Sectors to Include in a Multisectoral Response

Coordination

• Activate or establish a cholera coordination committee or task force that meets regularly to coordinate the response, identify challenges and mobilize resources to address those challenges. This committee is composed of relevant government institutions, agencies and local authorities, and national and international partners and NGOs.
• Based on the extent of the outbreak, this committee can be activated at national and/or subnational levels.
• This committee receives timely information and publishes and distributes daily updates and weekly situation reports that cover indicators on surveillance and epidemiology, WaSH, social mobilization, logistics and case management.
• This committee should estimate overall needs, orient and coordinate action and ensure that human resources and supplies for case management, WaSH, and social mobilization and information, education and communication (IEC) materials are available when and where needed.

Epidemiology

• Standard line lists or registers should be available and used in all treatment centres.
• Compile data daily from the treatment centres and describe the outbreak in terms of who is affected, where the outbreak is located and its evolution to guide control measures. Share reports with the cholera coordination committee and with relevant sectors (such as WaSH, case management, social mobilization) to target actions.
• Collect information on suspected cholera cases and deaths from the community (for example, interview community health workers, families of patients and village leaders; visit the burial area to verify the number of fresh graves).
• Conduct field investigations in the affected areas to identify patients in the community (active case finding), explore possible sources of contamination, and identify risk factors and transmission pathways. 
• If possible, collect geographic information system (GIS) points and create maps of patients’ households and water sources to help identify high-risk areas. Collection of geolocalization data may be done by teams visiting patients’ homes to carry out prevention activities. Share this data frequently with WaSH, social mobilization and case management teams in order to orient activities.

WaSH

• Assess the current conditions and identify risks for transmission in the community, including access to safe water and sanitation, environmental hygiene and key risk behaviours.
• Intervene with prompt WaSH measures; assure drinking water sources are adequately chlorinated at point of use at 0.5 mg/L of free residual chlorine (FRC). These measures can be prioritized in any high-transmission areas identified during the risk assessment.
• Water quality monitoring data should be shared with the coordination committee.
• Interventions to ensure access to chlorinated drinking water may include support to municipal systems or household water treatment.
• At household level, provide soap and water treatment products. Deliver WaSH messages to prevent cholera. This action is often oriented to the household and neighbours of patients admitted to cholera treatment structures, and should be coordinated with hygiene promotion colleagues.
• Visit the homes of cholera patients (when there are few and resources permit) and the affected communities to conduct active case finding, gather information and provide health education, water treatment products, soap and ORS.

Case Management

• Immediately set up oral rehydration points (ORPs) and cholera treatment facilities (CTUs/CTCs). Ensure staff are trained on treatment protocols, adequate supplies are available and job aids are in place.
• Ensure that ORPs and CTUs/CTCs are accessible to the most-affected populations.
• Work closely with epidemiology and logistics to predict supply needs and pre-position them as needed.
• Train health-care workers on the use of RDTs, specimen collection and transport procedures.
• Work closely with case management and logistics colleagues to ensure adequate IPC in treatment structures.

Oral Cholera Vaccination

• Consider vaccination with oral cholera vaccine (OCV) to contain ongoing outbreaks (if implemented early) and to limit the spread of the outbreak into new areas.
• OCV can also be used to prevent outbreak occurrence in settings with high risk of cholera (such as refugee camps and slums) and to reduce disease transmission and the incidence of the disease in endemic areas or hotspots.
• Clearly define the geographical areas and population to be targeted by vaccination based on the epidemiological situation, risk factors and the current local infrastructure and capacities.
• OCV should be used in conjunction with other cholera prevention and control strategies.

Social Mobilization and Community Engagement

• Investigate hygiene and sanitation infrastructure available in the area, including access to and use of these services. Identify at-risk populations and prioritize areas for rapid intervention.
• Engage the community to transmit health promotion and cholera prevention messages and to promote early treatment for diarrhoea.
• Messages should focus on recognizing symptoms of cholera and how it is transmitted, encouraging early treatment-seeking behaviour and increasing awareness of prevention practices and strategies.
• Focus messaging over time to address main risks and gaps (identified through field investigations and case control or knowledge, attitudes and practices [KAP] studies), with positive actions that can be taken (such as increasing household water chlorination, bringing sick people to the clinic immediately, improving handwashing and preparing food safely).

