Preparedness Plans

•  Preparedness is the process of ensuring readiness for a cholera outbreak in advance so that the  response will be more effective.
• Preparedness can lead to a faster, more efficient response, reducing both morbidity and mortality.
• A preparedness plan identifies the steps required to prepare for a cholera outbreak, including gap analysis and capacity-building activities, pre-positioning of supplies, adapting and pre-positioning of IEC materials, identification of partners and pre-defined agreements for response implementation and coordination. If a preparedness and response plan already exists, review the plan and update it regularly.
• When an outbreak is over, a retrospective evaluation is essential to pinpoint strengths and weaknesses of the response and to help improve preparedness for and response to future outbreaks.
• In countries where cholera outbreaks occur regularly, in addition to outbreak preparedness and response, long-term cholera control and elimination should be a priority. If not already initiated, outbreaks provide a good opportunity to initiate this type of discussion.
• Many programmes and activities that are part of preparedness planning will contribute to longer-term efforts.
• National cholera control and elimination plans (NCPs) should be developed in line with GTFCC’s Ending Cholera: A Global Roadmap to 2030.
• Preparedness activities include the following:
  • Reinforce surveillance and ensure reporting on cholera, including zero reporting.
  • Conduct periodic meetings with all key stakeholders involved in outbreak coordination and response to define and/or reassess the cholera coordination and information management system.
  • Identify geographic areas and populations at risk by reviewing epidemiological data, past situation reports and maps, WaSH and health coverage and any other contextual information, such as climate information, conflict updates and locations of refugee camps and migration routes.
  • Review key guidelines, protocols and procedures as available. If they are out of date, update them in line with the latest WHO standards.
  • Identify the national workforce, map all partners and describe their roles and areas of action. Assess the partners’ capacity to prepare for and respond to cholera outbreaks.
  • Identify and map the current availability of supplies and estimate the needs. Include these needs in the existing procurement system for storage and distribution.
  • Estimate the available funds and funding sources for prevention, preparedness and response.
  • Conduct periodic training and, if possible, conduct a simulation exercise, to practice the response process before an outbreak occurs.
  • In countries vulnerable to cholera, preparedness plans should also be in place at subnational levels, by region, district or equivalent area, depending on the size and structure of the country.

Recommendations for Improved Preparedness

Outbreak Detection

• Based on previous outbreaks, assess how health authorities were notified of the outbreak and identify the main weaknesses of the surveillance system, resources available and procedures in place in order to increase sensitivity of detection of cholera outbreaks and improve the timeliness and effectiveness of the response.
• Conduct periodic training sessions for health professionals and community health workers to increase their awareness of the disease, case definitions, data collection and reporting procedures (this should be part of training on case management).
• Reinforce or implement community-based surveillance for early detection of cases, immediate reporting and rapid implementation of control measures.
• Consider including private clinics, traditional healers, NGOs and National Red Cross and Red Crescent Societies, and use unofficial sources of information (such as journalists, community leaders, school teachers).
• Pre-position RDTs, rectal swabs and transport media at all health facilities in the areas at high risk of cholera. Conduct training on the use of RDTs and collection and transport of stool samples.
• Establish multidisciplinary teams trained and prepared for rapid deployment to conduct field investigations and implement initial control measures.

Outbreak Confirmation

• Disseminate standard case definitions to healthcare workers before the expected cholera season to help increase awareness and ensure adequate diagnosis.
• Ensure regular provision of laboratory supplies for collection and transport of stool samples to the reference laboratory for confirmation.
• Train laboratory staff to culture V. cholerae and conduct antimicrobial susceptibility testing.
• Ensure that peripheral laboratories in areas with recurrent outbreaks have adequate supplies to perform culture confirmation and antimicrobial susceptibility testing.
• Establish links with international reference laboratories for external quality control and for shipment of specimens for further characterization (such as DNA-based molecular testing).

Organization of the Response

• Establish a cholera coordination committee and ensure that they meet regularly in areas where cholera outbreaks are recurrent. This committee may need special funds in order to perform its essential coordination activities.
• Identify all stakeholders and their scopes of action and capacities and involve them in planning. Strengthen collaboration among the Ministry of Health, other government institutions and agencies in charge of WaSH, and partners.
• Develop and maintain good relationships with donors by organizing regular briefings to provide regular information on the epidemiological situation, the effectiveness of the outbreak response and any remaining gaps.
• Prepare a list of available supplies and anticipated needs before the outbreak.

Monitoring the Outbreak

• Periodically train healthcare workers in surveillance (case definitions, data collection and reporting) even when there is no outbreak. As with outbreak detection, this should be part of training that includes case management.
• Conduct regular analysis of baseline data (time, place, person) before the cholera season to be able to compare data between years.
• It may be valuable to conduct epidemiological studies to identify high risk activities or practices and to develop programmes to modify them in order to prevent cholera transmission.
• It is also recommended to identify “hotspots” (areas where outbreaks regularly occur).

