Estrategia Integral Prevencion y Control Colera 2013

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Coalition for Cholera Prevention and Control

August 2013

COMPREHENSIVE INTEGRATED STRATEGY

FOR

CHOLERA PREVENTION AND CONTROL


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TABLE OF CONTENTS

FOREWORD 1

ACKNOWLEDGMENTS 3

EXECUTIVE SUMMARY 5

DEVELOPMENT OF NATIONAL PLANS FOR CHOLERA PREVENTION ANDCONTROL 11

SURVEILLANCE AND DISEASE DETECTION 17

DIAGNOSIS AND TREATMENT OF CHOLERA 25

DRINKING WATER INTERVENTIONS 35

SANITATION INTERVENTIONS 41

HYGIENE INTERVENTIONS 47

USE OF ORAL CHOLERA VACCINE 53

INFORMATION, EDUCATION, AND COMMUNICATION AND COMMUNITY HEALTHWORKER TRAINING 59

PROCUREMENT AND LOGISTICS 63

OPERATIONAL RESEARCH 75

MONITORING AND EVALUATION OF ALL INTERVENTIONS 81

ABBREVIATIONS AND ACRONYMS USED IN THIS DOCUMENT 91

BIBLIOGRAPHY 93


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FOREWORD

Alan R. Hinman and Paul E. Farmer

Cholera, an ancient scourge, remains an important cause of morbidity and mortality around theworld, with an estimated 100,000or moredeaths each year. Many countries in Africa andsouthern Asia experience periodic epidemics, which dramatically impact these countries.Cholera was reintroduced to the Americas in 1991 and caused major epidemics throughoutLatin America. Over a decade, major efforts to improve water and sanitation led to the expulsionof cholera from the Americas. Unfortunately, in the wake of the major earthquake in 2010,cholera was introduced to Haiti, which had been free of the disease for many decades. Anexplosive outbreak ensued, causing more than 650,000 cases and 8,000 deaths as of 28 May2013 (1,2).

Effective interventions to prevent and control cholera during past decades include effectivedisease detection and diagnosis; effective treatment with rehydration (oral or intravenous) and,when appropriate, antibiotics; provision of safe drinking water; proper sewage disposal; andimproved hygiene (WaSH) (3). Unfortunately, these interventions may take many years toimplement fully, as was the case in Latin America during the 1990s.

An additional intervention has been developed in the last 1015 yearsoral cholera vaccine(OCV)but it has not been widely implemented. Reasons for its limited use include lack ofawareness of its possible impact; low vaccine production capacity; and concern that addinganother intervention might divert efforts and resources from traditional approaches, whichhistorically have been under-resourced. Moreover, there is no single statement of acomprehensive integrated strategy to prevent and control cholera incorporating appropriate useof OCV. Individual guidelines exist for a number of interventions, but no single document tiesthem all together. Thus, tragically, although we now have better tools than ever, choleraremains a serious burden that, in some areas, is getting worse.

To address this issue, in October 2011, the Bill & Melinda Gates Foundation awarded a grant toThe Task Force for Global Health and Harvard Medical School/Partners in Health to form theCoalition for Cholera Prevention and Control (CCPC) to accelerate development of acomprehensive global strategy to prevent and control cholera, building on recent developmentsin thinking about the appropriate use of oral cholera vaccines in preventing and controllingepidemic and endemic cholera. CCPC held its first meeting in Atlanta, Georgia, USA, on March1516, 2012, with 45 participants, including many of the most eminent investigators of choleraand those involved in its prevention and control. At the end of the meeting, participants issued aconsensus statement that concluded: The Coalition urges implementation of a comprehensivepackage of cholera prevention and control measures, including early detection, treatment andprevention with WaSH and oral cholera vaccines, appropriately tailored to the situation inspecific countries/regions. The statement subsequently was published as a letter to the editorof Vaccine(4).

After the March 2012 meeting, CCPC members set about developing the Strategic Frameworkthat is the body of this publication. This Framework summarizes existing recommendations andguidelines for preventing and controlling cholera, identifies outdated recommendations andgaps, and recommends new guidelines as suggested by existing research (or identifying areasfor further research).


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The process for developing the Framework was as follows: 11 individual sections wereidentified, and one or two CCPC members or consultants drafted each section. Each draftsection was reviewed and commented on by two to five other CCPC members, after which theauthors made appropriate revisions. The revised documents were then sent to an experiencedwriter-editor for review and revision to try to ensure relative uniformity. The entire document was

sent out to all members of the Coalition in advance of the second meeting of the Coalition onJune 34, 2013. At the second meeting the Framework was discussed thoroughly and endorsedin principle. Further minor revisions based on comments received at or after the meeting areincorporated into this final version. The Framework represents the sense of the Coalition andshould not be taken to imply institutional endorsement by any of the agencies represented onthe Coalition.

Authors of individual sections are not identified. The Acknowledgments section lists the authorsand the reviewers. Karen Foster served as the writer-editor and Alan Hinman as the overalleditor of the work.

The Strategic Framework is intended to be suitable for different audiences: policy makers, policy

implementers, donors, clinicians, researchers, and others. We hope it can be useful foridentifying the key issues around cholera for policy makers, as well as in providing links to thedetailed documents that policy implementers would use.

REFERENCES

1. Barzilay EJ, Schaad N, Magloire R, et al. Cholera surveillance during the Haiti epidemicthe first 2 years. N Engl J Med 2013:368:599609.www.ncbi.nlm.nih.gov/pubmed/?term=Cholera+surveillance+during+the+Haiti+epidemic%E2%80%94the+first+2+years(accessed May 18, 2013).

2. United Nations Office for the Coordination of Humanitarian Affairs (OCHA). Haiti cholera

snapshot [published June 5, 2013].http://gallery.mailchimp.com/ae620ada5956c2460fcad49f8/files/hti_cholera_Snapshot_June

_2013.pdf(accessed June 20, 2013).3. Waldman RJ, Mintz ED, Papowitz HE. The cure for choleraimproving access to safe water

and sanitation. N Engl J Med 2013:368:5924.www.nejm.org/doi/full/10.1056/NEJMp1214179(accessed May 18, 2013).

4. Hinman AR, Farmer PE. The Coalition for Cholera Prevention and Control meeting [letter].Vaccine 2013;31:2323.


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ACKNOWLEDGMENTS

We acknowledge the hard work of members of the Coalition for Cholera Prevention and Controland consultants who drafted the individual sections of this Framework, as well as those who

reviewed drafts and suggested revisions. We also thank Katie Baer and Tanner Hendrick fortheir help.

Section Authors

Jalaluddin AhmedPradip Kumar BardhanWilliam CarterLibertad GonzalezRobert HallJan Heeger

Louise IversAzharul Islam KhanPinar KeskinocakHelen MatzgerMartin MengelDima NazzalCarmen ParadisoFirdausi QadriDavid SackMonica VillarealSharmin Akhter Zahan

Section Reviewers

John ClemensVance DietzRobert HallThomas HandzelDerek HardyMyriam Henkens

Myron LevineMartin MengelEric MintzDavid OlsonJared OmoloJean William PapeFirdausi QadriEdward RyanDavid SackLorenz von SeidleinJesus TrellesRonald Waldman

Peter WrightZabulon Yoti


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EXECUTIVE SUMMARY

COMPREHENSIVE INTEGRATED STRATEGYFOR CHOLERA PREVENTION AND CONTROL

Cholera is an acute diarrheal illness caused by intestinal infection with the bacterium Vibriocholerae. Although sometimes mild, cholera can be severe, resulting in profuse watery diarrheaand other symptoms. Rapid loss of body fluids can result in dehydration, shock, and even death.Worldwide, more than 100,000 people die of cholera each year. Cholera is most likely to occurin places with poor sanitation and inadequate water treatment and hygiene (1).

Despite efforts to control cholera, global incidence is on the rise, and current response tocholera outbreaks tends to be primarily reactive. This document pulls togetherrecommendations from a variety of sources to outline a comprehensive integrated strategy forcholera prevention and control.

NATIONAL PLANS FOR CHOLERA PREVENTION AND CONTROL

Development of a national plan for cholera prevention and control has the potential to providedirection to a country or region in combating cholera. Some countries have developed nationalplans, although few incorporate the complete range of prevention and control strategies,including water, sanitation, and hygiene (WaSH) interventions and oral cholera vaccines(OCVs).

Ideally, a national plan for cholera prevention and control should bring together keystakeholders: community leaders, the media, relevant government bodies, public healthagencies and organizations, environmental agencies, and others. Active involvement of all key

stakeholders can mobilize support for the goals and help ensure successful implementation.Progress in cholera prevention and control will be faster if national guidelines can recommendbest practices based on existing research.

SURVEILLANCE AND DISEASE DETECTION

Reliable, timely, accurate, and relevant information about cholera is critical to learn where,when, and in whom the disease occurs. Cases of cholera are reported to the World HealthOrganization (WHO) through the Integrated Disease Surveillance and Response systems andpublished in WHOs Weekly Epidemiological Record(WER). However, countries with a highincidence of cholera often do not report complete data because they fear stigmatization and

economic losses if the world learns about their cholera problem. In general, countries vary in theextent to which they provide complete reporting.

Official notifications to WHO represent only a fraction of actual cases. Some countries haveexperimented with tools to reduce the delay in notification of outbreaks to national authorities;for example, Kenya uses short text messages sent by mobile phone.

To declare a cholera outbreak, WHO requires laboratory confirmation of cholera for the firstcases of acute watery diarrhea. Confirming cholera cases in remote areas without laboratory


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facilities is challenging; several rapid diagnostic tests have been developed to address thisproblem.

