of the IMS (Incident Management/Coordination, Operations, Plans, Logistics, and Finance & Administration) which were organized into eight response pillars and working groups. The eight response pillars identified were:

• Incident Management (Coordination)

• Plans and Surveillance

• Logistics

• Finance and Administration

• Risk Communication and Community Engagement (RCCE)

• Case Management

• Infection Prevention and Control (IPC)

• Water, Sanitation, and Hygiene (WASH)

To ensure data quality, each group’s discussions were led by an experienced facilitator and a pillar lead who guided discussions within their respective groups. An interactive feedback process, both within and between working groups, further enhanced the reliability of the data. Within-group feedback allowed members to review and refine their collective responses in real-time, promoting clarity and consensus. Between-group feedback sessions enabled groups to present their findings to others, allowing cross-validation, identification of overlaps or discrepancies, and enriching insights from multiple perspectives. Sticky notes were also used to capture real-time insights shared during discussions, ensuring both accuracy and inclusivity.

Data analysis

Qualitative data from the IAR were recorded in real time using the WHO note-taking template, which is inherently structured around Root Cause Analysis (RCA) principles [12]. For each of the eight response pillars, note takers captured best practices, their impacts and enabling factors, as well as challenges and their impacts with limiting factors, thus addressing both what happened and why it happened. Immediately after the IAR, these completed note-taking templates were synthesized into a final report guided by the WHO final IAR report template. During the post IAR analysis, all enabling and limiting factors were mapped to predefined thematic domains which are coordination, information flow, training, inclusivity, human resources, infrastructure, logistics, standard operating procedures (SOPs), equipment and technology. A structured “5 why’s” questioning probe was then applied within each domain to identify the underlying root causes. This template-driven approach ensured consistency across pillars and directly informed the development of evidence-based, pillar-specific prioritized actions.

Results

A total of 77 participants attended the IAR. These included representatives from Kadoma City Council (21), local authorities (19), the Ministry of Health and Child Care (MoHCC) (8), Office of the President and cabinet (2), Community Health Workers (CHWs) (8), cholera survivors (2), representatives of partner organizations (7) and leaders of various community groups (7). The private sector was also represented by stakeholders from laboratories, private health facilities, and pharmacies (3). A summary of the IAR participants composition is presented in Table 1.

The IAR reviewed cholera outbreak response activities implemented between January 4 and April 30, 2024. The index case had symptom onset on January 8, 2024, in Old Ngezi and was epidemiologically linked to six additional cases in the same area. The epidemic curve (Fig. 1) demonstrated a propagated transmission pattern, with successively higher peaks beginning February 5 and a major peak occurring on February 13. The observed four-day intervals between peaks aligned with the incubation period of cholera, indicating ongoing person-to-person transmission.

During the early phase of the response (January to mid-February), all cases were managed at Queen Mary CTC. In response to rising caseloads, a second CTC was established at Ngezi Clinic with a capacity of over 50 beds. Five additional ORPs were set up in high-burden areas, including Rimuka (2), Pixie Combie (2), and Waverly (1), improving access to care at community level and reducing pressure workload on CTCs. In April, a Knowledge, Attitudes, and Practices (KAP) survey was conducted to assess community awareness and behavior related to cholera prevention and control. A complementary survey on knowledge of prevention and response to sexual exploitation and abuse (PRSEAH) was also conducted among response partners and beneficiaries. Results of both surveys have been published separately.

The outbreak persisted for over 90 days. Although a decline in transmission was observed in April, new cases continued to be reported. The IAR served as a mid-response evaluation. Surveillance activities continued after the IAR, and the outbreak was officially declared over in July 2024. An epidemiological curve with a timeline of key events during the four-month response period evaluated by the IAR is presented in Fig. 1.

Fig. 1.

An Epi-Curve with Key Events During the Cholera Outbreak Response in Kadoma City, January to May 2024

The IAR assessed eight key response pillars: Incident Management (Coordination), Plans and Surveillance, Logistics, Finance & Administration, RCCE, Case Management, IPC and WASH. The overview of best practices, challenges, and priority actions identified within each of the eight cholera response pillars are outlined in Table 2.

