CHOLERAFRAMEWORKREPORTAuthor: ChristopheVALINGOTDELAURENTIFunction: CholeraAdvisor–ConsultantPlace: AfricaRegionalOffice–NairobiContract: February–April2017

InternationalFederationofRedCrossandRedCrescentSocieties

Tableofcontents#01 Background/SituationAnalysis p.3 #02 Reviewofexistingapproacheswithafocusonwhatworks p.10 #03 ReviewofRedCrossInterventions p.33 #04 CholeraStrategicFramework p.45 #05 Organizationandpreparednessworkfortheimplementationofthe

CholeraFrameworkp.50

#06 Donormappingandanalysis p.53

#01.Background/SituationAnalysisThe7thCholerapandemicisbelievedtohaveoriginatedinIndonesiainthemiddleofthe20thcenturybutreallyreachedamomentumwithitsexpansioninAfrica,afteranewstrainofvibriocholeraewasintroducedinGuineain1970probablythroughanasymptomatictravellercomingbackfromAsia(1).CholeraspreadrapidlyinWestAfricaalongthecoastandintotheinterioralongriversorbylandfollowingthemovementofnomadictribes(2).Withinafewyears,30ofthe46countriesoftheregionwereaffectedwithahighcasefatalityrate(CFR)rangingfrom4to12%(WHO1991).Sincethen,CholeraseemtohavenestedontheAfricancontinent,contributingtomorethan2/3ofthereportedoutbreaks(3).Sinceitsintroductionin1970ontheAfricancontinent,3620157caseswereofficiallyreported-morethan50%ofallreportedcasesworldwide.However,thosefiguresarelikelytobeunder-estimated,duetounder-reporting(fearofnegativeimpactontravelandtrade)andlimitationsin surveillance systems, inconsistencies in case definitions and lack of laboratory diagnosticcapacities.Recentcalculationsoftheglobalburdenofcholeraestimatethat451millionsofpeopleareatrisk of cholera in Africa, and projections of 1,4 million of cholera cases and 50 000 deathsannually(4).Table: Population at risk, estimated number of cholera cases and deaths per year inendemiccountriesandbyWHOregionSummarytable–Datasource:Theglobalburdenofcholera,Bull.WorldHealthOrgan2012;90:209-218A

WHORegion TotalPopulationatrisk

Estimatedannualnumberofcholera

cases

Estimatedannualnumberofcholera

deathsAFR 451068932 1411453 53632EMR 126277440 188793 6020SEAR 745276148 1224368 31718WPR 120530784 12055 120Total 1443153304 2836669 91490

AFR: African Region; EMR: Eastern Mediterranean Region; SEAR: South-East Asia Region; WPR: Western PacificRegion.CholeratrendsinAfricaWhereas the total annualnumberof cholera cases reportedglobally seems tobedecreasing,thetrendinAfricaisontherise(asshownongraphbelow)andthefatalityratesremainashighas2–5%(5).

Figure: Annual number of cholera cases reported in Africa between 1970 and 2015.Source:WHOdataEconomicBurdenTheeconomicburdenofcholeraisestimatedtorangebetween19and156millionUS$peryearfor the African region alone(6)(NB : those calculations were based on official figures ofreportedcaseswithouttakingintoconsiderationthelikelyunder-reporting).On top of this cost-of-illness calculation,which take into account both the institutional costs(hospitalisation,medicalsupplies,etc.)andindirectcosts,wehavetoconsiderthecostoftheassociatedhumanitarianresponse,andtheeconomiclossesforthecountry(tradeandtourismconsequences).ArecentstudydonebyOxfordeconomicsfortheIVIinstitute,showedthatinthefirstyearofanepidemictheeconomicconsequencescouldcostasmuchas2,5%oftheGDPoftheaffectedcountry.Humanitarian Aid transfers captured by the UN OCHA-FTS (Financial Tracking Service) oncholera emergency response funds reveals increasing emergency costs supported by thehumanitariansectoraround15millionUSDperyear(rangebetween5and35millionUSDperyear);ThesefiguresonlyaccountforpledgesthathavebeenregisteredthroughtheFTSandforthisreasonrepresentanincompletepicture;Moreover, if cholera poses a substantial health burden to poor countries, its impact on theeconomics of poor households –who are also themost affected – is non negligible. Cost-of-illness studies done in several locations (Zimbabwe, Bangladesh, Mozambique, India,Indonesia) showsdirect and indirect costs ranging from30-100US$per caseandup to206US$innorthernJakarta.Thepatientshareofthiscostofillnesscouldrepresentasmuchas21-65%oftheaveragemonthlyhouseholdincome(7–9).

EpidemiologyofCholerainAfricaEpidemiologyofcholerainAfricahavebeenwelldescribed,fromitsintroductioninWestAfricain the 1970’s tomost recent epidemiological reviews at regional (Africa) level, sub regionalleveloratnationallevel.

Figure: Identification of the major cholera transmission “basins” in both coastal andinlandAfrica(10,11)MainCholera transmission “basins”havealreadybeen identified, includingNigerRiver,LakeChad,Guineagulf andWestAfrica coastal area, theGreatLakes region,WhiteNileRiverandSudan,CongoRiverandadditionalsmallertransmissionfociaroundZimbabweandKenyaandinrelationwithIndianOceancoastalregionandislands.Mainfindings:! ThemajorityofcholeraoutbreakshappenedininlandAfricaratherthanincoastalareas.! Mostofthecoastalfociwerelocatednearestuaries,lagoons,andmangroveoronislands.! Maininlandfociareendemicsanctuaryzones,locatedaroundlakesandrivers! InCoastalregions,outbreaksaremorelikelytoappearincoastalcities,wherecholerais

likelytobeimportedfromdistantareas;! Cholera outbreaks rapidly intensify in densely populated urban slums and refugee

campsbeforespreadingtootherregions! Seasonality of cholera outbreaks appear driven by rain-fall induced contamination of

unprotectedwatersources,aswellasperiodicityofhumanactivitieslikefishing/trade! Humandisplacementsconstituteamajordeterminantofthisspread! LullsintransmissionperiodsofseveralyearsrepeatedlyrecordedincoastalareasIdentification of priority countries for a sustained effort in cholera preparedness,responseandpreventionTheWHOrevisedcholerastrategyusesapractical“typology”ofcountry/outbreaks,whichcanbeusedtoguidetheoverallcholeraefforts:

- Outbreaks that happen in countries that declare cases every year (endemicity). Forthose countries, most of the outbreaks are predictable – indicating that we can dosomethingtopreventtransmissiononthelongterm.

- Outbreakshappeningincountriesinacrisissituation,alsoreportingcasesonaregularbasis, butwhere access and securitymight be a problem. In those countries CFR are

often high;Most of the outbreaks are also predictable, and if long term solutions aredifficult to implement, at leastmortality can be reducedwith increasedpreparednessandanadaptableresponsecapacity(includingOCVifthereisawindowofopportunity);

- Unpredictableoutbreaks incountriesusually lessaffected. Inthosecountries, thestaff

andhealthsystemispoorlyprepared–andthereisaneedofasurgecapacitycomingintodiligentlyguidetheresponse;Speedofthedeploymentiskeybecausethereislikelynopreparation;

EndemicandmostaffectedcountriesLookingatwhatishappeningmorerecently(last10years),themostaffectedcountriesare:DRC, Somalia, Nigeria, Ghana, Cameroon, Chad, Sierra Leone, Mozambique, Tanzania, KenyaandNiger.

Figure:Numberofreportedcasespercountry(2010-2015)–sourceWHOdata.EndemicityisdefinedbyWHOas:“Countrieswhicharereportingcasesatleast3yearsoutofthelast5years”;LookingattheWHOdata,wefoundthatfortheperiod2010-1015,countriesreportingcholeracases4ormoreyearsoutofthe6yearswere:Somalia, Togo, Côte d’Ivoire, Burundi, Niger, Mozambique, Cameroon, Ghana, Nigeria, DRC,Liberia,Benin,Uganda,Angola,Tanzania,Malawi,Zimbabwe,Guinea,Kenya(18countries)PrioritycountriesDefinitionofprioritycountries,aspointedoutbyWHO,shouldincludenotonlyendemicitybutalsothecrisisfactor,aswellasseveralotherjustificationandenablingfactors:Forthesakeoftheexercise,thefollowingcriteriahavebeenused:

0 20000 40000 60000 80000 100000120000140000160000

Dem.Rep.Congo

Somalia

Nigeria

Ghana

Cameroon

Chad

SierraLeone

Mozambique

UnitedRepTanzania

Kenya

Niger

Toptencountriesrepor-ngcholeracasessince2010

! Historicalendemicity(numberofyearsreportingcholerasince1970>28)! Recentendemicity(numberofyearsreportingcholerasince2010>4)! Numberofcases>1000cases/year! Crisis-affectedcountry! Existence of a momentum in cholera preparedness and prevention (existing dynamic

aroundcholerapreventionandelimination)

Table:Prioritizationofcholera-affectedcountriesinAfrica

Map:Prioritizationofcholera-affectedcountriesinAfrica

PrioritizationofCholeraAffectedCountries

Region Country Points HistoricalEndemicity Recentendemicity #cases>1000cases/yearCrisisCountry Momentum

WCA Cameroon 5 1 1 1 1 1

WCA Dem.Rep.Congo 5 1 1 1 1 1

WCA Niger 5 1 1 1 1 1

WCA Nigeria 5 1 1 1 1 1

ESA Kenya 4 1 1 1 1

ESA Uganda 4 1 1 1 1

ESA UnitedRepTanzania 4 1 1 1 1

WCA Benin 3 1 1 1

ESA Burundi 3 1 1 1

WCA Chad 3 1 1 1

WCA Ghana 3 1 1 1

WCA Guinea 3 1 1 1

WCA Liberia 3 1 1 1

ESA Malawi 3 1 1 1

ESA Mozambique 3 1 1 1

WCA Togo 3 1 1 1

ESA Somalia 3 1 1 1 0

ESA Ethiopia 2 1 1

ESA Sudan 2 1 1

WCA CentralAfricaRepublic 1 1

ESA SouthSudan 1 1

Endemiccountries:Cameroon, Dem. Rep. Congo, Niger, Nigeria, Kenya, Uganda, United Rep Tanzania, Benin,Burundi,Chad,Ghana,Guinea,Liberia,Malawi,Mozambique,andTogo.Thosecountriesarehighlyendemic,bothhistoricallyandrecently,andaccountformostofthecases reported in Africa. Some of those countries are facing a crisis or report difficulties toaccesssomeareas.Itisinterestingtonoticethatsomeofthosecountriesarealreadyengagedinadynamictobetterprepareforandpreventcholeraoutbreaks.Crisis-affectedcountrieswithaspecialfocus:Somalia,Ethiopia,Sudan,CAR,andSouthSudan.Those countries are not amongst the historical affected-countries, and do not necessarilyreport a high number of cases compared to endemic countries.However, a special attentionshouldbegivenintheseareasaffectedbymultiple,complexcrisis.References1. MukhopadhyayAK,TakedaY,BalakrishNairG.CholeraoutbreaksintheElTorbiotypeera

andtheimpactofthenewElTorvariants.CurrTopMicrobiolImmunol.2014;379:17‑47.

2. SwerdlowDL,IsaäcsonM.TheEpidemiologyofCholerainAfrica.1janv1994;297‑307.

3. GriffithDC,Kelly-HopeLA,MillerMA.Reviewofreportedcholeraoutbreaksworldwide,1995-2005.AmJTropMedHyg.nov2006;75(5):973‑7.

4. ZuckermanJN,RomboL,FischA.Thetrueburdenandriskofcholera:implicationsforpreventionandcontrol.LancetInfectDis.août2007;7(8):521‑30.

5. MengelMA.CholerainAfrica:newmomentuminfightinganoldproblem.TransRSocTropMedHyg.juill2014;108(7):391‑2.

6. alKJet.EconomicburdenofcholeraintheWHOAfricanregion.-PubMed-NCBI[Internet].[cité4mars2017].Disponiblesur:https://www.ncbi.nlm.nih.gov/pubmed/19405948

7. PoulosC,RiewpaiboonA,StewartJF,ClemensJ,GuhS,AgtiniM,etal.Costsofillnessduetoendemiccholera.EpidemiolInfect.mars2012;140(3):500‑9.

8. SchaettiC,WeissMG,AliSM,ChaignatC-L,KhatibAM,ReyburnR,etal.Costsofillnessduetocholera,costsofimmunizationandcost-effectivenessofanoralcholeramassvaccinationcampaigninZanzibar.PLoSNeglTropDis.2012;6(10):e1844.

9. SarkerAR,IslamZ,KhanIA,SahaA,ChowdhuryF,KhanAI,etal.CostofillnessforcholerainahighriskurbanareainBangladesh:ananalysisfromhouseholdperspective.BMCInfectDis.2013;13:518.

10. RebaudetS,SudreB,FaucherB,PiarrouxR.EnvironmentaldeterminantsofcholeraoutbreaksininlandAfrica:asystematicreviewofmaintransmissionfociandpropagationroutes.JInfectDis.1nov2013;208Suppl1:S46-54.

11. RebaudetS,SudreB,FaucherB,PiarrouxR.CholeraincoastalAfrica:asystematicreviewofitsheterogeneousenvironmentaldeterminants.JInfectDis.1nov2013;208Suppl1:S98-106.