DIAGNOSIS AND TREATMENT OF CHOLERA

Cholera can be fatal; every third person who has severe cholera is at risk of dying unless he orshe receives prompt clinical diagnosis and management. Oral rehydration solution (ORS)therapy and intravenous fluid replacement are important approaches for replenishing a patientsloss of body fluids caused by diarrhea. Antibiotics can further limit the duration of disease.Ongoing clinical research suggests that zinc therapy may help reduce illness and death.Immunoprophylaxis with OCV is another promising approach.

Clinical evaluation focuses on the type of diarrhea and on other clinical signs and symptoms.Rapid diagnostic tests are being studied to determine their usefulness in detecting choleraepidemics. They are quick to conduct and do not require laboratory facilities.

As noted above, ORS is a key part of treatment for mild to severe cholera. ORS replaces body

fluids and electrolytes. Patients with more severe cholera might require emergency intravenousadministration of adequate volumes of polyelectrolyte rehydration solution. Antibiotics can curbthe excretion of V. choleraand decrease the total purging volume.

Adjunct therapy, such as zinc and vitamin A administration, has been shown to decrease theduration and severity of diarrhea. It typically is given to children.

Major complications of cholera include hypoglycemia, hypovolemic shock, septic shock,hypothermia, and other severe conditions, including acute renal failure.

ENVIRONMENTAL APPROACHES TO CHOLERA PREVENTION AND CONTROL (WaSH)

Drinking Water Interventions

Cholera is transmitted by the fecaloral route, i.e., a person contracts cholera by ingestingsomething (usually water or food) that has been contaminated with fecal matter infected with V.cholerae. Cholera can be reliably prevented and controlled only by stopping this contaminationcycle. Key elements of interrupting the cycle include providing safe drinking water, improvingsanitation conditions, and ensuring proper hygiene (personal hygiene and food preparation).

In particular, water of good quality needs to be provided in sufficient quantity so the populationcan practice good hygiene. Ensuring a safe and sufficient water supply should be a key elementin planning a cholera prevention and control strategy.

Sanitation Interventions

Proper and safe disposal of human waste (urine and feces) is essential to preventing andcontrolling cholera. Improved sanitation that hygienically separates human excreta from humancontact can substantially improve the health of individuals and communities.

Provision of latrines in communitiesespecially in public spaces, such as markets andschoolsgenerally will benefit cholera control. A ratio of one latrine for every 20 people in


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content is critical. Evidence-based information, education, and communication activitiesemphasize an approach that includes individual behavior change or reinforcement, as well aschanges in social and community norms. When carefully carried out, health communicationstrategies can help foster positive health practices. Key actions include developing,implementing, and monitoring a communication plan. The United Nations Childrens Fund toolkitis an excellent comprehensive guide to public communication activities for cholera outbreaks

(2). The toolkit does not specifically address OCV or communication issues related to OCV aspart of an outbreak response or as part of a national immunization program.

PROCUREMENT AND LOGISTICS

Procurement and logistics encompass a broad range of operations that aim to efficiently andeffectively match the demand for a product (or set of products) to its supply. Emergencyprocurement and logistics operations span the timeline from preparedness through responseand recovery to exit strategy. These operations are similar to those faced by traditionalbusinesses, but key differences make them more challenging. Demand is highly unpredictablein terms of timing, location, and quantity; stakes are high; and resources are constrained.

Advance planning and capacity building, effective management of response activities, andcollaboration and coordination across agencies increase efficiencies of logistics andprocurement activitiesand ultimately increase the number of lives that can be saved.

Cholera is not a complicated disease to treat, but it is transmitted quickly. Supplies needed toprevent and respond to a cholera outbreak, such as chlorine tablets; washing soap; and medicalsupplies like ORS, antibiotics, and vaccine (OCV), should be readily available.

Planning should address various phases of response: needs assessment; planning, forecasting,and preparation; resource mobilization; procurement; transportation and storage; distribution;and measurement and evaluation. Each phase includes a checklist of items and actions toensure a smooth implementation.

Prevention efforts canand shouldincorporate vaccination as a part of an overall strategy.One logistical issue this raises is the need for a cold chain to maintain proper vaccinetemperatures during storage and handling to preserve potency. The last mile often is the mostchallenging when communities lack a power source. Research is ongoing to determine the bestway to preserve optimal shelf life of, for example, the Shanchol vaccine.

OPERATIONAL RESEARCH

Operational research seeks to use advanced analytic methods to improve decision making. It isintended to evaluate the impact of interventions in diverse routine care settings rather than in

defined groups of patients. Operational research addresses problems related to specificprograms by using systematic data collection. Operational research can help address questionson oral cholera vaccine, such as the following:

How do different settings (e.g., refugee camps, urban slums, rural mountain areas) affectfeasibility, effectiveness, and cost-effectiveness?

Within countries, where should OCV be targeted to save the most lives? What is optimal timing for vaccination in various cholera situations?


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Research focusing on specific vaccines is important. For example, Shanchol, the most recentlyprequalified vaccine, is less expensive and easier to administer than Dukoral.

Critical knowledge gaps remain about vaccination strategies in endemic, epidemic, andoutbreak scenarios, as well as about integrated approaches to cholera treatment and controlthat include vaccination, WaSH interventions, and treatment.

MONITORING AND EVALUATION OF ALL INTERVENTIONS

The effectiveness of any response marks the difference between a humanitarian disaster and ascenario with minimal deaths. All organizations and agencies involved in cholera responseshould adopt rigorous monitoring and evaluation procedures and report results to Ministries ofHealth and WHO. Sharing information about their cholera response will help others facing asimilar dilemma. Feedback is critical to learning about the optimal response to choleraoutbreaks.

Key actions relate to the different phases of a cholera epidemic, including the early stages of an

outbreak (managing cases, minimizing transmission), the epidemic itself (treating cases,minimizing transmission), and monitoring and evaluation of interventions, such as WaSH andOCV. Similarly, managing endemic cholera involves a different set of interventions, which alsoneed to be evaluated.

CONCLUSIONS

This document represents combined efforts of members of the Coalition for Cholera Preventionand Control and consultants. It does not generate new recommendations but instead pullstogether existing guidelines from a variety of sources to describe a comprehensive integratedstrategy for cholera prevention and control.

REFERENCES

1. Centers for Disease Control and Prevention. CholeraVibrio choleraeinfection. Generalinformation. www.cdc.gov/cholera/general/(accessed May 19, 2013).

2. UNICEF. Cholera toolkit 2013. www.unicef.org/cholera/Cholera-Toolkit-2013.pdf(accessedMay 19, 2013).


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DEVELOPMENT OF NATIONAL PLANS

FOR CHOLERA PREVENTION AND CONTROL

DEFINITION OF ISSUE

Although considerable efforts have been made to control cholera, global incidence has beenincreasing steadily, and current responses to cholera outbreaks tend to be primarily reactive.Lack of a definitive national action plan; lack of appropriate community resilience, lack ofknowledge about cholera prevention, and lack of a coordinated multisectoral approach aremajor factors impeding optimal control of cholera in countries to which it is endemic (1).

The recent resurgence of cholera, uselessness of quarantine of people and restrictions on tradeas a means of controlling spread of cholera in countries, and fact that notification of cholera isnot mandatory through the International Health Regulation (2005) (2) all require a strongsurveillance system and national preparedness of countries to quickly identify and control the

spread of cholera. Oral cholera vaccine (OCV) has proven to be safe and effective as a part of acomprehensive and multidisciplinary approach to prevent and control cholera(3).

This section documents elements in developing a national plan for cholera prevention andcontrol in light of currently available knowledge, facts and figures, and recommendations fromvarious agencies on the issue.

RECOMMENDED ACTIONS

A national plan for cholera prevention and control has the potential to provide necessarydirections for a country or region based on strong epidemiologic findings and surveillance data

available over time. It should contain suggested activities based on successful models and bestpractices elsewhere. Several countries and organizations have developed national guidelinesthat, although not uniform, have captured the best practices and information applicable to thecountry or more generally. With few exceptions, these guidelines do not describe appropriateintegration of OCV into cholera control strategies that use water, sanitation, and hygiene(WaSH) interventions.

Examples of Cholera Control Plans (with and without OCV information)

KenyaWHO

GuidelinesOthers

The Ministry of Public Health and Sanitation developed MultisectoralCholera Prevention and Control Plan 20112016 in collaboration with theCenters for Disease Control and Prevention (CDC), United NationsChildrens Fund (UNICEF), Red Cross, Mdecins Sans Frontires (MSF),WHO, African Field Epidemiology Network (AFENET), US Agency forInternational Development (USAID), and other key partners and inconsultation with other government agencies and private sectors.

This detailed implementation plan prioritizes cholera activities under

(4)


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different thematic areas, such as advocacy, WaSH, disease preventionand health promotion, and disease outbreak preparedness and response.The plan details short-term and long-term actions and a monitoring andevaluation framework. It also includes an estimated budget.

Starting with country background and cholera situation, this plan

advocates fighting cholera through a well-coordinated multisectoralapproach that emphasizes continuous prevention rather than thetraditional focus on outbreak response only. However, the plan does notdescribe integration of OCV into overall activities.

Democratic Republic of the Congo (DRC)WHO

GuidelinesOthers

The DRC Ministry of Health (MoH) released its National Plan for theElimination of Cholera 20132017in March 2013. This plan was based onstudies of different levels of risk in the country that indicate that targetingcertain lake-bordering areas in eastern DRC could have lasting impact on

preventing recurrent cholera epidemics in the entire country. Use of OCVwas not specifically addressed.

