Cholera Response

Aim to provide a quick, step-by-step guide Inform cholera outbreak interventions and ensure public health programs are rapid community-based, well-tailored, gender diversity aware.

Divided in two parts 1st part

to design cholera-specific public health preparedness and response programs. tools for rapid assessment and monitoring examples of plans used in past Oxfam GB interventions

2nd part

Cholera- diarrhoeal disease caused by a bacterial infection of the intestine 20 % infected develop (AWD), and of these,10 20% develop severe watery diarrhoea with vomiting Typical presentation sudden profuse painless, watery stools,(sometimes like ricewater,) accompanied by vomiting. Dehydration appears within 1224 hours. NB. 1st 24 hrs of cholera - riskiest, and if the sufferer is not rehydrated, death can result.

Transmission

faecally contaminated
water hands food

Outbreaks in zones with inadequate

water supply Sanitation food safety Hygiene

Greatest risk over-populated communities, displaced populations and refugee settings, Characterization poor sanitation, unsafe drinking water increased person to-person contact

NB. Incubation period very short (2 hrs -5 days), number of cases can rise very rapidly

Contaminated water and/or food

raw/undercooked food.
through direct contact with contaminated hands. Contact (body fluids) during funeral ceremonies is also a major medium. hygiene/sanitation and isolation - inadequate

Person-to-person transmission

Corpses of cholera patients

Cholera treatment centers

Social, economic environment and unstable living conditions,

insufficient water supply (quantity and quality); poor sanitation and hygiene practices; high population density refugees/internally displaced persons (IDP) camps and urban slum populations; vulnerability pregnant women, children <5 yrs immune compromised people (e.g. HIV & AIDS patients)

b) Underlying diseases and conditions: tuberculosis and AIDS - increased susceptibility.

c) Gender: Women are often more at risk responsible for caring for those who are sick in the home Lack of awareness to the necessary precautions to prevent transmission.

d) Environmental and seasonal factors: Cholera epidemics often start at the end of Dry season/ beginning of rainy season- limited water sources , and become brackish and/or highly polluted. Reductions in water resources - force people to concentrate at fewer water sources Heavy rain - contaminated water from flooded sewage systems, latrines and septic tanks cross-contaminates shallow wells, leaky pipes or other unprotected

FACTS Past lessons indicate responses adopt a reactive approach. Uncoordinated, non-multi sectoral interventions failed to prevent occurrence and/or recurrence Endemic cholera- cholera bacteria exist in the environment, and infection of the population is ongoing and long-term

Cholera preparedness plans guide both technical and management staff on their roles and responsibilities. set out needs to be undertaken before the outbreak season. A good cholera preparedness plan should set out plans to implement heightened preventative activities at least two months prior to the expected cholera season.

Engaging stakeholders MoH; UN bodies (UNICEF, WHO); donor agencies etc Community leaders both male and female Overall goal Prepare and agree on cholera prevention and control preparedness plan. Mode of Engagement WASH coordination meetings etc

Use the preparedness plan to map key hotspots and define key steps to be taken

c) Identifyi, order and putting in place essential contingency stock Such items include: cholera prevention kits additional ORS sachets at least 400 sachets per month for every ORP; additional soap and Aquatabs for ORPs; WASH equipment: o hand-washing stations; o chlorinated lime/creoline; o high-test hypochlorite (HTH) chlorine granules; o large stock of 2ml syringes (for water point chlorination activity); o jerry cans (for 1 per cent sock solution storage for water point chlorination); o combined water treatment/chlorine tablets; o pool testers; o boxes of (DPD) No 1 tablets; o plastic disposable gloves and plastic aprons for water point chlorination activities; o masks, high grade/industrial rubber gloves and disposable plastic aprons for making up the 1 per cent stock solution for chlorinating water points. jerry cans for household distribution (one/every four households); additional materials for ORPs 1L jugs, spoons and 20L jerry cans; pre-tested cholera-focused IEC posters and flyers.

Example kit contents to include; 250g of hand soap/person/ month (using standard of 5 people per household =1.25kg of hand soap); 2 ORS sachets; Sufficient water treatment products to permit a minimum of 40L of drinking water/family/ day (see below); Flyers instructing the correct number of Aquatabs to add to 20L of water:

17mg/l strength Aquatabs = 240 tabs (24 strips for 1 month supply) = 4 tabs/20 litres 33mg/L strength Aquatabs = 120 tabs (12 strips for 1 month supply) = 2 tabs/20 litres 67mg/L strength Aquatabs = 60 tabs (6 strips for 1 month supply) = 1 tab/20 litres

Ensuring safe water supply Ensure that all domestic water is chlorinated and contains 0.5mg/L (FRC) at household level. Promote safe water handling practices; e.g. mass campaigns for the cleaning of water storage pots and jerry cans. Increase the amount of clean water supplied to identified cholera hotspots (if appropriate) Bucket chlorination points at hand pumps which are difficult to chlorinate directly. Make sure that chlorine monitors are available for monitoring and support in each section of the communities

f) Ensuring safe excreta disposal

Promote the nightly sprinkling of chlorinated lime and/or ash in latrines to neutralize smells and reduce flies. Latrine Decomissioning- Add 1 to2 scoops of chlorinated lime to old latrines before backfilling . Promote hand-washing after toilet Activities in marketplaces and other communal gathering places Conduct campaigns promoting water/food hygiene and hand washing to stall owners and market workers, targeting food stalls in particular. Consider training food stallholders, market workers and canteen/community kitchen staff on general cholera prevention. Seek support from religious leaders,other male and female leadership committees- to ensure communal areas, food vendors and food stalls, maintain hygienic conditions. Use locally acceptable means of communication to raise the communitys awareness of the hygiene implications of sensitive issues, such as food provision at funeral gatherings.

Triggers to signal the start of a cholera outbreak

Attack rates for diarrhoea cases in the defined area:

WHO- Attack rate of 0.6 in populations are living in cholera-endemic areas & poor sanitation The number of diarrhoea cases presented and treated at clinics: Number of cases is constant, but number of deaths attributed to diarrhoea increases- this may suggest that cholera is responsible. Please note that this information in itself does not indicate AWD or cholera outbreaks; diarrhoeal deaths would have to be investigated fully. Death or severe dehydration from AWD: If anyone five-years-old or over dies of AWD / develops severe dehydration- possible first indicator of cholera in the area, and therefore the potential start of an outbreak. Medical tests for confirmation of Vibrio cholerae species (the cholera bacterium) is important.