#02.Reviewofexistingapproaches-withafocuson“whatworks”Cholera is a proxy-indicator of high vulnerability, highlighting not only the heterogenicdistributionof inequalities inwaterandsanitationservices,butoftenalsorevealingthespecificfragilityorpovertyofaffectedpopulations–mostofthetimelivinginremoteunderservedruralareas,overcrowdedurbanslums,ordisplacedsituations.New approaches in Cholera control and prevention uses historical data, GPS mapping andepidemiological analysis to identify key “Hotspots” areas participating to the diffusion ofepidemicstootherregionsorevencountries.Understanding thepatternsof cholera transmissiononanationalor local scaleandknowing inadvancewhichareasandspecificpopulationswillbeaffectedgreatlyhelptoguidenotonlythepreparationandresponseefforts to contain futureoutbreaks,butalso to target theverymuch-neededbutmoreexpensivelong-termpreventionefforts,inabetterrisk-informedapproach;Thissectionwillpresentareviewofapproachestocholeracontrolandexistinginitiativesandlastupdateofevidencesoneffectiveinterventions.1.WestandCentralAfricaCholeraApproach(ShieldandSwordStrategy)2.TheGuineaExperience3.TheDRCExperience4.WestandCentralAfricaCholeraPlatform5.JointCholeraInitiativefor(Eastern&)SouthernAfrica:JCISA6.GlobalTaskForceforCholeraControlandPrevention7.OralCholeraVaccination(OCV)recentdevelopments8.Recentupdateonevidencesforeffectiveinterventionsincholeracontrol1-TheWestandCentralAfricaCholeraApproach(alsoknownastheShield&SwordStrategy)

DGECHO,2012:Towardsan integratedCholerapreparedness, responseandrisk reductionstrategyA new approach has been developed in West and Central Africa since 2007, following theobserved inadequation between the recurrent cholera outbreaks and the governmental and

TheEpidemicPreparedness,ResponseandPreventionCycle1Preparedness2Earlyresponse3Rapidscale-up,ifneeded4Lessonslearned5Long-termpreventionandriskreduction

humanitarianactorsresponse.Ananalysisofthelatestcholeraoutbreakresponsesrevealedthefollowingshortcomings:

! Recurrenceofoutbreakswithoutimprovingoutbreakmanagement! Responseistoolatetomakeadifference! Limitedresponsecapacities,absenceoftrainedandexperiencedpersonnel! Lackofpreparedness,eveninregions/areasregularlyaffected! Lackofcoherencebetweenactorsonhowtorespondtocholeraoutbreaks! Untargetedinterventions(genericresponseandabsenceofgeographictargeting)! Mixofpreparedness,prevention,andresponseactivities–whenitistimetodoemergency

responseonly.! Absenceofcross-bordercollaborationandinformationsharing

Acertainnumberofcoreprioritiesemergedasacommonvisionsharedbetweengovernments,humanitarianactorsanddonors:

! Theneedforabetterunderstandingofcholeraspread,affectedareas,riskfactors,exposedpopulations

! Theneedforanevidencebased,targeted,andcontextspecificapproach! Theneedforasustainedpreparednesseffortandearlyresponsecapacity! Theneedtoinvestnotonlyinemergencyresponsebutalsointhelongtermriskreduction

TheWCAintegratedCholerapreparedness,responseandpreventionstrategyinvolves:Abetterunderstandingofcholeratransmission,throughepidemiologicalstudies.Historicalreviewofpreviousoutbreaks– Identificationofatriskpopulations,hotspotareas, transmissionroutes,contextsduringwhichpeoplegestcontaminated,specificriskfactors,seasonality,etc.Thisopensthedoortoabetterrisk-informedprograming,usefulforpreparedness,responseandlong-termprevention;A targeted response.This requires investment inepidemiologyknowledge, skillsandcapacityand itsapplication toepidemiology-based interventions.TheShield and Sword strategymakethe distinction between immediate emergency response actions (Sword) in affected areas andpreparednessandpreventiveactions(Shield)inat-riskareas.BothShieldandSwordactivitiesaredefinedinrelationtoaspecifictransmissioncontext,describedfollowingafieldepidemiologyinvestigation.Thisriskinformedresponseallowstargetingspecificallyaffectedpopulations,withactivitiesprovento interruptthe identifiedtransmissionroutes, in theaffectedareasandat theappropriate time.Themain transmission contexts already identified inWest andCentralAfricaarepresentedbelow,butitshouldbenotedthatotherspecifictransmissioncontextsmayapplyinotherregions/outbreaks.Thisiswhytheresponseshouldbetailoredtothecontext,followinganinvestigationwork.

Figure:Fieldepidemiologicalinvestigationinformsthetargetedresponse–(SourceACF)Increased preparedness for an enhanced capacity to detect, and start an early response. Ananalysis of existing disease surveillance systems concluded to the need for strengtheninggovernmental surveillance and laboratory capacities and to include a community surveillancesystem in regularly affected areas; Investment in preparedness activities such as contingencyplanning, training and stockpiling emergency items, especially in hotspots, is also an essentialcomponent.Communication, mobilization and advocacy for long-term risk reduction investments inhigh-riskareas:Theemergencyresponsephaseisnottheappropriatetimetoinvestinlong-termrisk-reduction activities, such as sustainable behaviour change efforts or infrastructureconstructionandmaintenance.However,attheendofanemergencyintervention,thereisagoodopportunity window to capture lessons learned and summarize the necessary information tomobilize governments and their development partners on long-term risk reduction activities.Such mobilisation effort is best ensured in comprehensive “national cholera control plan” orstrategy, with a multisectoral vision for cholera control that can ideally be sealed betweenrelevantministries(Health,WaterandSanitation,Education,etc.)andsharedwithdevelopmentpartnersanddonors.

Figure:Epidemiologicalreviewsrevealessential informationonat-riskplaces(hotspots),populationsandriskcontexts,whichareusedtoinformpreparedness,responseandlong-termriskreductioneffortsforcholeracontrol(Source:UNICEF)SpecialReferences! DGECHOWestAfrica:TowardsanintegratedCholerapreparedness,responseandriskreduction

strategy,2012! TheWestandCentralAfricaCholeraPlatform:Overviewofthestrategytocontrolandprevent

cholerainWestandCentralAfrica.The“ShieldandSword”concept,2016! UNICEF WCARO Cholera Prevention and Control Initiative: Roadmap towards cholera

elimination,20172-TheGuineaExperience2.a.Improvedsurveillance,preparedness,andresponsecapacityFollowing an epidemic that occurred in 2007 in Guinea, ACF and UNICEF supported by ECHOstartedtoimplementtheWestandCentralAfricaCholerastrategy.Anhistoricalreviewofthepastoutbreakswasdone.Populationsat riskwere identifiedaswell as risk factors, seasonality, andunsafe practices. This led to the implementation of a preparedness programme, in goodcoordination with the Ministry of Health. Surveillance was reinforced in high-risk areas withcommunity sentinel sites; contingency plans were developed, emergency stocks prepositionedandpeopletrained.Intheabsenceofanoutbreaksince2008,simulationexerciseswereheldonayearlybasis.In 2012, the sameoutbreak hit simultaneously Sierra Leone andGuinea. After the outbreak, acomparisonoftheresponseinGuineaandSierraLeonewasdone,inordertoidentifythebenefitsof previous programmes inGuinea. A graphic summary of the response analysis inGuinea andSierraLeoneisshownbelow.

Figure: Essential steps inCholeraoutbreakResponsemanagement. ComparisonbetweenGuineaandSierraLeone,2012(SourceACF&DGECHO).A: Identificationof first suspectedcases;B:Officialdeclarationof thecholeraoutbreak;C:Startofmedical case management; D: Start of cholera control activities (WASH);E:FormalintersectoralcoordinationinplaceIn conclusion, preparedness efforts were key in identifying and confirming the first cases andtriggeringthestartoftheresponseinGuinea(8days)–whereasunconfirmedcholeracaseswereprobably circulating in Sierra Leone since January without being captured(>1month).IfitisnotpossibletoattributealowernumberofcasesinGuineacomparedtoSierraLeone to the preparedness work in Guinea, it can be noted that the overall response startedearlierinGuinea,allowingforaprobablymoreefficientintervention.2.b.TheShieldandSwordresponseimplementationinurbancontextTheShieldandSwordstrategywasimplementedforthefirsttimeinanurbancontextinConakryduring the 2012 epidemic. Urban interventions can get really complex due to the size of theaffectedpopulation–Conakrycity ishosting1,2millioninhabitants.Beingableto identifyriskyareas and at risk populations at a very fine scale is key in order to implement an efficientresponse.Thisnewapproachinvolvedgeo-referencingofpatientshome,usedtoproduceaweeklyspecialanalysisofcholeracasesdistribution.Clustersofcasesandrecurrentareasoftransmissionwereidentified.Fieldinvestigationsinpermanentclustersenabledtheresponseteamtoreconsiderthegenericapproachandtotailorinterventionsatafinergeographicalscale.

Toolsusedduringtheresponseincluded:! Identification of at risk areas/districts/neighbourhoods (based on historical review of

availableepidemiologicalinformationandneighbourhoodcharacteristicidentification)! Weeklyattackratesmapsbydistricts/blocks! Weeklymaps of cluster of cases (made possible throughGPS geolocalisation of cases home

addresses)! Identificationofpermanentclusterofcases! Fieldinvestigationinpermanentclusters

Figure:Epidemiologyinaction:RealtimeGISmappingofcholeracases(SourceACF)Examples ofmaps used: Left: Attack rate per district - Right: geolocalisation of cases and clusteridentification.Identification of affected districts can be interesting to identify pockets of vulnerability or toconductvulnerabilityassessments.However,suchgeographicalscale(thedistrict)istoobroadtobe able to conduct targeted response activities other than mass sensitization, due to theprohibitivecostofcoveringanentiredistrict.Precise identificationof localisationofcases (GPSgeo-referencing of patients homes) allowed for a more targeted intervention around affectedhouseholds. Identification of cluster of cases through weekly maps gave the indication of aparticulartransmissionpattern(asopposedtoarandomdistribution)happeninginthisspecificarea.Adetailedfieldinvestigationinidentifiedareaswasthenusedtoorientthecontextspecificcontrolmeasurestobeimplemented.Such intervention wasmade possible with the support and agreement of the government andothermedicalpartnerstoaccesstheirmedicalregisters/linelistingandwithaspecificeffortingeo-referencing each identified case house; Analysis of cluster of case was done with a scantechniquesoftwarebutitcanbedonevisually,andonlyrequiressimpletechnicalskills.SpecialReferences! ACF–GuineaandSierraLeoneCholeraresponselessonslearnedWorkshop–2012! ACF-GuidepratiquedeluttecontreleCholera–2013(inFrench)

http://www.plateformecholera.info/index.php/response-tools/guidelines/254-acf-guide-pratique-de-lutte-contre-le-cholera-septembre-2013

! DGECHOpresentation–PréparationauCholéra:LecasdelaGuinée,2013(inFrench)

3–TheDRCExperienceonlong-termriskreductionIn2006,anepidemiologicalreviewofexistingdataaboutcholerainDRCprovidesanewinsightonthecholeratransmissiondynamicandprovidesusefulinformationonhowitcanbecontrolled.Mainfindingsaresummarizedbelow:! Between2000and2008,208875choleracaseset7335deaths(CFR3,5%)werenotifiedto

WHO,i.e.15%ofcasesand20%ofdeathsreportedworldwide.! AffectedareasessentiallyinEastDRC,alongthegreatlakesregion.Smallareas(lessthan10%

of the region)were identified as responsible for cholera persistence and outbreakdiffusion(seebelowpicture);

! Seasonalvariationswithlowdiffusionindryseasonandepidemicresurgenceinrainyseasonwhere cholera can diffuse up to bigger towns with the favour of population movements(traders,fishermen);

! Persistenceofthosesmallcholerapocketsseemresponsiblefortherestartofanepidemicthenext rainy season, calling for a possible “metastability of thediseasewithin thepopulation”modelratherthanan“environmentalpersistence”model.

! Identificationofat-riskpopulations(traders,carriers,mineworkersandfishermen)

Figure:Hotspot identificationandmapping inDRC–Source:DRCMinistryofHealth.DRCStrategicMultisectoralPlanforCholeracontrolandElimination2013-2017Such informationwasdeemed sufficient toplan for cholera elimination inDRC. In2007, a firstnationalplanwaselaboratedtoeliminatecholerainDRC.Since2013,anewcholeranationalplan2013-2017isinplace.Thenationalcholeraeliminationplanisamultisectoralplan,conveningallrelevantministriesaround the table to participate in the plan; In DRC, participating ministries are: Health,Transports,Energy,Environment,Planning,andRuraldevelopment.Such document has the advantage of officialising theGovernment will to invest in durablecholeracontrolandevenhereelimination.Itgivesadirectiontowardswhichdevelopmentandhumanitarianpartnerscancontribute,andfacilitatestheadvocacyandfundraisingeffortsbyprovidingleadership,acoherentdirectionwithexplicittargetsandbudget.

Based on this experience, long-term investments have been considered together withdevelopment partners such as UNICEF, AFD (French Development Agency), and Veolia in 4importantcholerahotspots.SpecialReferencesFromresearchtofieldaction:exampleofthefightagainstcholeraintheDemocraticRepublicofCongo(1)EliminationofCholeraintheDemocraticRepublicoftheCongo:TheNewNationalPolicy(2)NationalCholeraEliminationPlan–DRC:http://reliefweb.int/sites/reliefweb.int/files/resources/PLAN%20ELIMINATION%20CHOLERA%202013%202017.pdfUNICEFWASHInvestmentsinCholeraHotspots(inFrench):http://reliefweb.int/report/democratic-republic-congo/lutte-durable-contre-le-chol-ra-en-rdc-2014-s-curiser-l-acc-s-l-eau4-TheWestandCentralAfricaCholeraPlatformAnumberofactors,interestedinCholeracontrolandpreventionattheregionallevel,decidedtoshare their experience and work together to strengthen Cholera control efforts in West andCentralAfrica;This led to thecreation in2011-2012of theregionalcholeraplatform.TheWCACholera platform is gathering the main WASH and Health actors involved in the fight againstcholeraintheregion,includingbutnotrestrictedto:ACF,ACTED,ALIMA,ECHO,IFRC,MSF,OCHA,UNICEFandWHO.http://www.plateformecholera.infoInitially,theCholeraPlatformwasmainlyusedtoshareinformation,alertwhenthesituationwasdeterioratingandcreateacommonunderstandingofthesituationintheregion.Oneofthemostuseful tools that have been developed is a real-time overview (weekly update) of choleraincidence for all the countries togetherwith anhistorical perspective (severalweeks followupandcomparisonwithpreviousyears).

The Cholera Platform has since developed many information products and tools, dedicated tomaketheexistinginformationavailabletothepublic,throughanon-lineknowledgemanagementplatform,tobuildthecapacityofallinterestedactorsorindividualsthroughinformationsharing,trainings, and on-demand support, to harmonize and facilitate coordination, to promote jointefforts through amulti-organization preparednessmatrix and to lead an advocacy strategy onbehalfofallstakeholdersandgovernmentsatregionalandgloballevel;

Since its creation in 2012, the Cholera Platform has been able to realize and publishepidemiological analysis for 12 countries in the WCA region, identifying the main cholera

hotspots, seasonality patterns, vulnerable populations, risky practices and main transmissioncontexts:http://plateformecholera.info/index.php/departments/unicef-cholera-factsheetIn depth analysis of vulnerability in identified hotspots and long-term solution proposals forcholerariskreductioninthoseareashasbeenrealisedin6countries.Next steps will include working with Governments and advocacy towards their DevelopmentPartners to integrate long-term risk reduction investments in cholera hotspots in their nextprogrammaticcycle.5-TheJointCholeraInitiativefor(Eastern&)SouthernAfricaA similar approach to theWCA Cholera Platform is currently being developed in Eastern andSouthernAfrica,alsoledbyUNICEF.The Joint Cholera Initiative for Southern Africa (JCISA) is amulti-agency technical partnershipbringingtogetherWHO,UNICEF,UNOCHAandOXFAM.Thegoaloftheinitiativeistostrengthenregional capacity and collaboration to ensure amore timely, integrated and effective technicalsupportforcholerapreparednessandresponse.https://www.humanitarianresponse.info/system/files/documents/files/ROSA%20Humanitarian%20Bulletin_August%202013_Cholera.pdfFornow,thisinitiativecoverstencountries,buttheideaistoextendthecoveragetoallEastern&SouthernAfrica.JICSA also aims at contributing to the reduction in morbidity and mortality due to cholera inSouthern Africa by putting in place appropriate systems and resources to support prevention,preparedness, riskreduction, rapidresponseandresilienceat thesub-regional levelandwithinendemiccountries.This initiative isyounger thantheWCACholeraPlatformandhasnotyetdevelopedtheon-lineknowledgemanagementplatformorproduceddetailedepidemiologicalstudies.However,Choleraweeklybulletinsarecomingoutonaregularbasis.