(5)

ZimbabweWHO

GuidelinesOthers

The Ministry of Health and Child Welfare and WHO developed ZimbabweCholera Control Guidelines, 2009, during an ongoing cholera outbreak,mainly to guide outbreak responders. The plan emphasized decreasingattack rates and case-fatality rates. The structure for multisector andmultiagency coordination was through establishment of the CholeraCommand and Control Centre (C4) in which organizations, such asUNICEF, Red Cross, MSF, and United Nations Office for the Coordinationof Humanitarian Affairs, participated under the overall leadership of theMinistry of Health and Child Welfare.

The document provides background information about cholera andtechnical guidance on cholera prevention, preparation for an outbreak,management of early response to the threat of an outbreak, managementof a patient with cholera, prevention of the spread of an outbreak, role ofthe laboratory, and reporting and surveillance.

The document contains useful practical annexes but mentions OCV useonly as information, not as a definitive recommendation. The OCVinformation needs to be updated to include adoption of OCV in the choleracontrol guideline.

(6)

Southern SudanWHO

GuidelinesOthers

Prepared by the MoH, Cholera Epidemic Preparedness and ResponseGuidelines for Southern Sudan, March, 2011, provides details of choleraepidemic preparedness and response plans and activities, includingmultisectoral strategic approach. The guideline contains information about

(7)


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OCV and mentions that WHO-recommended immunization with currentlyavailable cholera vaccines be used in conjunction with the usuallyrecommended control measures in areas to which cholera is endemic andin areas at risk for outbreaks.

Zanzibar

WHO

Guidelines Others

The MoH; WHO; and the University of California, Los Angeles, FieldingSchool of Public Health, developed Zanzibar Programme to EliminateCholera, a time-limited (10-year) plan for sustainable elimination ofcholera in Zanzibar. It recommends possible use of OCV combined withimproved WaSH.

Because of the negative impact of cholera on the health, economy, anddevelopment of the population, the Zanzibar government is keen toimprove cholera control by using approaches based on evidence from itspilot project called Preemptive Use of Oral Cholera Vaccination in High-

Risk Populations in Zanzibar (CHOZAN). The proposed 10-year programaims to eliminate indigenous transmission of cholera in Zanzibar bycombing OCV and improved WaSH.

(8)

WHOWHO

GuidelinesOthers

The 2004 WHO cholera outbreak guideline covers outbreak detection;outbreak confirmation; organization of the response; management ofinformation; case management; reduction in mortality; hygiene measuresin health care facilities; community involvement to limit disease spread;control of the environment; funeral practices; surveillance; andinvolvement of international partners. It includes a number of usefulannexes. OCV is mentioned as a new strategy for cholera preparedness,and further assessment is recommended.

(9)

OXFAM GBWHO

GuidelinesOthers

In June 2012, OXFAM GB published Cholera Outbreak GuidelinesPreparedness, Prevention and Control. These guidelines were originallydeveloped as an internal resource drawing on experience from OXMFMscholera response programs in Ethiopia, Sudan, Somalia, Haiti, Zimbabwe,and DRC. These practical field-level guidelines aim to provide quick, step-by-step guidance to inform cholera outbreak interventions and ensurepublic health programs that are rapid, community-based, well-tailored, andsex- and diversity-aware. However, the guidelines lackcomprehensiveness and must be used together with existing OXFAM andWASH Cluster public health guidelines. Integration of OCV also is not afocus of OXFAM GB published cholera intervention guideline.

(10)


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UNICEFWHO

GuidelinesOthers

The UNICEF toolkit aims to provide UNICEF offices, counterparts, and

partners with one source of information for prevention (or risk reduction)and cholera outbreak preparedness, response, and recoveryincludingintegration with regular/development programs. The guidelines pulltogether recommendations regarding a range of interventions to avoid thecontinuation of silo approaches for cholera prevention, preparedness,and response. Nevertheless, preemptive use of OCV in endemic, at-risk,and humanitarian settings and reactive use during outbreaks has beenrecommended on the basis of a sound risk assessment for clear decisionmaking. However, the UNICEF toolkit does not provide great detail aboutthe use of OCV.

(11)

The combination of programmatic and multidisciplinary approaches to cholera as part of

prevention and control activities for diarrheal diseases has proven effective in decreasing thecase-fatality rate during outbreaks and reducing the occurrence of epidemics. In general, anational plan for prevention and control of cholera should entail collaboration between variousactors and sectors, such as ministries of health, environment, and planning to develop theguideline and should be adapted to local and regional needs. Careful attention should be paid toallocating and using public and private resources. The plan should describe briefly theprocesses of developing a multisectoral action plan and analyze country-specific strengths andweaknesses, opportunities, and threats as it guides the nation to reduce the risk for cholera.Effective collaboration and links among different government departments, multilateral andbilateral development partners, and nongovernment organizations (NGOs) should bedemonstrated clearly to emphasize a coordinated and harmonious prevention effort at local andnational levels. The community should be put at the center of this effort to create ownership of

the problem and contribute to reducing risk for cholera through community-based preventionand control programs. Provisions are needed for updating the plan at timely intervals.

Thematic areas for developing a comprehensive national plan for cholera prevention and controlcould be Context: Current cholera situation; relevance for the national plan (endemic cholera); cost-

effectiveness, timeliness, responsiveness, etc. Objective of the national plan: What do the authors of the national plan hope to achieve,

e.g., cholera control or elimination in certain areas or at-risk populations? Stakeholders and actors relevant to cholera prevention and control. Advocacy and communication.

Available resource/needs assessment Resource mobilization: Who does what (i.e., logistics)? Cholera prevention and control: from WaSH to vaccination in endemic, epidemic, and high-

risk settings. Clinical guidelines for cholera management. Cholera surveillance and outbreak control. Monitoring and assessment/ evaluation. Knowledge gaps: identifying research areas.


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PROCESS FOR DEVELOPING A COMPREHENSIVE MULTISECTOR NATIONAL PLAN

Multidisciplinary engagement is required for developing a national plan for cholera preventionand control to help with standardized development and implementation of the interventions.Consultation should be sought with relevant stakeholders from all possible areas:

The community (including community leaders and persons of both sexes) to get input ofindividuals in protecting their own health.

The media: getting insight for disseminating information widely to the general public. Government bodies from different ministries and directorates; water, sanitation and public

health; education; finance; local government; social welfare; community development;information and communication; disaster management; and other ministries according to thelocal need.

United Nations bodies (UNICEF, WHO): these act both as donors and as technical supportfor other stakeholders.

Civil society organizations, including NGOs, community-based organizations, and faith-based organizations.

Private sector: representatives from hospitals, clinics, and pharmaceutical and vaccineindustries.

COMMENTS

Key stakeholders, such as MoHs, United Nations bodies (e.g., UNICEF, WHO), donoragencies, medical and nonmedical NGOs, political leaders, religious leaders, schoolteachersand community members of both sexes, need to work together on an agreed plan for choleraprevention and control. This collaboration can be coordinated with government and NGOsthrough existing forums in health and WaSH programs. Involvement of public in theimplementation process will ensure greater awareness of cholera prevention and prioritization oftheir participation in activities. Active involvement of all key stakeholders can mobilize supportfor the intended goals and help ensure that any intervention the guideline suggests isacceptable.

Implementation of a national plan for cholera prevention and control will have a tremendouseffect in mitigating the risk for cholera in vulnerable populations, provided it is accompanied bythe resources necessary for its implementation. Many of the best practices involving themultidisciplinary approach will reflect the principles of good practice for any multiagency publichealth effort. Progress in cholera prevention and control will be faster if a national guideline canrecommend for the preventing and controlling cholera, identifying gaps and outdatedrecommendations, and recommending new guidelines as suggested by existing research oridentifying areas for further research. Because cholera does not recognize national boundaries,

it is important to take a regional, not just national, view in developing plans and ensure thatneighboring countries have compatible approaches. If external agencies are involved indeveloping plans, it is important to ensure that national capacity exists to update and implementthe plans after these agencies depart. Development of national plans with sustainable andfocused approaches for cholera prevention and control within existing country health systems isimportant for epidemic, high endemicity, and low endemicity settings. Such plans provide aplatform for collaboration, resource mobilization, and deployment of interventions to prevent andcontrol this fatal disease.


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SURVEILLANCE AND DISEASE DETECTION

DEFINITION OF ISSUE

Surveillance is often described as gathering information for action. This description emphasizesthe need for a reliable supply of timely, accurate, and relevant information to efficiently preventand control diseases. Applied to cholera, this means that we have to know quickly, where,when, and in whom the disease occurs.

The classical model of surveillance includes three major processes: capture and collation ofdata, analysis and interpretation of data, and dissemination of information. Many considerresponse also to be a component of surveillance.

RECOMMENDED ACTIONS

World Health Organization : Role and Materials fo r Surveillance

Within the World Health Organization (WHO), the Global Task Force on Cholera Controlcoordinates cholera-related activities. The Task Forces website contains a variety of technicalguidelines, country information, maps, and current developments related to epidemics (1) andpolicies and recommendationsfor the prevention and control of cholera outbreaks (2). Choleracases and deaths are officially reported to WHO through the national Integrated DiseaseSurveillance and Response systems (IDSR) and published in the Weekly EpidemiologicalRecord(3). In addition, the Weekly Epidemiological Recordprovides annual summary tables ofcholera cases and deaths and short notes on cholera outbreaks. Reports of major outbreaksalso appear on the WHO website under Disease Outbreak News. However, countries with highincidence of cholera do not report or report only limited data because of fear of trade and travel

embargos that might follow such news.

