Overview of treatment

• Rapid access to rehydration therapy is the primary treatment for the full clinical spectrum of patients with cholera.
• Patients with no signs of dehydration are treated with oral rehydration solution (ORS) at household level, in the community or in health care facilities. Oral rehydration points (ORPs) are used to deliver ORS.
• Patients with some signs of dehydration are treated with ORS and monitored closely at a cholera treatment facility.
• Patients with severe dehydration require intravenous rehydration, antibiotics, and close monitoring at a cholera treatment facility.

Access to Cholera Treatment

• Select the location of oral rehydration points (ORPs) and in-patient cholera treatment structures (CTUs/CTCs) to ensure rapid access for patients from affected communities.
• ORPs should be as decentralized as possible and can refer patients to more centralized CTUs/CTCs.
• Factors to be considered in site selection:
  • areas with high incidence rates, large number of patients, high CFR or many deaths reported in the community;
  • areas with poor access to health care for geographic, economic or social reasons.
• Involve the community and local authorities in the site selection, if possible.

Oral Rehydration Points (ORPs)

• Providing rapid access to oral rehydration solution (ORS) saves lives.
• ORPs provide first-line, community-level rehydration, as a highly decentralized element of case management services.
• No specific structure is necessary for the delivery of ORS: ORPs can be fixed or mobile or integrated as part of a healthcare structure, but there is no provision for overnight care for patients. However, basic IPC measures should be implemented to prevent ORPs from being a source of infection.
• ORPs provide oral treatment for patients with suspected cholera and dehydration and refers patients with some or severe dehydration to the cholera treatment facilities (after starting ORS if possible).
• ORPs should provide care during all daylight hours, 7 days per week.
• Whenever possible, involve and train community health workers or community volunteers in the preparation and distribution of ORS in the community, assessment and treatment of patients, and referral of patients with some or severe dehydration for further treatment.
• Any programme delivering ORS is also a good mechanism for delivering health and hygiene education messages.

In-Patient Cholera Treatment Facilities (CTUs/CTCs)

• Cholera treatment centres (CTCs) and smaller cholera treatment units (CTUs) are in-patient health-care structures set up during outbreaks to isolate and treat patients.
• Traditionally, CTUs have a smaller capacity and are attached to existing health facilities, and CTCs are independent structures with larger capacity. However, there is no strict definition of a CTU or CTC, and the names are sometimes used interchangeably. The principles for patient care and hygiene are the same for both.
• CTUs/CTCs should be open 24 hours a day and provide oral and IV rehydration.
• CTUs/CTCs should be established to provide access to treatment for as many patients as possible in the affected areas. When setting up a CTU/ CTC, involve the community to ensure that they will use the facilities.
• Although there is no standard design for CTUs/CTCs, several principles should be followed, such as one-directional patient flow and the separation of patient care areas from staff-only areas.
• CTUs/CTCs can be established in isolated wards in hospitals or health centres, in a tent on the grounds of a health centre or in special units in community buildings such as sports facilities.
• During large epidemics, tent-based structures designed to accommodate large numbers of cholera patients may be easier to manage than other options.
• In urban centres or in specific contexts, an intermediate structure, sometimes referred to as a stabilization centre, may be used to provide oral rehydration and, when the patient is severely dehydrated, initiate IV fluid treatment before the patient is transferred to a CTU/CTC.
• CTUs/CTCs must follow strict IPC measures to minimize the risk of propagation.

