Spread of the disease within an area can be reduced through early detection and confirmation of cases, followed by an appropriate, well-coordinated multisectoral response. To facilitate rapid and effective response to outbreaks, countries at risk of cholera should develop and implement cholera preparedness plans and programmes.

Common Sources of Cholera Infection in the Community

• Faecal contamination of drinking water at the sources (unprotected wells, boreholes, standpipes), during transport or supply, or during storage (for example, by contact with hands soiled by faeces);
• Uncooked food made with or washed with contaminated water, drinks made with contaminated water that are not later boiled, ice made with contaminated water;
• Cooking and eating utensils washed in contaminated water;
• Food contaminated during or after cooking or preparation and allowed to remain at room temperature for several hours provide an excellent environment for the growth of V. cholerae;
• Seafood, particularly crustaceans and other shellfish, taken from contaminated water and eaten raw or insufficiently cooked or contaminated during preparation;
• Fruit and vegetables grown at or near ground level and fertilised with night soil, irrigated with water containing human waste or rinsed with contaminated water, and then eaten raw, or contaminated during handling, washing and preparation;
• Many of the above sources will be found at markets and/or food vendor stalls and at transport hubs (e.g. bus stations);
• Additional sources of contamination include bodies of people who have died of cholera, including during burial ceremonies where corpses are touched or where food is shared; and
• Household members and close neighbours of cholera patients are at increased risk of cholera in the days immediately following the patient’s illness. Risk decreases with time and distance.

Social Mobilization and Community Engagement

• An epidemic of cholera can be controlled more quickly when the affected people know how to protect themselves and their relatives and the community is engaged to help limit the spread of the disease.
• Develop or use a prepared set of harmonized messages on the prevention of cholera, pre-test them in the community and ensure that they are validated by the Ministry of Health and used by all partners. Focus group discussions, direct observations, KAP surveys, etc. can help to determine local knowledge and practices in relation to cholera to guide messages.
• The messages should have limited text and contain illustrations of practical demonstrations (such as images showing procedures for chlorination of water, preparation of ORS, handwashing) and be aligned with ongoing cholera prevention programmes (for example, if water treatment products are being distributed, adapt messages to these products).
• Adapt messages to local cultural beliefs about the disease and to the capacity for implementing control measures in the community (for example, if soap or chlorine are unavailable, recommend ash or lime for washing hands).
• Select the best way to disseminate messages to the community.
  • Communicate messages through mass media (such as radio, TV, press releases, social media, SMS), small media (including leaflets, posters, caps, T-shirts, songs), interpersonal communication (for example, briefing sessions with community or religious leaders and talks in places where people usually gather, such as healthcare facilities, hairdressers, churches, mosques, transport hubs, markets).
  • Adapt messages to target groups (such as males, females, adolescents, people who are illiterate) and give them in the local language.
  • This type of messaging should be part of multisectoral approach targeting areas reporting high numbers of patients.

For additional information see:

• Section 5 – risk communication and community engagement
• United Nations Children’s Fund (UNICEF). Cholera Toolkit 2013. Annex 7B, 7D and 7E. New York: UNICEF;2013
• World Health Organization (WHO). Hygiene promotion in emergencies. Geneva: WHO; 2013 .

Access to Safe Water

• Access to safe drinking water for the affected population is essential to reduce the spread of the disease in the community. When possible, also provide access to safe drinking water in the unaffected areas that are at high risk for cholera.
• Even if the drinking water source is safe, water can easily be contaminated during its collection, transportation and storage in the household. A safe water intervention should therefore begin with an improved water source and be followed by safe water collection, handling and storage.
• Analysis of the context will determine the best method for water treatment (at the source or at point of use). Selection of the water treatment method (such as filtration, disinfection, chlorination) will depend on the resources and techniques available and the parameters (physical and microbiological) of the water to be treated. Combining treatments (used together, either simultaneously or sequentially) will increase the effectiveness.
  • In high-turbid water, a pre-treatment (sedimentation, flocculation or coagulation) might be necessary to remove suspended particles and reduce turbidity before disinfection or chlorination. Turbidity levels can be tested with a turbidity tube.
• If water is chlorinated, regularly monitor FRC levels and maintain the appropriate level by adapting the dosing and frequency of chlorination as necessary.
  • Recommended FRC after 30 minutes of contact time is 1 mg/L for water at the source (wells and boreholes) and 0.5 mg/L at the point of use (at the tap, or storage container).
  • The optimal pH range in which chlorine is effective is 6.5–8.5. FRC levels and pH can be tested with a photometer or colorimeter (commonly known as a pool tester).
• When the quality of water at the source cannot be guaranteed, a treatment process is needed to disinfect the water at point of use (at the tap, vessels or storage containers).
• Various methods of household water treatment are available, including: boiling, disinfection, chlorination and filtration.
  • If household water treatment products are promoted, ensure that households understand the water treatment techniques and the residual effect of chlorine (if used).
  • To facilitate the correct preparation of household water treatment products, ensure that households have appropriately sized water containers, preferably closed and narrow-mouthed.
  • Ensure that households are involved in water quality monitoring programmes when chlorine is used for household water treatment.
• Safe water collection, transport, handling and storage also need to be ensured and water quality monitored regularly to minimize the risk of microbial regrowth. To minimize the risk of contamination:
  • encourage the use of closed, narrow-mouthed containers with a protected dispensers (spigot, spout) for extracting water. Containers should be cleaned regularly and good hand hygiene should be ensured to reduce potential contamination when filling or extracting water; and
  • if not available, ensure drinking water is kept in a clean, covered container such as a bucket or large pot.
• Deliver WaSH messages to prevent cholera. Provide household water treatment products and closed, narrow-mouthed water containers in the community to support good hygiene practices, as appropriate. Areas reporting cases should be prioritized
• Ensure health workers and staff or volunteers working in the community are trained to teach local people about safe water treatment methods, including collection, transport, handling and storage. Education around hand hygiene when filling or extracting water is also important to reduce the risk of contamination.
• Involve the community in development and monitoring of interventions that provide access to safe water to prevent cholera.
• See appendix 13 – methods for household water treatment.
• See appendix 14 – preparation and use of 1% chlorine solution to disinfect water.
• For additional information, see World Health Organization (WHO). Guidelines for drinking-water quality. Fourth edition. Geneva: WHO; 2011