Table 2.

Best practices, challenges and priority actions from the cholera IAR, kadoma, 2024

Pillar	Best Practices	Challenges	Priority Actions
Incident Management (Coordination)	- Timely activation of IMS which led to effective coordination, decision-making and resource mobilization. - Response was coordinated through an Incident management system and Incident action Plan (IAP) which were effective in initial response activities, particularly in ensuring availability of contingency stocks - Clearly defined roles, responsibilities and boundaries for partners through signing of memorandum of understanding (MOU).	- Weak coordination between city health authorities and local ministry of health and childcare (MoHCC) which resulted in s duplication of efforts at times. - Lack of a physical Emergency Operation Centre (EOC) affected coordination of activities especially across different organizations involved in the response. - Repurposing of departmental personnel and facilities resulted in gaps that affected continuity of other essential health services.	- Establish a physical PHEOC within Kadoma City Council/setup a makeshift PHEOC for coordinating response activities.
Plans and Surveillance	- Developed an Incident Action Plan (IAP) with clear objectives for each response pillar providing a strategic framework for responding to the outbreak. - Surveillance and epidemiological data/information was analysed routinely, producing critical information requirements (CIRs), essential elements of information (EEIs) and situation reports (SitReps), shared with all stakeholders and used to inform programming of response activities. - Use of community health workers (CHWs) enhanced public health surveillance through community event-based surveillance (CEBS). - Engagement of the community in response planning and implementation e.g. training of church leaders to assist with risk communication in the community.	- Use of paper-based data collection tools resulted in incomplete data, causing delays in analysis affecting ability to fully utilize epidemiological data to inform decision making. - Delayed sharing of Cholera Situation Reports, impacting the timely dissemination of critical information needed for strategic decision making. - Inadequate laboratory surveillance capacity, with limited capacity to meet the demand for RDT and culture testing resulting in a few cases being screened through RDTs.	- Digitize data collection tools to allow for real time sharing of information.
Logistics	- Use of locally available expertise and resources from previous outbreaks to set up a CTC with a capacity to accommodate over 50 patients and five community ORPs.	- Frequent breakdown of vehicles in the response. - Shortage of transport at the CTC for transporting patients, response personnel and supplies	- Collaborate with local leaders and business personnel to support city council with vehicles when needed during emergencies.
Finance and Administration	- Adequately trained human resources for emergencies - Engaged partners to support response activities (e.g. UNICEF, Red Cross, IMC, WHH) and the funds received from these partners were disbursed adhering to council procurement protocols.	- No incentives for staff involved in response leading to demotivation. - Lack of an emergency response fund for city council which delayed and affected implementation of some response activities.	- Setup an emergency response budget line for Kadoma City council
Risk Communication and Community Engagement (RCCE),	- Use of a multimedia campaign strategy that included Radio/Print/social media/digital and community-based channels. helped target different audiences, empower people with real-time information on how to prevent and protect themselves from cholera and encourage health-seeking behaviours. - Conducted a knowledge, attitudes, and practices (KAP) survey on cholera among residents which helped inform planning of RCCE activities. - Involvement of community leaders and stakeholders in planning, community mobilisation and response increased awareness at all levels and mobilisation of resources and ownership. - Use of cholera survivors to support RCCE activities and work at the Community ORPs.	- No adequate human resource to assist in risk communication and community engagement activities. - Duplication of efforts arising from poor coordination among response partners - Most of the IEC materials used had not been translated to local language (Shona/Ndebele). - Lack of social inclusion in information dissemination for people with disabilities	- Use of modern communication and information sharing platforms such as social media and AI chatbots to improve RCCE activities.
Case Management	- Engaged uniformed forces to assist with management of cholera cases, strengthening local case management capacity. - Establishment of a cholera treatment centre and community ORPs improved access to treatment services at community level. - Early dissemination of guidelines and SOPs for case management, coupled with training support on guideline implementation ensured standardisation of treatment and case management.	- Shortages of personal protective equipment - Transport challenges for movement of patients from the community and ORPs to CTC. - Staff shortages and long working hours led to work overload, staff fatigue and burnout - Shortage of Vomitus buckets at ORPs.	- Implement staff rotation schedules to prevent burnout and ensure adequate rest periods
Infection Prevention and Control	- CTC and ORPs established according to the GTFCC and Zimbabwe Cholera Control guidelines (4th Edition) (Hand washing facilities and footbaths were available at all entrances and exit points, Unidirectional patient and staff flow was maintained, a canteen was built at the CTC to prepare and provide food onsite). - Trained health care workers both professionals and non-professionals in public and private sectors on IPC.	- Shortage of IPC resources: scrubs, waterproof gowns, mops and bed linen. Shortage of staff at CTC - The transport used to ferry staff and patients was the same. - Inadequate sacks for foot bath	- Establish an IPC committee an capacitate its members to ensure effective IPC implementation during emergencies
Water, Sanitation, and Hygiene (WASH).	- Provision of Non-Food Items (NFIs) to the community through case area targeted intervention e.g. soap, tapped bucket and water guard/aqua tablets. - Regular water quality monitoring, at least 10 samples per week at all communal water points. - There was strict burial supervision, and no gatherings were allowed at funerals. - Waste generated at the CTC and ORP (Vomit and Faeces) was disinfected first and disposed at a designated pit offsite.	- Difficulty in ensuring a consistent supply of piped tap water by the city council due to inadequate infrastructure. - Public toilets in some residential areas were blocked leading to sewer bursts and overflow. - Refuse collection in suburbs/communities was not consistent contributing to illegal dumping by residents	- Unblocking and disinfection of areas with sewage overflows

