Public Health: Cholera Response and Epidemic Management

Cholera is an acute diarrhoeal disease that can kill within hours if left untreated. There are many ways to prevent and control the spread of cholera, which requires actions both inside the health sector and beyond, including access to safe water, sanitation and good hygiene practices (WASH). As cholera is a feco-oral disease, sanitation plays a key role in preventing and reducing transmission. Although the focus here will be mainly on cholera in emergencies it is important to recognise that where possible, efforts to control cholera should seek to build long-term systems and consider the longer-term prevention beyond reactive approaches.

Key Actions
  • In closed environments (e.g. displaced persons/refugee camps or urban areas, particularly slums), where the risk of transmission is particularly high, the aim should be to reduce this risk by ensuring that minimum sanitary standards are met and by eliminating open defecation:
    • at least install single pit latrines with a temporary superstructure – provided that the minimum distances (vertical and lateral) between the pits and water sources are respected.
    • If possible, try to prioritise neighbourhoods from which the cases originate and those with poor excreta management. This requires both the capacity to monitor cases in real time (mapping) in coordination with response teams and health partners, and appropriate diagnostic tools so that response teams can assess the status of sanitation in these neighbourhoods.
  • In flood-prone areas, rocky areas where it is difficult to dig or areas with a shallow aquifer close to the surface, alternative sanitation systems can be used to prevent pits overflowing or infiltrating directly into the aquifer:
    • Use of raised latrines with excreta collection in watertight tanks. Appropriate and safe emptying, transport and disposal of excreta must be provided for.
    • Waterproofing of pits (brickwork and waterproof rendering or use of containers). It is also necessary to plan for emptying, transport and unloading operations.
  • All new and/or rehabilitated sanitation facilities must include an adequate hand-washing station with soap and water.
  • in camps and densely populated areas, it is vital to maintain and clean the sanitation infrastructure. It is therefore essential to build latrines with surfaces that are easy to clean and disinfect. During epidemics, cleaning teams trained to follow disinfection protocols must be employed with a frequency proportional to the use of the sanitary facilities. Latrines should be disinfected regularly with a chlorine solution. They also need to ensure that soap and water are available in the hand-washing facilities. The use of these teams must be anticipated in financial and logistical terms.
  • Desludging and treatment: safe emptying and unloading operations should be planned, particularly during epidemic periods. Special precautions must be taken when emptying waste to limit the risks (personal protective equipment, mechanical emptying whenever possible, disinfection protocol for this equipment, the truck, and the collection site), particularly for operators (see health and safety of sanitation workers). In addition to conventional treatments, it is possible to carry out emergency lime treatment using available protocols (taking into account the potential impact of adding lime on the rest of the sanitation chain). For non-emptying latrines, after liming and disinfecting the superstructure, the pit should be closed, and the superstructure removed. In Haiti, where lime treatment of sludge from cholera treatment centers (CTC) was deemed unsuitable, other options were tested: the first system used coagulation/flocculation and disinfection with hydrated (slaked) lime, the second system the addition of hydrochloric acid, followed by pH neutralization and coagulation/ flocculation of suspended solids using aluminum sulfate (Sozzi, Fabre et al. 2015). Both systems use pH changes with the intent to inactivate the cholera bacteria. Removal rates in large scale (30,000 Liter) tanks in actual CTC situations were similar for both systems. It is unknown if the removal rate of thermotolerant coliforms would reduce transmission of cholera from the waste, but the risk of transmission would be reduced
  • Wastewater disposal: preventing cross-contamination in wastewater networks, ensuring the cleanliness of drainage systems, promoting, and supporting the repair of damaged sewer pipes and wastewater treatment plants.
  • Key points to monitor during interventions:
    • The toilet slabs must be disinfected in proportion to use.
    • Daily: Toilets must be safely and easily accessible to all people. Open defecation in densely populated areas must be eliminated, particularly near water sources or tapping points.
    • Weekly: the level of filling of pits and their emptying according to protocols.
    • Regularly in the form of discussions and surveys with the population: presence of functional hand-washing facilities.
  • Provision of sanitation systems and services to health facilities treating cholera cases. This includes toilets accessible to patients, separate for men, women, children and health staff, management of patient faeces and vomit, waste management (sharp, soft and organic), wastewater management and vector control. The provision of cleaning equipment and the human and financial resources dedicated to maintaining a clean and hygienic environment should also be considered. To assess sanitation needs in cholera treatment centre, use the WHO WASH Facility Improvement Tool.
  • Protection of workers: It is important to ensure that the people in charge of sanitation activities with a high risk of contact with the bacteria, and in particular those in charge of desludging, are properly equipped with personal protective equipment (boots, gloves, apron and above all systematic hand-washing equipment, mask, sprayer for cleaning equipment, chlorine) and adequately trained in the risks of exposure.
Author(s) (1)
Baptiste Lecuyot
Solidarité International (SI)
Reviewer(s) / Contributor(s) (3)
Daniele Lantagne
Tufts University
Marine Ricau
Tufts University
Laurent Sax
Global Task Force on Cholera Control (GTFCC)

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