International Health Regulations

Countries need to report cases to WHO when they are unusual or unexpected or when theypose a significant risk of international spread (4). The 2005 revised International HealthRegulations explicitly state that no travel or economic restrictions are to be established if acountry notifies cholera. Yet, reluctance to notify remains because of concerns aboutstigmatization and subsequent economic losses. Many countries notify only sporadic choleracases. Countries to which cholera is highly endemic, such as India, Bangladesh, and Ethiopia,did not notify any cholera cases to WHO in 2011 (3) although periodic epidemics did occur inthese areas.

Integrated Disease Surveillance and Response

Cholera was included as one of three notifiable diseases in the International Health Regulations1969. The IDSR guidelines classify cholera as a disease with highly epidemic potential. Theseguidelines define the modalities of reporting from the local to the national level and state indetail which reporting competences should be available at each level (5).


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The IDSR guidelines for community health workers ask them to report cases with plenty ofwatery diarrhea to the district health officers that feed these notifications into the IDSRsystems. In Cameroun, a change in the case definition (which, before 2010, was cases withacute watery diarrhea AND renal failure) to the WHO standard case definition led to aconsiderable increase in cases.

In summary, modalities, completeness, and case definition of reporting to WHO varies fromcountry to country. These variations decrease the completeness and specificity of the resultingdata.

National Cholera Plans

National cholera plans are unfortunately the exception, even among countries to which cholerais considered endemic. Kenya recently issued a draft Multi-Sectoral Cholera Prevention andControl Plan for 20112016 (not publicly available) and an Integrated Drought and CholeraPreparedness and Response Operational Plan (6). Exemplary work is also done in theDemocratic Republic of the Congo (DRC), where the national cholera team has been in placefor approximately 10 years but only recently published its first public yearly report (7). During the

recent epidemic in Guinea-Conakry, authorities circulated a weekly newsletter to partnersinvolved in cholera prevention and control called Infochol (not publicly available) (8). Diffusionat district and local levels could not be ascertained.

Regular comprehensive reporting and feedback to the regional level, the general public, and thehealth worker in individual cholera treatment centers remains sporadic and usually relies onoutside funding that is mostly not sustainable long term. Such was the case in DRC during theepidemic of 20072008. The Department for Disease Control there published a regular bulletincalled Belichol funded by UNICEF (9). After funding ceased, the publication was suspended.

Cross-Border Collaboration

WHO recommends that countries bordering a country with epidemic cholera prepare beforethey detect cases in their own countries (10). Cross-border collaboration, at least in the manycountries affected by cholera in Africa, is not yet well developed. A recent encouraging exampleis the epidemic in Guinea-Conakry and Sierra Leone that has been ongoing since February2012. The health authorities responsible for cholera control in both countries established across-border collaboration committee comprising senior technical staff from disease controldepartments and national reference laboratories. During October 31November 2, 2012, theymet to facilitate a platform for preparing for and responding to outbreaks of cholera and otherpriority communicable diseases along their common borders (11). Similar initiatives need to beencouraged in other countries where cholera is endemic or where new epidemics areanticipated (i.e., in Asia, Africa, and now in the Americas). Cholera epidemics do not stop atborders; thus, surveillance should not stop there either.

Limitations of WHO Data

Case Definition

WHO uses the following case definition for reporting suspected cases of cholera (2):

in an area where the disease is not known to be present, a patient aged 5 years or moredevelops severe dehydration or dies from acute watery diarrhea;


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in an area where there is a cholera epidemic, a patient aged 5 years or more developsacute watery diarrhea, with or without vomiting.

Underestimation of Disease Burden in Children


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Laboratory Confirmation of Cholera Cases

Laboratory confirmation of cholera for the first cases of acute watery diarrhea is a requirementfor the declaration of a cholera outbreak in accordance with WHO guidelines. The standard isconfirmation by growth of colonies of Vibrio choleraeisolated from patient stool samples onstandard culture media and on the selective thiosulfate citrate bile salts sucrose (TCBS) agar

(24). WHO recommends laboratory confirmation only at the beginning of an outbreak to verifythe outbreak. Thereafter, only sporadic sampling and confirmation is recommended to monitorstrains antibiotic resistance profiles and toward the end of an outbreak to ensure that no furthercases of cholera are occurring.

Confirming cholera cases in remote areas without laboratory facilities is challenging and candelay confirmation of a cholera outbreak and subsequently control efforts. To overcome thischallenge, several rapid diagnostic tests have been developed and successfully tested andhave been found to have a sensitivity of 67%100% and a specificity of 71%97% (2534).New diagnostic tools are under development, such as biosensors that are easier and lessexpensive (35) Another possibility is use of mobile laboratories in which strains can be isolatedand culture confirmation can be performed at any place at any time (36).

Surveillance in Humanitarian Emergencies and Natural Disasters

Surveillance is even more complicated when it has to be implemented in already overburdenedhealth systems that additionally face a humanitarian emergency caused by a natural or human-made disaster. WHO has developed several guides (37). A good overview of practicalconsiderations for surveillance in complex emergencies can be found in a dedicated chapter ofthe book Infectious Disease Surveillance(38).

KNOWLEDGE GAPS AND RESEARCH PRIORITIES

Surveillance

Reliable surveillance data and laboratory confirmation of suspected cases generally are scarce.However, both are crucial for designing reactive and preventive interventions as efficiently aspossible.

To better understand cholera epidemiology, affected countries need to notify cases by

Place, on subdistrict level and Sex and age group, e.g., 45 (retired).

Africhol, an ongoing research project, is addressing the problem of underreporting and absenceof data on cholera in Africa. Given the limited vaccine supply, these surveillance data are crucialin guiding the place and target populations for vaccine interventions. The surveillance sites of

Africhol can further be used in impact assessment for oral cholera vaccine (OCV) campaignsand other interventions and for other enteric disease-related interventions.


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Novel Methods for Diagnosis of V. cholerae(16,17)

Diagnosing V. choleraeinfection remains difficult and costly in patients with diarrhea and in fieldsettings, which results in delays in reporting to health authorities and implementing controlmeasures. The international community should encourage implementation of existing rapiddiagnostic tests and development of new, less expensive, and easier-to-use diagnostic methods

(particularly those that might be performed at the point of care) and strengthening of districtlaboratory capacities, whether stationary or mobile. (V. choleraediagnosis is one of the easiestand least expensive of the enteric pathogens).

Novel Methods fo r Timely Notification (1820)

The novel technologies described above have not been evaluated specifically in connection withcholera outbreaks or their prevention and control. Because these technologies already exist,they should be implemented to render cholera prevention and control efforts more efficient.Beyond notification, new technologies can be used to integrate surveillance and casemanagement, for example, by using electronic handheld records and other specially designedapplications for mobile phones and other mobile devices (39).

Health Systems Strengthening and Capacity Building

The management of epidemics could be improved considerably at low cost if the healthauthorities in countries with epidemic cholera acquired the habit of regular and thoroughreporting and analysis of data on cholera and other enteric diseases. The introduction ofadditional variables beyond reports of just suspected cases and deaths also would greatlyimprove existing data and should require little additional cost, given that national surveillancesystems are already in place.

Efforts to publish national surveillance data from the past decade from nine African countries towhich cholera is endemic showed that only one had staff processing cholera data with the intent

of publishing them. Only three of those countries had a coherent database on cholera.Surveillance data from countries in Asia also is needed urgently. Simple training interventionsand implementation of standard operating procedures for surveillance in cholera-pronecountries would already be a major improvement. Use of WHO definitions would also simplifyefforts.

REFERENCES

1. WHO. Cholera. www.who.int/cholera/en/(accessed April 12, 2013).2. WHO Global Task Force on Cholera Control. Prevention and control of cholera outbreaks:

WHO policy and recommendations.

www.who.int/cholera/technical/prevention/control/en/index.html(accessed April 12, 2013).3. WHO. Weekly Epidemiological Record. www.who.int/wer/(accessed April 12, 2013)4. WHO. International health regulations (2005). 2nd ed.

www.afro.who.int/index.php?option=com_docman&task=doc_download&gid=4015(accessed April 12, 2013)

5. WHO. Global Alert and Response (GAR). Integrated disease surveillance.www.who.int/csr/labepidemiology/projects/diseasesurv/en/index.html(accessed April 12,2013).


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6. WESCOORD Drought Response Kenya. Preparedness and response. Integrated droughtand cholera operational plan. 21st September 2011.http://wescoord.or.ke/documents/Keydocs/WESCOORD_CholeraPlan_20110921.pdf(accessed April 12, 2013).

7. Africhol. Report on cholera epidemiology in the Democratic Republic of Congo in 2011 [inFrench]. www.africhol.org/news/drc/report-cholera-epidemiology-democratic-republic-congo-

2011(accessed April 12, 2013).8. Africhol. Africhol in Guinea [processed content partly available].

www.africhol.org/country/guinea(accessed April 25, 2013).9. Ministry of Public Health, Authority for Disease Control; BELICHOL: bulletin du projet

delimination du cholra en RDC. www.minisanterdc.cd/Articles/d4/BELICHOL%20DEC3.pdf(accessed April 13, 2013).

10. WHO Global Task Force on Cholera Control. First steps for managing an outbreak of acutediarrhoea. http://whqlibdoc.who.int/hq/2010/WHO_CDS_CSR_NCS_2003.7_Rev.2_eng.pdf(accessed April 12, 2013).

11. WHO. Sierra Leone & Guinea concludes cross border meeting on cholera prevention &control. www.afro.who.int/en/sierra-leone/press-materials/item/5091-sierra-leone--guinea-concludes-cross-border-meeting-on-cholera-prevention--control.html(accessed April 12,

2013).12. Lanata CF, Mendoza W, Black RE. Improving diarrhoea estimates. Geneva: World Health

Organization; 2002.13. Deen J, von Seidlein L, Clemens J. Multidisciplinary studies of disease burden in the

Diseases of the Most Impoverished Programme. J Health Popul Nutr 2004;22:2329.www.ncbi.nlm.nih.gov/pubmed/?term=Multidisciplinary+studies+of+disease+burden+in+the+Diseases+of+the+Most+Impoverished+Programme(accessed May 19, 2013).