Incident management and coordination pillar

Under the incident management and coordination pillar, four key themes emerged which were, coordination, SOPs, human resources, and infrastructure. The cholera response in Kadoma was coordinated through the IMS, which was recognized as a best practice. The IMS provided a centralized framework for organizing and implementing response activities which were structured around its five core functions. This system was operationalized using an Incident Action Plan (IAP), which outlined pillar-specific activities and performance indicators to facilitate progress monitoring throughout the response. The structure of the IMS used during the cholera outbreak response in Kadoma is shown in Figure 2.

Fig. 2.

Kadoma City Cholera Outbreak Response Incident Management System,2024

Another best practice was the signing of Memoranda of Understanding (MoUs) between Kadoma City Council and partner organizations. These MoUs enabled effective resource mobilization, provided technical support, and clearly defined roles and responsibilities, which enhanced coordination and accountability among stakeholders.

Enabling factors which supported these best practices, included the existence of a pre-established IMS framework and the use of IAPs, which streamlined planning and monitoring. In addition, formal agreements through MoUs created a structured mechanism for partner engagement and clarified partner contributions.

Despite these best practices, several challenges under the coordination pillar were also identified. A weak linkage between Kadoma City Council and the Ministry of Health and Childcare led to duplicated efforts in some areas of the response. Furthermore, the absence of a dedicated physical Public Health Emergency Operations Center (PHEOC) limited real-time coordination across response pillars. Although a virtual coordination platform was used, the lack of a centralized physical space hindered joint planning, rapid information exchange, and timely decision-making. Human resource management was also affected, as departments resorted to ad hoc repurposing of staff without the guidance of formal SOPs or surge capacity plans. Root cause analysis using “5 Whys” probing linked these coordination and staffing challenges to the absence of PHEOC protocols and the lack of workforce surge planning. Based on the challenges observed, priority actions proposed included establishing a physical PHEOC and developing SOPs with clear guidance on staff deployment and surge planning.

Surveillance and planning

Under the Surveillance and Planning Pillar, the key thematic domains identified were information flow and technology. A notable best practice during the outbreak response was the daily analysis of surveillance data, which supported informed decision-making and enabled real-time adjustments to interventions. This facilitated adaptive outbreak management and contributed to a more responsive public health approach. However, several challenges were also identified. Surveillance activities relied on paper-based data collection tools, which often resulted in incomplete datasets. This compromised the flow of information, delayed data analysis, and affected the timely production of situation reports. Additionally, limited laboratory diagnostic capacity was noted as another challenge. The inability to conduct culture testing affected comprehensive case detection and case management strategies.