Safe Food Preparation

• Safe food preparation is important to reduce the transmission of cholera in the community.
• Food can be contaminated with V. cholerae during production, preparation or consumption.
• The basic rules for safe food preparation should be included as part of health and hygiene promotion programmes.
• For details on safe food preparation see appendix 15 – rules for safe preparation of food to prevent cholera.
• Street vendors and marketplaces with inadequate access to safe water and sanitation or inadequate hand hygiene can play an important role in spreading cholera.
  • Reinforce food safety laws and inspection of restaurants, food vendors and food processing factories and avoid unsafe agricultural practices (such as using sewer water to irrigate crops).
  • Train on or reinforce safe food preparation practices.
  • Promote hand hygiene and set up handwashing stations with soap and safe water in markets and places selling food.
  • Distribute IEC materials on safe food preparation and hygiene messages.

Hygiene and Access to Improved Sanitation

• It is important to isolate faeces to avoid contamination of food and water with faecal matter.
• Improve access to sanitation facilities (for example, latrines connected to a public sewer or to a septic tank, pour-flush latrines, simple pit latrines, ventilated improved latrines). Latrines should be placed in locations that will not contaminate any drinking water source of any drinking water source (at least 30 metres away from any water source and 2 meters above groundwater).
• Discourage open defecation and work with the community to ensure safe disposal of excreta.
• Ensure safe excreta management and disposal during the outbreak. However, avoid latrine emptying during cholera outbreaks. If latrines must be emptied, take all precautions to avoid contamination during emptying and ensure excreta is disposed of safely.
• Involve the community in all phases of design and implementation of on-site sanitation projects to ensure access to and use of the facilities. Set up handwashing stations with soap and safe water near all latrines.
• Ensure health workers are properly trained to teach local people about good hygiene practices and the links between sanitation, water supply, health and hygiene behaviours.
• Promote strong hygiene programmes to ensure the success of sanitation programmes. Focus should include handwashing after defecation and after handling the faeces of a child.

Safe funeral practices and handling corpses in the community

• Funerals for persons who have died of cholera can contribute to the spread of an epidemic.
  • Bodies of people who have died of cholera pose a risk of transmission because body fluids contain high concentrations of V. cholerae.
  • Funerals can contribute to the geographical spread of cholera, as people who attend the ceremony may be infected and take the disease back to their communities.
  • Contamination may occur during funerals when food and drinks are prepared by individuals who prepared or touched the body.
• Always consider social, cultural and religious beliefs and practices. The family must be fully informed about the dignified burial process and their religious and personal rights. Ensure that they agree to all modifications of cultural practices before starting the burial.
• It is important to have a discussion with community leaders to find a way to respect community practices and keep the population safe through preventive measures, including the following.
  • Avoid large funeral gatherings. If not possible, ensure all protective measures are in place, including handwashing facilities (soap and safe water, ABHR or, if these are not available, 0.05% chlorine solution) available to funeral participants.
  • Avoid allowing people attending funerals to touch the body of the deceased. If the body must be touched, those in contact with the body should immediately wash their hands and avoid touching their mouths. Disposable gloves that are immediately discarded can also be used. Kissing the body should not be allowed.
  • Avoid serving food at the funeral. If food is served, it should be eaten hot and handwashing should be compulsory before eating or preparing food. A designated health worker present at the funeral gathering can be helpful in supervising and supporting the use of hygienic practices.
• To prevent the spread of cholera, handling of corpses should be kept to a minimum and burial should take place as quickly as possible (preferably within 24 hours after death).
• Trained staff who wash and prepare the body must wear gloves, aprons and masks. The body should be cleaned with 2% chlorine solution. Do not empty the intestines. Trained staff should fill the mouth, nose and anus of the body (but not the vagina) with cotton wool soaked with chlorine solution.
• Minimize the handling of bodies of people who have died of cholera. For transport of people who have died of cholera, people carrying the bodies should wear gloves. The body should be carefully wrapped, preferably in a body bag. Only trained personnel should handle bodies during the burial process.
• Disinfect the dead person’s clothing and bedding with the appropriate chlorine solution (0.2%). If chlorine is not available, bedding and clothing 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.
• If requested, family members may be present during the preparation of the body for burial. They must be informed of how to protect themselves from infection and be provided with necessary personal protective equipment and handwashing facilities.

For additional information:

1. Cholera outbreak: assessing the outbreak response and improving preparedness. Global Task Force on Cholera Control. 2010 Click here
2. Communicating for cholera preparedness and response. UNICEF Cholera Toolkit. 2013 Click here
3. Hygiene promotion in emergencies. World Health Organization. July 2013.Click here
4. Managing a cholera epidemic. Chapter 4. Strategies for epidemic response. MSF. August 2017.Click here
5. Guidelines for drinking-water quality, fourth edition. World Health Organization. 2011 Click here