14. Sack DA, Cholera burden of disease estimates. www.jhsph.edu/departments/international-health/globalhealthresearch/cholera/index.html(accessed November 15, 2012).

15. Ali M, Lopez AL, You YA, et al. The global burden of cholera. Bull World Health Organ2012;90:20918A.www.who.int/bulletin/volumes/90/3/11-093427/en/(accessed May 19,2013).

16. Shikanga OT, Mutonga D, Abade M, et al. High mortality in a cholera outbreak in westernKenya after post-election violence in 2008. Am J Trop Med Hyg 2009;81:108590.www.ncbi.nlm.nih.gov/pubmed/?term=High+mortality+in+a+cholera+outbreak+in+western+Kenya+after+post-election+violence+in+2008(accessed May 19, 2013).

17. Zuckerman J, Rombo L, Fisch A. The true burden and risk of cholera: implications forprevention and control. Lancet Infect Dis 2007;7:52130.www.ncbi.nlm.nih.gov/pubmed/?term=The+true+burden+and+risk+of+cholera%3A+implications+for+prevention+and+control(accessed May 19, 2013).

18. Gujral L, Sema C, Gessner B, Jani I. Cholera epidemiology in Mozambique using nationalsurveillance data. J Infect Dis 2013. In press.

19. WHO. WHO report on global surveillance of epidemic-prone infectious diseases. Geneva:WHO; 2000:40. www.who.int/csr/resources/publications/surveillance/en/cholera.pdf

(accessed December 7, 2012).20. Goma Epidemiology Group. Public health impact of the Rwandan refugee crisis: what

happened in Goma, Zaire in July 1994? Lancet 1995;345:35961.www.ncbi.nlm.nih.gov/pubmed/?term=Public+health+impact+of+the+Rwandan+refugee+crisis%3A+what+happened+in+Goma%2C+Zaire+in+July+1994%3F(accessed May 19, 2013).

21. Zurovac D, Talisuna AO, Snow RW. Mobile phone text messaging: tool for malaria control inAfrica. PLoS Med 2012;9:e1001176. www.ncbi.nlm.nih.gov/pmc/articles/PMC3283546/(accessed May 19, 2013).


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22. Breslauer DN, Maamari RN, Switz NA, Lam WA, Fletcher DA. Mobile phone based clinicalmicroscopy for global health applications. PLoS ONE 2009;4:e6320.www.ncbi.nlm.nih.gov/pubmed/?term=Mobile+phone+based+clinical+microscopy+for+global+health+applications(accessed May 13, 2013).

23. Ministry of Health, Indonesia; WHO; Global Outbreak Alert and Response Network(GOARN) partners; Centers for Disease Control and PreventionUSA; EpicentreFrance;

European Programme for Intervention Epidemiology Training (EPIET)Sweden, et al.Epidemic-prone disease surveillance and response after the tsunami in Aceh, Indonesia.Euro Surveill. 2005;10:pii=2700.www.eurosurveillance.org/ViewArticle.aspx?ArticleId=2700(accessed May 19, 2013).

24. WHO. Laboratory methods for the diagnosis of epidemic dysentery and cholera, 1999.www.who.int/topics/cholera/publications/WHO_CDS_CSR_EDC_99_8_EN/en/index.html(accessed April 12, 2013).

25. Qadri F, Hasan JA, Hossain J, et al. Evaluation of the monoclonal antibodybased kitBengal SMART for rapid detection of Vibrio choleraeO139 synonym Bengal in stoolsamples. J Clin Microbiol 1995;33:7324.www.ncbi.nlm.nih.gov/pubmed/?term=Evaluation+of+the+monoclonal+antibody%E2%80%93based+kit+Bengal+SMART+for+rapid+detection+of+Vibrio+cholerae+O139+synonym+Ben

gal+in+stool+samples(accessed May 19, 2013).26. Nato F, Boutonnier A, Rajerison Grosjean MP, et al. One-step immunochromatographic

dipstick tests for rapid detection of Vibrio choleraeO1 and O139 in stool samples. ClinDiagn Lab Immunol 2003;10:4768.www.ncbi.nlm.nih.gov/pubmed/?term=One-step+immunochromatographic+dipstick+tests+for+rapid+detection+of+Vibrio+cholerae+O1+and+O139+in+stool+samples(accessed May 19, 2013).

27. Wang X-Y, Ansaruzzaman M, Vaz R, et al. Field evaluation of a rapidimmunochromatographic dipstick test for the diagnosis of cholera in a high-risk population.BMC Infect Dis 2006;6:17.www.ncbi.nlm.nih.gov/pubmed/?term=Field+evaluation+of+a+rapid+immunochromatographic+dipstick+test+for+the+diagnosis+of+cholera+in+a+high-risk+population(accessed May19, 2013).

28. Kalluri P, Naheed A, Rahman S, et al. Evaluation of three rapid diagnostic tests for cholera:does the skill level of the technician matter? Trop Med Int Health 2006;11:4955.www.ncbi.nlm.nih.gov/pubmed/?term=Evaluation+of+three+rapid+diagnostic+tests+for+cholera%3A+does+the+skill+level+of+the+technician+matter%3F(accessed May 19, 2013).

29. Mukherjee P, Ghosh S, Ramamurthy T, et al. Evaluation of a rapid immunochromatographicdipstick kit for diagnosis of cholera emphasizes its outbreak utility. Jpn J Infect Dis2010;63:2348.www.ncbi.nlm.nih.gov/pubmed/?term=Evaluation+of+a+rapid+immunochromatographic+dipstick+kit+for+diagnosis+of+cholera+emphasizes+its+outbreak+utility(accessed May 19,2013).

30. Harris JR, Cavallaro EC, de Nobrega AA, et al. Field evaluation of crystal VC Rapid Dipsticktest for cholera during a cholera outbreak in Guinea-Bissau. Trop Med Int Health

2009;14:111721.www.ncbi.nlm.nih.gov/pubmed/?term=Field+evaluation+of+crystal+VC+Rapid+Dipstick+test+for+cholera+during+a+cholera+outbreak+in+Guinea-Bissau(accessed May 19, 2013).

31. Centers for Disease Control and Prevention. Global disease detection (GDD) manual. Rapiddiagnostic tests for epidemic enteric diseases. Watery diarrhea. Differential diagnosis:outbreaks of acute watery diarrhea.www.cdc.gov/cholera/pdf/gdd_manual_cholera_chapters_2012_1_11-508c.pdf(accessed

April 25, 2013).


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32. Bhuiyan NA, Qadri F, Faruque AS, et al. Use of dipsticks for rapid diagnosis of choleracaused by Vibrio choleraeO1 and O139 from rectal swabs. J Clin Microbiol 2003;41:393941.www.ncbi.nlm.nih.gov/pubmed/?term=Use+of+dipsticks+for+rapid+diagnosis+of+cholera+caused+by+Vibrio+cholerae+O1+and+O139+from+rectal+swabs(accessed May 19, 2013).

33. Centers for Disease Control and Prevention. Laboratory methods for the diagnosis of

epidemic dysentery and cholera. www.cdc.gov/cholera/pdf/Laboratory-Methods-for-the-Diagnosis-of-Epidemic-Dysentery-and-Cholera.pdf(accessed April 12, 2013).

34. Sinha A, Sengupta S, Ghosh S, et al. Evaluation of a rapid dipstick test for identifyingcholera cases during the outbreak. Indian J Med Res 2012;135:5238,www.ncbi.nlm.nih.gov/pubmed/?term=Evaluation+of+a+rapid+dipstick+test+for+identifying+cholera+cases+during+the+outbreak(accessed May 19, 2013).

35. Columbia University, Professor Virginia Cornish working to engineer yeast to detect cholera.http://news.columbia.edu/research/2806(accessed April 12, 2013).

36. Ouedraogo RT, Njanpop-Lafourcade B-M, Jaillard P, et al. Mobile laboratory to improveresponse to meningitis epidemics, Burkina Faso epidemic season 2004, Field ActionsScience Reports 2008;1. http://factsreports.revues.org/144(accessed April 12, 2013).

37. WHO. Acute diarrheal diseases in complex emergencies: critical steps,

www.who.int/cholera/publications/criticalsteps/en/index.html(accessed April 12, 2013).38. Valenciano M, Moren A. Communicable disease surveillance in complex emergencies. In:

M'ikanatha M, Lynfield R, Van Beneden CA, de Valk H, editors. Infectious diseasesurveillance. Malden, Massachusetts: Blackwell Publishing; 2007:26580.

39. The University of Vermont. Medical student Wilkie builds portable EHR system for DoctorsWithout Borders. www.uvm.edu/~uvmpr/?Page=news&storyID=12670&category=ucommall(accessed April 12, 2013).


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Treatment

Management of dehydrationWHO

guidelinesOthers

Oral Rehydration Solution (ORS)

For mild-to-moderate cases, ORS is used both for rehydration (toreplace fluid and electrolytes) and for maintenance of hydration once thedeficit has been replaced. In addition to glucose ORS, use of rice ORSis useful in reducing stool output.