Root cause analysis linked these limitations to the absence of digital surveillance systems, and inadequate investment in diagnostic infrastructure. Priority actions proposed included digitizing data collection tools to improve real-time reporting and expanding laboratory diagnostic capacity.

Under the Logistics Pillar, the key thematic domains that emerged were coordination and equipment. A notable best practice involved the effective use of locally available expertise and resources from previous outbreaks to establish a CTC with a capacity to accommodate over 50 patients, along with five community-based ORPs. The enabling factors for this best practice included institutional memory from prior outbreak responses, existing relationships with community stakeholders, and a flexible local leadership structure that allowed for the rapid repurposing of available assets.

Despite these best practices, several logistical challenges were noted. The response was affected by frequent vehicle breakdowns and insufficient transport resources to support patient transfers, staff mobility, and the delivery of medical supplies. This disrupted timely service delivery and field operations. Root cause probing linked these issues to a shortage of functional vehicles and the absence of a structured fleet maintenance system. The impact of these logistical constraints included delays in referral of patients and restricted mobility for response teams.

A key recommendation was to improve coordination with local leaders and business stakeholders to support emergency transport needs during outbreaks.

Finance and administration

Under the Finance and Administration Pillar, the key thematic domains identified were coordination and human resources. A key best practice was the collaboration with partners such as UNICEF and the Red Cross, which ensured financial support for response activities. These contributions were aligned with existing council procurement protocols, promoting transparency in resource allocation and enabling timely procurement and operational continuity.

A major challenge identified was staff demotivation, stemming from the lack of financial or non-financial incentives. Additionally, the city’s reliance on external partner funding highlighted a lack of financial autonomy and raised concerns about the sustainability of future outbreak responses. Root cause analysis linked these issues to the absence of both a structured emergency human resource motivation strategy and a dedicated emergency response funding mechanism within the Kadoma City emergency preparedness and response framework. These gaps contributed to staff fatigue, reduced morale, and overall inefficiencies in response implementation.

Priority actions proposed were establishment of a dedicated emergency response budget line within the Kadoma City Council’s annual budget. This would ensure rapid access to funds, reduce dependence on external partners, and enhance the timeliness and sustainability of future outbreak responses.

Risk communication and community engagement (RCCE)

Under the RCCE Pillar, the key thematic domains identified were inclusivity, human resources, and technology. Best practices identified were, implementation of a multimedia communication strategy, which included the use of radio, television, print media (posters and flyers), public address systems (e.g. loudhailers), and face-to-face community engagement. Kadoma City Council further strengthened RCCE efforts by engaging cholera survivors and community leaders in outreach activities. This served as a key enabling factor that facilitated acceptance and uptake of key health messages.

Despite these best practices, several challenges were identified. These included a shortage of trained personnel dedicated to RCCE activities, limited translation of information, education, and communication (IEC) materials into local languages, and insufficient inclusivity for persons with disabilities. These gaps reduced the accessibility of risk communication, particularly among vulnerable and marginalized populations. Root cause analysis linked these issues to inadequate planning for inclusive communication and limited investment in the development of IEC materials in local languages.

Priority actions proposed were adoption of modern digital communication tools, such as social media platforms and AI-powered chatbots, to improve message dissemination and real-time interaction with the public. Additionally, RCCE efforts should prioritize the translation of IEC materials into local languages and ensure that communication formats are inclusive of persons with disabilities.

Case management

Under the case management pillar, the key thematic domains identified were infrastructure, human resources, and logistics. A key best practice was the establishment of a CTC and five community-level ORPs, which improved access to treatment and facilitated timely case management in affected communities. In addition, the early dissemination of national cholera treatment guidelines, followed by targeted staff training, supported the delivery of standardized clinical care and ensured consistent treatment protocols across all treatment sites. These efforts were enabled by strong coordination between the clinical and logistics teams, as well as the availability of trained personnel at the onset of the outbreak.

