Cholera Activity Guide

Public Health: Disease Outbreak Preparedness & Response Planning For Acute Watery Diarrhoea (Awd) & Cholera

PART I: PREPAREDNESS

Objective: Increase communities’ capacity to respond to a cholera/AWD outbreak

1. Map potential key hotspots: disease trend pattern, current surveillance data, areas prone to AWD & cholera outbreak, identify at-risk areas prone to reduced access and collect gender, age, and disability disaggregated population data (triangulate information with health actors – MoPH & NGOs). Initial mapping will include talking to women community leaders and young men and women in order to rapidly assess gendered transmissions.
2. Prepare teams: (internal training & access to information) – conduct in-house refresher training and induction for Oxfam and partner staff to ensure they understand cholera transmission, prevention, alert system & referral pathways (formal and informal case reporting systems) and know and understand the response plan. 
3. Pre-position WaSH contingency stock: at the district/governorate or province level, engage with WaSH Cluster, Health, and district-level stakeholders to identify gaps and ensure resources are in place (including replenishment capacity) – coordination is key!
4. Re-orientation of Community Health Volunteers (CHVs), and community focal points: target informal health care providers and community leaders on outbreak preparedness and response – based on information from social and stakeholder mapping (this can also include teachers if Oxfam is working in schools & schools are open). Oxfam sets clear selection criteria for volunteers who are selected to represent cross-sections of different areas and different social groups that exist within targeted communities.
5. Camp, Community level preparedness and communication plan: mapping out roles and responsibilities, key priority actions, communication chains, and support areas (by Oxfam / community-based groups, local NGOs / INGOs).
6. Community health promotion: identification of major health risks (map all water sources & health-seeking behavior actions, including non-traditional health), supporting CHV & community focal points in developing community action planning and implementation of targeted promotional activities to inform the community about cholera/AWD risk and support them to adopt preventive measures (including targeted NFI items).
7. Ensure weekly health monitoring and analysis: according to PH weekly monitoring form used by CHV, crosscheck community data with data from health posts/ health centers/hospitals and medical partners.
8. Active listening & closing the feedback loop: the continuous gathering of community perceptions throughout the intervention to respond to communities’  questions/concerns/beliefs and practices to improve our response/or adjust our cholera response activities (eg. use of CPT, etc.)
9. Support communities in safe water supply: routine analysis of water quality at the source and especially household levels (0.5mg/L free residual chlorine (RFC) at HH level & 1mg/liter (FRC) in the tankers at the point of filling for water trucking), promotion of water treatment at HH level, quick fixes of water supply systems – if possible
10. Ensure safe excreta disposal: increase latrine coverage using WaSH mapping, training, and, support of CHV / community focal points on monitoring of latrine use and maintenance (update community maps, use sanitation ladder model involving CHV in the monitoring), latrines are always accompanied by hand washing stations. Remember to plan for safe and continuous desludging, if necessary. 

Coordination with WaSH / Health Cluster & MoH

PART II: RESPONSE

Objective: Reduce epidemic spread through an integrated WaSH and Health response 

Both parts of the response need to take place simultaneously – a continuous rollout of the outbreak response plan outlined below in section 1 in combination with a targeted HH intervention through the CATI approach

Rapid Public Health Assessment:to verify if it is an outbreak (see BOX II: Triggers for declaring an AWD & cholera outbreak), identify main transmission pathway route and high-risk areas.

1. Activate outbreak response plan with communal key stakeholders

1. Activate outbreak response plan with communal key stakeholders
   • Improve water quantity and quality: distribution and promotion of aquatabs (CHVs & community focal points) organisation of water tank/jerry can cleaning campaigns, promotion of hygienic water points, free residual chlorine testing at household level, and routine water analysis at source
   • Appropriate health-seeking behavior: Rapid referral to health centers/ if needed – establish ORS corners if required / promotion and distribution of ORS by CHVs / traditional healers/health extension workers.
   • Sanitation: sanitize toilets with chlorinated lime if appropriate, if needed, scale up of emergency latrine construction
   • Community Health Promotion: around prevention and management (promote safe drinking water/chain, hand washing with soap at 5 key moments, signs and symptoms, early referral, cleaning of HH if confirmed or suspected case – utilizing community platforms and forums, public gathering places, schools, health talks, scale up mass communication where appropriate (community radio programming.) using CPT data (or other identified tools) to gather community perceptions in order to adapt HP activities and close feedback loop.
   • Support vaccination campaign (when appropriate): access to information on vaccination, support on outreach to vulnerable communities, action plan to roll out vaccination at a community level (decentralization of vaccination campaign if possible) 
   • Surveillance: support community surveillance – camp & community mapping, linked with national surveillance and referral plan. 
   • Case management: temporary: based on health-seeking behaviour mapping & needs, support IPC/WaSH in hospitals, health centers & CTC.

2. Simultaneously activate CATI approach with RRT:

Targeted HP information and support: CHVs / community volunteers support families around suspected and confirmed cases for follow-up rapid referral & key prevention actions to reduce chances of transmission. 

Access to cholera prevention kit: Ensure access to a cholera prevention kit within 24H of case identification (pre-identify range of coverage based on population density/ mobility). NFI kits need to be distributed within 24H of case identification.

Spot water treatment: Targeted water treatment of shared water sources.

References

“Where attack rates have already reached a peak, preventive interventions are not likely to have much impact, although caution should be taken when analyzing the end of the peak of cholera, especially in localized areas. Pre-emptive targeting of at-risk areas through public health promotion and distribution of cholera prevention kits could be much more effective at reducing the spread of disease.” Oxfam’s Cholera Outbreak Guidelines – Preparedness, Prevention & Control

If data does not exist – estimate more or less 15% of total population in the targeted area is living with a disability.

When mapping out those living in situations of higher vulnerability at a community level consider women who have the largest burden of prevention and the least support, whether widows, polygamous mates, those tending to people with disabilities or who are sick, or single mothers who must carry their babies while they work and who lack access to hand washing facilities, as well as the physically and mentally disabled, child-headed households, and newcomers who have weaker social networks

For cholera prevention kits – recommend stocking enough kits for full coverage / single distribution of the largest single target area. REMEMBER – this is the minimum; Oxfam should scale up based on program target areas.