Staff and Supplies at CTUs/CTCs

• During the outbreak, a CTU/CTC must be functional 24 hours a day. Establish a plan for rotation of staff.
• Conduct training in clinical case management so health professionals are able to treat dehydration and common complications. Use protocols validated by the country’s Ministry of Health.
• Conduct training in IPC measures, including prevention of transmission at the facility level, use of protective equipment such as gloves and aprons, safe preparation and use of different chlorine solutions, disinfection procedures and waste management.
• Post job aids with treatment and IPC protocols in work areas for quick reference.
• Provide sufficient supplies at every healthcare facility and ORP that might have to treat cases of cholera. Supplies should not be limited to IV fluids; most patients can be treated with ORS alone.
• Prepare sufficient quantities of ORS, using safe water, to cover daily needs.
• ORS should be discarded after 12 hours if kept outside a refrigerator or 24 hours if refrigerated.
• A 3-day supply of water should be stored on site at all times.
• Organize adequate provision of WaSH supplies, including chlorine, residual chlorine testers, cleaning materials, buckets for chlorine solution preparation, protective gear, handwashing stations, waste bins and trolleys/wheelbarrows, body bags, etc.
• Stock management is a key part of running health facilities and ORPs. The rate of use of supplies can vary greatly during the course of an epidemic. A minimum supply to cover 3 days or longer should be kept on site, depending on reliability and regularity of supply delivery. There should be dedicated staff to manage supplies, if possible.

Organization and Functions of a CTU/CTC

• The organization of the CTU/CTC should facilitate the caring for patients with cholera while minimizing the risk of becoming a source of infections.
  • The different areas of the structure (such as patient treatment areas and areas for staff only) must be clearly delineated.
  • Patient flow is one-directional and follows strict rules.
  • Only one caregiver should be present with each patient.
  • There are clear entry and exit points.
  • CTUs/CTCs must have separate latrines and baths/showers for patient use only. If possible, staff should have separate facilities.
  • Patient care areas should be gender segregated whenever possible.
  • Special considerations should be made for vulnerable groups, such as persons with disabilities, elderly people and pregnant women, when constructing latrines and showers/bathing units.
• Main functions to be ensured in the CTU/CTC include:
  • assessment of patients’ dehydration status;
  • registration of patients;
  • provision of treatments, including IV fluids, ORS therapy, zinc, and antibiotic therapy;
  • provision of direct patient care, including feeding and personal hygiene;
  • prevention and control of infection through appropriate measures related to water treatment, cleaning and disinfecting the treatment structure, food preparation, clothes washing and laundry, waste management, cleaning and disinfecting patient transport vehicles and the handling of corpses;
  • offering health and hygiene education for patients, relatives and caregivers; and
  • ensuring security and a protected environment by having a watchman for information and patient flow control and protection of stocks (food, drugs, supplies) and fences, as needed.
• Organize the CTUs/CTCs into the following areas (figure 2):
  • Entrance and exit (screening of patients and handwashing area)
  • Observation area for patients with no or some dehydration (Plan A and B)
  • Hospitalization area for patients with severe dehydration (Plan C)
  • Staff area for supplies, offices, etc.
  • Recovery area for patients with no remaining signs of dehydration
  • Waste area (laundry, waste pits, etc.)
  • Morgue

Figure 2. Layout of a CTU/CTC

IPC measures at a CTU/CTC

Infection prevention and control measures are critical to prevent treatment structures from being a source of cholera infection. Adequate water, sanitation and hygiene services are indispensable elements for patient care and for infection prevention and control in and around CTUs/CTCs.

• Organize the CTUs/CTCs in clearly separated areas and with a one-way flow of patients.
• Ensure that handwashing facilities with soap and safe water are available and maintained in the CTC for health professionals and patients’ caregivers in each ward and at the entrance and exit.
• Guarantee regular provision of buckets, clothes, chlorine, cleaning material, protective gear, sprayers, waste bins and cholera cots.
• Ensure there are measures in place for the safe disposal of excreta and vomit. When possible, latrines for cholera patients should be separate from latrines used by others. When possible, latrines should be gender segregated.
• Ensure there is enough water to cover the daily needs of patients, caregivers and staff, estimated to be 60 litres per patient per day and 15 litres per person per day for caregivers, although this might vary according to context, culture and climate. If there is not a water source on site or nearby that is protected from contamination and well managed, and which can provide sufficient water for the facility, then ensure provision with water trucks.
• Prepare chlorine solution for disinfection according to use (see appendix 9 – chlorine solutions according to use).
  • Use 2% chlorine solution for disinfecting corpses and body fluids (including vomit, faeces).
  • Use 0.2% chlorine solution for disinfecting all parts of the cholera wards, floors, latrines, kitchen, toilets and shower/bathing units, beds or cots, patient’s bedding and linens, clothing, utensils, containers and dishes, waste containers and covers, vehicles used for transporting patients and personal protective equipment (gloves, apron, goggles, etc.).