Challenges noted included transport constraints, shortages of medical supplies, and staff fatigue due to high workloads. Root cause analysis linked these limitations to the absence of a surge capacity plan and the lack of a buffer stock of essential supplies. The observed impacts included delays in patient transfers, inconsistent availability of medical supplies, and burnout among healthcare workers.

Priority actions recommended were implementation of staff rotation schedules to prevent burnout and ensure adequate rest periods. This should be complemented by the development of a surge capacity plan and stockpiling of essential supplies.

Infection prevention and control (IPC)

Implementation of IPC measures at the CTC and ORPs followed Global Task Force on Cholera Control (GTFCC) guidelines, which was identified as a best practice. Facilities incorporated elements such as unidirectional patient flow and designated areas for food preparation, supporting infection containment. These practices were enabled by knowledge of international standards and prior training among IPC focal persons. However, IPC implementation was compromised by resource shortages, particularly scrubs, bed linen, and personal protective equipment (PPE). Root cause analysis linked these challenges to inadequate prepositioning of supplies and funding gaps. As a result, the infection control environment was inconsistent, and healthcare worker safety was at risk.

Priority actions were to establish a dedicated IPC committee and capacitate its members with the necessary training and resources.

Water, sanitation, and hygiene (WASH)

Best practices under the WASH Pillar included the distribution of hygiene kits through Case Area Targeted Interventions (CATIs), regular water quality monitoring, enforcement of safe burial practices, and provision of psychosocial support. The enabling factor was the city’s prior experience in implementing CATIs in past outbreaks.

Challenges identified included erratic water supply, blocked public toilets, sewer overflows, and irregular refuse collection. These issues contributed to sustained environmental contamination and increased the population’s exposure to cholera transmission pathways, especially in high-density residential areas. Root cause analysis attributed these challenges to aging infrastructure and limited municipal capacity for rapid repairs. The observed impact was a compromised environmental health landscape that undermined infection prevention efforts and heightened the risk of recurring outbreaks.

Priority actions were the unblocking and disinfection of areas affected by sewage overflows.

Discussion

The 2024 cholera outbreak in Kadoma City was part of Zimbabwe’s broader national outbreak, which began in Chegutu in early 2023 and spread across multiple provinces. Kadoma’s history of recurring cholera outbreaks (2008–09, 2010, 2018, and 2023), informed response efforts in 2024, particularly through implementation of the Incident Management System for a structured outbreak management. The IAR helped identify pillar-specific and cross-cutting best practices, response gaps, and challenges while generating recommendations for improving the multisectoral cholera response efforts in Kadoma.

Under the coordination pillar, one of the best practices identified during the IAR was the successful operationalization of the IMS, which facilitated coordinated decision-making, resource mobilization, and response implementation. The timely setup of the IMS, guided by an Incident Action Plan, ensured a structured approach to outbreak management ensuring early mobilization of resources and operational efficiency. Similar findings were reported in Liberia during the 2014–2015 Ebola outbreak, where adoption of the IMS improved coordination, clarified authority and accountability, and enhanced operational follow-up [12]. Additionally, the signing of Memoranda of Understanding (MoUs) between Kadoma City Council and partner organizations played an important role in mobilizing financial and technical resources while preventing duplication of efforts. This contrasts with findings from a 2020 COVID-19 IAR in Indonesia, where challenges in coordinating multiple sectors with varying capacities, characteristics, and competing priorities at subnational level were noted [9].

Despite these best practices, coordination challenges between city health authorities and the Ministry of Health and Child Care at local level were noted resulting in siloed operations, duplication of efforts, and resource misallocation. This was partly attributed to the absence of a pre-existing physical PHEOC and lack of training in use of the IMS. While a virtual coordination mechanism was in place, the absence of a physical PHEOC negatively affected the efficiency of real-time coordination, partner engagement leading to siloed operations across governmental organizations and departments involved in the response. Similar challenges were observed during the 2014–2016 Ebola outbreak in West Africa, where a lack of centralized emergency coordination structures affected coordination, delaying information flow and response actions [12–14]. Establishing a physical PHEOC in Kadoma could enhance future outbreak coordination by serving as a centralized hub for decision-making, epidemic intelligence, data analysis, improve multisectoral integration, and enhance emergency preparedness at the subnational level.