First Steps to Control a Cholera Outbreak

1. Activate the Cholera Coordination Committee

• Create a multidisciplinary cholera coordination committee for coordination between relevant sectors (such as WaSH, education, communication, hygiene promotion) with representatives from relevant ministries and local authorities, international agencies, NGOs, and others as appropriate.
• Clearly establish the lead organization or institution of the committee. It is usually led by the ministry of health in the country.
• During large outbreaks, there may be a national committee and subcommittees to treat more technical subjects (such as surveillance, laboratory, WaSH, case management, logistics, social mobilization). Not all members in a technical group will attend the national committee meetings, but at least one representative from each group should attend to ensure communication exchange.
• If a cluster approach is activated, facilitate the participation of all relevant partners. Roles and responsibilities of the different coordination bodies must be clearly defined.
• Assess the need for subnational coordination structures. Depending on the extent and magnitude of the outbreak, the size of the country and its health service structure, similar committees may be created at subnational or more peripheral levels.
• The cholera coordination committee should meet frequently during the outbreak period (at least once or twice a week, and even daily in the initial phases) and should be action-oriented based on the context and progress of the outbreak.
• The committee should try to coordinate fundraising for the emergency response.

Functions of the Cholera Coordination Committee

This committee provides strategic direction, including the rapid and efficient development, execution and monitoring of the outbreak response plan, as well as implementation and monitoring of activities. Main functions include the following:

• Estimate the potential amplitude of the outbreak and the expected number of cases based on risk assessment and available epidemiological data. Identify priority areas for all interventions.
• Identify human resources and supplies available and needed (see appendix 3 – district-level supply forecasting tool). List unfulfilled needs with required external support.
• Establish cholera treatment facilities in the affected areas to ensure prompt access to treatment. The committee identifies a partner or institution with sufficient capacity to do this or to provide additional support as necessary.
• Provide health-care professionals with approved case management protocols. If these are not available, a subcommittee may be created to develop them.
• Procure and distribute necessary supplies in a timely manner to avoid any shortages.
• Coordinate all partners involved in the response to avoid duplication and overlaps, and to maximize overall response efficiency and effectiveness (see appendix 4 – matrix for coordination of cholera control activities).
• Develop or update a multisectoral cholera response plan as rapidly as possible.
• Create and distribute regular situation reports (at least weekly) on surveillance and epidemiology, laboratory, WaSH, case management, and social mobilization. Include needs identified, implemented measures and recommended actions. Share with donors, government and public.
• Organize regular briefings and meetings and provide regular, concise and updated information on the epidemiological situation and on the effectiveness of the outbreak response, including: — description and monitoring of the outbreak: magnitude, evolution over time (epidemiological graphs to show improvement or deterioration of the situation), geographical extent and other significant features (such as high attack rate, high case-fatality risk, and other problems, such as natural disasters, displaced populations or difficult to reach populations); — regularly updated needs for resources, including personnel and supplies; — control activities undertaken and planned.
• Organize relevant trainings in surveillance, case management, laboratory sampling, chlorine solution preparation, infection prevention and control (IPC) measures and other topics as needed.
• Produce or update information, education and communication (IEC) materials adapted to the context for health education. Ensure best practices for effective risk communication and use adequate dissemination means (such as radio, posters, TV and local leaders).
• Mobilize, train, and equip community focal points (for example, community health workers, local leaders, village chiefs, heads of household) for health promotion messaging, rapid case detection, dehydration management at home with ORS and treatment-seeking behaviour.
• Arrange provision and ensure access to sufficient quantities of safe water and sanitation in all affected areas.
• Assess potential use of OCVs and, if necessary, support the Ministry of Health in preparing and submitting the request to the global stockpile. Conduct microplanning and implement and coordinate OCV campaigns (see section 9 – oral cholera vaccines).
• Supervise, monitor and evaluate control activities and interventions implemented.