Treatment and Cholera Treatment Facilities

• Organize regular specific training in case management aimed at health professionals. Establish a training plan to achieve the goal of training all healthcare workers. Training should also include case definitions and reporting to improve outbreak detection and monitoring.
• Identify sites for CTUs and CTCs before an outbreak occurs. Ensure provision of adequate supplies to treat patients.
• Prepare in advance individual job descriptions for personnel in CTUs/ CTCs.
• Reinforce IPC measures through regular trainings for all staff working in health care facilities.
• Provide standard treatment protocols to all health facilities.
• Ensure that WaSH activities, including waste management, are in place at healthcare facilities and based on national standards. Organize specific training as necessary.
• Store supplies at district levels in areas at high risk of cholera to facilitate rapid distribution.
• Do not limit pre-positioned supplies to supplies to treat patients, such as IV fluids and ORS. Include WaSH supplies such as soap, chlorine, water quality monitoring equipment, buckets, handwashing stations, cholera cots and personal protective equipment.
• In remote health facilities, ensure provision of supplies and drugs to treat the first 10–20 patients as it may take time to deliver supplies to these areas once an outbreak begins.

Health and Hygiene Promotion, Social Mobilization and Community Engagement

• Engage at-risk communities in the cholera preparedness plan. Identify and train community-appointed people, such as respected members of the community, religious representatives and youth and women’s group members.
• In advance of the cholera season, organize focus group discussions in high risk communities to identify gaps in knowledge about cholera prevention.
• Prepare, update and distribute IEC materials in at-risk areas before an outbreak occurs.
• Check whether soap and products to treat water are available and affordable for the community and develop programmes accordingly.
• Assess the impact of the messages used previously and improve or adapt the communication with communities.
• Maintain social mobilization and community engagement about the prevention of diarrhoea throughout the year as part of community-level activities, with intensification before the cholera season, especially in high-risk areas.
• Conduct long-term promotion on hygiene and sanitation practices such as handwashing with soap, safe disposal of children’s faeces and use of sanitary facilities for defecation.

Risk Communication

• Develop a communication strategy and define key cholera prevention messages before an outbreak. Identify effective means of communication with the population.
• Designate a spokesperson and define risk communication procedures to answer the most common questions about cholera and how to prevent it.
• Link with and use mass media to promote community engagement activities, and use local structures to discuss public health advice.
• Use local communication channels (such as information boards, meetings, social media) to deliver preventive messages.

Access to Safe Water and Hygiene

• Include emergency provisions of water treatment chemicals, water quality testing equipment, standby power generators, and materials and supplies for emergency prefiltration, storage and sedimentation as part of emergency stocks.
• Reinforce food safety, including handwashing stations in public places (such as marketplaces, street vendors) and at gatherings such as funerals.

Ensure burial practices are safe and dignified

• Before the cholera season, prepare a simple list of the main recommendations for healthcare workers to safely prepare corpses for burial.
• Train appropriate community members for safe and dignified burials.
• If possible, investigate local funeral practices to identify any that may transmit cholera, and identify alternative practices.

Vaccination with OCV

• Ensure all procedures for vaccination importation, such as registration, are completed for OCV.
• Inform decision-makers and health staff on OCV, including how to access it and how to conduct a campaign.
• Develop tools for a vaccination campaign such as model tally sheets and communication messages for the use of OCV to prepare for its use in the event of an outbreak or humanitarian crisis.

Long-term Interventions

• In many countries, cholera occurs seasonally and in limited areas (hotspots). Comprehensive and multisectoral interventions targeted at these hotspots should lead to long-term control and even elimination of cholera.
• Long-term measures to control cholera and other diarrhoeal diseases should focus on sustainable improvements in water supply, sanitation, food safety and community awareness of preventive measures.
• Cholera-endemic countries or countries experiencing recurrent cholera outbreaks should consider cholera as a high-priority public health problem and develop and implement NCPs.
• NCPs should include a multidisciplinary approach to ensure that long-term interventions are complementary and implemented in synergy.
• Interventions should target identified cholera hotspots throughout the country and should focus on:
  • WaSH – implementation of an adapted, long-term, sustainable WaSH solution for the population most at risk of cholera;
  • surveillance and reporting – effective routine surveillance and laboratory capacity at peripheral levels to confirm suspected cases, inform the response and track progress towards elimination;
  • healthcare system strengthening – enhanced readiness for cholera outbreaks through capacity-building for staff, pre-positioning of resources and supplies for diagnosis, patient care and emergency WaSH intervention;
  • use of OCV – large-scale vaccination to immediately reduce disease burden while long-term cholera control measures are put in place;
  • community engagement – enhanced communication on cholera control strategies, hygiene promotion and cholera risks by mobilizing community leaders; and
  • leadership and coordination – intersectoral coordination and building of a strong preparedness and response strategy.

For additional Information:

1. Cholera outbreak: assessing the outbreak response and improving preparedness. Global Task Force on Cholera Control. 2010 Click here
2. Ending Cholera. A Global Roadmap to 2030. Global Task Force on Cholera Control. 2017. click here