Daily analysis of surveillance data, use of CHWs in community event-based surveillance and producing key documents (CIRs and SitReps) which informed the response were identified as best practices under the plans and surveillance pillar. CHWs were instrumental in early case detection and real-time reporting, contributing to timely interventions. Several studies have demonstrated how useful CHWs can be in early detection of cases through event-based surveillance in the community [15–18]. During the cholera outbreak in Haiti, CHWs played a key role in timely case identification and community engagement, significantly reducing the spread of infection [19, 20]. However, despite these best practices noted in Kadoma, reliance on paper-based data collection tools contributed to delays in epidemiological data analysis, production of situation reports, and real-time decision-making. Studies have demonstrated that digital surveillance systems enhance data accuracy and timeliness, improving public health response outcomes [21]. Based on the findings and recommendations from the IAR, transitioning to digital data collection tools for surveillance systems in Kadoma was proposed to strengthen future outbreak monitoring and control efforts.

The outbreak response benefited from locally sourced expertise and partnerships with governmental and non-governmental organizations. This facilitated the rapid establishment of a CTC and ORPs in the community, ensuring timely access to treatment services. However, logistical constraints, including frequent vehicle breakdowns, limited transport for patients and supplies, and staff shortages leading to burnout, affected response activities. Similar challenges have been reported in other outbreak settings, where human resource shortages have been linked to increased fatigue and reduced response effectiveness [12, 13].

The establishment of a CTC and community-level ORPs was reported as a good practice during the IAR. They improved access to timely treatment, particularly in high-burden residential areas. This decentralization of care helped decongest the main CTC and expanded reach to patients with mild to moderate symptoms. Early dissemination of national treatment guidelines also contributed to standardized case management across all treatment facilities. As reported in the literature, rapid access to appropriate treatment, whether at CTCs or within the community, has been shown to reduce preventable morbidity and mortality, helping to maintain a case fatality rate below 1% [22, 23]. However, despite these successes, several operational challenges were reported. Shortages of personal protective equipment (PPE), transport constraints, and overwhelming patient loads led to staff fatigue impacting implementation of outbreak response activities. Similar challenges were noted by Berhe et al. (2024) where a shortage of staff and essential logistics including drugs, fluids, transportation, and gloves, complicated the investigation and control of the cholera outbreak in Ethiopia [24].

Furthermore, limited laboratory surveillance capacity was reported during the IAR. Only a few cases were screened using rapid diagnostic tests (RDTs) and confirmed through laboratory culture, affecting early detection and accurate diagnosis of Vibrio cholerae and other pathogens associated with diarrheal diseases. This limitation may have also contributed to the inappropriate use of antibiotics, compromising the effective management of cholera cases.

Under the RCCE pillar, a multimedia approach, integrating social media, radio broadcasts, news channels, and community leader engagement, proved effective in maintaining cholera awareness among residents and promoting appropriate health-seeking behaviour. Furthermore, involving cholera survivors in community outreach activities, such as assisting at oral rehydration points, increased trust, improved message uptake, reduced stigmatization, and facilitated their reintegration into the community. This strategy has also been recommended and proved effective for Ebola virus disease survivors in West Africa [12, 14]. Despite the good practices noted under the RCCE pillar, limited translation of IEC materials into local languages and inadequate consideration of persons with disabilities posed challenges in inclusive risk communication.

Strengths and limitations

A key strength of this IAR was the use of the WHO IAR methodology and principles, incorporating a participatory approach that enabled a structured, real-time evaluation of the cholera response. Furthermore, the involvement of diverse stakeholders, including government agencies, community representatives, cholera survivors and international partners, provided comprehensive insights into best practices and challenges. However, a key limitation was the reliance on qualitative data, which may be subject to recall bias particularly in the reporting of intervention timelines and effectiveness. To minimize this, participants were guided by a timeline of key outbreak milestones that were discussed during the IAR, which helped anchor their reflections in actual events. Standardized note-taking templates were also used during the working group sessions to ensure consistency in data capture. In addition, triangulation across multiple stakeholder groups helped validate recurring themes and reduce the influence of individual subjectivity.

