WASH cholera/AWD EP&R training Role of WASH in Management of cholera / AWD Session 3.4 WASH Cholera / AWD EP&R training
Jan 12, 2016
WASH cholera/AWD EP&R training
Role of WASH in Management of cholera / AWD
Session 3.4WASH Cholera / AWD EP&R training
WASH cholera/AWD EP&R training
Learning objectives By the end of the session the participants will be able to
• identify criteria for opening, relocating and closing cholera/AWD treatment facilities.
• describe water, hygiene and sanitation requirements within cholera/AWD treatment facilities and identify appropriate technology choices and approaches.
• list standard chlorine solutions and their uses for disinfection within cholera/AWD treatment facilities
WASH cholera/AWD EP&R training
Management of Cholera - Reducing Mortality
• Interventions to reduce mortality aim at providing early rehydration treatment and the organisation of cholera treatment facilities, their location and staffing are all based on this principle.
• Cholera is an emergency – treatment facilities must be set up rapidly.
• Flexibility is key as the epidemic progresses – facilities must be rapidly multiplied or relocated as the situation evolves.
• Cholera is highly contagious – patients must be isolated and infection control procedures put in place.
WASH cholera/AWD EP&R training
Cholera Treatment Facilities- Definitions
• Cholera Treatment Centres (CTC) and Units (CTU) are inpatient structures where severe cases are isolated and receive specialised care, including IV rehydration.
• Oral Rehydration Points (ORP) or ORS Corners are simple structures that provide oral rehydration to moderate cases and refer severely dehydrated patients to CTC/CTU.
WASH cholera/AWD EP&R training
Locating Cholera Treatment Facilities
• The number of cases per location will determine priority areas where treatment facilities will be set up.
• CTC are placed at central level while CTU are smaller, decentralised facilities.
• ORP are decentralised and widespread to provide early rehydration for moderate cases and identify severe cases for quick referral to CTC/CTU.
WASH cholera/AWD EP&R training
In rural settings multiple, decentralised CTUs are recommended to increase coverage and access.
WASH cholera/AWD EP&R training
In urban settings & refugee camps it is preferable to have one single CTC and
several ORPs.
WASH cholera/AWD EP&R training
ORPs can be decentralised to the community level.
WASH cholera/AWD EP&R training
Estimating the Capacity of Cholera Treatment Facilities
Rough ‘standard’ figures are used at the beginning of an epidemic in planning interventions [MSF]:
Location Refugee Camp / Slum District Town / Rural Area
Estimated AR 5% 1%
Peak Week 3-4 Week 6-10
No. Cases During Peak 30% 10 -30%
Av. Length of Stay 2 days 3 days
% Severe Cases (of those coming to CTC)
75% 75%
These first estimates are based on high AR and high proportion of severe cases and must then be adapted to each specific situation.
WASH cholera/AWD EP&R training
Using Existing Building for CTC/CTUsBuilding Type Advantage Disadvantage
Existing Health Facility
Location is known by patients
Staff available
Concrete floor
Disruption to normal health service function
Isolation from other patients difficult or impossible
Temporary Structure (to construct)
Location is adapted to suit situation
Time to construct
Tents Location is adapted to suit situation – isolation possible
Easy to add extra capacity
Hot
No concrete floor
Hygiene can be difficult to maintain
School Large capacity
Easy to adapt, separate rooms
Education is blocked
Warehouse Large capacity
Easily adaptable & available
Poor ventilation – very hot
No partitions, no light
Private House Small
Close to other buildings
Last choice
WASH cholera/AWD EP&R training
Source: MSF
Structures for Cholera Treatment Facilities
WASH cholera/AWD EP&R training
Structures for Cholera Treatment Facilities
Source: MSF
WASH cholera/AWD EP&R training
Criteria for Site SelectionHealth Authorities & communities should be actively involved in site selection and the following criteria considered:
• Position – look for high ground with good drainage• Distances – other buildings 100m, water sources 40m,
markets 100m• Access – vehicle access for materials delivery• Space – consider needs for future expansion, • Floor - concrete preferable, if a temporary structure can
use plastic sheeting• Ventilation & Light
WASH cholera/AWD EP&R training
Design of Cholera Treatment Facilities
Organisation & design of treatment facilities are based on two key principles:
1. Isolation of the entire facility from other public structures such as schools, health services and markets.
2. Separation of patients (contaminated area) from the ‘neutral area’ (not contaminated).
WASH cholera/AWD EP&R training
Simplified Design of CT Facilities
WASH cholera/AWD EP&R training
Group Work
In your groups consider the given scenario and design the layout of a CTU of the
specified capacity, considering isolation & patient flow.
Draw a plan of the layout. Indicate the type of building selected.