6-TheGTFCCTheGlobalTaskForceonCholeraControl(GTFCC)isanetworkofcholeraexpertswhichbringstogethergovernments,non-governmentalorganizations,UNagencies, and scientific institutions,whosharethebeliefthatcollectiveactioncanstopcholeratransmissionandendcholeradeaths.ThesecretariatoftheGTFCCisensuredbyWHO.http://www.who.int/cholera/task_force/en/TheGlobalTaskForceforCholeraControlandPreventionhasbeenrevivedin2014followingthe2010GeneralHealthAssemblyresolutiononCholera.ThespecificobjectivesoftheGTFCCareto:! Support the design and implementation of global strategies to contribute to capacity

developmentforcholerapreventionandcontrolglobally.! Provide a forum for technical exchange, coordination, and cooperation on cholera-related

activities to strengthen countries’ capacity to prevent and control cholera, especially thoserelated to implementation of proven effective strategies and monitoring of progress,disseminationandimplementationoftechnicalguidelines,operationalmanuals,etc.

! Supportthedevelopmentofaresearchagendawithspecialemphasisonevaluatinginnovativeapproachestocholerapreventionandcontrolinaffectedcountries.

! Increase the visibility of cholera as an important global public health problem throughintegration and dissemination of information about cholera prevention and control, andconductingadvocacyand resourcemobilizationactivities to support cholerapreventionandcontrolatnational,regional,andgloballevels.

To deliver on these objectives, working groups were established in key areas of cholerapreventionandcontrol:surveillance/epidemiologyandlaboratory;oralcholeravaccines(OCVs);case management; water, sanitation and hygiene (WASH); communication/social mobilizationand advocacy. Eachworking group has its own research and guidelines/directions publicationagenda.

Followingasystematicreviewofscientificliteratureontheeffectivenessofseveralinterventionstocontrolcholera,agap inqualityevidencewas identified.Aresearchagendahasbeendefinedand research projects are now being implemented to measure the effectiveness of different

interventions(seebelowsection8-Reviewofevidencesoneffectiveinterventionsforcholeracontrol).7.OralCholeraVaccination(OCV)recentdevelopmentsUseofpre-qualifiedOralCholeraVaccine(OCV)asanemergencyresponsetoolonlystartedveryrecently, in 2013,with the creationof an emergency vaccination stockpilemanagedby the ICG(Inter-agencyConsultativeGroup:WHO,UNICEF,MSF, IFRC), and fundedby theGAVI initiative(B&M.Gates Foundation). Since 2013,OCV campaigns have been implemented in 14 countries,andunderseveralcontexts.Uptonow,atotalof41vaccinationcampaignshavebeenrealized,foratotalof7,6milliondoses.Averagesizeofavaccinationcampaignnowreaches500000doses.Table:OCVcampaignssincetheICG-OCVstockpilecreationin2013

Source:WHO,GTFCCWASHworkinggroupmeetinginDakar,2017Withsuchrapiddevelopments inOCVuse,andsuch increased focusonOCVfromGovernmentsandDonors, it is importanttoensurethatthisfocusonOCVenhancesaswellcoordinationwithwater,sanitationandhygieneactivitiesandothercholeracontrolmeasures.8.RecentupdateonevidencesforeffectiveinterventionsincholeracontrolCholera has often been associated with the idea of poverty, be it at household level(3) or atcountry level(4,5). However, this link can be better understood with regards to the level ofservices(andinparticularwaterandsanitationservices)accessibletothosepopulations,asithasbeenshowninrecentpublications(6–8).WASH interventions have historically been effective in reducing the number of cases andpreventing thereappearanceofcholeraandotherwaterrelateddiseases–asshown in the lastcenturyinEuropeandAmerica–andmorerecentlyinLatinAmericainthe1990s.Cholera is transmitted mainly through the fecal–oral route, and the ingestion of fecallycontaminatedwaterplaysaprimaryroleinthespreadofthedisease,especiallyduringepidemics.Stopping the fecal–oral contamination cycle can reliably prevent cholera; ensuring use ofappropriatesanitationandproperhygiene(personalandfood)andaccesstosafedrinkingwaterfor the whole population are of utmost importance. In an epidemic, there is only one way tocontract cholera: by swallowing something (usuallywateror food) thathasbeen contaminatedwith fecal matter that contains Vibrio cholerae. Consequently, if fecal material is not ingestedorally,thespreadofcholeracanbecompletelystoppedandinfectioncanbeentirelyprevented.

Year Type of Campaign

Number Countries

2013 Endemic 2 Haiti (2)2014 Endemic 10 DRC, Guinea, Haiti (8)

Humanitarian Crisis

7 South Sudan (6), Ethiopia

2015 Outbreak 4 Malawi, South Sudan (Juba and Torit), Iraq, Nepal

Humanitarian crisis 6 South Sudan (3), Tanzania, Cameroon, Malawi

2016 Endemic 4 Sudan, Haiti, MalawiHumanitarian crisis 4 Niger, South Sudan (2), Haiti

Outbreak 5 Malawi, Zambia (2), Mozambique, DRCTOTAL 41

Other interventions used to control cholera during the past decades include effective diseasedetection and diagnosis; effective treatment with rehydration (oral or intravenous) and, whenappropriate,antibiotics;More recently, another effective intervention have been developed – Oral Cholera Vaccination(OCV)—butithasnotyetbeenwidelyimplemented.Reasonsforitslimiteduseincludelackofawarenessofitsexistenceandlowvaccineproductioncapacity,bothofwhicharecurrentlybeingaddressed;Thisnewtool forcholerapreventionandcontrolwill soonbepartof thecommonlyusedcholeratoolbox.OralRehydrationTherapy(ORT)Choleracankillevenhealthyadultsinamatterofhoursifuntreated,oriftreatmentisdelayedorinadequate.Effectiveandtimelycasemanagementofsymptomaticcasesiskey.However,Choleraisaneasilytreatabledisease.Thepromptadministrationoforalrehydrationsaltstoreplacelostfluidsnearlyalwaysresultsincure.Inseverecases, intravenousadministrationoffluidsmayberequired to save the patient's life.Mild andmoderate cases (80%of cases) can be successfullytreatedwithoralrehydrationsalts(ORS)only(9).ORTisthereforeknowntobeoneofthemostcosteffectiveinterventiontopreventmortalityindiarrhealinfections(10).TargetedChemoprophylaxisinContactsofPatientswithCholeraA recent meta-analysis have provided evidence that targeted chemoprophylaxis (use ofantibiotics) for household contacts, which are at highest risk of getting sick than the generalpopulation,couldhavesomeprotectiveeffectsinpatientscontacts(11).However,therehavealsobeen evidences thatmass or targeted chemoprophylaxis can increase antibiotic-resistance andcontributetoselectresistantcholerastrains.WHO does not recommend the use of antibiotics for mass or targeted chemoprophylaxisdistribution,andrestrictitsuseforseverecholeracasesonly(12).OCVRecent reviews of evidences on the effectiveness of cholera vaccination report indicate theefficiencyofa2dosesperperson(recommended)vaccinationtovarybetween85%at6monthsand65%at3years(13,14).Efficiencyofasingledosevaccinationiscurrentlybeingassessedforemergencyresponse,withaninitialbetof6monthsprotection.Onedosecosts1,85USD.Inspiteofdelaysrelatedtoorder,supplyandimplementation,thiscanbeconsideredaneffectivenewtoolforcholeraprevention,inparticularinendemicsettings(wherehotspotsandvulnerablepopulations are already identified) and in crisis countries where traditional control measureswouldbemoredifficulttoimplement.WASHandotherinterventionsWASH interventions have historically proven to be effective in cholera control and prevention(CholeraeliminationinEurope&NorthAmerica,andmorerecentlyinSouthAmerica).However,theavailablescientificliteratureonwasheffectivenessisscarce.InanattempttoquantifytheeffectivenessofWASHinterventions,anumberofreferencestudiescan be referred to (10,15). Several hypotheses have beenmade on the effectiveness ofWASHinterventions,startingwithEsreyetal.1991–usinganumberofqualitystudies.

NB:Most of the available studies relate to overall diarrhea reduction – and do not specificallytargetcholera.EstimationoftheeffectivenessofseveralWASHinterventionsondiarrheareductionTable:AssumedReductionsindiarrheaattributabletoseveralWASHinterventionsWASHIntervention Corresponding

RelativeRiskReductionin diarrhea(%)

WaterSupply–Improvedpublicsource* 1,20 17Watersupply–additional(houseconnection)* 2,70 63Excretadisposal* 1,56 36Hygienepromotion* 1,92 48Waterquality–source** 1,37 27Waterquality–HHFiltration** 2,70 63Waterquality–HHchlorination** 1,58 37Waterquality–Solardisinfection** 1,45 31Waterquality–Flocul/Disinf** 1,45 31*Source:DCP2,Jamison2006.** Source:Water Quality Interventions to Prevent Diarrhoea: Cost and Cost-Effectiveness (Clasen,2008)NB:DCPauthorsmentionthatthesereductionsareconsideredtobeindependentofoneanother,sothatthebenefitsforseveralinterventionscouldbeadditional.Regarding the impact of WASH interventions designed specially to prevent cholera, recentsystematic reviews (16–18) found a clear lack of evidence to help guide implementers decidewhatapproachandinterventiontoselectduringacholeraoutbreak–partiallyduetothedifficultytosetupgoodevidencecollectionsysteminemergency/epidemicsetting.The recent introduction of an effective solution in the form of OCV pose the question of thecomparative advantages of WASH interventions, their effectiveness as well as their cost-effectiveness. After identifying the evidence gaps and the need to include also non-academicdocumentation for further research, GFTCC engaged discussions with TUFT University to re-conduct a systematic review, including not only published academic papers but also greyliteraturedocumentsfromNGOsandotheroperationalorganisations;The first results of this work (not yet published) were shared during the last GTFCC WASHworkinggroupmeetinginDakarinMarch2017.Thepreliminaryresultsarepresentedbelow.

EvidenceSynthesis:WASHinterventionsindiseaseoutbreakresponse

Source:TUFTUniversity,GTFCCWASHworkinggroupmeetinginDakar,2017The study found low to moderate quality evidence of some effectiveness of interventions onhealthoutcomeforthefollowinginterventions:! Welldisinfection! Sourcebasedtreatment! Householdwatertreatment(HWT)chlorinetablets! AWASHactivitypackage(mixofactivities)! Distributionofhygienekits! Socialmobilization! Communitydrivensanitation! Hygieneeducation! HWTsolutionswithliquidchlorine,flocculent/disinfectantorothersolution.Verylittleornoevidencewasfoundforthefollowingactivities:! Watertrucking! Wellrehabilitation! Bucketchlorination! Latrinebuilding! Handwashing! Householdspraying! Environmentalclean-upOverall, the key programme characteristics for success were simplicity, timing, communityengagementandpresenceofacommunityhealthprogrammebeforehandinthearea;

Sourcetreatmentandpoint-of-collectionwatertreatmentRationale:Thecommunitywatersource/pointmaybethesourceofcontamination–ormightgetcontaminatedbysickpersons,asymptomaticcholeracarriers,casecontacts,caretakersorunsafeenvironment;Previous studies found out direct well disinfection to be only partially effective, theimplementationoftheinterventionbeingoftenlimitedtoaone-offdisinfection,withnoresidualchlorineafter24hours.Moreover,experienceshowedadecreaseduseofHHWTsolutionafterthestartofwellchlorination,paradoxicallyincreasingtheriskofbeingexposedtocontaminationforhavingafalsesenseofprotection(19).Locallymadewellchlorinedispenserswerefoundeffectiveinsomestudiesforupto3daysbutwithnodemonstratedresultsonsustainedappropriateuse.Welldesignandwellprotection(cover)arealsokeyelementstoconsiderinprotectingwellwaterfrombeingre-contaminated,andforthisreasonwellwatermayoftennotprovideasecuredwatersource.Forallthesereasons,directwell chlorination isnotrecommendedasaneffectivesolution,andalternative options should be considered. Other solutions include point-of-collection waterchlorinationorpoint-of-usewatertreatmentoptions(HHWT).Amongstalreadyimplementedpoint-of-collectionwaterchlorinationsolutions,wecanfind:! Bucketchlorination:Thisisaneffectiveandsimplewayofproposingachlorinationservice

atthepointofwatercollection,togetherwithsensitization.

! Chlorine dispensers: Free chlorine dispensers next to point-of-collection with an initialsensitizationphasewasfoundtoyieldmoreintakeinchlorinationusethatfreedistributionofHHWTsolutionsathomeinruralKenya(20)andprovenverycost-effective.

However, there is not yet any good quality documented evidence of effectiveness of suchinterventiononcholeraincidencereduction.Wherewateraccessisdeliveredthroughacollectivewatersupplyservice,safeandcontinuouswatersupplyiskey.ArecentstudydoneinDRCshowedadirectcorrelationbetweentemporaryservice interruptions and the upsurge in cholera cases(21). One reason could be that duringinterruptionsofwaterservicepeoplerelyonotherlesssafewatersources.StoragevesseldisinfectionRationale: Water is a possible vehicle of the vibrio, and several studies have shown possiblerecontaminationofcleansourcewaterduringtransportandstorage.Regularcleaningofhouseholdwaterstoragecontainersshouldbeencouraged.85%reductionincoliformcountswasobservedinastudyincleanedstoragecontainers,butitshouldbenotedthatthisalonedidnotprotectstoredwatertoberecontaminatedathouseholdlevel(22),andthatonlychlorine will provide a temporary remanant disinfection power in the form of free residualchlorine(FRC).

HouseholdWaterTreatment(HHWT)solutionsRationale:Whenwateraccesscomesfromseveralwatersources(riverbanks,neighbourprivatewells,communityboreholes,streetvendors)itmaybemoreefficienttotargetat-riskhouseholdsdirectlyandgivethemthepossibilitytoprotectthemselvesthroughhouseholdwatertreatmentsolutions(HHWT).AmongstHHWTmethodologies, filtration,Sodis(UVdisinfectionthroughsunexposure)anduseof chemical products as chlorine or flocculent/disinfectant for turbidwaters have been proveneffective to reduce bacterial contamination in household water; However, only the HHWTsolutions that provide residual disinfection potential (chlorine solutions) will be effective toprotectfrompossiblerecontaminationathouseholdlevel;Distribution of Household treatment in the form of chlorine or flocculent/disinfectantproductsseemtobeoneoftheproveneffectivesolutioninprovidingsafewatertoaportionofthepopulation–andhasbeenproventoreducecholerariskamongstusers.Adherencetotheprogrammeandmaintenanceofthebehaviouriskeytoprotecthouseholds.Pre-existenceoftheproposedtechnologyinthecommunityanddemonstration,withfollow-upvisitsarekeyelementsforcommunityacceptanceandincreaseduse.HandwashingRationale: Cholera infection is faecal-oral. Main transmission route include ingestion ofcontaminated water OR ingestion of contaminated food. Unsafe handling of foods withcontaminatedhandsordirectcontactbetweenhandsandmouthcanleadtovibrioingestion.A recent review investigated the effect of handwashingwith soap,water quality improvementand excreta disposal on reducing diarrhoeal disease found that handwashing with soap couldreduce diarrhea by 42%-48% compared to water quality (17%) and excreta disposal (36%)interventions(23). In several epidemiological studies, handwashing with soap behaviour wasreportedasaprotectivefactorwhencholerawasnotassociatedwithawatersource,butratherwithfoodorunidentifiedsource.Focus should not be on water quality only, when proper hand hygiene practice can preventperson-to-person transmission as well as food and household water contamination. Hygienepromotion,andespeciallyhandwashingwithsoap, shouldbean integral componentofanycholeracontrolprogram(17).SocialmobilizationRationale:Choleraisadeadlydiseasethatcanleadtoseveredehydrationanddeathinamatterofhours if left untreated. The cure is very simple, but needs to be implemented quickly. Simplerehydrationwithsalt/sugarsolutionormanufacturedORS(OralRehydrationSalts)sachetsmixedwithcleanwatercantreatabout80%ofalllightandmoderatelydehydratedsymptomaticcases.Beingawareofthedeadlydisease,signsandsymptoms,andurgentneedtoseekforrehydrationcareinthecommunity(atORPs)ortobereferredtohealthcentersorCTCsiskey;Existing studies looked at several interventions aiming at increasing cholera awareness andknowledge about cholera transmission and protection measures. The majority of studiesconcluded tohaveagood impactonknowledge,notalways followed inobservedpractices(17).