Conclusion

The cholera outbreak response in Kadoma City was coordinated through the Incident Management System, enabling structured decision-making and resource mobilization. Best practices identified during the IAR included the timely setup of the IMS, daily epidemiological data analysis, the establishment of community-based ORPs, and strong community engagement. However, challenges such as the absence of a physical PHEOC, resource constraints, and inadequate laboratory capacity affected the overal response efficiency. 

Recommendations and public health actions

To strengthen outbreak preparedness and response, we recommended that Kadoma City Council should establish a PHEOC to enhance coordination and streamline decision-making. Digitizing data collection tools will improve real-time information sharing and facilitate timely epidemiological analysis. We also recommended establishing an emergency response budget line to ensure financial sustainability for outbreak response activities, reducing delays in resource mobilization. Additionally, to enhance risk communication and community engagement we recommended using modern digital communication tools such as social media and AI chatbots, translating information into local languages, and ensuring inclusivity for people with disabilities.

Based on the priority actions and recommendations made during the IAR, several public health actions were implemented. Kadoma City established a multi-hazard PHEOC to enhance coordination and standardize outbreak response efforts. To strengthen risk communication and community engagement, a WhatsApp chatbot was developed and launched to disseminate key public health messages to the community more efficiently. In addition, further Public Health Emergency Management trainings were conducted to build local capacity for preparedness and response to future outbreaks.

Lessons and recommendations for policy and practice

The IAR identified several key lessons that should inform future outbreak preparedness and response efforts. These lessons include the use of IMS framework and establishment of PHEOCs to provide a centralized structure for coordinating outbreak responses, enabling timely decision-making, efficient resource deployment, and real-time information sharing. Transitioning from paper-based systems to digital platforms can improve data accuracy, accelerate reporting, and enhance the timeliness of outbreak detection and response. Furthermore, inclusive communication strategies, such as translating outbreak messages into local languages and ensuring accessibility for people with disabilities, can strengthen community engagement and ensure equitable access to health information.

Based on these lessons, the Ministry of Health and Child Care (MoHCC) and local health authorities are encouraged to formalize the establishment and operationalization of subnational PHEOCs through appropriate policy frameworks. In addition, investment in digital health infrastructure and routine use of digital surveillance tools should be prioritized. Risk communication policies should also mandate the use of inclusive formats and languages to ensure that outbreak messages are accessible to all population groups, particularly vulnerable communities.

Abbreviations

Africa CDC

Africa centres for disease control and prevention

CHW

Community health worker

IAP

Incident action plan

IAR

Intra-action review

IEC

Information, education and communication

IMS

Incident management system

PHEOC

Public health emergency operations center

RCA

Root cause analysis

RCCE

Risk communication and community engagement

WHO

World health organization

Authors’ contributions

“CM conceptualised the study. CM, CZ, HG, PB, ST and SM collected the data, while CM, CZ and DC analysed the data. CM, CZ and DC drafted the initial manuscript, which was subsequently revised for important intellectual content by all authors. All authors read and approved the final manuscript.”

Funding

The intra action review was supported by UNICEF as part of the cholera outbreak response. No specific funding was received for writing and publishing this manuscript.

Data availability

This Intra Action Review did not generate any primary research data for analysis. However, the full review report and supporting documentation, such as meeting minutes and response pillar reports generated during the review process, are available from the corresponding author upon reasonable request, subject to approval by the relevant health authorities.

Declarations

Ethics approval and consent to participate

Ethical approval was not required, as the study focused on routine outbreak response activities and did not involve human participants or patient-level data. However, the Kadoma City Health Department Institutional Review Board (IRB) authorized the writing and publication of these IAR findings. The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and the Belmont Report. No identifiable personal information was included, ensuring confidentiality and compliance with local ethical standards.

Consent to participate was not applicable, as the study did not involve human participants requiring individual consent.

Competing interests

The authors declare no competing interests.

Conflict of interest

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.