Development of national cholera plan

Using the conclusion of the situational analysis, countries will develop operational plans for each pillar with budgeted activities targeted at cholera hotspots Operational plans should include activities that are budgeted, and for which a timeline, available resources and responsible person are identified. These plans should be reviewed and updated on a regular basis (see Monitoring and Reporting section) .

This section focuses on providing guidance on the type of interventions that may be included in an NCP, depending on the context and the needs of each country. The interventions are organized by the pillar to which they are most linked. The interventions should be adapted to the context and capacities of each country.

In each of the sections, a set of GTFCC references has been identified to help countries conduct the activities . In addition to GTFCC material, partner resources are available in Appendix 2.

A. Surveillance and reporting

Strengthening epidemiological and laboratory capacities to rapidly detect, investigate, confirm and monitor cholera cases are key parts of the Global Roadmap . Surveillance activities should be integrated within the existing surveillance system (e.g., Integrated Disease Surveillance and Response) and focus on improving the ability of a country to detect and confirm cholera cases promptly and quickly respond to cholera outbreaks. Surveillance must also allow close monitoring of cholera incidence and case fatality over time in hotspots to inform and adapt strategic planning, implementation priorities and progress toward NCP goals .The strengthening of cholera surveillance should encompass all aspects of surveillance including event-based based surveillance (i.e., non-health, informal sources, etc.), the media, indicator-based surveillance (i.e., healthcare-based surveillance, laboratory, sentinel surveillance, etc.) and community-based surveillance.

Strategic objectives:

• To rapidly detect all signals potentially related to cholera through all relevant sources, to verify these signals in a timely manner (i.e., within 48 hours between the occurrence of the signal and its verification) and to allow for timely implementation of full control measures (i.e., within five days of laboratory confirmation).
• To maintain, regularly update, analyse and share datasets² at each administrative area (down to the same level used for hotspots). This data should be integrated into existing surveillance systems and include a "zero reporting" feature.

Proposed interventions to be included in an NCP:

1. Engage communities

• Develop and disseminate materials to the community (e.g., recognition on cholera symptoms, how to report suspected cases and deaths). Ensure that materials are provided in local languages using local wording and/or pictures and categories that ensure comprehension.
• Conduct regular trainings for community health workers (CHW), traditional healers and volunteers to ensure that they can identify cholera symptoms.
• Develop and communicate a clear process for the reporting of suspected cases and deaths to health facilities .
• Consider the establishment of structured community-based surveillance systems that are integrated into the overall surveillance framework (i.e., event-based and indicator-based) to both empower communities and to improve early detection and reporting.

2. Regularly update cholera surveillance protocols and tools ⁽⁵⁾

• Develop and regularly update national cholera surveillance guidelines, including standardized case definitions, standard operational procedures (SOP) for early signal detection, data collection, analyses and reporting; including community-based surveillance and environmental surveillance, SOP for specimen collection, SOP for the use of rapid diagnostic tests (RDT) ⁽⁶⁾ and testing strategies and SOP for transportation and storage.
• Standardize data collection and reporting in a format allowing data integration at country-level and ideally at regional or global level, either by developing or adapting existing tools to the national context .

3. Build capacity for early detection and reporting of suspicion of cholera

• Deliver adapted training in early warning procedures to health care workers (HCWs), community health workers (CHW), traditional healers, volunteers and other stakeholders in cholera hotspots; training in understanding and applying the case definitions; and training in the criteria and procedures for timely reporting a signal to the investigation/response teams.
• Integrate volunteers and traditional healers in the surveillance framework (i.e., event-based surveillance and/or community-based surveillance according to the context) and train them on what to report, to whom, at what frequency and provide them with the means to do so.
• Adapt or develop/update suspected cholera investigation tools, such as standardized questionnaires, reporting forms, investigation logbooks and mobile applications (as required).

4. Build capacity for data collection, reporting and analyses

• Integrate all potential sources of information at hotspot administrative level (district or lower) to adequately capture and report signals (e.g., informal sources and non­medical sources, such as schools, pharmacies, religious institutions, water supply services, etc).
• Develop plans to train surveillance officers and data clerks at central and peripheral levels, including community-based surveillance.
• Regularly analyse data (population at risk, cholera risk factors, estimation of burden, updating cholera hotspots data, etc).
• Routinely disseminate surveillance data to all levels, including multisectoral partners, and adapt the support of the feedback to the audience (e.g., partners health facilities, community health workers, affected communities, etc) .
• Routinely report surveillance data globally (including zero reporting) to contribute to the global monitoring of cholera transmission patterns.
• Train stakeholders on data interpretation and when to alert the presence of a potential outbreak.

5. Build capacity for sample collection and transportation and rapid diagnostic test (RDT) use

• Update or develop/disseminate job aids, standard operating procedures, training materials for RDTs, SOP for specimen collection and transportation, etc.
• Procure sufficient supplies (i.e., cholera RDTs, specimen collection kits and transport media) at all peripheral health care facilities .
• Update or develop testing protocols defining SOPs for cholera confirmation by RDT, culture and/or PCR .
• Adapt the testing strategies to account for specific situations (e.g., during outbreaks, intra-epidemic phase, seasonality, high endemicity or close to elimination).⁽⁵⁾

6. Build capacity for laboratory confirmation of suspected cases in cholera hotspots ⁽⁷⁾

• Strengthen laboratories to ensure they have the capacity to conduct culture or polymerase chain reaction (PCR) testing.
• Ensure that all hotspots have access to the needed laboratory capacity to screen suspected cholera cases and confirm the presence of Vibrio Cholerae with culture/ PCR (e.g., establish procedures for access to reference laboratories, decentralize laboratories where relevant, add additional human resources focused on cholera, upgrade equipment or improve access to central laboratories) .
• Update/develop multi-year training plans and roll out trainings on laboratory testing procedures and packaging/transport of samples .
• Provide sufficient hardware, reagent and supplies in all laboratories.
• Set up a reporting system to collect information on the number of tests performed and the procedures used to analyse samples .