Studies suffered variousmethodological limitations, and did notmeasure any effect on choleraincidenceormortalityreduction.SanitationRationale:Thefaecal-oraltransmissionstartswithdealinginappropriatelywithfaeces,whichcanlead to the presence of the vibrio in the environment and possibly source water. Improvingadequateandsafe latrineusecouldreducetheenvironmentalcontaminationandriskof furthertransmission.Nothavinga latrineorsharinga latrinewithaneighbourhasbeenidentifiedasasignificantriskfactorinZambia.Nostudieswerefoundlookingattheimpactofsanitationoncholera.Moreresearchisprobablyneeded.However,sanitationinterventionswouldprobablyneedaconsequenttime,whichmightnotbecompatiblewiththeneedforanimmediateresponse,butratherconsideredinalong-termriskreductionperspective.ImprovementofWASHinfrastructuresRationale: WASH infrastructures have historically proven to be effective in reducing choleraincidence(Europe&NorthAmericaandmostrecentlySouthAmerica);Few studies were found looking at the impact of infrastructures on cholera with no or littleevidence provided. One study in DRC could link the quality of the service (water deliveryinterruptions)withcholeraincidence(21),arguingfortheneedofasafeandreliableservice.Contextsoftransmission–otherthanwaterborneThe large majority of existing studies focussed on water quality interventions only, othertransmissionroutesliketheconsumptionofcontaminatedfoodasaresultofpoorhandhygiene,and person-to-person transmission appear to be overlooked in the literature. This seems tohighlightthegenerallyheldbeliefthatcholeraisexclusivelywaterborne,therebyignoringotherroutesoftransmission–whereastransmissioninacommunityislikelytooccurthroughseveralroutesatthesametime,indicatingtheneedforamorebroader,integratedapproach.Asalreadypresentedinthefirstsection(1-TheWestandCentralAfricaCholeraApproach-Shield& Sword Strategy), several transmission contexts during which an individual potentially getinfectedwereidentified,followingfieldinvestigationwork:! Drinkingcontaminatedwater,! Householdandneighbourhoodtransmission,! Transmissionaroundfuneralritualsandcorpsehandling,! Transmissionduringsocialgatheringsandinpublicplaces! TransmissionInandaroundcholera/healthfacilities,! Ortransmissionwithinparticularsocio-professionalgroups.Household and neighbourhood transmission: Household spraying, Hygiene/Disinfectionkitsdistributionornotaddressingtherisk?Rationale:Several studies showan increasedrelative risk to contract cholera for casecontacts (50 to100folds higher), this risk decreasingwith time but still being higher for a sustained period of 23days;Thepossibleroleofcontaminatedsurfacesiscurrentlybeingexplored.

Amongsttheon-goingresearchwork,TUFTUniversityisworkingtoprovidenewinsights-basedonevidencesandnotonpresumptions–on theriskof transmissionathousehold leveland theefficiencyofdifferentinterventionstoaddressthisrisk.

Traditionalapproachestoaddresstheriskhavebeen“Householdspraying”,meaninghouseholddisinfectionwith thesupportofadisinfection team,but the lackofprotocolsandcleardosages

Figure: Relative risk (RR) of contracting cholera –functionofthedistancetoarecentlydeclaredcholeracaseandevolutionwithtime.Source:TuftUniversity.

Figure: Cholera Infection incidence in Householdcontacts in Bangladesh compared to generalpopulation.Source:JohnsHopkinsUniversity.

instructions,andthecost/timerequiredbysuchinterventionshaveledtoquestionitsinterestincholeraresponse.Currentrecommendationsaretonotcompletehouseholdspraying,becausethereisnoevidencein the efficiency of a one-off spraying process (asymptomatic or convalescing householdmembers may shed vibrio in the environment for several days and could be responsible forrepeatedhouseholdcontaminations).> As identified in the risk chart, any intervention trying to address this transmission contextshouldbeencouraged forasustainedperiodof time,probablyat least2 to3weeksandshouldstartasearlyas1-3daysaftertheidentificationofthecase,whentheriskisatitsmaximumandwheretheinterventioncouldyielditshighestbenefitinpreventingnewcontaminations.Instead, current recommendations are to deliver and train household members to use a“householddisinfectionkit”tosupportdisinfectingtheirownhomes.AfirststudyledbytheJohnsHopkinsUniversity(24)inBangladeshshoweda47%reductionincholeraincidenceamongsthouseholdswithasustained7daysinterventionofanHospitalbaseddeliveryofWASHinterventionincluding:Distributionofsoapandaquatabs,chlorinesolution,anda Household water storage and distribution jerrycans with tap. The results are promising forcholera risk reduction amongst households, and a follow up study showed a sustainedimprovementinwaterqualityandhandwashingbehaviourinsensitizedhouseholdscomparedtothegeneralpopulation.Because the Relative Risk (RR) is higher also for the neighbours, it could be useful to providesensitization, distribution of hygiene/disinfection kits and counselling around the house of acholera case, as a ring intervention strategy; This could provide a good “epidemiology-based”entrypoint fordistributions inurbanareas, rather than the socio-economicentrypointusuallyusedbyRedCrossduringinterventions(oldpeople,disabled,singleheadedhousehold,etc.),andcould alleviate the stigma on a particular family (principle of a blanket intervention in at riskarea);TransmissionaroundfuneralritualsandcorpsehandlingRationale: Community / family management of deceased relatives are often reported to be asourceoftransmissionduringcholeraoutbreaks.Thereportedriskcanbelinkedtodirectcorpsehandlingandpreparation,aswellastraditionalceremoniesthatmaygotogetherwiththeburial.Possibleinterventionsincludebutnotlimitedto:! Participating in the corpse preparation, ensuring the safety and hygiene precautions with

respectofreligiousbeliefsandtraditions! Limitthenumberofpeoplewithdirectcontactofthedeadbody! Useofdisinfectant(chlorine2%)solutionforwashingpossiblestainsandmaterials! Washinghandswith0,05%chlorinesolution! If ceremonies are not forbidden, consider participating in ceremonies, with sensitization,

hand-washingfacilities,hygienekits,etc.Therewasnoquantitativestudymadeon thisparticular transmissionriskandefficiencyof themethodstopreventfurthercontamination.

TransmissionduringsocialgatheringsandinpublicplacesRationale: Investigations showed an increased risk associated with public markets, streetrestaurants,publicorreligiousceremonies,busortrainstations,portsandlandings,andpossiblychurches/cultorschools.Possibleinterventionsinclude–butnotlimitedto:! Mobilizationofadministrativeauthoritiestotemporarysuspendmarketsandceremonies! Masscommunication/choleraawarenessandhealthpromotion! Installationofhandwashingfacilities,providedwithwaterandsoap! Demonstrationsitesanddistributionofhygienematerials! Mobilizationofreligiousauthoritiestoriseawarenessandprovidehealthinformation! Mobilization of teachers and school directors to rise awareness and provide health

informationandensurecleanwaterdistribution,properhygienicbehaviours,latrinescleaning

Therewasnoquantitativestudymadeon thisparticular transmissionriskandefficiencyof themethodstopreventfurthercontamination.However,acasestudydoneinTouba,Senegal,showeda sustained reduction of cholera transmission following a pack of hygiene and safetymeasuresorganizedbythehealthandwaterauthorities,inconjunctionwiththereligiousleader.TransmissionInandaroundcholera/healthfacilitiesRationale:Casemanagementdoneinaninappropriatesettingareplenty.Lackofadequatehumanresources,materialsandinfrastructurecanleadtosuchsituationwhereHealthcentersorCholeratreatment centers may constitute a risk for visiting or accompanying family members, healthpersonnelandneighbours.Possibleinterventionsinclude–butnotlimitedto:! Ensuringtheappropriateisolationofcases(cholerapatientsnotmixedwithothers)! EnsuringIPCproceduresareinplaceandinparticularEntry/Exitdisinfection! Non-medical case management support – as well as accompanying family members

managementandsensitization! Ensuringthereisanadequateandsafesupplyofwater! Ensuringlatrinesdisinfectionisdone! Etc.There was no quantitative or qualitative study made on this particular transmission risk andefficiencyofthemethodstopreventfurthercontamination.Transmissionwithinaparticularsocio-professionalgroupRationale: Specific population groups, such as fishermen, traders, nomadic herders and mineworkers have been identified in certain regions to be responsible for the spread of cholera toothers regions. Reasons are often linked to poverty and poor hygiene practices, with possiblelong-distancedisplacements.Possibleinterventionsinclude–butnotlimitedto:! Identifyingvulnerablegroupsandtheircharacteristics(movementdatesanddirections,etc.)! EncourageandfacilitatereferraltohealthcentreorCTC! OnsitesensitizationanddistributionofhygienekitsandORSsachets! Etc.

There was no quantitative or qualitative study made on this particular transmission risk andefficiencyofthemethodstopreventfurthercontamination.References1. PiarrouxR,BompangueD,OgerP-Y,HaaserF,BoinetA,VandeveldeT.Fromresearchtofield

action:exampleofthefightagainstcholeraintheDemocraticRepublicofCongo.FieldActionsSciRepJFieldActions[Internet].16janv2009[cité26mars2017];(Vol.2).Disponiblesur:http://factsreports.revues.org/188

2. MuyembeJJ,BompangueD,MutomboG,AkilimaliL,MutomboA,MiwandaB,etal.EliminationofcholerainthedemocraticRepublicoftheCongo:thenewnationalpolicy.JInfectDis.1nov2013;208Suppl1:S86-91.

3. GerolomoaM,PennabML.Cóleraecondiçõesdevidadapopulação.RevSaúdePública.2000;34(4):342–7.

4. AckersML,QuickRE,DrasbekCJ,HutwagnerL,TauxeRV.Aretherenationalriskfactorsforepidemiccholera?ThecorrelationbetweensocioeconomicanddemographicindicesandcholeraincidenceinLatinAmerica.IntJEpidemiol.avr1998;27(2):330‑4.

5. TalaveraA,PérezEM.Ischoleradiseaseassociatedwithpoverty?JInfectDevCtries.2009;3(6):408‑11.

6. NygrenBL,BlackstockAJ,MintzED.Choleraatthecrossroads:theassociationbetweenendemiccholeraandnationalaccesstoimprovedwatersourcesandsanitation.AmJTropMedHyg.nov2014;91(5):1023‑8.

7. LeidnerAJ,AdusumilliNC.Estimatingeffectsofimproveddrinkingwaterandsanitationoncholera.JWaterHealth.déc2013;11(4):671‑83.

8. WaldmanRJ,MintzED,PapowitzHE.TheCureforCholera—ImprovingAccesstoSafeWaterandSanitation.NEnglJMed.14févr2013;368(7):592‑4.

9. WHO|Firststepsformanaginganoutbreakofacutediarrhoea[Internet].WHO.[cité23mars2017].Disponiblesur:http://www.who.int/cholera/publications/firststeps/en/

10. JamisonDT,BremanJG,MeashamAR,AlleyneG,ClaesonM,EvansDB,etal.,éditeurs.DiseaseControlPrioritiesinDevelopingCountries[Internet].2ndéd.Washington(DC):WorldBank;2006[cité24mai2016].Disponiblesur:http://www.ncbi.nlm.nih.gov/books/NBK11728/

11. ReveizL,ChapmanE,Ramon-PardoP,KoehlmoosTP,CuervoLG,AldighieriS,etal.ChemoprophylaxisinContactsofPatientswithCholera:SystematicReviewandMeta-Analysis.PLoSONE[Internet].15nov2011[cité23mars2017];6(11).Disponiblesur:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3216950/

12. WHO|Preventionandcontrolofcholeraoutbreaks:WHOpolicyandrecommendations[Internet].WHO.[cité23mars2017].Disponiblesur:http://www.who.int/cholera/prevention_control/recommendations/en/

13. LuqueroFJ,GroutL,CigleneckiI,SakobaK,TraoreB,HeileM,etal.UseofVibriocholeraeVaccineinanOutbreakinGuinea.NEnglJMed.29mai2014;370(22):2111‑20.

14. BhattacharyaSK,SurD,AliM,KanungoS,YouYA,MannaB,etal.5yearefficacyofabivalentkilledwhole-celloralcholeravaccineinKolkata,India:acluster-randomised,double-blind,placebo-controlledtrial.LancetInfectDis.déc2013;13(12):1050‑6.

15. ClasenTF,HallerL.Waterqualityinterventionstopreventdiarrhoea:costandcost-effectiveness.2008.

16. RameshA,BlanchetK,EnsinkJHJ,RobertsB.EvidenceontheEffectivenessofWater,Sanitation,andHygiene(WASH)InterventionsonHealthOutcomesinHumanitarianCrises:ASystematicReview.PLoSONE[Internet].23sept2015[cité23mars2017];10(9).Disponiblesur:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4580573/

17. TaylorDL,KahawitaTM,CairncrossS,EnsinkJHJ.TheImpactofWater,SanitationandHygieneInterventionstoControlCholera:ASystematicReview.PLoSONE[Internet].18août2015[cité24mai2016];10(8).Disponiblesur:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4540465/

18. Evidencereviewonresearchforhealthinhumanitariancrises[Internet].ODI.[cité23mars2017].Disponiblesur:https://www.odi.org/projects/2693-lshtm-hpg-health-humanitiarian-review

19. CavallaroEC,HarrisJR,daGoiaMS,dosSantosBarradoJC,daNóbregaAA,deAlvarengadeJuniorIC,etal.Evaluationofpot-chlorinationofwellsduringacholeraoutbreak,Bissau,Guinea-Bissau,2008.JWaterHealth.juin2011;9(2):394‑402.

20. KremerM,Miguel,E,MullainathanS.SourceDispensersandHomeDeliveryofChlorineinKenya|TheAbdulLatifJameelPovertyActionLab[Internet].2008[cité23mars2017].Disponiblesur:https://www.povertyactionlab.org/evaluation/source-dispensers-and-home-delivery-chlorine-kenya

21. JeandronA,SaidiJM,KapamaA,BurholeM,BirembanoF,VandeveldeT,etal.Watersupplyinterruptionsandsuspectedcholeraincidence:atime-seriesregressionintheDemocraticRepublicoftheCongo.PLoSMed.oct2015;12(10):e1001893.

22. SteeleA,ClarkeB,WatkinsO.Impactofjerrycandisinfectioninacampenvironment-experiencesinanIDPcampinNorthernUganda.JWaterHealth.déc2008;6(4):559‑64.

23. CairncrossS,HuntC,BoissonS,BostoenK,CurtisV,FungICH,etal.Water,sanitationandhygieneforthepreventionofdiarrhoea.IntJEpidemiol.avr2010;39Suppl1:i193-205.