2. Develop a Cholera Response Plan and a Preparedness for Areas at Risk

• Develop an integrated and multisectoral cholera response plan based on risk and needs assessments.
• Objectives:
  • a) Reduce the mortality due to cholera.
  • b) Reduce transmission of the disease in affected areas.
  • c) Prevent and/or minimize the risk of introduction of the outbreak to other high-risk areas.
• The cholera response plan should include sections on coordination, early warning and surveillance, case management and IPC measures, WaSH, OCV, risk communication and community engagement, essential supplies and logistics, prevention of spread into neighbouring areas and countries, and budget.
• Each section should have clear activities and indicators for monitoring and evaluation.
• Integrate and strengthen prevention activities, mainly WaSH, social mobilization and surveillance in areas that are unaffected but at high risk.

3. Implement Control Measures

• Control measures should be implemented rapidly, as soon as there is an indication of a cholera outbreak. Control measures focus on reducing mortality and limiting the spread of the disease. See section 6, section 7 and section 8.
• Key actions to reduce mortality include:
  • Set up decentralized cholera treatment facilities (CTUs/CTCs) and oral rehydration points (ORPs) for rapid access to treatment.
  • Distribute ORS in the community and to households. Explain how to prepare and administer the ORS.
  • Employ early detection, triage and transfer of severe cases for IV fluid treatment.
  • Train health professionals using standard case management protocols and IPC measures.
  • Distribute validated treatment protocols to health facilities and CTUs/ CTCs.
  • Estimate supplies; procure and distribute needed supplies to avoid any shortage.
  • Inform the public about what people should do if someone is ill with diarrhoea; include instructions about rehydration with ORS at home or on the way to a treatment facility and how and where to seek immediate treatment.
• Key actions to reduce the spread of the disease:
  • Identify possible sources of contamination and main transmission routes to target interventions.
  • Provide safe water in sufficient quantity and improve sanitation and safe excreta disposal and management.
  • Monitor water sources regularly for FRC levels and report findings to coordination committee; emphasize gaps in chlorination.
  • Identify gaps and promote hygienic conditions and practices (such as handwashing, household water treatment and storage, safe preparation of food, safe burials) and report findings to the coordination committee for immediate action.
  • Strengthen IPC measures and WaSH at CTUs/CTCs.
  • Strengthen epidemiological and laboratory capacity for surveillance.
  • Conduct epidemiological studies (such as KAP and case control studies) to identify risks and gaps.
  • Communicate often to the public through appropriate means (including press releases, TV, radio, social media) and strengthen community engagement.
  • Conduct GIS mapping of cases, water sources and other features to identify regions of high disease burden or emerging areas of high transmission to target interventions.
  • Include oral cholera vaccine (OCV) as part of the multisectoral interventions to control cholera.

4. Procure Cholera Kits

• Cholera kits help countries to prepare for a potential cholera outbreak and to support the initial response.
• The overall package consists of six different kits, each divided into several modules. The kits and modules can each be ordered separately.
  • Three kits are designed for the treatment of cholera patients within existing structures at the central, peripheral and community levels.
  • One kit provides the necessary material to set up a provisional structure for patient care when no existing structure is in place.
  • Two kits list the equipment needed for the investigation of cholera outbreaks and for the laboratory confirmation of suspected cholera cases.
• Some items – especially in regards to water abstraction, treatment and distribution, safe excreta disposal and management, and IPC – may not be included in the cholera kits and will require local procurement.

For more information about cholera kits, see WHO revised cholera kits and a tool to guide estimating the number of each kit required

Procurement

• United Nations (UN) agencies can order cholera kits via WHO or United Nations Children’s Fund (UNICEF) procurement.
• Non-UN entities should contact WHO Procurement Services at procurement@who.int. Put the words “Cholera kits” in the subject line of the email message. WHO Procurement Services will provide guidance for a direct procurement.

For additional Information:

1. Cholera outbreak: assessing the outbreak response and improving preparedness. Global Task Force on Cholera Control 2010 Click here
2. Technical Guidelines for Integrated Disease Surveillance and Response in the African Region. Second Edition 2010.Click here
3. Revised cholera kits and cholera kit calculation tool. World Health  Organization 2019. Click here