Prior to departure

1. Verify the source of the alert
   • Verify that the information is from a reliable source and reflects conditions suggesting a true outbreak.
2. Obtain the required authorizations
   • In addition to official authorizations, make sure to include permission from local leaders or persons of influence in the community.
3. Prepare materials and supplies for surveillance and to collect and transport specimens
   • Standard line lists or registers, case definitions and procedures for surveillance;
   • Materials for handwashing (water, soap and bleach to disinfect water), gloves, boxes for collection and disposal of contaminated supplies and equipment; and
   • Rapid diagnostic tests (RDTs) and materials for specimen collection and transport: stool containers, rectal swabs and Cary-Blair transport medium.
4. Prepare supplies for patient care, infection prevention and control (IPC) and health and hygiene education
   • ​​​​​​​​​​​​​​Copies of treatment protocols, oral rehydration solution (ORS), chlorine for water treatment, medical supplies (such as Ringer’s lactate, giving sets, IV cannulas), soap;
   • Information, education and communication (IEC) materials and body bags.
5. Arrange transport, security and other logistics
   • ​​​​​​​​​​​​​​Organize transport under secure conditions for the team and supplies.
   • Organize transport of specimens to the reference laboratory.
6. Review the registers at the health facilities
   • ​​​​​​​​​​​​​​Check the register, if available, or speak to clinicians about any previous cases.
   • Collect data from the register, including numbers of patients and deaths from suspected cholera per age category (under 5 years of age and 5 years of age and older) per week.
   • Try to collect data from at least 1 month prior to the first suspected cases to identify when the number of cases increased.
   • Collect data on where patients live when available.
   • Provide data collection tools (register, line list) and training in case definition, data collection and reporting.
7. Examine patients and review clinical management
   • ​​​​​​​​​​​​​​Assess the clinical presentation of the cases.
   • Review current case management practices and protocols.
   • Ensure adequate patient flow and adapt as necessary, anticipating arrival of additional patients if appropriate.
   • If the CFR is greater than 1 %, conduct an assessment of the health facility to identify gaps and priority actions to ensure appropriate access and treatment.
   • Provide protocols and job aids, training and medical supplies as needed.
8. Collect laboratory specimens to confirm the diagnosis
   • ​​​​​​​​​​​​​​Collect faecal specimens (liquid stool or rectal swabs) from suspected patients.
   • If RDTs are available, prioritize sending specimens from RDT-positive samples to the laboratory for confirmation.
   • Send stool samples to the laboratory following standard procedures.
   • Verify that health-care workers can safely collect, store and transport samples.
   • Provide training in sample collection, storage and transport and provide job aids and supplies, if needed.
   • Collect faecal specimens (liquid stool or rectal swabs) from suspected patients and send them to the laboratory for confirmation under appropriate conditions. See section 2 – outbreak confirmation.
9. Review water, sanitation and hygiene (WaSH) and IPC measures at the health facility
   • ​​​​​​​​​​​​​​Evaluate water supply and sanitation facilities and IPC measures and reinforce good practices, as appropriate.
   • Ensure there is enough water to cover the daily needs of patients and caregivers and adequate measures for the safe disposal of excreta and vomit.
   • Ensure that handwashing facilities and chlorine solutions for disinfection are available. As needed, provide protocols, training and supplies (such as buckets, clothes, soap, alcohol-based hand rubs, chlorine, cleaning materials, and personal protective equipment such as gloves, waste bins and cholera cots).
10. Conduct a community WaSH investigation
    • ​​​​​​​​​​​​​​Investigate the possible sources of contamination and likely modes of transmission (such as water sources, markets, gatherings, funerals and cultural practices).
    • If possible, test for free residual chlorine (FRC) in water that is expected to be chlorinated and test for faecal contamination in other water sources. Chlorinate these sources if FRC levels are low.
    • Engage with the community through health and hygiene promotion, using IEC materials to deliver cholera prevention messages and to promote early treatment for diarrhoea. ​​​​​​​​​​​​​​​​​​​​​​​​​​​
11. Conduct active case finding, social mobilization and community engagement
    • Actively search in the community for additional cases with similar symptoms and refer to the health facility for treatment.
    • Train community health workers in case definition, data collection and reporting. Community health workers can also carry out active case finding.
    • Assess the knowledge of the community on cholera prevention and control measures. Deliver key messages to the community to prevent cholera.
    • Deliver ORS, soap for handwashing and products for water treatment.
    • As with community WaSH investigations, engage with family and neighbours of sick people through health and hygiene promotion, using IEC materials to deliver cholera prevention messages and promote early treatment for diarrhoea.
12. Conduct household visits and interviews
    • Interview sick people and their relatives to identify water sources and potential risk exposures. If possible, test chlorinated drinking water sources for FRC and other drinking water sources for faecal contamination. Chlorinate these sources if FRC levels are low.
    • Provide prevention messages to the family members.
    • Deliver soap for handwashing and products for household water treatment.
13. Conduct risk and needs assessments
    • Conduct a risk assessment to evaluate the risk of spreading and the impact of the disease.
    • Conduct a needs assessment to identify the available resources (human and supplies) and list the additional necessary resources.
14. Debrief with appropriate authorities, summarize main findings and provide recommendations
    • Describe cases and laboratory findings.
    • Define areas and populations affected and at risk.
    • Identify possible causes of the outbreak and the potential mode(s) of transmission.
    • Describe the preventive and control measures already implemented.
    • Identify the resources needed for responding to the outbreak.
    • Provide specific recommendations and actions to be implemented.
15. Report the findings of outbreak investigation
    • Prepare an outbreak investigation report.
    • Disseminate the report among appropriate authorities and partners.