24. GeorgeCM,JungDS,Saif-Ur-RahmanKM,MoniraS,SackDA,RashidM,etal.SustainedUptakeofaHospital-BasedHandwashingwithSoapandWaterTreatmentIntervention(Cholera-Hospital-BasedInterventionfor7Days[CHoBI7]):ARandomizedControlledTrial.AmJTropMedHyg.3févr2016;94(2):428‑36.

#03.ReviewofRedCrossInterventionsandperception

AnextensivereviewofRedCrossoperations(DREFsandEAs),evaluationsandreviews,lessonslearned exercises, and existing guidelineswasmade, aswell as a qualitative evaluationof theperceptionoftheRedCrossworkincholeraresponse,thoughinterviewswithNationalSocieties,PNSs,IFRCstaff,andexternalexperts(DGECHO,UNICEF,WHO,MSF,SavetheChildren).

3a.ReviewofRedCrossInterventionsduringthepast10years(2008-2017)

AresearchwasmadeontheIFRCwebsitetoretrieveallcholeraoperationsreportssince2008.The search resulted in a list of 30 DREF and Emergency Appeals final reports, covering 17countriesfrom2012upto2017.ThetotalofDREFandEmergencyAppealsforcholeraresponseoverthepast6yearsrepresentsa totalbudgetof11,4millionCHF (10,6millionEuros).This amountdoesnot include choleraprogrammesfundedbyotherdonorsorsupportedbyPartnerNationalSocieties.The average (median) budget of an operation was 192’000 CHF, with an average (median)113’000peopleassistedperDREF.Amongstallcholeraoperations,16/30wereresponsestooutbreakswhichfinallyrevealedtobesignificant outbreaks (more than 5000 officially reported cases), the other half being earlyresponses to smaller rapidly contained outbreaks. Only one DREF (in Gambia in 2012) wasissued without having cases being reported in country (10 cases had been reported in theneighbouring region of Tambacounda in Senegal, coinciding with high risk period - majorreligiouseventinTouba).An analysis of the RC response thoughDREF and EA reports showed a high heterogeneity ofcholera response activities betweenoperations.Not less than46 types of activities havebeenidentified,whichcanbesortedin9majorcategories:

! Coordination! Surveillance! Epidemiologicalreasoningandtargeting! Participationinvaccinationcampaigns! Casemanagement! Participationinsafe&dignifiedburials! Communitymobilization,choleraawareness,sensitization! Waterandsanitationactivities! Specificschoolinterventions

Table:RedCrossOperationsAnalysis-Frequencyofactivitiesbycategory

Overall,100%ofoperationreportsmentionedsome formofcommunitymobilization togetherwith water, hygiene and sanitation activities. Direct or indirect surveillance and casemanagement activitieswerementioned in 73% and activities specifically targeting schools in57% of operations. Specific investment in participating to coordination efforts with thegovernmentandotherpartnerswerementionedin47%ofreports.Activitieslinkedtotheuseofepidemiologicaldatatoguidetheresponseorparticipationinsafeburialswerelessrepresented(13%),aswellasparticipationinvaccinationcampaigns(onlymentionedin2reports).NB:Onecaveatofthisanalysisisthatitdependsonthequalityofnarrativeoperationsreports.Improvements in the overall monitoring, evaluation and reporting of operations couldgreatlybenefittothequalitycontrolandcredibilityofRedCrossinterventions.CoordinationSpecific coordination effortswere onlymentioned in less than 50% of the operation reports;However, as previously mentioned, there is a possibility that coordination activities wereimplementedduring theoperationwithoutbeing specifically captured in thenarrative report;Would it be the case, this could still be interpreted as not valuing enough the importance ofcoordinationamongsttheresponseactivities.>Whyisitimportant?Contributiontogeneralcoordinationeffortsisadutyofeveryhumanitarianactor(coordinationsaves lives). Sharing information; allowing for a common programmation; avoiding gaps inresponse distribution and duplication of efforts. Coordination contributes to the overall aideffectiveness; Interest in gathering data/information from GVT and other active partnersinterventionson the field.Equal interest to sharedata/informationwithGVTandotheractivepartners.Aplacetosharespecificissueswithotherpartnersandharmonizeresponsestrategies.An ideal place for advocacy. A place to showcase Red Cross role and activities in choleraresponse;RecommendationsHave ‘Coordination’ listed as a specific activity for cholera response – set specific activityindicatorsforreporting.Dedicateenoughtimeandresourcestocoordination.NB:Coordinationisakeyelement,specificallyinepidemicresponsewherethesituationcanevolverapidly,withaffectedareas(interventionhotspots)changingveryquickly.

ActivityCategory N %Coordination 14 47%Surveillance 22 73%EffectiveuseofEPIDatatoleadtheresponse 4 13%ParticipationinOCV 2 7%CaseManagement 22 73%Participationinsafeburials 4 13%CommunityMobilization&Sensitization 30 100%WASH-Reductionoftransmission 30 100%Schoolinterventions 17 57%

SurveillanceActivities listed under the category “Surveillance” included: Participation in outbreakinvestigation, active case finding, contact tracing and referral, community surveillance and/ormortalitysurveillance,anduseofGPSforcaselocalisationandmapping.

OnlyonereportmentionedtheuseofGPStogeolocalizecasesandreportthemonmapsusedforspatialanalysis–intheKenya2015EmergencyAppeal.Fewreports(2/30)mentionedtheRCparticipationinoutbreakinvestigations;Communitysurveillancewasmentionedin6operations,howeverthedescriptionoftheactivityrelatedmoretoactivecasefindingthanestablishingapropercommunitysurveillancesystem.Active case finding seem to be an activity reported in a vastmajority of interventions (70%).However,fewinformationswereprovidedinthereportsonhowthisactivitywasimplementedand only a few reports gave figures on the number of cases found and/or referred to healthcenters; Referral is also regularly mentioned, sometimes linked (but not always) with ORSadministrationbeforeorduringthetransportation.>Whyisitimportant?Surveillance is oftenpointed out as one of themajorweaknesses in outbreakmanagement inAfrican countries; Weak official health surveillance systems are to blame, for a number ofreasons; Lack of good communication infrastructures; Lack of resources. But the rarelymentioned under use of health services need to be taken into consideration – rending healthfacilities based surveillance unable or not sensible enough to detect outbreaks and deathshappeninginthecommunity,especiallyfornewoutbreakdetection;Intheseconditions,apre-established community based surveillance system, complementary to the existing one andimplementedinperfectcoordinationwithhealthauthorities,couldproveveryusefulinhighriskareas for early detection of cases and consequently triggering an early et more effectiveresponse.RecommendationsGuidelines on community surveillance, active case finding, dehydration evaluation, ORSadministration,referral, transportation,andnotificationofcasesformonitoringpurposesshouldbethebasisforthisexercise.Specificactivityindicatorsshouldbedefinedandusedfor reporting. Participation in outbreak investigations could also be very useful inidentifying specific transmission contexts and addressing them in the design of theresponse.UseofGPSandcasemappingcanbeaverypowerfultooltorefinetheanalysisandallow for a more precise targeting strategy (specifically in urban contexts) but requirestechnicallyqualifiedpersonnel.

Activity N %Outbreakinvestigation 2 7%Activecasefinding,contacttracing,andReferral 21 70%Communitysurveillanceandmortalitysurveillance 6 20%GPSmapping 1 3%

EpidemiologicalreasoningandtargetingUseofexistingepidemiologicalinformationandanalysistoguideandorientactivitieswasonlymentionedin4recentoperations(Ghana2014,Kenya,NigeriaandSouthSudan2015).Inthosereports,referenceismadetodatacollectionandanalysisthroughnewfieldassessmentsratherthan exploiting the already existing information. None of the reports mentioned thatepidemiological knowledge pre-existed to this particular outbreak, which could be useful toguidetheon-goingoperation.>Whyisitimportant?In a resource-limited setting, targeting the population most in need with the most effectiveinterventions-inthatparticularcontext-arekeyelementsofaneffectiveresponse;ManyDREFsmentionedthatalltheneedswerenotcovered/orthatitemswerenotenoughtosupplyallthepopulation in the affected area. Targeting the correct population and prioritizing effectiveinterventionsoverlesseffectiveonesareanecessity.Anyinterventionshouldbejustifiedandasmuch as possible proven effective, if possible cost-effective, and implemented in the mostefficientmanner. Reducing the intervention to itsmost efficient version in order tomake thebestuseof theavailableresources isamust.However,usual targetingmethodologiesusedbythe Red Cross (such as social vulnerability status: ederly woman/orphans, child headedhouseholds, etc.) will not be of great help when it comes to save lives and interrupt diseasetransmission (despite the fact that this was described as the targetingmethodology inmanyreports).Tosavelivesandreducetransmission,oneneedtouseatargetingstrategybasedonathoroughepidemiologicalanalysis,andconstantlyadapttotheevolvingsituation.In an emergency operation, pre-existing epidemiological information is a very useful tool,allowingtosavescarceresourcesandhelpingwithtargeting1)mostatriskpopulationwith2)adaptedsolutionstoavoidriskypractices - ifalreadyknownin3) themostatriskareas;Thispre-existing knowledge fromprevious outbreaks is oftenpresent, sometimes readily availablebutsurprisinglynotnecessarilyre-usedforanewoutbreakresponse.RecommendationsIn countries regularly affected by cholera outbreaks, ensure that an historical review ofpreviousoutbreaksandinterventionsisavailable,withkeyfindingssummarizedinareportandsharedwithallthestakeholders.Inalloperations:atminimum,makesuretoattendallcoordinationmeetingstoadapttheresponse to the rapidly evolving epidemiological trends; and to assist to partnersepidemiologistsorsocio-anthropologistsreportspresentations, inorder to integrate theirfindings into the on-going response; If possible, hire the services of epidemiologists andsocio-anthropologiststoadapttheresponsetothecontext.Participationinvaccinationcampaigns2 reportsmentioned the participation of theRC in a vaccination campaign (Guinea&Ghana).Despite the fact that in Ghana, the participation of the RC in Government vaccination did notseemdirectlyrelatedtocholera,thereportstillmentions“TheDREFoperationprovedtobeverytimelyforsocialmobilizationforcholeravaccinationperformedbythegovernment,aswellasforthe introduction of twonew vaccines (Pneumococcal andRotavirus)”. In Ghana, the RC did nothave specific activities for the vaccination but rather extended themessages delivered to thecommunitytoalsocovervaccination.Inthisparticularcase,thisactivitymightbedebatable,asthe vaccination campaign was not related to cholera – possibly inducing confusion in thepopulation’smind (aswell as theNational Society apparently). InGuinea, participation in the

immunizationcampaignwasmentioned,butnotincludedasanactivityintheDREF.>Whyisitimportant?OralCholeraVaccination(OCV)isanewtooltohelpprotectpopulationfrombeinginfectedbycholera,thushelpingtoreducemorbidityandmortality;Whilethereisstilladebateonwhereandwhen OCV campaigns should be implemented, its efficiency seem to be proven – and itsusefulnessrecognizedparticularlyinclosedsetting(eg.inIDP/Refugeecamps)orinareaswithinsufficienthumanitarianaccesstoprovidelongtermclassicalhealthandWASHsupport.Thereisagrowinginterestfromagenciesandgovernmentstoimplementvaccinationcampaigns,andtheRedCrosscouldhaveakeyroletoplayinthepreparationandtheimplementationofthosevaccinationcampaigns,forexamplethroughcommunityawarenessandmobilization;RecommendationsReports capturing the experience of RC societies involved in OCV campaigns could helpspreadthewordandshowcasetheRCroleandaddedvalueinthisnewresponsemechanismimplementation; There is also a need to better informNational Societies onOral CholeraVaccination(OCV)andthepotentialroleofRCinorganizingthosecampaigns.Casemanagement22outof30reportsmentionsomeactivitiesrelatedtocasemanagement.Detailsareprovidedinthetablebelow:

Directmanagement of cases in a dedicated CTC structurewasmentioned in 4 operations (InKenya, Sierra Leone and Chad). To date, medical management was realized only during ERUresponse in Sierra Leone andChadwith the exceptionof theKenyanRC,whichprovided thisserviceonrequestofthegovernmentwithoutexternalsupport.More frequent, punctual support to existing CTC in the formofmaterial equipements, humanresourcesormedicalsupplies,hasbeenreportedinnearlyhalfoftheoperations;Non-medicalsupporttoexistingCTC,asinvolvementofvolunteersinregistration,disinfection,burials, and psychological support to patients and family members was only reported in 2reports.However, it isprobablymore frequentbutnot reported inDREF reportsbecausenotconsidered as part of the DREF response – often done in partnership with other medicalorganizationslikeMSF;Itshouldbenotedthatmassoreventargetedprophylaxisforcasecontactsisnotrecommendedfor cholera; Targeted prophylaxis for case contacts was only mentioned once in Kenya, insupportoftheMinistryofHealth.

Activity N %CTCSetupandoperation 4 13%SupporttoexistingCTCs(material,equiments) 4 13%SupporttoexistingCTCs(Medicalteams) 3 10%SupporttoexistingCTCs(Provisionofmedicalsupplies) 10 33%SupporttoexistingCTCs(Non-medicalactivities:registration,disinfection,safeburials,familymanagementandpsychologicalsupport) 2 7%TargetedprophilaxisforcasecontactsinlinewithMoHpolicy 1 3%Communitycasemanagement(ORPs) 5 17%DistributionofORSsachets 13 43%

Community casemanagementwas only reported in 5 of the 30 operations. Itwas sometimesplannedbut“notimplementedasplanned”;FewoperationsdirectlymentionORPsasanactivity,somementiongivingORSsachetstoidentifiedcasesinthecommunitybeforereferral.ORSdistribution ismentioned in13operations.But it is oftenmentionedas aWASHactivity,togetherwithaquatabsorsoapdistribution.Itisunclearhowtheoperationwasdone,andwhatwastheobjectivebehind.SomeoperationsmentionORSdistribution,wheninfactitwasgiventoCTCsorHealthcenters.>Whyisitimportant?Communitycasemanagement(ORT)shouldbethebasisofanycholeraintervention.ORTsaveslives. Implementing a community based ORT strategy may be one of the most effectiveinterventions toprevent escalationof dehydrationbyproviding a local, immediately availableeffective solution for light ormoderate cases, andby reducing the caseloadof severe cases inhealthcentersorcholeratreatmentcenters.RecommendationsInemergency,targetingalreadyaffectedareaswithORT(Sword)aswellasnotyetaffectedhigh-riskareas (Shield)canprovidea timelysolution for identifyingand treatingmostofthecases in thecommunity–aswellas to increasereferralof severecases todesignatedhealthpostsornearestCTU/CTCs.Inpreparednessandprevention intention,ORT implementedasa year roundprogram inpre-identifiedhotspotsintheformofORPs(OralRehydrationPoints),canalsobeusedasorconnectedtoacommunitybasedsurveillanceandearlywarningsystem–ablenotonlytodetect abnormal upsurge in diarrhoea cases or suspicion of cholera cases and alert thehealthauthorities,butalsotoimmediatelyprovidealocalresponsewithanalreadyprovenefficientintervention–ortoreferthemoreseverecasesdirectlytohealthcenters.PartnershipwithWHO/UNICEFandMoHforORSsuppliesmayprovideaveryusefulsolutioninidentifiedhotspotsareas;DirectmedicalmanagementofcasesinCTCsshouldonlybedonebyprofessional,experiencedhealthorganizations.Suchactivitiesrequireveryqualifiedemergencystaff,professionallogisticsandarealsohighlyHRconsuming.ThismaysometimesbeidentifiedasanacuteneedwhentheGovernment is overwhelmed, butRC societies should only engage in this activity if they havesufficientcapacitytorespond–withpotentialsupportfromtheIFRCorotherpartnersocieties;SupporttoexistinghealthcarefacilitiesorCholeratreatmentcentersmayalsobeakeyelementof the response,whenhealth structures are understaffed. Support in the formof non-medicalactivitiesasWASH/IPCactivities, registrationanddealingwithaccompanying familymemberscan also play an important role. Health centers are not alwayswell structured andmay lackefficient IPCmaterials and protocols,with a risk of becoming a source of transmission in theneighbouringcommunity.RecommendationsNon-medical support such as WASH/IPC activities can be key helping Healthstructures/CTCs ensure the security and safety of caretakers and neighbouringcommunities. Being involved from the start in the registration process can help gatheressential informationon the localisationof incomingpatients–andaddress thesituationthrough investigation and possible orientation of the response teams. Being in directcontact with family case contacts can help spread important information on cholerapreventionandhowtolimitthespreadtohouseholdmembersandneighbours.