Table 1. Mode of Transmission and Essential Rules at the CTU/CTC

For additional information, see GTFCC. Technical Note – Organization of case management during a cholera outbreak. June 2017

• Soapy water should be used in hand-washing stations for bare hands and skin. If soap is not available, use alcohol-based hand rubs (ABHR). If soap and ABHR are not available, use 0.05% chlorine solution.
• Healthcare workers should perform handwashing according to WHO’s “Five moments of hand hygiene”:
  • before touching a patient
  • before performing clean or aseptic procedures
  • after body fluid exposure/risk (that is, after handling any potentially contaminated equipment or material such as laundry, wastes, dishes, vomit and stool buckets)
  • after touching a patient
  • after touching patients’ surroundings
• Other important moments when healthcare workers should wash their hands include upon entering and exiting patient areas, after using a latrine (or handling a child’s faeces), after handling corpses and before food preparation and handling.
• Patients’ bedding and clothing should be disinfected with 0.2% chlorine solution and dried in the sun. If chlorine is scarce or not available, they can be disinfected by stirring for 5 minutes in boiling water and drying in direct sunlight, or by washing with soap and drying thoroughly in direct sunlight.
• Ensure adequate management of waste, as well as drainage.
  • Establish a functional drainage system in the CTU/CTC to avoid flooding of contaminated areas (latrines, laundry, waste area).
  • Ensure CTC/CTU site drainage is managed and does not flow into neighbouring areas or contaminate the water table.
  • Ensure body fluids (including stool and vomit) are emptied regularly in the latrines of cholera patients.
  • Pouring chlorine directly into latrines is not recommended.
  • Plastic buckets or other containers used to transport body fluids should be disinfected using 2% chlorine solution.
  • Cleaners, staff working with chlorine, and waste managers should be adequately trained in IPC and equipped with appropriate protective equipment. Protective equipment and clothing should be washed with a 0.2% chlorine solution and dried in the sun.
• Ensure essential rules are respected at the CTU/CTC to minimize the risk of propagation (table 1).

Evaluation of the CTU/CTC

• Timely access to appropriate rehydration is key in preventing deaths due to cholera. If treatment is managed appropriately, no admitted patient should die due to cholera.
• Deaths can occur from delays in arriving to the CTU/CTC or from delays in receiving adequate emergency treatment due to, for example, overwhelmed staff, lack of adequately trained staff or insufficient supplies.
• During an outbreak, many patients may require emergency care at the same time, therefore it is essential that CTUs/CTCs and other health facilities be prepared in advance to respond.
• Conduct an evaluation of the health facilities to identify gaps and actions that should be implemented to ensure appropriate access to treatment (see appendix 10 – CTU/CTC evaluation form).
• Main elements that should be assessed include:
  • water supply, storage and quality
  • IPC measures
  • facility layout and organization
  • screening, admission and observation areas
  • hospitalization area
  • kitchen and meal preparation areas
  • water and sanitation, latrines, laundry and baths/showers, including drainage and potential to contaminate the water table
  • waste management
  • management of corpses
  • procedures and protocols in place
  • stocks and supplies
  • data management
  • staffing
  • health and hygiene education

For additional Information: 

1. Technical Note Organization of Case Management during a Cholera Outbreak. Global Task Force on Cholera Control. June 2017 Click here
2. Cholera outbreak: assessing the outbreak response and improving preparedness. Global Task Force on Cholera Control. 2010 Click here
3. Managing a cholera epidemic. Chapter 6. Setting up cholera treatment facilities and chapter 7. Organisation of cholera treatment facilities. MSF. August 2017. Click here
4. Case management and infection control in health facilities and treatment sites. UNICEF Cholera Toolkit. 2013 Click here
5. Technical Note: Water, Sanitation and Hygiene and Infection Prevention and Control in Cholera Treatment Structures. Global Task Force on Cholera Control. January 2019 Click here