(1,17) (3,4)

IV Fluid

All cholera patients with severe dehydration, and many with moderatedehydration, require emergency administration of adequate volumes ofpolyelectrolyte rehydration solution rapidly administered intravenously to

expand their intravascular volume, raise blood pressure, and enhancerenal blood flow. Once IV rehydration has replaced the fluid deficit, ORScan be initiated to keep up with ongoing fluid losses from continuingpurging of watery diarrhea. If the purge rate exceeds 500 mL per hour inan adult, keeping up with ongoing losses is not possible by oralrehydration alone. Purging rates


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Adjunct TherapyZinc and Vitamin A

Zinc has been shown to decrease the duration and severity of diarrhea.It is given to children (6 monthsto 5 years of age) with diarrhea,including those with cholera, as an adjunct therapy to rehydration and

antibiotics (where indicated, as for treatment of cholera) for 10 days. Forseverely malnourished children with diarrhea, zinc treatment isrecommended for 14 days.

Vitamin A is given to children who have not received it under thenational biyearly program in Bangladesh (6 months1 year100,000units; >1 year200,000 units). Normal diet can be resumed as soon asthe patient is stable and can swallow, particularly in children.

(18) (19)

Critical management issuesWHO

guidelinesOthers

Diagnosis and Management of Complications

It is Important to determine severity of disease in managingcomplications of cholera cases.

The major complications of cholera are hypoglycemia, hypovolemicshock, septic shock (rare), hypothermia, hypernatremia, acidosis,hypokalemia, and abdominal distension. Other serious complicationsare acute renal failure and circulatory failure. Spontaneous abortion andstillbirth have been reported in pregnant women.

Specialattentionshouldbepaidtochildren


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guidelines.

Immunoprophylactic Measures Using Vaccines

Use of OCVs during outbreaks and epidemics, especially when cholera

occurs in new settings with limited expertise of clinical management, isone strategy for controlling and preventing the spread of cholera.

(17) (24,25)

KNOWLEDGE GAPS

WHOguidelines

Others

Research on care of pregnant women with cholera is needed to avoidcomplications resulting in fetal loss.

Because available cholera vaccines are not registered for use inpregnant women, safety data are not available.

Studies are needed on use of antibiotics to prevent spread of cholera,especially among household contacts.

Interventions are needed after discharge.

Awareness needs to be created on the mode of spread of cholera topatients and attendants;

OCV can be used in outbreaks and epidemics.

Zinc should be given to children with cholera. OCV should be given to

household contacts and those in the cluster of homes around theepicenter of cholera cases (and water supply) in the community.

Emphasis should be placed on children, rather than on adults, ofhousehold members with a cholera index patient (because children aremore susceptible). First-degree relatives are more at risk than moredistant relatives.

(21,22)

REFERENCES

1. WHO. Treatment of diarrhoea: a manual for physicians and other senior health workers.

Geneva: WHO; 1990.2. Harris JB, LaRocque RC, Qadri F, Ryan ET, Calderwood SB. Cholera. Lancet2012;379:246676.

3. Bardhan PK. Acute infectious diarrhoea. In: Rakel RE, Bope ET, editors. Conns currenttherapy 2005. Philadelphia: Saunders; 2005:1824.

4. ICDDR.B. Management of diarrhea at ICDDR.B Hospital. www.icddrb.org/what-we-do/publications/cat_view/52-publications/10042-icddrb-periodicals/10078-glimpse/10292-vol-31-no-2-2009/11072-management-of-diarrhoea-at-icddrb-hospital(accessed January 3,2010).


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5. WHO. Guidelines for the control of shigellosis, including epidemics due to Shigelladysenteriaetype 1.http://whqlibdoc.who.int/publications/2005/9241592330_eng.pdf(accessed April 8, 2013).

6. Speelman P, McGlaughlin R, Kabir I, Butler T. Differential clinical features and stool findingsin shigellosis and amoebic dysentery. Trans R Soc Trop Med Hyg 1987;81:54951.www.ncbi.nlm.nih.gov/pubmed/?term=Differential+clinical+features+and+stool+findings+in+

shigellosis+and+amoebic+dysentery(accessed May 19, 2013).7. WHO. Cholera 2009. Wkly Epidemiol Rec 2010;85:293308.

www.who.int/wer/2010/wer8531.pdf(accessed May 19, 2013).8. Bhuiyan NA, Qadri F, Faruque AS, et al. Use of dipsticks for rapid diagnosis of cholera

caused by Vibrio choleraeO1 and O139 from rectal swabs. J Clin Microbiol 2003;41;393941.http://www.ncbi.nlm.nih.gov/pubmed/?term=Use+of+dipsticks+for+rapid+diagnosis+of+cholera+caused+by+Vibrio+cholerae+O1+and+O139+from+rectal+swabs(accessed May 19,2013).

9. Benenson AS, Islam MR, Greenough WB 3rd. Rapid identification of Vibrio choleraebydarkfield microscopy. Bull World Health Organ 1964;30:82731.http://apps.who.int/iris/bitstream/10665/73717/1/bulletin_1964_30%286%29_827-831.pdf

(accessed May 19, 2013).10. Nelson EJ, Chowdhury A, Harris JB, et al. Complexity of rice-water stool from patients with

Vibrio choleraeplays a role in transmission of infectious diarrhea. Proc Natl Acad Sci U S A2007;104:190916.www.ncbi.nlm.nih.gov/pubmed/?term=Complexity+of+rice-water+stool+from+patients+with+Vibrio+cholerae+plays+a+role+in+transmission+of+infectious+diarrhea(accessed May 19, 2013).

11. WHO. Guidelines for cholera control.https://apps.who.int/chd/publications/cholera/cholguid.htm(accessed April 4, 2013).

12. Rahman M, Sack DA, Mahmood S, Hossain A. Rapid diagnosis of cholera bycoagglutination test using 4-h fecal enrichment cultures. J Clin Microbiol 1987;25:22046.www.ncbi.nlm.nih.gov/pubmed/3693549(accessed May 19, 2013).

13. Sjoling A, Wiklund G, Savarino SJ, Cohen DI, Svennerholm AM. Comparative analyses of

phenotypic and genotypic methods for detection of enterotoxigenic Escherichia colitoxinsand colonization factors. J Clin Microbiol 2007;45:3295301.www.ncbi.nlm.nih.gov/pubmed/?term=Comparative+analyses+of+phenotypic+and+genotypic+methods+for+detection+of+enterotoxigenic+Escherichia+coli+toxins+and+colonization+factors(accessed May 19, 2013).

14. Schwartz BS, Harris JB, Khan AI, et al. Diarrheal epidemics in Dhaka, Bangladesh, duringthree consecutive floods: 1988, 1998, and 2004. Am J Trop Med Hyg 2006;74:106773.www.ncbi.nlm.nih.gov/pubmed/?term=Diarrheal+epidemics+in+Dhaka%2C+Bangladesh%2Cduring+three+consecutive+floods%3A+1988%2C+1998%2C+and+2004(accessed May19, 2013).

15. Sack DA, Lyke C, McLaughlin C, Suwanvanichkij V. Antimicrobial resistance in shigellosis,cholera and campylobacteriosis.

www.who.int/drugresistance/Antimicrobial_resistance_in_shigellosis_cholera_and_cam.pdf(accessed April 2, 2013).

16. Sack DA, Sack RB, Nair GB, Siddique AK. Cholera. Lancet 2004;363:22333.www.ncbi.nlm.nih.gov/pubmed/14738797(accessed May 19, 2013).

17. WHO Global Task Force on Cholera Control. Prevention and control of cholera outbreaks:WHO policy and recommendations.www.who.int/cholera/technical/prevention/control/en/index.html(accessed November 26,2012).


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18. WHO, UNICEF. WHO/UNICEF joint statement on clinical management of acute diarrhea.www.who.int/maternal_child_adolescent/documents/who_fch_cah_04_7/en/index.html(accessed April 2, 2013).

19. Fischer Walker CL, Fontaine O, Young MW, Black RE. Zinc and low osmolarity oralrehydration salts for diarrhea: a renewed call to action. Bull World Health Organ2009;87:7806. www.who.int/bulletin/volumes/87/10/08-058990/en/(accessed May 19,

2013).20. Khan MR, Rahman ME. Community pediatrics. In: Essence of pediatrics. 3rd ed. Dhaka:

Mrs. Anwara Khan; 2004:14398.21. Hirschhorn N, Chowdhury AK, Lindenbaum J. Cholera in pregnant women. Lancet

1969;293:12302.22. Mdecins Sans Frontires. Cholera guidelines. 2nd ed. New York: Mdecins Sans

Frontires; 2004.www.bvsde.paho.org/texcom/cd045364/choleraguide.pdf(accessed April23, 2013).


24. Shin S, Desai SN, Sah BK, Clemens JD. Oral vaccines against cholera. Clin Infect Dis2011:52;13439.www.ncbi.nlm.nih.gov/pubmed/21498389(accessed May 19, 2013).

25. Ali M, Emch M, Park JK, Yunus M, Clemens J. Natural cholera infectionderived immunity inan endemic setting. J Infect Dis 2011:204:9128.www.ncbi.nlm.nih.gov/pubmed/?term=Natural+cholera+infection%E2%80%93derived+immunity+in+an+endemic+setting(accessed May 19, 2013).


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Annex: Diagnosis and Management o f Diar rhea

Assessment of Dehydration of Diar rhea

Assessment of dehydration

Assess Condition Normal Irritable/Less active than

usual*

Lethargic/Comatose*

Eyes Normal Sunken

Tongue Normal Dry

Thirst Normal Thirsty (drinks eagerly) Unable to drink*

Skin-pinch Normal Goes back slowly*

Radial

pulse

Normal Low volume* Uncountable or absent*

Diagnose No sign of

dehydration

If at least 2 signs,including 1 of theasterisk (*)-marked signs,

are present, diagnosesome dehydration.

If some dehydration + 1 of

the asterisk (*)-marked

signs are present,

diagnose severedehydration.

Treat Prevent dehydrationReassess periodically

Rehydrate with ORS.Frequentreassessment.

Rehydrate with IV fluidsand ORS.Frequent reassessment .

Management

Rehydration

No sign of dehydration

Send patient home with packets of ORS after observation for 24 hours and counseling ofmothers about the use of ORS and continued feeding. Advise mothers on the volume of ORS togive in accordance with the following schedule:

o Children 10 years: as much as wanted.

Some dehydrationTreat with ORS, 75 mL/kg over ~4 hours. The patient should be kept under observation. Thefollowing age-specific plan can be used for giving ORS:o Infants 15 years: 22004000 mL in 4 hours.

ANDo Reassess dehydration status periodically.o Manage most cases by using ORS only.


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o In case of frequent vomiting (>3 times in 1 hour) with persistent dehydration, considertreatment with IV fluid.

o If signs of severe dehydration appear, treat with IV fluids.o Continue normal feeding, including breastfeeding.

Severe dehydration

Start IV fluid immediately (100 mL/kg).o Young children 1 year) and adults: 30 mL/kg in first 30 minutes. 70 mL/kg in next 2 hours.

Encourage the patient to take ORS as soon as he/she is able to drink. The IV fluid of choicefor management of severe dehydration is cholera saline.

For both adults and children, initial bolus therapy should be repeated if danger signs (i.e.,shock) are present after the initial bolus. For children


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DRINKING WATER INTERVENTIONS

DEFINITION OF ISSUE

Cholera is transmitted mainly through the fecaloral route (1), and the ingestion of watercontaminated with feces plays a primary role in spreading the disease, especially duringepidemics. Cholera can be reliably prevented and controlled only by stopping the fecaloralcontamination cycle, where ensuring use of appropriate sanitation and proper hygiene (personaland food) and access to safe drinking water for the whole population is of utmost importance(28). In an epidemic, cholera can be contracted in only one way: by swallowing something(usually water or food) that has been contaminated with fecal matter containing Vibrio cholerae.Consequently, if fecal material is not ingested orally, the spread of cholera can be completelystopped and infection can be entirely prevented (9).

The World Health Organization/United Nations Childrens Fund (WHO/UNICEF) JointMonitoring Program for Water Supply and Sanitation monitors access to safe drinking water

through the proxy indicator of improved drinking water sources, which are defined as Thosethat are by nature of their construction protected from outside contamination, in particular fromcontamination with fecal matter (10). During a cholera outbreak, water treatment and safewater storage are commonly recommended additional measures.

Although the provision of safe water for drinking and food preparation is crucial to choleraprevention and control, some references suggest that during an outbreak, water used for alldomestic purposes (including washing and bathing) should be safe because it could be ingestedand thus be a potential vehicle for cholera transmission.

Water of good quality needs to be available in sufficient quantity to enable the population toexercise healthy hygiene practices.

RECOMMENDED ACTIONS

Prevention

Water supply actionsWHO

guidelinesOthers

Ensure Safe and Sufficient Water Supply

Implement protection of at-risk water sources identified through

sanitary surveys or water safety plans as situations and locations withincreased potential for outbreak.

(5,7,11) (12)

Develop water sources to reliably provide a minimum quantity of safewater for all domestic purposes, including personal hygiene.

(57,11) (9,12)

Promote acceptable household water treatment; recommendedtreatment is chlorination or boiling.

(57,11) (9,12)


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Ensure safe water handling and storage (e.g., through provision ofadequate narrow-mouth water containers or covered containers withtaps combined with promotion of their use)

(6,7,11) (9,12)

Monitor water quality at all main water points or systems, and take

appropriate action where needed.

(57,11) (9)

Control

Water supply actionsWHO

guidelinesOthers

Preparedness

Ensure effective coordination, collaboration, and information sharingwith authorities and responders from relevant sectors (cholera task

force).

(1,4,7,11,13) (8,12,14)

Conduct a risk assessment to identify cholera season, priority areasof intervention, key actions, and gaps in capacity.

(1,4) (9,12,14)

Contribute to the development of a comprehensive and effectiveresponse strategy in collaboration with relevant stakeholders.

(1,7,13) (9)

Strategically preposition sufficient stocks of identified WASHmaterials, supplies, and equipment for community- and facility-basedoutbreak response.

(7,11) (9,12,14)

Identify and train people on effective community- and facility-basedoutbreak response, particularly in regard to water treatment andinfection control.

(9)

Contribute to the identification and preparation of potential sites forisolation to ensure water and sanitation standards can be met. (e.g.,does the selected site have access to a safe water supply?).

(1,7,11) (14)

Responsecommunity-based

Identify with relevant authorities and stakeholders the maintransmission routes, and agree on responding for priority

interventions with authorities and stakeholders.

(7,11) (9)

Identify contaminated water sources, and ensure follow-up action(e.g., treatment, rehabilitation, or closing if alternative source of watercan be provided).

(57,11) (9,12,14)

Provide sufficient safe water (20 liters per person per day can beused as indicator).

(6,11,13) (9,12,14)


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Ensure that all domestic water (for drinking, cooking, and bathing) istreated using a culturally acceptable proven method, and monitorwater quality. If household water treatment products are provided,avoid gaps. Preferred method of treatment is chlorination.

Recommended levels of residual chlorine are as follows:

0,5mg/L at sample point of piped water system.

1,0 mg/L at stand posts in system with stand posts.

2,0 mg/L in tanker trucks at filling.

(5,6) (9)

Provide people with the knowledge and the means to safely handleand store water (e.g., by providing narrow-mouth storage vessels orcovered containers with taps combined with promotion of their use).

(6,7,11) (9,12)

Monitor water quality at all main water points or systems, and takeappropriate action where needed.

(57,11) (9)

Responsehealth facilitybased (cholera treatment center, choleratreatment unit, oral rehydration points)

Ensure provision of sufficient safe treated water with substantialstorage capacity to avoid shortages. (60 litres of water is needed perpatient per day, including for cleaning, laundry, bathing, foodpreparation, etc.).

(15) (9,14)

Ensure frequent production of various chlorine solutions:

0.05% chlorine for hand washing, dish rinsing, and bathing ofsoiled patients.

0.2% chlorine for disinfecting floors, beds, clothes, and footbaths.

2% for disinfecting of vomit, faeces, and corpses.

(15,16) (9,14)

Ensure sufficient functioning hand-washing facilities are in place(e.g., for examination rooms, kitchens, toilets) and are appropriatelymanaged.

(15,16) (9,14)

Ensure sufficient shower facilities in each area of cholera treatmentcenter. (Guidance: one shower per 50 patients; ensure minimum onefor male, one for female; and minimum one for male and one forfemale staff).

(15) (9,14)

At ORP, ensure sufficient safe/treated water for maintaining hygieneand preparation of ORS (estimated at 10 liters per patient per day)

(14,15)

OUTDATED GUIDELINES, SUGGESTED GUIDELINES

In some literature, person-to-person transmission was considered of minor importance (8).However, new evidence showing the protective factor of washing hands with soap (1820)


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suggests that person-to-person transmission can be a possible transmission route. Theprovision of appropriate and well-managed hand-washing stations at critical places is, therefore,vital.

A guideline on water needs during a vaccination campaign is needed.

KNOWLEDGE GAPS AND RESEARCH PRIORITIES

Potential areas for research the context of cholera prevention and control are as follows:

Different guidelines recommend different strengths of chlorine solutions for disinfection. Astudy to determine the correct doses for various purposes would avoid confusion.(21).

More research might be required to better understand seasonality and environmental factorsthat lead to increased risk for cholera outbreaks to allow targeted prevention actions.

Questions can be raised about the risk factors (21) that lead to outbreaks and rapid spreadof cholera in certain slums. Some slums have been seriously affected in the last years, e.g.,Harare, Zimbabwe (20082009); Lusaka, Zambia (2005, 20082009); and Kampala,Uganda (1997), whereas other slums with possibly similar or worse environmental

conditions have not yet experienced any mayor outbreak (Nairobi, Kenya; Addis, Ethiopia). Most guidelines recommend chlorination and boiling at point of use when system

chlorination is not feasible. Few evaluations of interventions exist about distributing chlorinetablets or promoting boiling or about the effectiveness of other alternative household watertreatment products, such as the biosand filter or the ceramic pot filter that, compared withboiling, might have less risk of post-treatment contamination.

REFERENCES

1. WHO. Outbreak surveillance and response in humanitarian emergenciesWHO guidelinesfor EWARN implementation. Geneva: WHO; 2012.

2. WHO. Cholera 2011. Wkly Epidemiol Rec 2012;87;289304.www.who.int/wer/2012/wer8731_32.pdf(accessed April 21, 2013).

3. WHO. Cholera fact sheet no. 107. July 2012.www.who.int/mediacentre/factsheets/fs107/en/index.html(accessed April 21, 2013).

4. Global Task Force on Cholera Control. Oral cholera vaccine use in complex emergencies:what is next? Report: WHO meeting, 1416 December 2005, Cairo, Egypt.www.who.int/cholera/publications/cholera_vaccines_emergencies_2005.pdf(accessed April20, 2013).

5. WHO. Guidance on formulation of national policy on the control of cholera.www.who.int/csr/resources/publications/cholera/whocddser9216rev1.pdf(accessed April 20,2013).

6. WHO. Guidelines for cholera control.

http://www.mona.uwi.edu/cardin/virtual_library/docs/1273/1273.pdf (accessed April 20,2013).

7. WHO. Cholera outbreak: assessing the outbreak response and improving preparedness.http://whqlibdoc.who.int/hq/2004/WHO_CDS_CPE_ZFk_2004.4_eng.pdf(accessed April 23,2013).