15 min
WASH cholera/AWD EP&R training
Water Supply Principles & Standards
Water Quantity• CTC/CTU – 60 litres/patient/day + 15 litres/carer/day• ORP – 10 litres/patient/day
Water Storage• Ideally, sufficient for 3 days, but as a minimum 1 day
Water Quality (for consumption) • Residual chlorine 0.5 mg/l (pH<8)• Turbidity <5 NTU (up to 20 NTU in initial emergency
phase)
WASH cholera/AWD EP&R training
Calculation exercise in plenary
Let’s estimate the water supply & storage requirements for your given scenario.
WASH cholera/AWD EP&R training
Hygiene Principles
• Movement through the facility should be strictly controlled.
• Disinfection of shoes/feet and hand washing should take place on all entry and exit points to the facility and between different areas.
• Strict disinfection procedures should be followed throughout the facility.
WASH cholera/AWD EP&R training
Entry to a CTU
WASH cholera/AWD EP&R training
Chlorine Solutions & Cleaning Equipment
WASH cholera/AWD EP&R training
Spraying at CTC Entrance
Source: MSF and OGB
WASH cholera/AWD EP&R training
Sprayers & Footbaths
• Sprayers or footbaths are compulsory on the entry-and-exit route between the different areas of the CT facility to ensure disinfection of shoe soles & feet.
• Footbaths are rather inefficient as they become dirty very quickly
• Sprayers or footbaths can also be an important psychological barrier between the facility and outside.
• Both use a 0.2% chlorine solution.• Staff should be equipped with boots to avoid the
irritation caused by repeated contract with chlorine.
WASH cholera/AWD EP&R training
A word about spraying of patient’s houses
To spray or not to spray?
No scientific proof either way
+ Can be used as an access to further
investigate the epidemic e.g. common
causes / risks among the households
affected / sprayed
- Logistically challenging
- Can increase stigma
WASH cholera/AWD EP&R training
Guard and hand washing facility at exit Hand-washing facilities should be available throughout the CT facility, in all patient treatment areas, and at latrines, footbaths, the kitchen, mortuary and waste area.
Hand-washing should be done with a 0.05% chlorine solution
WASH cholera/AWD EP&R training
Bathing
WASH cholera/AWD EP&R training
Bathing Areas
Use Ratio Minimum
Patients / Carers 1:50 2 showers (m/f) in each area
(observation, wards, recovery)
Staff: Neutral Area - 2 showers (m/f)
• Patient showers should be big enough for 2 persons – carer & patient
• A concrete slab or plastic sheeting floor covering are more functional than a layer of gravel as they are easier to clean & disinfect
• Showers should drain to a soakaway within the CT facility.
WASH cholera/AWD EP&R training
Laundry Areas
WASH cholera/AWD EP&R training
Laundry
• A laundry should be set up to wash all soiled items from the facility, including blankets, gowns and protective clothing.
• Where sinks are not available, large plastic tubs can be used.
• Laundry should be immersed and disinfected first in a 0.2% chlorine solution for 10 min, then washed as usual and hung to dry.
WASH cholera/AWD EP&R training
Cleaning the CT Facility
• Ideally floors should be made of concrete, or covered in plastic sheeting, for ease of cleaning. Floors in the wards should be mopped with a 0.2% chlorine solution up to 4 times a day.
• Cholera beds should be sprayed with a 0.2% solution as appropriate and between each occupancy.
• Latrines should be cleaned several times a day with a 0.2% solution, either mopped or sprayed.
WASH cholera/AWD EP&R training
Chlorine SolutionsStandard chlorine solutions used for disinfection within cholera treatment facilities:
Solution Utilisation Storage Period
0.05% Disinfection of skin, mainly hand-washing One day
0.2% Disinfection of floors, walls, beds, stretchers, clothes, eating utensils, and vehicles (spray)
Spraying latrines
Foot sprayers & footbaths
One day
1.0% Mother/Stock Solution
For potable water treatment
One week
2.0% Disinfection of patient’s stools and vomit
Dead bodies
One week
WASH cholera/AWD EP&R training
Protective Clothing
• Staff should be provided with protective clothing, including boots and overalls.
• Gloves should be available for those in contact with blood, chlorine or chlorine solutions.
• Gowns or clothes should be made available to patients on hospitalisation, after bathing.
WASH cholera/AWD EP&R training
Promotion of Hygiene in the CTC or CTU
The organisation of a CT facility is based on a set of actions (disinfection of hands, feet, stools, etc.), that are simple, but often new for patients and carers who just stay for a short time. These new actions need to be assimilated and put into practice quickly by new arrivals. Hence it is recommended to:
1. Equip the facility in such a way to make actions automatic or compulsory
2. Inform staff, patients & carers of the reason for, and nature of, the actions
3. Monitor and make actions compulsory
WASH cholera/AWD EP&R training
Group WorkGroups 2 & 4: consider the
important hygiene practises which
should be promoted to patients and
carers, just prior to discharge. How
could this be done?