Participationinsafe&dignifiedburialsParticipation in burials and dead body management was mentioned in 4 operations inCameroon, Congo, Ghana and Guinea; Some of the operations mentioned dealing with deadbodiesinCTCs,otherreportsmentionedprovidingsupportintothecommunitiestoensurethatthereisnocontaminationduringcorpsehandling,preparationofthebodyforthefunerals,anddealingwiththedeceasedbelongings.>Whyisitimportant?Inappropriate handling of dead bodies, without adequate disinfection and Handwashing, hasbeen known to be the source of secondary cases in the community. Special funeral gatheringevents,withfamilyrelativesandfriendscomingfromfar fortheevent,canalsobeasourceofspreadoftransmissiblediseases;Suchoccasionsconstituteaparticularopportunitytopreventtransmission,byprovidinginformationorsupporttothefamilyforthepreparationandburialofthe body and to raise awareness and inform family members, neighbours and sometimesrelativescomingfromdistantcommunitiesoncholera,itssymptomsandroutesoftransmission,how to prevent contamination and the immediate measures to take in case of apparition ofsymptoms;RecommendationsProviding guidance and/or direct support for dead body management and funeralceremonyorganisationshouldbeakeyactivityincommunitieswithnodedicateddeadbodymanagementorganizations.Communitymobilization,choleraawareness,sensitizationCommunitymobilizationwaspresentinallofthe30operations(100%).Key mentioned interventions were raising cholera awareness through public meetings andcommunity leaders (90%), House-to-house sensitization (80%), distribution of IEC materials(80%)andMassmediamessagingthroughradio,sms,videosetc.(70%).Whenreportsprovidesomedetailsonwhatwasincludedinthemessages,Handwashingcomesfirst(73%)followedbywatertreatmentandsafedisposal(50%),hygienicfoodhandling(37%)andsafefaecalmatterdisposal(17%).In3operations,thereportsmentiontheorganizationofashortKAPsurveyinordertoidentifyknowledgegaps,atriskpractices,beliefsandtoadaptthemessagestothecommunity;

>Whyisitimportant?

Activity N %KAPsurveystoadaptmessaging 3 10%Choleraawarenessthroughpublicmeetings,religiousleadersandlocaladministrators27 90%Housetohousecholerasenzitisation 24 80%MassMediaRadio/videosmessaging/sms 21 70%DistributionofpostersandotherIECmaterials 24 80%HygieneandHealthpromotion 26 87%Handwashingpromotion 22 73%promotionofwatertreatment,safestorageandhandling 15 50%promotionofsafefaecalmatterdisposal 5 17%promotinghygienicfoodhandling 11 37%

Cholera knowledgemight not pre-exist in affected communities. The severity and rapidity ofdehydrationisoneofthemajorcharacteristicofcholera,possiblyleadingtodeathinamatterofhours; Informing communities about the existence of a cholera outbreak, the risk of severedehydrationanddeathinamatterofhours,identifyingsignsandsymptoms,theneedofpromptrehydrationortobereferredtoanappropriatehealthcentreorCTC,andtheessentialmeasurestopreventcontaminationcansavemanylives.Choleraawarenessisalifesavingactivity.Radio,videoor smsmessagingcanreachmillionsofpersons inamatterofhours, andcanbeaverypowerfulcommunicationchannel.However,house-to-housevisitsmaybecomplementaryinthesense that messaging can be validated in a bidirectional exchange, and potentialmisunderstandingsorfearsaddressedatthesametime.Thereisalsoagoodopportunitytolinkthisactivitywithhygienepracticesobservation,hygieneitemsdistributionormoreinterestinglyvoucher distribution, which can provide also a feedback on the impact of messaging onadherencetothedesiredbehaviouradoption.RecommendationsCommunitymobilizationisakey,life-savingactivityinepidemicresponse–asitcanreducethe critical time between the moment where symptoms arise and the “seeking fortreatment”behaviour,andassuchshouldbeoneofthefirstmeasuretoimplement.Thereisalso a high potential of transmission reduction if people adopt the adequate hygienebehaviours.Messagesshould ideallybe tailored to the identifiedriskpracticesandnotbelimitedtoHandwashingandsafewatertreatment;WaterandsanitationactivitiesWaterandsanitationactivitieswerereportedin30/30(100%)ofcholeraoperations.However,amoredetailedanalysisrevealsahighdiversityofinterventions.ThemostfrequentlyreportedinterventionswerethedistributionofHHWTsolutionsintheformofaquatabsorPURsachets(83%)andsoaps(80%).Otherreportedinterventionsarelistedinthetablebelow.

>Whyisitimportant?

Activity N %waterqualitymonitoring(HHorsystem) 6 20%chlorinationofwaterstoragetanks 1 3%Welldisinfection/wellchlorination 10 33%Installationofwaterdistributionpointandwatertrucking 2 7%Bucketchlorination 2 7%Distributionofwaterbottles 1 3%distributionofaquatabs/PUR 25 83%distributionofwaterfilters 1 3%Distributionofjerycansandbuckets 14 47%Distributionofsoaps 24 80%CleanupactionsinpublicplacesandaroundCTCs 16 53%Installationofhandwashingfacilities 12 40%Householddisinfection(vomit,faeces,etc.) 10 33%Latrinedisinfection 9 30%Hardware:Drillingnewboreholesand/orrehabilitationofwells 9 30%Hardware:Latrineconstructionorrehabilitation 11 37%

Cholerabeingafaecal-oraldisease,waterandsanitationactivitiesarekeytolimitthespreadofthevibrioandpreventnewcontaminations.Thediversityof interventions isnotperse surprizing,andcould indicate thewill toadapt theresponsetoaparticularcontext.Mostoftheinterventionsseemtobetargetingpossibleroutesof transmissionorpossiblehigh-riskcontextswith immediateandefficientresponses,but thishypothesis could not be confirmed as no justification was provided in the reports on thesituationanalysisandtherationalebehindthechoiceofaparticularsolution;Itshouldbenotedthatrehabilitationorconstructionofwaterpointsandlatrineswereincludedintheresponseinrespectively30%and37%oftheoperations.Suchinterventionsareusuallyimplementedintheviewoffulfillinganeed,thelackofadequatewaterandsanitationservicesoftenbeingidentifiedastheprincipalreasonwhycommunitiesareaffected.Withtheexceptionof very few particular situations, engaging in infrastructure projects will go far beyond theemergency period of 2-3months andwill not provide any response to the actual emergencyneedstoreducetransmission.Consideringthatemergencyworksareoftendonewithoutpropertimeneededforanalysisandimplicationofthecommunity,whichcouldresultinnewproblemsorconflictsinthecommunity,consideringalsothattheworkswillmostprobablybefinishedfaraftertheoutbreakisover,buildingnewinfrastructuresisthereforenotseenasaneffectiveuseofemergencymoney,atatimewherewewanttouseeachpennyavailabletosavethemaximumoflives.SuchinterventionswilladvantageouslybedoneAFTERtheemergencyphase,withmorelong-termdevelopmentfundsandwiththeneededcommunitydialogueandimplication.RecommendationsWater and sanitation activities are key in limiting the spread of vibrio cholerae and inreducingtheriskofnewcontamination.Thechoiceofoneparticularinterventionshouldbelinked to the analysis of the situation on the field, and to the knowledge of pre-existingworkingsolutionsinthecountry.Investmentsshouldbelimitedtoproveneffectiveandcost-effectiveemergencyinterventions,inordertobeabletorespondtothemaximumofaffectedcommunities–ratherthaninvestingininfrastructureworkswhichwilloftennotrespondtotheemergencyneedsinthetimeallowedfortheresponse.SpecificschoolinterventionsSpecificinterventionsinandaroundschoolswerementionedin17/30(57%)ofoperations.School interventions,however, seemtobemoreastrategicorientation thana response to theidentification of a particular transmission risk amongst school children, which was nevermentioned.

Generic sensitization activities in schools were reported in 14/30 (47%) of all operations,whereas specific hygiene promotion programmes like PHAST and CHAST were mentioned in10%.Equipmentssuchasbuckets/jerrycans/handwashingstationsweredistributedinschoolsin27%ofcases,withsoapbeingdistributedonlyin2operations(7%).>Whyisitimportant?

Activity N %schoolsprovidedwithwithstoragetanks,jerrycans,bucketsanddrinkingwaterstations8 27%CHASThygieneeducationinschools 3 10%Sensitizationinschools 14 47%Soapdistributionforschoolchidren 2 7%

Areschoolchildrenaparticularlyvulnerablegroup inacholeracontext? Isschoolaparticulartransmission context?Well, possibly, but ultimately epidemiological data analysis can help usidentifyandtargetthevulnerablegroups,andidentifyspecificcontextswheretransmissionriskishigh.Specific interventionsinschoolsareoftenmorerelatedtothebeliefofspecificvulnerabilityofchildren,aswellastothehighvalueofusingchildrenasefficientchangeagentsforhouseholdhygienepractices.RecommendationsBecauseschoolchildrenarerecognisedtobeefficientchangeagentsforhouseholdhygienepractices,becauseschoolteacherscanbeusedasefficientrelaysforhealtheducationandhygiene promotion, school interventions have a highpotential to complement communitymeetings and house-to-house interventions; In that sense, a specific intervention modelshouldbedesignedforschoolinterventions.Overall, each operation reported between 4 and 25 different activities,with an average of 15activities reported per operation. Improvement in cholera response could benefit fromsimplification and prioritization of activities to be implemented during cholera responses, inrelationwithajustificationoftheinterventionbasedonacontextanalysis.3b.ReviewofCholeraResponsesEvaluations

Evaluations and reviews were available for Uganda, Kenya, Nigeria, Ghana, Sierra Leone andBenin.Themainfindingsarepresentedbelow.RCwidelyrecognizedfor:

! Communitymobilization,includinghouse-to-house! Distributionofhygieneitems,includingaquatabsandsoapsRecommendations&roomforimprovement:

! Speed/timingoftheresponse(inadequate:mostofthetimeafterthebattle)! Needtobemoreinvolvedincoordinationatalllevels(national/district/local)! ActivitieswhereRCshouldengageornot (inparticularwith regards tocasemanagement)

shouldbeclarified.! SupporttoCTC(WASH,IPC)hasbeenprovenveryuseful! OtheractorsrequestahigherimplicationoftheRCinCommunitybasedSurveillance,cases

followup,mortalitysurveillanceandactivesearchandreferral! Needtoimprovegenerallogisticsupportwithregardstodelaysandqualitychecks(reports

ofexpiredproducts)! Reported inadequation of the quantity of items > Design a distribution strategy based on

epidemiologicalfindingsandreasoning>targetmostatriskpopulations! Increasevisibility/RedCrossidentification! Needfor increasedvolunteersupport/coaching/guidance/supervision. Invest inspecialised

HRatnationalandregionallevels(publichealthspecialists,epidemiologists,GISspecialists)! Investinpreparedness(contingencyplans,stocks)andreadiness(trainings,simulations)at

Nationallevels+surgecapacitiesatregionallevel(RDRTs)! Needtohavededicatedguidelinesforeachactivities

Additionalconsiderations

Operation reviews were generally found somewhat partial, low quality evaluation reports.Suchworkwouldbenefitfromanexternalevaluationpointofview,inordertobemoreneutralonthefindingsandtoimprovetheoverallqualityoftheresponse.

Between the lines readingof the evaluation reports allows to identify oneof themost criticalissue:The timingof the response.Averygoodresponseprovided2-3monthstoolateisnotacceptable:Itissimplynotprovidingrelieftotheaffectedpopulation,norcontributingtosavinglives.AnditisnotcontributingtobuildingthereputationoftheRedCrossincholeraresponse.Itwouldbeadequatetostartanearlyresponsewithadedicatedcontingencyfundatnationallevelfollowedby a quickDREF release if needed. Cholera outbreaks usually last 2-3months and adelay in the start of the emergency intervention could possibly render it useless (start of theresponseafter thepeekof theepidemicwhenthere isnomorecases). Incase theepidemic isover, consider adapting or stopping activities and not pursuing with distributions; Timing ofeachresponseactivityduring theresponseshouldbeoneof themost importantcriteria tobereportedagainst–andevaluatedaftereachintervention.ORT is a very important but apparently not vey well understood activity; ORT is a casemanagementactivity,notaWASHactivity.Thereisaneedforclarificationatall levelsoftheorganization.RedCrosscholeraoperationsoftenhavemultipleactivities, inmultiple locations,butwith fewexperttrainedmanagersforcoachingandsupervision.Thereisaneedtosimplifytheresponseandfocusonemergencyactivities(nottomixwithlong-termpreventionactivities,whichcanbedonelateron),inmostaffectedareas.SpeedandprofessionalismintheresponsecouldbeincreasedthroughpreparednessstocksandplansandHRcapacitybuildingdonebeforehand.Buildingcapacitiesiskey.Howevertoomuchtrainings are being done in emergency – when it is not the adequate time to train all thevolunteerswithmultiple (CBHFA,ECV,PHAST,etc.).Adhoccholera trainingshouldbereadilyavailableandquicklyimplementedduringthestartofanemergency.Emergency management, supervision and monitoring of the intervention should be done byexpert/specialisedstaff–presentlyinsufficient.Considerre-enforcinghealthstaffoftheNSwithadditionalpublichealthstaff,epidemiologistsandGISspecialists.ReviewofRCandotherstakeholders’perceptions

A summary of qualitative findings from interviews with National Societies, Partner NationalSocieties,IFRCstaffsandexternalstakeholdersispresentedbelow.

Graphic:PerceivedexpertiseoftheRedCrossincholeraresponsepersector.