7. Develop national reference laboratory capacity

• Consider pooling resources for a supra-national reference laboratory that integrates cholera and other diarrhoeal diseases or establishing/strengthening a national reference laboratory (e.g., identify location, trained staff, etc) to reinforce technical and diagnostic capacity.
• Organize annual quality controls in reference and peripheral laboratories.

8. Establish collaboration with national and international reference laboratories

• Develop and implement a quality assurance programme at central and peripheral level.
• Establish cross-border communication and collaboration mechanisms between the reference laboratories of neighbouring countries .
• Establish a mutually beneficial partnership with an international reference laboratory for global epidemiology investigations and support for country priority capacity-building needs.

9. Establish/strengthen international collaboration

• Establish procedures for timely cross-border communication of cholera alerts.
• Promote elaboration implementation of coordinated cross-border early response measures .

10. Enhance surveillance during outbreaks

• In the affected area(s) and the area(s) at risk of spread, reinforce awareness on cholera case definitions and reporting procedures to support early detection and timely reporting, both at community level and health facility level .
• If reporting to district level is not weekly (at minimum), increase data reporting frequency (weekly or daily) .
• Ensure adequate supplies are available (i.e., reporting forms, cholera RDTs, specimen collection kits and transport media) at all peripheral health care facilities, and ensure samples can be shipped and processed for confirmatory laboratory tests in a timely manner.
• Consider implementing active case findings in the population(s) at risk.
• Increase the periodicity of routine surveillance data analysis to closely monitor trends and promptly identify any population(s)/group(s) at risk.

B. Health care system strengthening

To reduce cholera mortality, individuals with cholera must have access to quality treatment as soon as symptoms appear. The health care system should be prepared to treat individual cases within the existing system, as well as have the capacity to scale-up treatment response in the event of an outbreak. The capacity to treat cholera cases within the existing system will reduce mortality and limit the spread of the disease .This includes the engagement of a cholera treatment network and the implementation of strategies ranging from home-based or community care through overnight stay structures with highly trained medical staff as soon as cholera is suspected. Depending on the context, the treatment network may need to be scaled-up during a cholera event or outbreak

Strategic objective:

• To increase access to early effective treatment at community and health facility levels to reduce overall cholera deaths by 90%.

Proposed interventions to be included in an NCP:

1. Engage with communities to improve early access to treatment

• Building on existing programmes where possible, engage communities, including community leaders and traditional leaders, to develop locally adapted messaging, programmes and activities to help community members prevent and identify symptoms of cholera and the need to seek early treatment.
• Engage with communities to build trust among local health care service providers, in the use of Oral Rehydration Points (ORP) and Cholera Treatment Centres (CTC) and seeking early treatment.
• Train traditional healers and volunteers so they can identify cholera symptoms and encourage referrals to ORPs and CTCs.
• Collaborate with local media to promote knowledge and behaviours related to the identification of cholera symptoms, prevention and the need to seek early treatment.
• Develop the interpersonal communication and counselling skills of frontline health care workers (HCWs) to promote early treatment.

2. Build capacity of community health workers to identify, provide treatment and refer patients with suspected cholera

• Include cholera prevention and the identification, treatment and referral of patients with suspected cholera in the curricula of community health workers (CHWs).
• Train CHWs on standard infection prevention and control (IRC) and WASH measures to be implemented in homes and when to provide treatment to suspected cholera patients in the community.
• Develop the interpersonal communication and counselling skills of frontline CHWs to promote early treatment .
• Plan for and provide supplies in sufficient quantities throughout the year.
• Monitor and supervise CHWs and implement feedback sessions and refresher trainings.

3. Build capacity to treat patients at health care facility level

• Include identification and treatment of suspected cholera in the national responsibilities for health care workers (HCWs).⁽⁸⁾.
• Develop a training plan for HCWs on cholera case management.
• Train HCWs on the standardized tools for health care-based data collection; ensure that they know what to report, to whom and at what frequency. Additionally, ensure that HCWs have the means to do this .
• Regularly develop and update all guidance, job aids, protocols and SOPs regarding triage, diagnosis, clinical management and IPC, including dead body management, etc.
• Distribute SOPs, protocols and job aids, and display them for easy access at all levels .
• Implement minimum WASH and IPC standards in health care facilities, including separate wards or units to isolate cholera patients from other patients, safe food preparation and safe waste disposal.⁽⁹⁾
• Implement annual supply plans to estimate supply and infrastructure needs at all levels and reassess regularly.
• Plan for, stock and manage supplies in sufficient quantities throughout the year in health care facilities at all levels, depending on the calculated need.
• Develop emergency response plans; identify sites where CTCs and ORPs can be established in the event of an outbreak, surge capacity and stock management.

4. Monitor and evaluate the interventions at community and health facility levels

• Integrate cholera into the existing supervision plans for the assessment of the quality of treatment given in hotspots .
• