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Cholera ToolkitUNICEF

UNICEF - Programme Division3 United Nations PlazaNew York, NY 10017 USAwww.unice.org

Commentaries represent the personal views o the authors and do not necessarily reectthe positions o the United Nations Childrens Fund.

The designations employed in this publication and the presentation o the material donot imply on the part o the United Nations Childrens Fund (UNICEF) the expression oany opinion whatsoever concerning the legal status o any country or territory, or o itsauthorities or the delimitations o its rontiers.

This document is accompanied by a USB

device containing the three components

o the UNICEF Cholera Toolkit: the Main

Document, the Annexes and Additional

resources. These components are meant to

work together to make the best use o the Toolkit.

2013

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1. Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

1.1. Background to the Toolkit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61.2. UNICEFs roles and responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71.3. Purpose, target audience and structure o the Toolkit . . . . . . . . . . . . .10

2. Cholera the basics 12

2.1. Overview o Chapter 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

2.2. Cholera: history, classifcations and mechanism o action . . . . . . . . . . .13

2.3. Epidemiology & risk actors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

3. Understanding the situation and monitoring. . . . . . . . . . . . . . . . . . . . . . 24

3.1. Overview o Chapter 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243.2. Cholera-related assessment and monitoring . . . . . . . . . . . . . . . . . . . . . . . .25

3.3. Determining an outbreak and its magnitude and scale . . . . . . . . . . . . . .26

3.4. Monitoring when there are no cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

4. Cholera prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

4.1. Overview o Chapter 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

4.2. How to prevent cholera through improved water,sanitation and hygiene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

4.3. Use o cholera vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

4.4. Incorporating cholera prevention into development /regular programming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

5. Coordination, responsibilities andinormation management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

5.1. Overview o Chapter 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

5.2. Co-ordination or cholera prevention, preparedness and response . . . . . .53

5.3. Stakeholder responsibilities related to cholera . . . . . . . . . . . . . . . . . . . . . 645.4. Data and Inormation Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70

6. Cholera preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

6.1. Overview o Chapter 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

6.2. National policies, strategies and guidelines . . . . . . . . . . . . . . . . . . . . . . . . .76

6.3. Preparedness & response planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76

6.4. Human resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81

6.5. Supplies / stockpiles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

6.6. Resource mobilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

7. Communicating or cholera preparednessand response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

7.1. Overview o Chapter 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

7.2. Introduction to communication or cholera . . . . . . . . . . . . . . . . . . . . . . . . . .91

7.3. How to develop a communication strategy and plan . . . . . . . . . . . . . . . 93

7.4. Developing messages; visual aids, relevant IEC and othercommunication materials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

7.5. Mobilising or community action. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

8. Case management and inection control inhealth acilities and treatment sites . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

8.1. Overview o Chapter 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

8.2. Clinical assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112

8.3. Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114

8.4. Health acilities and treatment sites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1268.5. Inormation or patients and their caregivers, psychosocial

support and protection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135

9. Community ocussed interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138

9.1. Overview o Chapter 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138

9.2. Improving access to adequate quantity and quality osae water supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144

9.3. Improving ood saety and hygiene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147

9.4. Improving access to and use o sae excreta disposal . . . . . . . . . . . . . 148

9.5. Improving handwashing practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150

9.6. Disinection o vomit and aeces in householdsand transport vehicles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151

9.7. Promotion o sae handling o the dead . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

9.8. Provision o supplies / Non-ood items . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154

9.9. Good environmental hygiene in markets and other public places . . . . . 155

9.10. Cholera response in institutions and other public settings . . . . . . . . . 156

9.11. Community Case Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1579.12. Accountability to communities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161

10. UNICEF procedures or emergency preparednessand response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162

10.1. Overview o Chapter 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162

10.2. Human resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163

10.3. UNICEF implementation arrangements or generalemergency response. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168

10.4. UNICEF supply procurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173

10.5. Resource mobilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176

Contents

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The UNICEF Cholera Toolkit was developed by UNICEF Programme Division (PD) Healthand WASH sections with input rom Communications or Development (C4D), Nutrition,Child Protection, Education, Ofce o Emergency Programmes (EMOPS), SupplyDivision (SD) and the Regional Ofces (RO) and Country Ofces (CO).

The ollowing UNICEF sta was involved in the development and review o thisdocument and their contribution is grateully acknowledged: Heather Papowitz, JesusTrelles, Cecilia Sanchez Bodas, Andrew Parker, and Patricia Portela Souza.

The Toolkit has been derived through a compilation o existing global, regional and nationallevel guidance and tools rom multiple sources and adapted or use by UNICEF CountryOfces. UNICEF would like to acknowledge the outstanding work done by the consultantteam who developed the drat versions o the main Toolkit document, associated Annexesand Additional resources, Sarah House (Independent Consultant), Dr. Ron Waldman(George Washington University) and Suzanne Ferron (Independent Consultant).

The Toolkit was developed through signifcant review o existing guidance and tools,consultation with experts and a validation workshop to provide country level input. Thevalidation workshop was held in Zimbabwe in August 2012 with participation and inputrom UNICEF Health, WASH, Communications and sta rom Zimbabwe, Nigeria, Zambia,Burundi, South Sudan, Somalia and Haiti, UNICEF West and Central Arica and East andSouthern Arica Regional Ofces as well as participation rom partners, the Centers orDisease Control and Prevention (CDC), the World Health Organization (WHO) and Oxam.

In addition, the drat version o the Toolkit was shared with the ollowing partnersor input: WHO, CDC, Medecins Sans Frontieres (MSF), the International Centre orDiarrhoeal Disease Research, Bangladesh (ICDDR,B), Oxam, Action Contre la Faim(ACF), the Water, Engineering and Development Centre, Loughborough University(WEDC) and International Federation o Red Cross and Red Crescent Societies (IFRC).

UNICEF would like to acknowledge the signifcant technical review and contributionsprovided by Filipo Busti (ACF), Julie Gauthier (ACF), Eric Mintz (CDC), Tom Hadzel (CDC),Susan Cookson (CDC), Mark Pietroni (ormerly Medical Director ICDDR,B, Dhaka,Bangladesh ) Amanda McClelland (IFRC), William Carter (IFRC), David Sack (Johns HopkinsSchool o Public Health) Jean-Francois Fesselet (MSF), Andy Bastable (Oxam GB), FoyekeTolani (Oxam GB), Marion O-Reilly (Oxam GB), Elizabeth Lamond (Oxam GB), Erin Boyd(UNICEF), Mendy Marsh (UNICEF), Saji Thomas (UNICEF), Kit Dyer (UNICEF), DonatellaMassai (UNICEF), Francois Bellet (UNICEF), Ilham Abdelhai-Nour (UNICEF), Fabio Friscia(UNICEF), William Fellows (UNICEF), Mike Smith (WEDC) Peter Mala (WHO), MargaretMontgomery (WHO), Claire-Lise Chaignat (WHO), Bruce Gordon (WHO), Eric Fewster(Independent Consultant), and Jan Heeger (Independent Consultant). We would also wantto acknowledge the contribution to the edition and design made respectively by Jim Protosand Steven Bornholtz (independent consultants).

The Toolkit is a living document and will be updated as new guidance and tools emerge.Please send your comments, suggestions and new materials to incorporate in the [email protected]

UNICEF would like to thank CDC, DFID and other donors or their unding support orthe development o this Toolkit.

AoR Area o Responsibility (Cluster Approach)

AWD Acute Watery Diarrhoea

AWP Annual Work Plan

BCA Basic Co-operation Agreement (UNICEF)

BCC Behaviour Change Communication

C4D Communication or Development

CA Cluster Approach

CAP Consolidated Appeals Process

CATS Community Approaches to Total Sanitation

CBO Community Based Organisation

CCC Core Commitments or Children in Humanitarian Action (UNICEF)CCPD Common Country Programme Document (UN)

CEE/CIS RO Central and Eastern Europe and the Commonwealth o IndependentStates Regional Ofce (UNICEF)

CERF Central Emergency Response Fund

CHAP Common Humanitarian Action Plan

CHF Common Humanitarian Fund (UN)

CHW Community Health Worker

CLA Cluster Lead Agency

CLTS Community Led Total Sanitation

CO Country Ofce (UNICEF)

COTS Cholera Outbreak Training and Shigellosis

CPD Country Programme Document (UNICEF)

CRC Convention on the Rights o the Child

CRC Contracts Review Committee (UNICEF)

CSC Communication or Social ChangeCSO Civil Society Organizations

CTC Cholera Treatment Centre

CTU Cholera Treatment Unit

DCT Direct Cash Transer (UNICEF)

DaO Delivering as One (UN)

DHR Division o Human Resources (UNICEF)

DIK Donation In Kind

EHO Environmental Health Ofcer

Acknowledgements Acronyms

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1EMOPS Ofce o Emergency Programmes (UNICEF)

EPF Emergency Programme Funds (UNICEF)

ERC Emergency Relie Co-ordinator (OCHA)

ERF Emergency Response Fund (UN) also known as a HRF or by other names

ESARO Eastern and Southern Arica Regional Ofce (UNICEF)

EWARN Early warning alert and response network

FA Flash Appeal

FBO Faith Based Organisation

GIS Geographical Inormation System

GM Gender Marker (CAP)

GPS Global Positioning System

HACT Harmonised Approach to Cash Transer (UN)

HC Humanitarian Co-ordinator (UN)HCT Humanitarian Country Team (UN)

HIV Human Immunodefciency Virus

HP Hygiene Promotion

HQ Headquarters (used in this instance or UNICEF HQ)

HR Human Resources

HRBA Human Rights Based Approach

HRF Humanitarian Response Fund (UN) also known as a ERF or other names

HWTS Household water treatment and sae storage

HWWS Handwashing with soap

IEC Inormation, Education and Communication

IKA/IKC In Kind Assistance / In Kind Contribution

IM Inormation Management

IND Immediate Needs Document (UNICEF)

INGO International Non-Governmental Organisation

IO International OrganisationIOM International Ofce or Migration

KRA Key Results Areas (UNICEF)

LFA Logical Framework Analysis

LNGO Local Non-Governmental Organisation

LoU Letter o Understanding

LTA Long Term Agreement (UNICEF)

MENARO Middle East and North Arica Regional Ofce (UNICEF)

MoU Memorandum o Understanding

MTSP Mid-Term Strategic Plan (UNICEF)

NatCom National Committees or UNICEF (established or the sole purpose oundraising or UNICEF)

NFI Non-Food Item

NGO Non-Governmental Organisation

OCHA Ofce or the Co-ordination o Humanitarian Aairs

OHCR Ofce o the UN High Commissioner or Human Rights

OR Other Resources (UNICEF)

ORC Oral Rehydration Corner - also sometimes called an Oral RehydrationTherapy Corner (ORTC/ORC) or an Oral Rehydration Point (ORP)

ORE Other Resources Emergencies (UNICEF)

ORP Oral Rehydration Point (also sometimes called ORTC/ORC)

ORS Oral Rehydration Solution

PAHO Pan-American Health Organisation, Regional Ofce o WHO or LatinAmerica and the Caribbean

PCA Project Co-operation Agreement (UNICEF)

PFP Private Fundraising and Partnership Division (UNICEF)

PHAST Participatory Hygiene and Sanitation Transormation

PLA Participatory Learning and Action

PLWHA People Living with HIV/AIDS

PoUWT Point o Use Water Treatment

PoUWT&SS Point o Use Water Treatment & Sae Storage

RC Resident Co-ordinator (UN)

RDT Rapid Diagnostic Test

RO Regional Ofce (UNICEF)

ROSA South Asia Regional Ofce (UNICEF)

RR Regular Resources (UNICEF)

SSA Special Service Agreement (UNICEF)

SSFA Small Scale Funding Agreement (UNICEF)

TACRO The Americas and the Caribbean Regional Ofce (UNICEF)

ToTs Training o Trainers

UNICEF United Nations Childrens Fund

WASH Water, Sanitation & Hygiene

WCARO West and Central Arica Regional Ofce (UNICEF)

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1.1 Background to the ToolkitCholera is on the rise with an estimated 1.4 billion people at riskin endemic countries and an estimated 3 million to 5 million casesand 100,000-120,000 deaths per year worldwide.1 In many endemiccountries, children under 5 account or more than hal o the globalincidence and deaths. Cholera has remained endemic in some Asiancountries or centuries, has become endemic in an increasing number oArican countries with epidemics throughout the years, and has recentlyreturned to the Americas with on-going transmission in Haiti and theDominican Republic. New, more virulent and drug-resistant strains oVibrio cholerae continue to emerge, and the requency o large protractedoutbreaks with high case atality ratios has increased, reecting the lacko early detection, prevention and access to timely health care. Thesetrends are concerning, signal a growing public health emergency andhave gained the interest and investment o UNICEF at all levels.

1 WHO.Cholera Fact Sheet N 107. Geneva, Switzerland, World HealthOrganization. (2011d).

UNICEF currently provides strategic technical support and guidance, surgecapacity, training, supplies and logistical support or cholera and diarrhoealdisease outbreak prevention, preparedness and response worldwide. Itsmulti-sector approach health, water, sanitation and hygiene (WASH),nutrition, education, protection and other sectors as well as services oremergency operations and supply management oers the possibility oan integrated eort towards risk reduction, preparedness, capacity buildingand response in cholera and diarrhoeal disease outbreaks.

Multiple resources both internal and external are compiled andconsolidated in this UNICEF Cholera Toolkit, to make them easilyaccessible and widely available or use by UNICEF and partners globally.

Summar o Annexes

Annex 1A UNICEFs mandate and guiding principles

1.2 UNICEFs roles and responsibilitiesUNICEF supports child survival and development, mainly ocussingon the sectoral areas o Child Protection, Education, Nutrition, Health,Communications or Development (C4D) and Water, Sanitation and Hygiene(WASH). Its programmes comprise strategic and upstream work includingstrengthening o governments and their systems and other national actors aswell as downstream programme implementation. Many country programmeswork across the development humanitarian spectrum and provide anopportunity to build capacity through risk-inormed programming andpreparedness or emergencies, including disease outbreaks such as cholera.

UNICEF works in countries at the request o national governments and byagreement with them. It works in support o and in partnership with nationalgovernment institutions, local government, and a range o civil society and

other organisations, such as NGOs and the Red Cross/Crescent Movement.

1.2.1 Integrated cross-sectoral approach to cholera

To reduce the risks rom cholera, including limiting the spread o outbreaksand preventing deaths, an integrated approach is needed with collaborationacross the Health, WASH and other related sectors and crosscuttingareas (such as C4D, Education, Nutrition, Child Protection) as well as keysupporting services such as Emergency Programmes (EMOPS)and Supply Division (SD).

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For all cholera-related activities, UNICEF Health and WASH Sections at alllevels should work closely together with other key sections, such as C4D andsupporting services. See Annex 1A or an overview o UNICEFs mandate,guiding principles and approaches.

UNICEFs roles in cholera prevention, preparednessand response

Advocac:

Advocate with partners to increase the visibility and resourcemobilization or cholera control at all levels, including the work onprevention and preparedness.

Co-ordination:

Provide support and technical input into national co-ordinationmechanisms and taskorces through UNICEFs relevant sectors: Health,WASH, Communications or Development (C4D), Nutrition, Education,Child Protection and supporting services, such as Supply Division(SD) and Ofce o Emergency Programmes (EMOPS). UNICEFs CoreCommitments or Children in Humanitarian Action (CCCs) includes itssupporting role in sectoral co-ordination.

Act in some cases as the relevant cluster lead (i.e., or WASH, Nutrition,Education) i the cluster system has been activated at the national level.

Function as a key partner participating in sectoral (i.e., or Health, WASH,C4D, etc.) technical meetings and consultations at the global level.

Assessments, planning and prioritisation:

Contribute to the national cholera risk and needs assessment, as well as

cholera preparedness and response planning.Especially in endemic countries, contribute and inuence to identiycholera at-risk areas and to include cholera as a risk actor within thenational defnition o sectoral strategies, planning and prioritisation or allcholera related sectors (i.e. Health, WASH, C4D, etc.).

Surveillance, earl warning sstems and alert mechanisms:

Support the Ministry o Health (MoH) and WHO to collect surveillanceand early warning data through UNICEF Health and WASH programmesin country and across borders.

Support the MoH and WHO to implement an alert system and ensurerapid notifcation, verifcation and response rom UNICEF WASH,Health and C4D programmes at minimum and key implementingpartners or action.

Contribute to outbreak investigation through UNICEF Health andWASH programmes.

Integrate cholera as part o UNICEFs internal Early Warning/Early Actionsystem to ensure preparedness and response to outbreaks are in placeand considered as part o UNICEFs responsibilities.

Service deliver:

Provide technical support with MoH, WHO and partners to developguidelines and training materials or to ensure that existing guidelines andmaterials are operational.

Support MoH, WHO, and partners to train national and internationalpartners on all aspects o cholera management, including co-ordination,inormation management, surveillance, case management, WASH andC4D approaches.

Identiy, develop agreements with, support and build capacity o non-governmental organizations (NGOs) to deliver services or surveillance,case management, C4D and WASH interventions.

Provide supplies or setting up cholera treatment centres, casemanagement and WASH interventions, including procurement locally,regionally or globally rom SD, as well as shipping, storage and

distribution o supplies in country.

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Communication(advocacy, behaviour change communication, communication orsocial change and social mobilization):

Function as a key partner in co-ordination mechanisms or communicationor behaviour and social changes and social mobilization interventions.

Develop and implement risk communications and behaviour andsocial change communication strategies with government and keypartners or ensure existing strategies are operational and support theirimplementation.

Provide technical support to develop or use existing inormation, educationand communication (IEC) messages and supporting materials, and to planand implement campaigns.

Cholera prevention and control in UNICEFs regular programming:

Address cholera prevention and control as an opportunity andresponsibility in UNICEFs regular programming across all relevant sectorsas an aid organisation that is present beore, during and ater choleraoutbreak occurs.

SeeSection 4.4or additional details.

1.3 Purpose, target audience and structure o the Toolkit

1.3.1 Purpose

The UNICEF Cholera Toolkit aims to provide UNICEF Ofces, counterpartsand partners with one source o inormation or prevention (or risk reduction)and control o cholera outbreaks, preparedness, response and recovery including integration with regular/development programmes.

The Toolkit provides guidance primarily or the Health and WASH sectors;nevertheless guidelines are presented in an integrated manner, to avoidthe continuation o silo approaches or cholera prevention, preparednessand response. In addition, the Toolkit includes specifc content linked toEducation, Nutrition, C4D, Child Protection and other relevant sectors.

1.3.2 Target audience

The primary target audience or this Toolkit is UNICEF sta at all levels andacross all divisions and sections in the UNICEF Country, Regional and HQOfces. It may however also be useul or government counterparts andpartners such as NGOs, UN and Civil Society Organisations (CSOs) workingin cholera prevention, preparedness and response.

1.3.3 Structure o the Toolkit

The Toolkit comprises this Main Document, a series o Annexes (templates,checklists, spread sheets and more detailed reerence inormation availableonly in electronic copy) and a selection o Additional Resources (an electroniclibrary including published papers, IEC materials, cholera guidelines, trainingpackages, examples o mapping and a range o other practical inormation,available in the companion USB). Links to web-based resources are includedthroughout the electronic version o the Main Document.

Key resources mentioned across the Main Document and Annexes arelinked to the website where this additional inormation is available and/or tothe companion USB. For accessing the documents in the companion USB,click on the icon next to the document.

KEy RESOURCES

UNICEF,Delivering better results or children: A handy guide on UN coherence (2010).

UNICEF,UNICEF water, sanitation and hygiene strategies or 2006-2015(2005).

UNICEF,UNICEF joint health and nutrition strategies or 2006-2015 (2005).

UNICEF,Core Commitments or Children in Humanitarian Action (2010).

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2.1 Overview o Chapter 2This chapter provides important background and contextual inormationor understanding the types and characteristics o cholera bacteria, themechanism or inection, means o transmission and risk actors, andgender and age considerations or inection.

Summar o Annexes

Annex 2A Vibrio cholera - ecology data

Annex 2B Common misunderstandings about cholera

2.2 Cholera: history, classifcations and mechanism

o action

2.2.1 Histor and classications

Cholera is one orm o acute, watery diarrhoea, a symptom that canbe caused by any number o bacteria, viruses and parasites. Cholerais caused by a bacterium (gram-negative rod), Vibrio cholerae. Thereare about 200 serogroups o V. cholerae, but onlytwo, V. choleraeO1and O139 are known to cause the specifc disease known as cholera. 2

Serogroup O1 is urther divided into three serotypes, Inaba, Ogawa, andthe rare Hikojima and into two biotypes, classical and El Tor.

In its most severe orm, cholera is one o the switest lethal inectiousdiseases known characterized by an explosive outpouring o uid andelectrolytes within hours o inection that, i not treated appropriately, can leadto death within hours. In places where drinking water is unprotected romaecal contamination, cholera can spread with stunning speed through entirepopulations. These two characteristics o cholera have yielded a reputation thatevokes ear and oten panic. However, with prompt and appropriate treatment,mortality can be kept low. Furthermore, cholera outbreaks can be prevented orcontrolled through a combination o public health interventions, predominatelythrough disease surveillance and early warning, provision o sae water,adequate sanitation, health and hygiene promotion and early detection,prevention interventions, including oral cholera vaccine, and treatment.

To date, there have been seven cholera pandemics, six o which have beenmost likely due to the classical biotype. The current pandemic began on theIndonesian island o Sulawesi in 1961 and resulted rom the El Tor biotype.During this current pandemic, the classical orm seems to have beenalmost entirely replaced by El Tor, which survives well on zooplankton andother aqueous ora and auna. This act is commonly cited as one reasonor the persistence o the current pandemic, along with the act that El Torevokes less durable immunity than does the classical biotype.

2 The letter O reers to the serogroup-specifc lipopolysaccharide cell wall (O) antigen.

Cholera the basics

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From a clinical standpoint, cholera caused by the El Tor biotype has a higherproportion o asymptomatic cases, who are silent excretors o inectiousV. cholerae. However, most experts agree that recently the proportion oall cases o symptomatic cholera presenting with severe dehydration hasincreased and that this trend is attributable to the emergence o a variantstrain o El Tor that produces the classical cholera toxin. Generally, themajority o people inected are asymptomatic (approximately 75 per cent).O the symptomatic cases (25 per cent), a minority leads to severe cholera(20 per cent o those with symptoms, or 5 per cent o all inected cases)with a greater proportion presenting mild to moderate disease (80 per cento those with symptoms, or 20 per cent o all inected).

2.2.2 Mechanism o action

It is very important to understand that the cholera bacterium itsel is not

responsible or disease; it does not invade the cells o the bowel wall,nor does it cause any destruction o the intestine or cross the intestinalbarrier. Its behaviour diers rom the bacterium that causes shigellosis, orexample, which crosses the intestine, invades intestinal cells and causesan inammatory response, all o which result in a bloody diarrhoea that isdistinct rom the watery diarrhoea that characterizes cholera.

Vibrio choleraeacts by attaching to cells that line the intestine where itproduces a toxin that intereres with the normal cellular processes oabsorption and secretion o uid and electrolytes. Specifcally, the choleratoxin activates an enzyme system that helps regulate the ow o uid andelectrolytes across the bowel wall and locks a part o what is normally abi-directional pumping mechanism into a one-way outow position.Secretion o uid thereore exceeds absorption, leading to a potentiallymassive depletion o uid and electrolytes rom the body, causingdehydration. Up to 50 per cent o inected people could develop severedehydration with high mortality risk i let untreated. The diagram inFigure 1 demonstrates this mechanism and explains why the undamentalprinciple o cholera treatment is rapid replacement o uid and electrolyteslost. I replacement is handled efciently and eectively, mortality can bekept to less than one per cent o those displaying clinical symptoms.

The incubation period or cholera ranges between 12 hours and fve days, arelatively short period allowing or quick progression to onset o symptoms,shedding o the bacteria and transmission, and resulting in explosive outbreaks.The duration o the disease lasts as little as one day and up to one week inrare cases, with the usual duration being three days until the diarrhoea stops.Shedding o bacteria, however, continues in symptomatic patients rom twodays to two weeks and in asymptomatic ones or a ew days.

Additional detail on the mechanism o cholera can be ound in an animatedonline presentation produced by the Department o Microbiology andImmunology at the University o Rochester. See liesciences.envmed.rochester.edu/curriculum/SEPAClass/MM.sw

2.3 Epidemiology & risk actors

2.3.1 Epidemiolog

According to the World Health Organization (WHO), the number o reportedcases o cholera has increased over our old since 2000. In 2011, 58countries reported a total o 589,854 cases and 7816 deaths to the WHO.However, this number is considered to be a signifcant underestimate due topoor surveillance and underreporting. Nevertheless, cholera is on the rise withan estimated 1.4 billion people at risk in endemic countries and an estimated3 million to 5 million cases and 100,000-120,000 deaths per year worldwide. 3

3 WHO. (2011d). Cholera Fact Sheet N 107. Geneva, Switzerland, World Health Organization.

FIGURE 1

Bowel wall

cAMP

More secretion o chloride

Less absorption o sodium

Water, potassium, &bicarbonate ow intothe bowelsWatery stool with

sodium, potassium,chloride & bicarbonate

Secretor Diarrhea

Vibrios

Attaches

ActivatesProduces

Toxin

ATP

Source: Adapted rom CDC

Mechanism o cholera action

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In many cholera-endemic countries, children under fve years old account ormore than hal o the global incidence and deaths. These fgures representless than one per cent o all estimated cases o diarrhoea and less than10 per cent o estimated diarrhoea deaths annually. However, cholerashistorical impact, requent occurrence in explosive outbreaks, dramatic clinicalpicture, regular attacks on adults as well as children, highly contagious natureand potentially high lethality, make it one o the most conspicuous, and mosteared, diseases.

Cholera has remained endemic in some Asian countries or centuries. Ithas become endemic in an increasing number o Arican countries withepidemic peaks throughout the years. Recently it returned to the Americaswith ongoing transmission in Haiti and the Dominican Republic. New, morevirulent and drug-resistant strains o Vibriocholeraecontinue to emerge,

and the requency o large protracted outbreaks with high case atalityratios has increased, reecting the lack o early detection, prevention andaccess to timely health care.

Cholera occurs in both endemic and outbreak settings

Endemic:Country settings where cholera cases have been reported orthree o the past fve years (WHO), or where cholera cases are constantly

present in a given geographic area or populat ion group (WHO EWARN).

Outbreak:Endemic or non-endemic country settings where more caseso cholera occur than are expected in a given area, or among specifcgroup o people, over a particular time period (WHO EWARN).

An outbreak is more limited in geographic scope and number o people

aected than an epidemic, which signifes a greater magnitude and

degree o propagation.

In endemic countries, where people may have been exposed to choleraon numerous occasions during their lietime, many people, especiallyadults, possess a level o acquired immunity that can protect them duringoutbreaks (in other words, prior inection gives protection against re-inection and less severe illness or several years, although probably notor lie). In these endemic settings, children, who are less likely than adultsto have been exposed, are the most vulnerable to symptomatic inectionand severe illness and death. On the other hand, when outbreaks occur incountries where cholera is not endemic, all people, children and adults,are equally susceptible to the disease and the consequences o inection.

2.3.2 Transmission the aecal-oral route

The predominant route or cholera transmission is aecal-oral. In an epidemic,there is onl one wa to contract cholera: b swallowing something(usuall water or ood) that has been contaminated with aecal matterthat contains V. cholerae. Consequently, i aecal material is not ingestedorally, the spread o cholera can be completely stopped and inection canbe entirely prevented. Other requently cited risk actors represent dierentroutes o getting to this single end-step. For example, people coming togetherat a uneral or cholera victims do not get cholera simply by virtue o theirattendance at the mass gathering; they must consume ood and/or drink thathave been prepared by people whose hands have been contaminated withaecal matter which contains V. cholerae. Occasionally cholera is acquired romeating inadequately cooked shellfsh that have accumulated V. choleraein theirnatural environment; however, during an epidemic it is the aecal-oral routethat is signifcant.

Although the transmission o cholera is sometimes described as person-to-person, this conception can be misleading because the term personto-person has been used in dierent ways by dierent authors. Cholera is nottransmitted through the air or merely by being in close proximity to someoneelse who has it. Transmission generally occurs through the aecal-oral route,whether the intermediary is water, ood, hands or other means. Cholera canalso be transmitted by vomitus; however, there are more V. choleraeper gramo watery diarrhoea, and thereore many more grams o watery diarrhoea thano vomitus to transmit the disease eectively.

Cholera cannot occur where the bacterium is not present, but i thebacterium is already present or is introduced within a setting, adequatelevels o public sanitation, sae water suppl and personal hgienewill inhibit its transmission. Vibrio choleraeo many dierent subgroupsare ound in virtually all coastal water, especially in the tropics and sub-

tropics. Toxigenic Vibrio choleraeO1 have been identifed in the environmentalong the Gul Coast o North America, in certain rivers o Australia, as wellas in many locations aicted by epidemics in many parts o the world.Only certain regions remain cholera endemic, particularly in the tropicsand subtropics, and the presence o the disease is likely to relate to bothenvironmental and socioeconomic actors.4 Even i cholera is brought intoa more developed country, the disease is unlikely to spread because o

4Lipp, E., Huq, A., Cowell, R.R., Eects o global climate on inectious disease: theCholera Model, Clinical Microbiology Reviews, vol. 15, no.4, Oct 2002, pp. 757-770.

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the relatively high level o coverage o sae water and sanitation. However,even when environmental conditions are grossly inadequate, amilies andindividuals can protect themselves rom ingesting cholera by taking appropriatemeasures personally and at home as discussed later in this Toolkit. At alltimes, the ke is to keep aecal material rom being ingested b mouth.

At the beginning o a cholera outbreak, large numbers o people can becomeinected rom a single contaminated water or ood source. Most tend to becomeinected rom surace water, well or piped water sources rather than rom ood,although contaminated oods at mass gatherings can pose the risk o inecting

large groups o people. When a number o people are inected, dependingon their degree o over-crowding and water, sanitation and hygiene practices,multiple overlapping aecal-oral transmission routes can advance thespread o the disease. Thereore, while priority should be given to identiyingand blocking the main source o contamination, it is also extremely important towork on blocking all other possible transmission routes at the same time.

A fnal point about transmission: Cholera is more inectious and communicablewhen propagated through the stool o an inected person versus when it existsin the environment, a mechanism known as a hyper-inectivity state.

2.3.3 Risk actors

The risk o transmission, illness and death rom cholera is proportional to theinteraction o cholera with the host and the environment. It should be stressedagain that the onlywa to become inected with cholera is to ingest thebacteria orall.

Table 1 Cholera risk actors

Risk actors ortransmission

Poor access to and use o water and/or limitations tomonitoring and maintaining water quality

Practice o open deecation / poor access to and useo appropriate sanitation

Poor hygiene practices (handwashing, sae

ood preparation)

Crowded settings: dense urban slums, reugee ordisplaced sites, institutions (schools, prisons) gatherings(weddings, unerals)

Seasonal upsurges: increase spread during dry seasonwith water shortages or during rainy season withooding and contamination o water sources

Displacement or population movements

Risk actors orsevere illnessand death

Low level o immunity to cholera (children andnon-endemic settings)

Underlying conditions: malnourished, elderly, children,pregnant, chronic diseases, AIDS, low gastric acidity(elderly, inants, persons on antacids or gastric acidinhibitors), persons with blood group O

Lack o access to early detection and proper treatment (including individual knowledge and belies)

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Note: Consideration o the impact o climate change on cholera risk:

Climate change increases the risk o cholera in several ways: (1) the growtho bacteria, like Vibrio vulnifcusand Vibrio cholerae(non-O1 and non-O139),in the sea and brackish waters substantially increases at higher temperaturesand (2) severe disaster events damage water and sanitation inrastructureand create conditions conducive to aecal-oral contamination and highertransmission risk. Both warmer sea surace temperatures and extremeweather are inuenced by El Nio Southern Oscillation variability. Exampleso this pattern have been observed in areas o South America, and the Bay oBengal, and in the Great Lakes Region o Arica.5,6

Extensive research over the last two decades has linked cholera burden inmany parts o the world to predictable changes in climatic conditions suchas sea surace temperatures, ambient temperatures and rainall patterns.

Based on this evidence, multiple global collaborative projects are working toestablish cholera early warning systems using climatic data and models.

For urther details and reerence inormation with respect to cholera risks,see Annex 2A.

5Lipp, E., Huq, A., Cowell, R.R., Eects o global climate on inectious disease: theCholera Model, Clinical Microbiology Reviews, vol. 15, no.4, Oct 2002, pp. 757-770.

6Bompangue Nkoko, D., Giraudoux, P., Plisnier, P., Tunda, A.M., Piarroux, M., Sudre, B., Horian, S.,Tamum, J.M., Ilunga, B.K., Piarroux, R.,Dynamics o cholera outbreaks in Great Lakes Region oArica, 1978-2008, Emerging Inectious Diseases, vol.17, no.11, Nov 2011.

Noteworth characteristics o Vibrio cholerae(V. cholerae01 and 0139)

Inective dose & concentrations:

The inective dose, the amount o bacteria required or the disease-to develop, is related to a persons health status and the conditions in

their stomach For example, someone with lower levels o gastric acid in

their stomach, i.e., higher pH, require a lower inective dose because V.

choleraedo not survive in acidic environments.

The dose at which 50 per cent o people will become inected is-approximately 106 (1,000,000) V. cholerabacteria.

A single inected organism, e.g., a copepod or plankton, in surace waters-

can carry 104-106V. cholerae bacteria, and rice water diarrhoea rom aninected person can contain 107-109V. choleraeper milliliter o volume.

Survival times:A ew hours on dry suraces-

1-35 days at 2-4- oC (ice box temperature)1-14 days at room temperature-5-24 days in well water-

1-2 years in warm coastal waters, estuaries-28-35 days in ice cubes in an ice chest-

1-2 days on metal utensils-

Possibly over 6 months in rozen seaood.-

Survival limits:

At 65- oC, almost all pathogens die within 12 seconds, although somecholera bacteria die at a temperature as low as 48oC (Note: the WHO

guideline is to bring water to a rolling boil, which provides confdence that

all bacteria are killed).V. cholerae- survives best in alkaline waters and less well in acidic

environments (pH range or V. choleraesurvival is rom 5 to 9.6).

Reservoirs or multiplication; growth and doubling times:

The- Vibrio choleraebacterium is known to multiply in the human intestine,in interaction with copepods associated with water-borne zooplankton and

phytoplankton, and on moist, warm, non-acidic oods, such as cooked rice,

grains and seaood.The time needed or cholera growth to begin on suitable oods is less than-one hour at greater than 30oC and somewhat longer at 22oC.

At 22- oC, the time needed or the bacteria to double in number is lessthan one hour.

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2.3.4 Cholera considerations b gender and age

Age and gender dierences with respect to roles, social norms andpersonal behaviours vary by context and can lead to distinctions in exposuresensitivity to the V. choleraeand to likely outcomes when severe cholera iscontracted. Vulnerability may also vary in endemic and epidemic contexts.

Examples o how age and gender may aect susceptibility to inection:

Women and girls oten bear greater responsibility or the preventiono cholera because o their traditional roles in the preparation o ood,collection and treatment o water, construction and cleaning o sanitationacilities, and enorcement o household hygiene.

Women and girls are more likely to bear responsibility or the care o sickand dying amily members, including washing and disinecting clothes and

bedding, preparing the bodies or burial, and preparing ood or gatherersat unerals.

Men are more mobile and more likely to eat outside the home, makingthem more vulnerable to inection due to poor hygiene in ood outlets. Inaddition, more men undertake economic migration, and workers with highmobility, such as truck drivers and merchants, comprise a potentially high-risk group.

Children (rom age 6 months to 10 years) may be at relatively higher risko inection than young babies because they requently put objects in theirmouths, spend considerable time in settings with poor hygienic conditionssuch as schools, possess a less-developed understanding and practice ohygiene, have more mobility and acquire less immunity than older peopledue to greater levels o environmental exposure.

For clarifcations o common misunderstandings related to cholera,seeAnnex 2B.

KEy RESOURCES

ICDDR,B, COTS Program: The Whole Program.

Mdecins Sans Frontires, Cholera Guidelines 2004, 2nd ed., Chapter 1,September 2004.

Ministr o Health and Population in Haiti/U.S. Centers or DiseaseControl and Prevention,Haiti Cholera Training Manual: A Full Course orHealthcare Providers, pages 4-8, (French version)

WHO, 64th World Health Assembly Resolution: Cholera: mechanism orcontrol and prevention,January 2011.

WHO, Weekly epidemiological record, Cholera, 2011, 3 August 2012.

The Lancet,Seminar on Cholera, 2012

WHO,Bulletin o the World Health Organization, The Global Burden oCholera, 24 January 2012.

WHO, Global Task Force on Cholera Control,Prevention and control ocholera outbreaks: WHO policy and recommendations.

WHO, Global Task Force on Cholera Control,Cholera Country Profles.

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3 Understanding the situationand monitoring

3.1 Overview o Chapter 3This chapter covers inormation required to understand and monitorthe situation and to make inormed decisions or prevention,preparedness and response, including (1) how to determine anoutbreak, its magnitude and scale or response; and (2) monitor andreport when there is no outbreak.

Summar o Annexes

Annex 3A Algorithm or alert verifcation and outbreak investigation

Annex 3B Cholera outbreak rapid assessment template

Annex 3C Inormation on laboratory, RDT and environmental testing

Annex 3D Sample alert register

Annex 3E Alert system template

Annex 3F Line listing template and additional inormation

Annex 3G Example o data collection spread sheet

Annex 3H Epidemiologic indicators and analysis o data

Annex 3I Epidemic curves and interpretation

Annex 3J Example o planning sheet

Annex 3K Template or daily reporting

3.2 Cholera-related assessment and monitoringKnowing the characteristics o a given area access to services, culturalactors determining amily care behaviours, etc. to determine its levelo risk and capacity to handle cholera is a necessary part o any choleraprevention and preparedness strategy and ollowing plan o action.

During a cholera outbreak, a close monitoring o the situation(cases reported and where they come rom) and continuous assessmento the situation will allow actions to be undertaken in a timely manner tocontain the disease, limit its spread and reduce mortality. Collaborationamong all concerned sectors (especially health and WASH) is o theutmost importance.

Chapter 3 covers only assessment and monitoring related to choleracases and reporting (during an outbreak).

The ollowing scheme identifes the dierent elements o assessment andmonitoring suggested to be included as part o prevention, preparednessand response to cholera.

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3.3 Determining an outbreak and its magnitude and scale

Determining an outbreak and its magnitude and scale includes the ollowing

key actions (adapted rom WHO EWARN Guidelines 2012 ).7

Actions may notnecessarily occur in the order presented and can be taken at the same time.

3.3.1 Action 1: Trigger and veri an alert

The detection o unusual numbers o cases o acute watery diarrhoea (AWD)reported through traditional surveillance methods or through rumours coming romthe community or media should trigger an alert. Alerts must be verifed within 24hours o notifcation. I cholera is suspected, an outbreak investigation must ollow.

7WHO, Outbreak surveillance and response in humanitarian emergencies: WHO guidelines orEWARN implementation. Geneva, 2012.

TIpData must be collected on a routine basis, shared

immediatel, and used to promote action.The vital role o data cannot be understated. Timely, relevant data

must be collected regularly, analysed or use and shared

immediately with key multi-sectoral partners (health, WASH,communication, education, media, government and local ofcials,

communities, and donors) to prompt and support urgent action,

and to adjust response interventions based on changingepidemiology and the quality o response operations.

Prevention Preparedness

Timeline

Outbreak ResponseOn-going monitoring

Feedback or prevention/prepardness/response

Contextual Inormation

Accesstowaterandsanitation

Healthsystemsandsurveilancecapacity

Hygienerelatedbehaviours

Capacit assessment

Cholera related health centres/acilities (inc. WASH)

Communit case management

Provision o WASH services

Communication:channels/messages.

Survelliance

Howmany?,where?

Outbreak: Intervention (inc. WASH elementsas particular risk actors or transmission.)

Rapid initial assessments:

Health centres (including WASH acilities)

WASH conditions (only i not a change oconditions occurs beore outbreak*)

Communit/household level + line listing

* Such as in case o displaced population,otherwise assessments on WASH conditionsshould be done as part o preparedness

Risk Assement

Accesstosevices(waterandsanitation,health)

Cholerarelatedbehaviours(hygiene,family

care, health seeking)

Capacit/needs assessment

Coordinationcapacity

Technicalcapacity

Logisticsandsupplies

Identication/Mapping

Rolesandresponsibilities

Humanresources

Communicationchannelsandmessages

Resources

Suggested elements or assessments and monitoring relatedto cholera revention, rearedness and resonse

IGURE 2

Learning Evaluationand Documentation

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To review an algorithm or alert verifcation and outbreak investigation (bothadapted rom WHO EWARN Guidelines 2012 ), see Figure 2 andAnnex 3A.

Alerts can be verifed by asking a ew simple questions which can be done byphone or SMS.

Whataretheage,signsandsymptomsofthesuspectedcase(s)?

What was the date o onset o symptoms o the frst andmostrecentcases?

Whatwasthelocationanddateofthehealthconsultation?

Wherewastheplaceofresidenceatonsetofillness?

Where are cases occurring (including any geographical, personal and timerelationships between cases, e.g., same community, attended the same

school,wedding,healthcentre,funeral)?

What is the situation status or outcome to date, i.e., casemanagement,death?

3.3.2 Action 2: Conduct an outbreak investigation

Once an alert is verifed and cholera is suspected, an Outbreak Investigationmust be conducted to confrm cholera, to identiy the population at risk and torapidly put in place control measures. Response speed is critical; suppression

Alert verication

Veriy with reporter, by askingspecifc quesions, i it is a true alertbeore sending team to the feld

Health Facilit/Communit

Immediatenotication o alert

Via phone or SMS toalert hotline

Outbreak investigation

Caseconrmation(collect lab samples)

Implementcontrolmeasures

Communicatendings

Triggers to signal an alert or susected cholera,to be verifed within 24 hours

In non-endemic areas: There is a rapid increase o the number o childrenover 5 years o age or adults who develop AWD.

In an endemic area: There is a rapid increase in the number o cases oAWD compared to the expected number o cases* based on trends rom

previous years.

*Expected number o casesThis fgure is determined by analyzing past AWDdata in the aected province, district, village, etc. Ideally, surveillance data shouldbe collected and reviewed at the district level, or even smaller areas, beore beingaggregated at higher levels, which will lead to more sensitive outbreak detection.A monthly (or even better a weekly) average number o cases or the non-epidemicyears can be compared to the current situation.

District should askor additional help or

outbreak investigation& response romprovincial and nationallevel as needed

District EWARN

ocal point

Provincial &

Central levels

DistrictOCT

3rdStep

1st Step

2nd

Step

Suspectedcholera

SMS

Stes in the rocess o notifcation, alert verifcation andoutbreak investigation and resonse (WHO EWARN system)

IGURE 3

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The EWARN system requires the necessary resources to record, transmit(SMS, phone, email, radio) and manage data, as well as or transportation andadequate supervision or feld investigation and rapid response (See WHOEWARN Guidelines, Section 2-4 or more inormation on the EWARNstructure, management.)

I there is an existing EWARN, coverage should be expanded and reportingrequency increased as required. Ideally, an EWARN should be establishedduring the preparedness phase in areas o high risk or cholera outbreaks.I there is no EWARN in place, it needs to be established to ensureimmediate alert notifcation o hot spots or rapid response and daily andweekly reporting and analysis or response and adjustment o programs.

Action 3A: Set up an immediate alert notifcation or hot spotsto identiy and report on:

New cases and deaths in areas that have not reported

Upsurges o cases and deaths in areas that have already reported cases

Alarming gaps in supplies, human resources, accessibility or security.

The alerts should be immediately reported to a central notifcation cell,

such as the Zimbabwe C4 (see Annex 5A), that signals Health, WASH andother relevant sta or response actions. Such notifcations oten makeuse o telephone, cell phone, text messaging and other means o rapid

communication. Access to supportive services such as ree hotlines orimmediate alerts is increasingly being provided by mobile communications

companies during outbreaks.

See Annex 3Dor a sample alert register, and Annex 3Eor asample alert template.

Action 3B: Establish or strengthen the EWARN

Develop and communicate a case denition agreed b all partners1)or the outbreak. The case defnition and instructions on where andhow to report suspected cases should be circulated widely. Personnelat health acilities at all levels o the health system should be taughthow to recognize cholera and how to report it. It is important that acommon case defnition is used consistently.

Examles o case defnition duringan eidemic

AWD with or without vomiting in a patient aged 5* years ormore (WHO 2012) OR

Any individual experiencing 3 or more liquid stools with orwithout vomiting during a 24 hour period (MSF 2004)

*Although the WHO case defnition uses an age range o over 5 years (overthe age o 2 was also previously used) it is important to note that children

under 5 are still aected by cholera and still need to be registered in theline listing (see below) and need to be treated immediately or AWD.

Establish line listing o cases b all health acilities receiving cases.2)Cholera registers should be prepared in advance and distributed widelyas needed; every acility should keep a line listing in a dedicated choleraregister. A line listing helps tabulate and analyse case inormation byestablishing the system o data collection and monitoring during acholera outbreak, including inormation such as patient name, age,gender, address, date o onset o symptoms, date o frst visit, degreeo dehydration, treatment and outcome. SeeAnnex 3For a sampleline-listing orm and urther details on data.

Inormation can be gathered rom patients and their relatives in atreatment acility, when stafng resources allow, which can assist in theidentifcation o possible transmission risks which will help establish moreocussed responses. Once an outbreak has been confrmed, diagnosis opatients can rely on symptoms alone, i.e., during an outbreak o cholera ina defned area, almost every case o AWD with or without vomiting will bedue to cholera.

Data rom line listings should be analysed and used at the acility/local leveland transmitted to the central level daily (i early in the outbreak) and weekly.Data can also be entered into a spreadsheet or quick interpretation o trendsin numbers and pictorially through graphs. SeeAnnex 3Gor an example oa data collection sheet.

Collect inormation on cases and deaths through active surveillance3)to complement ocial reporting channels. It is important to employa variety o means to actively review inormation obtained rom

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communities (i.e., rumours), religious leaders, political authorities, pressreports, blogs, and any other unofcial inormation sources. Not all casesor deaths are seen at a health acility and may be let unnoticed and notincluded in the alert system.

3.3.4 Action 4: Describe the epidemic

Regular and timely epidemiologic updates are necessary to describe theprogress and trends o the cholera outbreak and to monitor response actions.Updates can be perormed daily (especially at the beginning o an outbreak),weekly or monthly, depending on the progression o the outbreak.

Data should be used to inorm action. It should be monitored at the lowestadministrative level to update response interventions and at national orregional levels to support advocacy and undraising, predict spread, estimate

resource needs and signal neighbouring countries o epidemic proximity.See Annex 3Hor the defnition o data, calculation methods and analysis.

Data should be analysed and reported using a mix o numbers, graphs andmaps to describe:

Person: who is aected (data broken down by sex, age, or risk actor);

Time: trends over time (see Action 4B);

Place: location/place (see Action 4C).

See the inormation in Annex 3Fon line-listings or more inormation onunderstanding person, place and time rom collected data.

Action 4A: Conduct daily reportingCases, deaths and the case atality rate (CFR) (see Annex 3H) need to bereported on a daily basis to signal trends and initiate or adjust responseinterventions. The analysis o these trends should be conducted at the

lowest administrative level to allow immediate adjustment o the preventionand case management interventions. Inormation or daily reporting o casesand deaths can be drawn rom alerts and acility-reported data rom linelisting. For details, see Annex 3K or a daily reporting template.

Action 4B: Conduct weekly reportingWeekly reporting involves more analysis than daily reporting and provides amore robust picture o an epidemics time trends, which can be illustratedin tables, line graphs or histograms.It covers daily and cumulative case datareported over the course o a week (incidence rate), CFR and attack rates

(AR) (seeAnnex 3H). Weekly data can also be described by age or genderto yield a more detailed analysis o trends. For an example, please reer toZimbabwe weekly epidemiologic bulletins .

Epidemic curves (seeAnnex 3I) are used to determine whether cases areclustered in time, place or by person, i.e., by age and sex, to predict whenthe peak o the outbreak might occur; to develop hypotheses explainingexposure and disease, i.e., the source o the outbreak and the mode otransmission; and to estimate the end o the outbreak. Each acility shouldestablish an epidemic curve, as well as district, provincial, and nationalepidemic curves, and they should be updated requently and regularly.

Action 4C: Create epidemiologic mapsMaps are a useul tool to determine the geographic origin and likely path

o cases; to monitor their progress, the CFR and AR; and to prioritisepreventive and preparedness actions in surrounding areas and acrossborders. Spot maps or hand-drawn maps can show where, how and whythe outbreak is moving and the locations o cases, roads, water sourcesand health acilities in more than larger country-level maps.

Action 4D: Identiy sources o transmissionAnalysis o the inormation gathered or estimated in Actions 2, 3 and 4should help identiy the source o transmission through the observation ocommon patterns among reported cholera cases. Assessments o choleratransmission rom particular bodies o water, ood outlets or other sourcesmay rely on case control studies, sanitary surveys around water points,inspections o ood hygiene and saety at ood outlets, and testing othermo-tolerant coliorm, such as E. coli, in water sources as an indicatoro the aecal contamination level and the potential risk o the presence oV. cholerae. Additional studies, including laboratory tests and environmentalstudies, can be conducted as necessary, although they can be time and

resource consuming and the capacity l imited in low-income countries.

3.3.5 Action 5: Estimate the populations at risk and number oexpected cases

The estimation o risk is based on a number o combined actors thatinclude water, sanitation and hygiene coverage; environmental actors suchas seasonality or ooding; levels o crowding; population displacement andmovement; systemic capacity to respond; population immunity; and otheractors such as marginalization, economic stress and water supply limitsaced by populations.

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Action 5A: Estimate the populations at riskEstimates o at-risk populations will reect broad numbers in locations basedon pre-determined risk actors (seeSection 2.3.3) and will typically includethe entire population in a defned geographic area (village, camp, province,etc.). See Annex 6C or details on risk and capacity assessment. While thesepopulations are at risk o exposure, not everyone will become inected ordemonstrate symptoms that require medical care (seeAction 5B) and willthereore not be counted as cases in the reporting system.

Risk assessment methods can include: reviews o existing data on coverage,use and knowledge o sae water, sanitation and hygiene services and healthservices, observation, sanitary surveys, measurement o residual chlorine,key stakeholder interviews and ocus group discussions.

Targeted prevention interventions to reduce the spread o disease - includingwater, sanitation and hygiene eorts, communications measures and oralcholera vaccines where indicated - should be ocussed on populations at risko exposure. These areas should undertake preparations to manage casesthrough community and health sta capacity building (see Chapters 7 and 9or communication and WASH interventions).

should be rounded up to ensure there are adequate supplies (which canbe used to address other diarrhoeal disease eorts ater the outbreak).The estimated AR used or planning purposes is dierent rom thecumulative attack rate calculated ater an outbreak to determine the eectso control measures (seeAnnex 3H).

Estimated attack rates (AR) or eidemic lanning

0.5-2%: low-medium risk settings (less crowded, open settings,rural or may have better access to services)

2-5%: higher risk settings (crowded places with poor water andsanitation, urban slums or camps)

over 5%: typically very high risk settings (high population density, poor water, sanitation and health services, low populationimmunity and high vulnerability)

Note:The AR can exceed 5%, as in Haiti and Goma where oulations havehad little immunity and risk actors are many.

These AR estimates can be used to approximate the number o peopleexpected to become ill (and who will seek medical care) among thepopulations at risk o exposure. These quantities will be used to determinethe number and type o treatment acilities and their medical supply andWASH needs.

The ollowing estimates (rom MSF guidelines 2004) can be used to estimatethe amount o resources needed during a specifed time period or an outbreak:

For all settings: The proportion o cases expected to be seen beore thepeak o the epidemic is 40%

For low-medium risk settings: The peak o the epidemic is expectedto be reached ater 1.5-3 months, and the duration o the epidemic is3-6 months (slower time to spread across the population due to lowpopulation density and open setting)

For higher risk settings: The peak o the epidemic is expected to bereached ater 1-2 months, and the duration is 2-4 months

For very high risk settings: The peak o the epidemic is expected to be reachedater 2-4 weeks, and the duration is 1-3 months (quicker time to spread acrossthe population due to high population density with other risk actors).

TIpStart water, sanitation, hgiene andcommunication interventions in at-risk areasbeore cases occur

Areas that are identifed to be at risk should be immediatelytargeted or WASH and communication activities in order to

prevent transmission to and within these areas. EWARN system

strengthening and capacity building or health sta to improvecase detection and management is also critical in these areas.

See Sections 7and9or response interventions.

Action 5B: Estimate the expected number o casesThe number o new cases expected - and ultimately the magnitude o anoutbreak - is very difcult to predict and depends on many dierent actors.An estimated attack rate (AR) can be used to determine potential numbers ocases and thereore areas that require signifcant attention and supplies orcase management and inection control. The AR can be estimated using thehistorical AR data in that area or what is likely based on known parametersrom previous outbreaks globally. The estimated AR should be based on anassessment o risk perormed with partners. It is oten a best guess and

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Target outcomeHousehold, communit and institutional practices Actions required (may involve sustained behaviour change)

Practitioners Actions required

Inants areexclusivelbreasted and ineeded, givensae fuids andood

Babies under 6 months are exclusively breasted.

Older inants continue to be breasted and are also givencomplementary oods prepared hygienically.

Where ormula milk is used it is prepared hygienically usingboiled water that remains hot enough to kill bacteria in theormula (but cooled beore serving).

Advocacy, communication and social mobilisation sessions or and promotion oexclusive breasteeding or inants under 6 months o age (including motherssupport group sessions) and promotion o breasteeding with complementaryeeding or older inants (including education on ood hygiene or caregivers).

Theenvironmentis ree romexcretabecause

people disposeo it sael

Latrines with unctional hand-washing acilities are usedand kept clean.

People do not deecate in the open (i people dont haveaccess to a latrine they always bury their aeces).

Childrens aeces are disposed o saely in a latrine or buried

Excreta disposal acilities are provided in markets, otherpublic places and institutions with unctional and wellmanaged hand-washing acilities.

Excreta disposal acilities are culturally appropriate and asustainable cleaning and maintenance system is establishedor communal or public acilities.

Especially vulnerable groups are catered or.

Advocacy or and acilitation o processes to encourage community ledsanitation action.

Support to government authorities to ensure institutions and public places haveadequate accessible latrines with unctional hand-washing acilities as well assystems to ensure they are cleaned and maintained.

Communication or behaviour and social change interventions or latrine useand maintenance and open deecation ree communities.

People washtheir handswith soapand water atcritical times

Hands are washed with water and soap at the critical times(ater deecation or handling aeces, beore preparing ood,eeding a child or eating).

I soap is not available then ash or another appropriatedisinectant is used.

Because a shared cloth or towel can become contaminatedhands should be dried in the air.

Particular care is taken at unerals and other gatherings toensure acilities or hand-washing with soap are available

and used at critical times (including ater contact with thedeceased and his/her clothing, bedding, etc.).

Behaviour and social change communication, education and socialmobilisation activities on the importance o handwashing with soap at criticaltimes are undertaken.

Construction, operation and maintenance (including provision o soap) ohandwashing acilities is supported in all public places, particularly next topublic latrines and in ood preparation and serving areas.

Environmentalhgiene isadhered to inmarkets andother publicplaces

Drainage systems are kept clean.

Solid waste is saely disposed o to prevent y breeding.

Functional and clean latrines, with handwashing acilities andsae water, are available.

Particular care is taken with the disposal o solid wastewhich also includes (i applicable) aeces in plastic bagswhich are collected in a ormal system (ying toilets).

Municipal authorities are supported to establish and sustain an eective solidwaste collection and management systems in urban areas with particularattention to markets and other public places.

Solid waste education and communication sessions are undertakenwithin schools and market places. RESpONSEactionson

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These activities are critical or prevention o cholera. Additionalinterventions will be needed in ormulating appropriate responses. SeeSection 9.1 or urther details on community-ocussed actions orcholera response.

4.3 Use o cholera vaccinesVaccination is becoming increasingly important to cholera control ora number o reasons, including: the availability o new, improved, lessexpensive and prequalifed vaccines; growing awareness o large andprotracted epidemics receiving extensive response operations and mediacoverage; increased interest by partners and donors in new technologies toaddress the worrisome growth in incidence o cholera worldwide; and, closercollaboration with technical vaccine experts and partners who implement

traditional cholera control eorts.

There are currently two WHO pre-qualifed cholera vaccines. Both oer themajor advantage o being relatively easy to administer in a short time and odepending more reliably on unctioning health systems and their partnersthan on the actions o amilies or individuals.

Vaccination: A recommended deence

Engagement with governments, WHO and partners is recommended to

consider oral cholera vaccine (OCV) use pre-emptively in endemic, at-risk

and humanitarian settings and reactively in outbreaks. In all contexts, thedecision-making process must be based on a sound risk assessment.

Vaccination does not replace the need or improved water andsanitation services and hgiene education at all levels, nor doesit replace the need or rapid diagnosis and appropriate

management o cases that occur. It should also not be allowed todetract rom necessar on-going attention to diarrhoeal diseaseso other origin, which remain a major cause o childhood mortalitin all developing countries.

It has become increasingly clear that the appropriate implementation o amass cholera vaccination program should be consideredas a potentiallyimportant element o any cholera prevention and control eort, togetherwith the other areas o intervention discussed in this Toolkit.

See Annex 4A or:

Specifcations o the two pre-qualifed vaccines

General considerations on the use o OCVs

Pre-emptive and reactive use o OCVs - why, when and how to usethem, as well as who should administer them, where, and whatadditional easibility considerations should be made during largeoutbreaks and humanitarian crises)

UNICEFs role as a supporting agency

Contact details or technical support and to access OCVs

Link to CDC and WHO Webinar, Cholera and Cholera Vaccines:an update or UNICEF.

Note: Although OCVs are covered in this Section o the Toolkit, they areused pre-emptively as a preparedness measure and reactively in responseto outbreaks. They are intended to prevent the spread o cholera and toreduce mortality through preventing inection.

KEy RESOURCES

WHO,Weekly epidemiological record, Cholera vaccines: WHO positionpaper,26 March 2010.

WHO,Oral cholera vaccines in mass immunization campaigns: Guidance orplanning and use, 2010.

WHO,Background paper on the integration o oral cholera vaccines intoglobal cholera control programs, 2009.

WHO,Technical Working Group on creation o an oral cholera vaccinestockpile,April 2012.

WHO,Global Task Force on Cholera Control, Oral cholera vaccines use incomplexemergencies:whatnext?Meeting report, December 2005.

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