0

1

2

3

4

5Coordina/on

Surveillance

Effec/veuseofEPIDatatoleadthe

response

CaseManagementPar/cipa/oninsafe

burials

CommunityMobiliza/on&Sensi/za/on

WASH-Reduc/onoftransmission

RedCrossPercep,on

0

1

2

3

4

5Coordina/on

Surveillance

Effec/veuseofEPIDatatoleadthe

response

CaseManagementPar/cipa/oninsafe

burials

CommunityMobiliza/on&Sensi/za/on

WASH-Reduc/onoftransmission

Externalpercep,on

This qualitative analysis confirms the main findings from the operation review and theevaluations. The perceivedmain strengths of theRed Cross response are at community level,especiallyforsocialmobilization,choleraawarenessandhealthpromotion.The externalpartnersperception is valuing specifically thevolunteers’ network–whichgivestheRedCrossan incomparableadvantage– itsability todeployan interventionatcommunitylevelonanationalscale.Ontheotherhand,volunteersarenot“specialists”andshouldbegivenadequate training, supervision and as much as possible simple tasks. This reflects on theperceptionoftheRedCrossasawhole,perceivedasanefficientcommunityorganizationbutnotveryspecializedor“professional”.Thesystematicsearchanduseofavailableepidemiologicaldatatoprioritizeinterventionsandtargetmost affected areas, togetherwith the contributionof apool of trained cholera expertswithintheRedCrossfamily,couldcontributetoimprovetheoperationsresultsaswellasbuildthecredibilityoftheRedCrossmovement.Thissaid,externalpartnersconsultationalsorevealedthattheRedCrosshadanunder-exploitedadded-valuethatshouldbemoreexplored: itspermanentpresenceinthecommunitiesanditsintimate relations with the communities. Such capacity should be exploited in the choleraprevention and response to provide immediate community based interventions when anoutbreak happens (cholera awareness information, rehydration therapy together withcommunitybasedsurveillance,andparticipationtoburialsandburialsceremonies).Participationinregional,national,subregionalcoordinationforaisprobablyanareawheretheRed Cross should be more present, with a professional and quality participation to thediscussionsinordertopromotetheRedCrossexperienceinthecholeraresponseandshowcaseitsparticularexpertise,throughcasestudies,qualityevaluationsreports,orpublications.

#04.CholeraStrategicFramework

A Cholera Framework representing all cholera related activities and their contribution to the

general objectives at different level of implementation (individual or household, community,

township,province/district,nationalorsupranational)couldbesummarizedasfollow:

Figure:OverallCholeraFrameworkforinterventionsincontrolandpreventionatdifferentlevelofimplementation.

ObjectivesThisCholeraFrameworkhastwomainobjectives:

! Contribute to the reduction of the excess morbidity and mortality associated with cholera

outbreaks(ashorttermimmediatelife-savingobjective)

! Contributetothereductionoftheexposureandvulnerabilitytocholerarisk(alongtermrisk

reductionobjective)

TheRedCrossMovementCholeraStrategicFrameworkshouldfitwithinthisoverallCholeraFramework, even if it does not cover all the possible interventions – taking into consideration

political choices, complementaritywithotherstakeholders’ role,and thespecificitiesof theRed

Crossmovement.

The proposed approach was built with the idea to combine the existing Red Cross role and

experience, up-to-date evidences on interventions that are life-saving and proven effective,

consider the specificity of the Red Cross as an organization and evaluate where possible and

relevantstrategicpartnershipwithotherstakeholders.

Foreachsituation,thechoiceofactivitiestobeimplementedneedtobetailoredtothecontext,on

thebasisofexistingepidemiologicalinvestigations,andtakingintoconsiderationthecapacityof

thenationalRedCrossNationalsociety,whichmayvaryaccordingtoexperience.

Theproposed interventionsalsohave tobeadapted to the context inwhich theoperationsare

implemented. A matrix of possible strategic directions according to different scenario can be

foundbelow:

Figure:Matrixofstrategicdirectionsbasedoncontextualscenario

"Forallcontexts,thefollowingkeyrecommendationsshouldapply:

Keyprinciplesforemergencyresponse:

1. Useavailableepidemiologicalinformationandreasoningtoinformtheresponseandtargetmostat-riskpopulations

2. Focusonsimpleandimmediate,community-based,efficient&life-savingactivities3. Minimizedelaysinthestartoftheresponsebyhavingreadyclearcontingencyprocedures,

choleraguidelines,trainingmodules,andexperiencedsurgestaff

4. Whenever possible, increase the number of experienced professional staff for themanagementoftheoperations,volunteerssupervisionandcoaching–includingthepotential

useofepidemiologistsandGISspecialists

5. Improve monitoring and reporting against specific indicators and hold systematicevaluationandlessons-learnedexercises

"Foreachofthepre-identifiedcontexts,specificorientationshouldapply:

InEndemic/regularlyaffectedcountries

Inendemicorregularlyaffectedcountries,governmentsandhumanitarianpartnersincludingthe

Red Cross should not be surprised by cholera outbreaks. Existing epidemiological knowledge

allowsmakinginformeddecisionsforpreparedness,responseandpreventionefforts.

Forthosecountries,thefocusison:

! Increased preparedness, especially in identified hotspots. Because outbreaks arepredictable, most of the caseload and associated mortality is preventable. Preparedness

activitiesareessential,inhotspotsareasandatdistrictandnationallevel;

! Speedandqualityoftheresponse,andsurgecapacityatnationallevel.WithincreasingRedCrosscholeraexperience,additionalactivitiescanbeaddedtotheminimumresponsepackage,

basedontheidentifiedneedsandcomplementaritywithotherstakeholders;

! Long-termriskreductioninpre-identifiedhotspots.Becausemultipleresponsestorecurrentcholera outbreaks is not the ultimate solution, identifying the specific vulnerabilities and

possibletechnicalsolutionsincholerahotspotscouldhelptheRedCross,theGovernmentand

itsdevelopmentpartnersheadtowardsajointlong-termriskreductioneffort.

Atregional(IFRC)level,possiblesupportincludes:

! Facilitatecross-border / regional communication and coordination between countries inthesamecholerabasin;

! Support preparedness efforts in Cholera Endemic countries (contingency plans, stocks,trainingnationalresponseteams);

! Support response efforts with rapid DREF and experienced HR deployments (maintainRDRTandsurgeexpertrosterforcholeraoperations).

InEpidemicsinnon-endemiccountries

Innon-endemiccountries,itislikelythatthelevelofpreparednesswillbeverylow,andthatthe

choleraresponsewillsufferimportantdelaysanderraticstrategicdecision-makingonwhattodo

andwheretoconcentratetheefforts.Thereisalsononeedofdedicatedpreparednessinadvance

becausecholeraoutbreaksarenotforeseenonaregularbasis.

Forthosecountries,thefocusison:

! Setting up as quickly as possible a good surveillance and epidemiological informationanalysissystem,inordertobeabletoinformtheresponse;

! Initiatingaquicksupportrequesttotheregion(IFRC)intheformofanexperiencedcholeraoperationcoordinator,RDRTsandDREF

! Receiveanddeployexperiencedsurgepersonnelfromtheregionallevel(RDRTs)! Implementtheminimumsetofemergencyactivitieswithquick,simple,provenefficient

life-savingactivities

Atregional(IFRC)level,possiblesupportincludes:

! Providing expert support for epidemiological analysis & disease mapping (GIS,epidemiologist)

! Respondingquicklytothesupportrequestintheformofanexperiencedcholeraoperationcoordinator, RDRTs and DREF (by maintaining a trained roster of RDRTs and experienced

choleraoperationmanagers)

! Preparing in advance all necessary guidance (Response architecture, guidelines, tools,trainingpackagesforvolunteers)forexampleintheformofaCholeraCDmissionassistant.

InCrisis-affectedcountries

Crisis-affectedcountrieshaveahighlyversatileprofile,butshareacommoncharacteristic:They

areoftenoverwhelmedwithseveralcomplexissuestodealwithatthesametime,andveryfew

capacities to respond to an additional crisis. It is even possible that a cholera crisis will go

unnoticedforaperiodoftime.

Forthosecountries,thefocusison:

! Stay alert on a possible emergence of an outbreak – which can overload Government and

humanitarian actors and quickly lead to a high case fatality if existing capacities already

limited

! Initiatingaquick support request to the region (IFRC) in the formof experienced cholerasurgeexpertsandfunding,ifneeded

! Receiveexperiencedsurgepersonnelfromtheregionallevel! Focusonlife-savingactivitiesinareaswhereaccessispossible! Reinforcewherepossiblecommunityself-resiliencecapacity–withORPsandpromotionof

homemadeORS

! If possible, protect vulnerable and hard to reach populations troughparticipation in OCVcampaigns

Atregional(IFRC)level,possiblesupportincludes:

! Regional and cross-border situation monitoring, and early warning for Crisis-affectedcountries

! Providingexpertsupportforepidemiologicalanalysis! Respondingquickly to the support request in the formofanexperiencedcholeraexperts

andDREF

! Preparing in advance all necessary guidance (Response architecture, guidelines, tools,trainingpackagesforvolunteers)forexampleintheformofaCholeraCDmissionassistant.

! Advocacy, coordination with OCV actors and technical support for OCV campaignimplementation

As a result, amatrix of pertinent interventions, from life-saving activities to preparedness and

preventionhasbeendrawn,withseveralpossibleactivityselectionoptions,basedonthecountry

situation,contextualanalysisandavailablebudget/capacities.

SeeattachedCholeraActivitiesMatrix(excelfile)

Asanexample,anextractofthematrixforemergencyresponserevealsasetof10activitiesthat

havebeenselectedamongstthemostessentialactivities:

Figure:CholeraActivityMatrix-Minimumsetofessentialactivitiesforcholeraresponse

Status Level Objective Category Activity Target

Essential 1 Reducingmortality Coordination ActiveparticpationinallCoordinationfora Nationallevel

Essential 1 Reducingmortality CommunitymobilisationCholeraawareness–signs&symptoms,riskofdeath,andurgencytoseekimmediaterehydration

AffectedRegions

Essential 1 Reducingmortality Casemanagement Oralrehydrationtherapy(ORT)intheformofCommunityORPs AtriskCommunities

Essential 1 Reducingmortality Surveillance Activecasefinding&Earlyreferraltohealthcenters/CTCs AffectedCommunities

Essential 1 Reducingtransmission Epidemiologicalreasoning Epidemiologyanalysisandidentificationofriskpractices,populations,areas Nationallevel

Essential 1 Reducingtransmission Burials Participationinsafeanddecentburials AffectedCommunities

Essential 1 Reducingtransmission Communitymobilisation Mediasensitization(radios,videos,sms) Nationallevel

Essential 1 Reducingtransmission WASHinterventionsSourcewatertreatment(Networkchlorination,Bucketchlorination,Chlorinedispensersinstallation)

AtriskCommunities

Essential 1 Reducingtransmission WASHinterventions Householddisinfectionkits(jerycanwithtap/disinfectant/aquatabs/soap) AffectedBlocks/HH

Essential 1 Reducingtransmission WASHinterventionsWASHandcommunitymobilizationinmarkets,streetrestaurants,stations,publicplaces,religiouscenters,schools

AtriskCommunities

#05.OrganizationandPreparednessworkfortheCholeraFrameworkimplementationWhatdowealreadyknow?! Weknowwhatwearealreadydoing,whatactuallyworks,andwhatweshoulddo! We know where we need to work and what type of activities we should implement

dependingonthesetting(endemic,non-endemicepidemic,andcrisis-affectedcountries)! We know what minimum and optional activities we should concentrate on during

emergencyresponse! Weknowthepreparednessworkweneedtodobeforebeingabletoprovidethequickand

qualityresponsewewant! Andweknowtheworkweneedtostartdoingtoshiftthefocusfromemergencyresponse

tomoredurablesolutioninendemic/regularlyaffectedcountriesButhowdowegetthere?ItisproposedtohaveanimplementationoftheCholeraFrameworkinlayers,dependingontheavailabletimeandresources:

Implementation of the Cholera Strategic Framework in layers (not necessarily inphases)

[Focusison:ImprovingEmergencyResponseCapacitiesandResults]Workwithwhatwealreadyhave–DREF/EAresponsesalreadyconstituteaverygoodbaseforcholeraresponse.Butbebetteratwhatwedo(quickandefficient).ThereisaneedtobemoreconsistentonwhatRedCrossisdoingandonthespeedandqualityofinterventions.Result:Improved,timelyandqualityemergencyinterventionsAdditionalBenefit:BerecognizedasanefficientactorincholeraresponseSo,Howdowegetthere?Weneedto:! Pilottheprocess:Attheregionallevel,withadedicateCholeraProgrammeManagerand

inclosecollaborationwithallinterestedNationalSocieties(Choleraworkinggroup)

! Buildregionalcapacity:EstablisharegionalsurgeCholeraresponseteamRosteroftrainedand experienced professionals (RDRT and cholera operationmanagers) to be deployedwitheachcholeraoperation(atleastatthebeginningtokickstarttheresponse).

! Developoperationsguidelines/tools(Choleramissionassistant)! Developquicktrainingpackagesforthefield! Regional support (accelerated DREF instruction and surge Cholera specialists

deployments)! Systematic response evaluations and integration of practical lessons learned in existing

guidance

[Focusison:BuildingRegionalCholeraresilienceandriskreductionapproaches]ImplementacomprehensiveCholeraapproachinanumberofselectedcountries.InvestinEpidemic/Regularlyaffectedcountries.Chooseprioritycountries(ideallyatleast2countries in a same “cholera basin” to increase coherence, exchanges and cooperation), inwhich to implement a more comprehensive cholera approach, including risk-informedpreparednessandlong-termprevention.Bepro-active in thenewemergingapproach tocholeracontrolatregionallevel.Connectwithpartnersatnationalandregionallevelsandwork in networks (Regional cholera platforms). Build local and regional epidemiologicalunderstandingandexpertise,andincreasenationalpreparednessandresponseefficiencyforpredictableoutbreaks;Useevidence-basedinformationandexistingcountrycasestudies(eg.DRC) to advocate for long-term approaches for cholera control with the government andother stakeholders. Feedback lessons learned to other stakeholders through the RegionalCholeraplatforms.Result: Increased preparedness and response capacity in Endemic countries, andcontributiontotheshifttowardslong-termriskreductionsolutions.Additional benefits: Be recognized as a key Regional partner in cholera response andpreventionSo,Howdowegetthere?Weneedto:! Selectprioritycounties–withinaCholeraBasinsapproach! Develop a partnership with UNICEF, WHO and other regional actors for country

epidemiological understanding (review of available information or contribution to theepidemiological review through consultancies for identification of key hotspots, at-riskpopulationsandpractices)

! Supportcontingencyplanningandpreparednessatnational level(Contributetoamulti-stakeholdernationalcontingencyplan)

! Pre-establish Agreements & contracts with UNICEF, WHO and other private/publicorganisationsforthefundingoftheresponse

! Developspecificpreparednessprogrammesinidentifiedhotspots(seeCholeraActivitiesMatrix–Endemiccountries–preparednesssection)

! Buildnationalunderstandingandresponsecapacity:EstablishanationalCholeraresponseteam Roster of trained and experienced professionals (NDRT and cholera operationmanagers)tobedeployedincholeraoperation.