8. WHO. Global defense against the infectious disease threat, chapter on cholera. Geneva:WHO; 2003; 749,


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10. WHO, UNICEF. Rapid assessment of drinking water quality. A handbook forimplementation. October 2012.www.wssinfo.org/fileadmin/user_upload/resources/RADWQHandbookv1final.pdf(accessed

August 20, 2013).

11. Global Task Force on Cholera Control. Acute diarrhoeal diseases in complex emergencies:critical steps. Decision making for preparedness and response.http://whqlibdoc.who.int/hq/2010/WHO_CDS_CPE_ZFK_2004.6_Rev.1_eng.pdf(accessed:

April 20, 2013.12. Lamond E, Kinyanjui J. Cholera outbreak guidelines, preparedness, prevention and control.

Oxford, UK: OXFAM GB; 2012. http://reliefweb.int/sites/reliefweb.int/files/resources/ml-cholera-guidelines-preparedness-prevention-and-control-030512-en.pdfOXFAM(accessedMay 15, 2013).

13. WHO Global Task Force on Cholera Control. Prevention and control of cholera outbreaks:WHO policy and recommendations.www.who.int/cholera/technical/prevention/control/en/index.html(accessed April 20, 2013).

14. Mdecins Sans Frontires. Cholera guidelines. 2nd ed. New York: Mdecins Sans

Frontires; 2004. www.bvsde.paho.org/texcom/cd045364/choleraguide.pdf(accessed May13, 2013).

15. WHO. Water, sanitation and hygiene in cholera treatment centres in emergencies. Technicalnotes on drinking water, sanitation and hygiene in emergencies. No. 18.www.washclustermali.org/sites/default/files/wash_in_cholera_treatment_centers_in_emergencies_tech_brief_who.pdf(accessed April 24, 2013).

16. WHO. Water, sanitation and hygiene (WASH) in healthcare facilities in emergencies. AdamsJ, Chartier Y, Harvey B, Maison D, editors. Geneva: WHO; 2012.www.washclustermali.org/sites/default/files/wash_in_health_facilities_in_emergencies_who.pdf(accessed May 19, 2013).

17. Centers for Disease Control and prevention. Oral rehydration points (ORPs). Planning andguidance. www.cdc.gov/haiticholera/pdf/ORP_Guidance&Planning_finalcleared.pdf

(accessed May 15, 2013).18. Dubois AE, Sinkala M, Kalluri P, Makasa-Chikoya M, Quick RE. Epidemic cholera in urban

Zambia: hand soap and dried fish as protective factors. Epidemiol Infect 2006;134:122630.www.ncbi.nlm.nih.gov/pmc/articles/PMC2870514/(accessed May 15, 2013).

19. Quick RE, Thompson BL, Zuniga A, et al. Epidemic cholera in rural El Salvador: risk factorsin a region covered by a cholera prevention campaign, Epidemiol Infect 1995;114:24955.http://europepmc.org/articles/PMC2271272/pdf/epidinfect00050-0027.pdf(accessed May15, 2013).

20. Sasaki S, Suzuki H, Igarashi K, Tambatamba B, Mulenga P. Spatial analysis of risk factor ofcholera outbreak for 20032004 in a peri-urbanarea of Lusaka, Zambia. Am J Trop Med Hyg2008;79:41421. http://public.beuth-hochschule.de/~kred/Literatur/GIS_Med_Geo/PDF/Sasaki_et_al_2008-

1744621058/Sasaki_et_al_2008.pdf(accessed May 15, 2013).21. Emergency Environmental Health Forum 2013 5th Conference Report, Public Health

Promotion in Water and Sanitation Programmeswww.shareresearch.org/LocalResources/EEHF_17th_and_18th_Meeting_Report_150113.pdf(accessed July 19, 2013).


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SANITATION INTERVENTIONS

DEFINITION OF ISSUE

Sanitation generally refers to the provision of facilities and services for the safe disposal ofhuman urine and feces, wastewater, and other wastes that can negatively impact human healthand well-being. Inadequate sanitation is a major cause of infectious diseases, and improvedsanitation that hygienically separates human excreta from human contact substantially improvesthe health of individuals and communities.

Cholera is transmitted mainly through the fecaloral route, and the ingestion of fecallycontaminated water plays a major role in the spread of the disease. Cholera can be reliablyprevented and controlled only by stopping the fecaloral contamination cycle, where ensuringuse of appropriate sanitation and proper hygiene (personal and food) and access to safedrinking water for the whole population is of the utmost importance (16).

In an acute outbreak situation, constructing latrines or setting up solid-waste managementsystems may not be realistic or practical as a priority measure because of time requirements(4,7,8); however, a later improvement in the sanitary conditions is likely to significantly decreasefuture outbreak risks.

Immediate isolation of cholera patients in specialized health facilities (cholera treatment centers[CTCs], cholera treatment units [CTUs]) is advisable to improve patient care and reduce the riskfor further spread of the disease. These facilities should be established and operating within 24hours after an outbreak is confirmed (9). Timely identification and preparation of adequatesanitation in these facilities is therefore required, including strategic prepositioning of materials,supplies, and equipment, as well as staff training.

RECOMMENDED ACTIONS

Prevention

Sanitation actionsWHO

guidelinesOthers

Ensure Adequate Sanitation and a Fecal MatterFree Environment

Improve access to adequate and culturally acceptable sanitary facilitiesand services.

(16,10,11) (8,9)

Integrate cholera into planning and implementation of developmentprograms.

(8)

Provide more than one latrine per 20 people in camps and crowdedsituations.

(11)


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Strengthen quality control of sewage treatment plants. (4)

Control use of wastewater for agricultural purposes. (4)

Emphasize the need for adequate disposal of childrens feces. (5,6) (8)

Control

Sanitation actionsWHO

guidelinesOthers

Preparedness

Ensure effective coordination, collaboration, and information sharingwith authorities and responders from relevant sectors (Cholera Task

Force).

(3,6,1012) (79)

Conduct a risk assessment to identify cholera season, priority areas ofintervention, and capacity gaps.

(3,12) (79)

Contribute to the development of a comprehensive and effectiveresponse strategy in collaboration with relevant stakeholders.

(6,10,12) (7,9)

Strategically preposition sufficient stocks of identified water, sanitation,and hygiene (WaSH) materials, supplies, and equipment forcommunity- and facility-based outbreak response.

(6,12) (79)

Contribute to the identification and preparation of potential sites forisolation to ensure water and sanitation standards can be met (wasteand wastewater management, drainage).

(6,11,12) (9)

Identify and train people in safe handling of dead bodies and in burialpractices.

(6,11)

Establish inventory of existing sanitation facilities to evaluate risks. (6)

Response, Community-Based

Promote use of latrines, and ensure that they are cleaned and

maintained. (5,6,13) (8)

Construct latrines at public places where needed (markets, schools),and ensure that they are cleaned and maintained.

(79)

Dispose of cholera wastes in latrines. (9)


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Coat latrine pits with unslaked/chlorinated lime. (5) (7)

Ensure drainage and sewers are functional. (79)

Provide materials for latrine disinfection. (7,8)

Collect so-called flying toilets separately from other wastes, anddispose of them safely.

(8)

Remind people of the importance of hand-washing with soap at criticaltimes (e.g., after using latrines, after handling patients, beforepreparing food, before eating).

(4,5,10,11,13) (8,9)

Ensure the provision of sufficient hand-washing facilities with soap orash at public toilets or latrines and at markets, restaurants, andeateries.

(6) (8,9)

Conduct simple fly control measures. (9)

Clean and disinfect market places. (12) (9)

Ensure appropriate handling and management of dead bodies. (6,11,13) (7,9)

Identify appropriate burial grounds. (7)

Control funeral procedures. (6,11,12) (9)

Provide hand-washing facilities with soap or ash at funerals. (5) (7,8)

Disinfect soiled surfaces and materials with water and chlorine. (8)

Response, Health FacilityBased (CTC, CTUs)

Provide sufficient separate sanitary facilities (e.g., sex-segregatedtoilets and showers, laundry, waste disposal) for patients at isolationunits.

(6,14,15) (7,9)

Do not connect toilets to a main sewer system. (8,9)

Provide separate toilets for staff. (14) (79)

Make sure that toilets and latrines are regularly cleaned anddisinfected.

(14) (79)

Ensure provision of sufficient hand-washing facilities with soap orchlorinated water (0.05%) at critical areas: entrances; areas of patient

(5,6,15) (8,9)


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care; latrines/toilets; kitchen; morgue; exits for staff, patients, andcaretakers.

Remind users of correct hand-washing procedures though visual aids(e.g., posters).

(15)

Dispose of wastewater from hand-washing facilities in latrines or soak-pits.

(14,15) (8,9)

Ensure appropriate management of liquid waste from cholera patients,including treatment and disinfection and safe disposal (pit latrine orburial).

(5) (79)

Segregate wastes, and ensure their appropriate treatment, storage,and disposal.

(14) (8,9)

Equip and train cleaners and waste handlers. (14)

Safely manage and incinerate semisolid wastes. (5,6)

Install a waste area inside the CTU/CTC, consisting of drum burner,organic pit, ash pit, sharps pit. Pits should be lined.

(8,9)

Frequently disinfect materials, supplies, and equipment used for patientcare before reuse.

(6,1315)

Appropriately prepare and dispose of dead bodies as soon as possible. (6,15) (79)

Seek specialist advice on issues such as installation of pit latrines and

sludge management from CTCs.(14)

Regularly clean and disinfect contaminated surfaces. (14)

Consider the use of plastic sheeting on floors to facilitate cleaning anddisinfection.

(14) (9)

Dispose of wastewater from hand-

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