Groups 1 & 3: consider the
important hygiene practises which
should be promoted to staff, patients & carers regarding
activities within the CTU. How could this
be done?
WASH cholera/AWD EP&R training
Sanitation Principles & Standards
Excreta Disposal
Area Ratio Minimum
Patients: Observation, screening, recovery
1:20 2 toilets (m/f)
Patients: Wards 1:50 2 toilets (m/f)
Staff: Neutral Area - 2 toilets (m/f)
In addition, provide buckets for all cholera beds & some in observation. Contents should be disinfected prior to disposal. Either place 1 cm of 2% solution in the bucket before use and then empty into the toilet or latrine, or construct an excreta disposal facility specifically for the disinfection & emptying of buckets.
WASH cholera/AWD EP&R training
Excreta Disposal Methods
• Excreta Disposal Pit – specifically for the emptying of buckets. First disinfect stools and vomit in a 2% solution for 20-30 minutes in a plastic barrel prior to emptying in the pit.
• Temporary Simple Latrines – for staff, carers and patients in the convalescent phase.
• Existing Facilities – not ideal but sometimes necessary. Patients’ stool should be disinfected prior to emptying into toilets. Toilets connected to a sewer network should never be used directly by patients.
WASH cholera/AWD EP&R training
Temporary Latrines
WASH cholera/AWD EP&R training
Sanitation (cont)
Waste Water• All waste water from showers, laundry, kitchen,
etc can be considered contaminated and should treated in CTC.
• Rainfall run-off may contain some contamination but is considered low risk, so may therefore be collected and, where possible, drain out to an existing drainage system.
WASH cholera/AWD EP&R training
Sanitation (cont)
Vector Control In areas where vector transmitted diseases exist and are of concern, appropriate vector control measures may include:• general hygiene measures (e.g. cleanliness, washing & exposure of bedding to direct sunlight)• prevention of breeding or elimination of breeding sites (e.g. effective excreta disposal, solid waste management, waste water management)• other methods such as indoor residual spraying or flytraps.Note: the use of bed nets is not appropriate in CTC & CTUs
WASH cholera/AWD EP&R training
Mortuary
• In CTCs a mortuary should be constructed near to the waste zone. It should have an entrance from inside the CTC and access from outside to collect the body.
• A closed tent can be set up as a temporary mortuary. Whatever structure is used it should enable effective cleaning inside, with drainage channels that flow into a soakaway pit (body fluids are likely to be highly contaminated).
• In CTUs, there may not be the possibility to build a mortuary, in which case rapid burial should be promoted.
WASH cholera/AWD EP&R training
• The body should be moved to the mortuary as soon as possible as fluids will start to evacuate the body
• Disinfection of the body should be done inside the mortuary, with 2% chlorine solution
• Where body bags are available, they should be used to transport the body for burial. If not available, the body can be wrapped in a sheet soaked in 2% chlorine
• Where many bodies must be stored, quicklime (calcium oxide, CaO) can be used to neutralise liquids and reduce odours.
Management of Dead Bodies
WASH cholera/AWD EP&R training
Group Work
Locate sanitation, waste management and mortuary facilities on your existing
CTU layout.
WASH cholera/AWD EP&R training
Sanitary Staff
• Sanitary staff include supervisor, cleaners, sprayers/watchmen, chlorinator, laundry workers and mortuary workers.
• Staffing levels depend on the size of the facility but can be significant – e.g. CTC with 300 patient capacity with 67 sanitary staff on start up and 118 at epidemic peak. [ACF]
• Even if there has been cholera preparedness in recent months, training will need to be conducted for all staff.
WASH cholera/AWD EP&R training
Closing Cholera Treatment Facilities
• The key indicator is when the number of patients is small enough that patients can be treated in separate wards within the existing health structures.
Managerial factors to consider include:• possibility of integration of remaining cholera
patients into a regular health structure,• possibility to isolate patients,• adequate staffing in the health structure.
WASH cholera/AWD EP&R training
Water, Hygiene & Sanitation in Cholera Treatment Facilities
Sources of Information:• National Standards or Guidelines• MSF – Cholera Guidelines, 2004• ACF – Water, Sanitation & Hygiene for
Populations at Risk, 2005• SPHERE – Humanitarian Charter & Minimum
Standards in Disaster Response, 2004• WHO – Guidelines for Drinking Water Quality,
2004
WASH cholera/AWD EP&R training
Learning objectives By the end of the session the participants will be able to
• identify criteria for opening, relocating and closing cholera/AWD treatment facilities.
• describe water, hygiene and sanitation requirements within cholera/AWD treatment facilities and identify appropriate technology choices and approaches.
• list standard chlorine solutions and their uses for disinfection within cholera/AWD treatment facilities