! Ask/welcomeRegionalsupportandlearning(eachcholeraoperationisanewoccasiontobuildtheregionalresponsecapacity)

! Systematicevaluationofpreparednessefforts(Howdidthepreparednesseffortincreasedthe speed of the response or the resilience of the community?) and capitalization ofpracticallessonslearnedintheformofcasestudies

! Use existing epidemiological information on hot spots identification and existing casestudiesinadvocacycommunicationtowardsGVTanditsdevelopmentpartners,tofosterjointcollaborationtowardslong-termcholerariskreduction;

! Ifpossible,contributetotheinvestmentcasebuildinginconductingvulnerabilityanalysisandtechnicalevaluationsofpossiblesolutionsinidentifiedhotspots

! If possible, contribute to the long-term risk reduction effort in investing in WASHprogrammesinidentifiedhotspots

! Work in close collaborationwithRegional Platforms andGlobal CholeraTask forces formonitoringandevaluationof the impactofpreparednessand long-term investmentsoncholerariskreduction

! Contributetobuildingthecaseforcholeralong-termriskreductionwithcapitalizationofcasestudies

! Develop a fundraising strategy through the establishment of technical partnerships atnationalandregionallevel

[Focusison:Globalthinkingandapproachesforefficientlong-termcholeracontrol]BepartoftheGlobalandRegionalpictureinthefightagainstCholera.Share experiences, showcase successes. Contribute to building a case for the long-termCholeracontrolandpreventionefforts.Evaluate.WorkonM&Erequirementsformeasuringimpactsofpreparednessandpreventionactions.ContributetotheGlobalThinking.InvestinResearchincollaborationwithAcademicinstitutions.Partnerwithotherglobalstakeholderslike UNICEF, WHO, and MSF. Have political leverage on Regional Policies (African Union,ECOWAS,EAC,SADC,etc.)anddevelopmentagendas(ACP-UEprogrammes).Results:Contributetotheunderstandingandadvocacyefforttowardasuccessfullong-termCholeracontroldirectionAdditionalBenefits:BerecognizedatgloballevelasamajorstakeholderinthefightagainstcholeraSo,Howdowegetthere?Weneedto:! Be actively involved in all the Regional and Global Cholera Initiatives (WCA Cholera

Platform,JICSA,GTFCC,etc.)! InvestinPreparednessandPreventionprogrammesEvaluationandexperiencesharingin

theformofCaseStudies! Partner with Academic institutions to respond to the lack of evidence-based guidance,

evaluateandpublishpeer-reviewedresults! Partnerwithglobalinstitutionstohaveastrongervoiceinajointadvocacyefforttowards

Decision-Makersaboutlong-termriskreductioneffortsforCholeracontrol! Contributeto themobilizationof theglobaldonorcommunity forsustainedCholerarisk

reduction

#06.DonormappingandanalysisTotal reported contributions for cholera humanitarian response per year since 2010 variesbetween1millionand36millionUSDollars,withanaverage(median)of14,9millionUSD.Table#:TotalDonorcontributionsforcholerainAfricancountries,peryear,2010-2106

Source:UNOCHA–FTS(NB:Onlyfundsdeclared/registeredtoOCHA-FTSareincludedinthisfigures)MajorCholeraDonorsinAfrica(2010-2016)

Figure: Total reported contributions perDonor for cholera response in Africa between2010and2106(source:UNOCHAFTS)Main funding sources for cholera response during these yearswere: TheUN emergency fund(CERF),EuropeanCommission(DGECHO),andthecrisiscountriesemergencypoolfunds(CHF).! TheCERFistheUnitedNationsCentralEmergencyResponseFund(CERF).Itisanenvelope

of450millionUSD/year,dedicatedtosupportemergencyresponseofUNorganizations.OnlyUN organization can request / apply for CERF funding, but operational partners canindirectlybenefitofCERFfundsviapartnershipswithrecipientUNorganizations;

! DGECHO(withanaverage3,2millionUSDperyear).MainlyfundingNGOsandUNICEFforadirect operational response. Rarely WHO. Supporting the West & Central Africa CholeraplatformandtheworkofUNICEFtobuildabettercholeraresponseandpreventioncapacityintheregion.Differentfundinglinesincountriesandatgloballevel(oneofthembeingtheEpidemicdecision,nowundertheEmergencyToolboxDecision).EmergencyToolbox:http://ec.europa.eu/echo/files/funding/decisions/2017/HIPs/DRF_HIP.pdf

Year 2010 2011 2012 2013 2014 2015 2016Donorcontributions 9667930 25133403 36066589 16617853 14921824 1147903 5072609(reportedtoFTS-inUSD)

Donor USDCERF 39880996ECHO 22972610CHF 16073340USAID 7641004Sweden 5325289Germany 3169921UK 2794708UNICEF 2474900Canada 1846063Japon 1320800Australia 1320179Belgium 995770ERF(OCHA) 786962Korea 600000Denmark 383584Privatesector 366730Luxembourg 187484Startfund 120510Russia 114114Switzerland 107991Ireland 69156 0 10000000 20000000 30000000 40000000

IrelandSwitzerland

RussiaStartfund

LuxembourgPrivatesector

DenmarkKorea

ERF(OCHA)BelgiumAustralia

JaponCanadaUNICEF

UKGermanySwedenUSAIDCHF

ECHOCERF

! CHF, Common Humanitarian Fund. (DRC, South Sudan, Somalia). Common HumanitarianFunds(CHFs)arecountry-basedpooledfundsthatprovideearlyandpredictablefundingtoNGOs and UN agencies for their response to critical humanitarian needs. CHFs enableHumanitarian Country Teams—who are best informed of the situation on the ground—toswiftly allocate resources where they are most needed, and to fund priority projects asidentifiedinaConsolidatedAppealProcess(CAP),orasimilarhumanitarianactionplan.

Otherbilateralcontributionsinclude:! USAID/OFDAfundsaremainlyorientedtowardsinternationalNGOs.Applicationsaremade

atnationallevelratherthanregionalorgloballevel,however,USAIDissupportinganumberof regionalprogrammesand initiativesaspartof itsDRRapproach(includingasmallDRRprogrammeinGuineaforcholeraprevention);High-leveldiscussionswithUSAIDcouldleadtothecreationofaspecificbudgetlineforCholeraoratleastforEpidemics(notyetexisting).

https://www.usaid.gov/who-we-are/organization/bureaus/bureau-democracy-conflict-and-humanitarian-assistance/office-ushttps://www.usaid.gov/what-we-do/working-crises-and-conflict/crisis-response/resources/usaid-ofda-regional-contactsUSAIDDRRprogramming(2009):http://www.unisdr.org/files/14099_fullreport1.pdf! Sweden:Humanitarianfundingrepresentsabudgetof450millionperyear–50%ofwhich

goes to Africa. Humanitarian funding goes both for NGO and UN organizations, pluscontribution to Emergency Country Pool funds (CHFs). In our review, cholera fundedoperationsweremainlylocatedintheSahel(Mali,Niger).

https://openaid.se/aid/sweden/world/all-organisations/emergency-response/2016/#activities! Germany. Only one contribution (3 millions, to WHO in Kenya). But known to fund

developmentWASHprogrammesinAfrica;! UK-Aid (DFID); FTS review indicates funding going to both NGOs and UN organizations.

TotalHumanitarianAidbudgetis2,3billionUSDayear(2014data),representing16%ofUKtotalODA.

DFIDispresentinAfricainthefollowingcountries:DRC,Ethiopia,Ghana,Kenya,Liberia,Malawi,Mozambique, Nigeria, Rwanda, Sierra Leone, Somalia, South Africa, Sudan, South Sudan,Tanzania,Uganda,ZambiaandZimbabwe.DFIDfundsareavailableforAfrica,intheformofregionalbudgetlines.Anexampleofaregionalfundthatcouldbemobilizedforsuchprogrammeis:https://www.gov.uk/international-development-funding/regional-infrastructure-programme-for-africaDFIDhasalsoadedicatedbudgetlineforEbola.High-leveldiscussionswithDFIDcouldleadtothecreationofaspecificbudgetlineforCholeraoratleastforEpidemics(notyetexisting).

MajorDonorRecipientOrganizationsinAfrica(2010-2016)

Figure: Total reported contributions for cholera response per recipient organization inAfricabetween2010and2106(source:UNOCHAFTS)UNICEFisbyfarthebiggestrecipientofallcholerafundsinAfrica,followedbyWHO.Looking at operational partners, Solidarités, OXFAM, IRC, ACF, and IMC are the mostrepresented;In comparison, the IFRC funding for cholera during the same period (2012-2016) was 10,6millions Euros (DREFs and EA), not including specific projects funded through othermechanisms (Donors like DG ECHO, Partnership Agreements with UNICEF, private sector, orfundsprovidedbyPNSs).MainRecipientcountriesinAfrica(2010-2016)

Figure:TotalreportedcontributionsforcholeraresponseperrecipientcountryinAfricabetween2010and2106(source:UNOCHAFTS)

Donorrecipients USDUNICEF 44602940WHO 16444859Solidarités 13700408OXFAM 8615723IRC 8059419ACF 4679471IMC 1931096Medecinsd'afrique 1241117CRRDCTD 1031250UNPF 1022199

Recipientcountry USDDRC 42632266Chad 21012151Mali 12721064Niger 10694927Somalia 4822867SouthSudan 4502260Kenya 4372401Zimbabwe 2274254Cameroun 1930200CoteIvoire 1625725CAR 1544969Nigeria 237268Guinea 137115GuineaBissau 120644

It is not surprising that DRC has received the biggest contribution so far, due to the largestburdenofcases.However, top receiving countries arenotnecessarily theone reporting thehighestnumberofcases.Itappearsthatmaincountryrecipientsarecrisis-affectedcountries,wherehumanitarianinternationalattentionlies–countrieslikeChad,MaliorSouthSudanforexample.This may be explained by a higher presence of active humanitarian partners, or with anincreased availability of humanitarian funds in donor envelopes for such countries (eg.availabilityofpoolfundssuchasCHFswhicharenotavailableinnoncrisis-affectedcountries).SummaryoffindingsrelatedtoDonorAnalysis! There is no particular cholera champion amongst donors and a highly variable interest in

cholera response. Funding is not predictable and varies every year and in every country,dependingonthecontextbutnotnecessarilydirectlyrelatedtothecholeracaseload;

! Mostof the fundsare coming through theCERF fundingmechanism,accessibleonly toUNorganizationssuchasUNICEFandWHO;

! DG ECHO is one of themajor global donor for cholera response, and is probably the onlydonortohaveadedicatedbudgetlineforepidemicpreparednessandresponse;

! Atcountrylevelandincrisis-affectedcountriesonly,CHFfundscanbeaccessedforcholeraresponseevenbyNGOsdirectly.

! AdditionalpotentialdonorsincludeUSAIDandDFID,incountrieswherethehaveaphysicalpresence.

! UNICEFandWHOarethemajorrecipientorganisations,abletomobilizefundingfromCERF,CHFandvariousdonors.

Strategicorientations! UNICEFandWHOPartnership

Strong partnerships should be sealed with UNICEF and WHO for cholera response andpreparedness,astheyarethemajorrecipientorganisationsforcholerafunds.UNorganizationsare often not direct implementers but instead rely on operational partners for the response.Contracts in the form of PCAs (Programme Cooperation Agreements) and SSFA (Small ScaleFundingAgreements)canbesignedinadvanceandactivatedwhenneeded.AMoUbetweenUNICEFandIFRCalreadyexistsatgloballevel,whichcouldbeusedtoreinforcethecooperationonaregionalscaleforAfrica,oncholerapreparednessandresponse.Atnationallevel, pre-agreed / pre-signed PCAs could be prepared by the IFRC or by National Societiesdirectly in order to allow for a quick activation of the partnership in case of epidemic alert;Partnership with UNICEF and WHO could include: supplies of ORS, aquatabs or other HWTsolutions,soaps,andbuckets/jerrycansandpossiblyevenfundsforcommunitymobilization.Ifnotalreadyexisting,asimilarMoUcouldbesealedwithWHO.TheRedCrosspotentialroleinSurveillance,OralCholeraVaccinationcampaigns,andCommunitycasemanagementshouldbeemphasizedbyastrongerparticipationoftheRedCrossintheGTFCCworkinggroups–givingsomeargumentstoWHOtoadheretoastrategicIFRC-WHOpartnership.

! DGECHODG ECHO is already funding some of the RC operations through the “DREF budget line”,participatingtosometheresponsetosmalloutbreaksintheformDREFreplenishmentsafterafirst evaluation of the quality of theproposed intervention; In regular occasions, IFRCorPNShavealsobeenfundedoutsidetheDREFframeworktorespondtobiggeroutbreaks.IfDGECHOhasfundedandwillbefundingasignificantnumberofDREFs,itshouldbenotedthatHowever, ECHO does not value the contribution of the Red Cross in cholera response as a“quality”response;ImprovingespeciallythequalityofthesmallbutnumerousDREFresponses,whichmightrepresentmostoftheRedCrossmovementresponsetocholeraoutbreaks,isakeystep towards being recognized by Governments, operational partners and donors as a keyCholeraresponder.DGECHOhasalreadybeenapproachedbyIFRCtofundspecificregionalCholerapreparednessand response programmes (in Niger/Guinea/Sierra Leone, and in Ghana) – but thoseprogrammeshaveunfortunatelynotbeenabletodemonstratearealaddedvaluetotheregionalandglobalCholeraapproaches;BeingabletodeliverqualityinterventioninDREFresponsesandto show a renewed, harmonized and efficient strategy for cholera response based on theparticular strength of the Red Cross movement would be beneficial for asking more regularfundingtoDGECHO.! Fundsmobilizationatcountrylevel,foremergencyresponseandlong-termriskreductionAdhocmobilizationofGovernmenttraditionaldevelopmentDonorsandCHFpoolfundscanbebestrealizedlocallywhenthereisanoutbreakinthecountry.Samefortheprivatesector;However, thoseGovernment traditionaldevelopmentDonorswouldbebestmobilized to fundthe long-term risk reduction investments in identified Cholera Hotspots; Such mobilizationeffortswillbefarmoreeffectiveifcomingfromacountrylevelallstakeholderspartnershipforcholeracontrol, summarized inaCholeraControl/EliminationNationalPlan,asshown in theDRCexample.

! FundsmobilizationatRegionalorGloballevel,forlong-termpreparednessandpreventionHigh-leveldiscussionswithRegionalorGlobalOrganizationssuchasAfricanDevelopmentBank,WorldBank,EU institutions,USAIDorDFIDcould lead to the initiationofadedicated fundingopportunity.PartnershipwithotherUNorganisationssuchasUNICEFandWHOcouldbekeytoleveragespecificglobalfunding.AHighLeveladvocacymeetingisbeingorganizedinGenevainSeptember by the GTFCC,where IFRC should be present andwell represented; In the GTFCCadvocacy-working group is being defined an advocacy and funding strategy, including theprivatesectormobilizationandpartnership;! MobilizealreadyexistingIFRCfundingsources,bothforresponseandlong-termpreventionDREF is a very useful funding mechanism for early cholera response, and has probablycontributedtomostoftheRCfundinginemergency;Potentially, existing funds for long-term investments to achieve the WASH SDGs such as theGWSIinitiativeshouldalsoincludecholeravulnerabilityasanimportantcriterion.Thisdoesnotnecessarilyinvolveactivitiesotherthantheonesalreadyplanned,butrathertostrategicallyre-orientpartoftheseactivitiesintopre-identifiedhighlyvulnerableareas(cholerahotspots).

Thekeyprincipleoftheriskreductionpillaroftheproposedcholerastrategyisthatitispossibleandcost-effective toreduceoverall cholera incidence inacountrywith limited investments incholerahotspots.Integration of the cholera strategy principles in already existing IFRC programmes is a smartwaytoincreaseconsistencyofthecholerariskreductioneffortswithintheorganisationandtobeabletoshowcoherenceandcredibilitytoexternalpartners,governmentsanddonors.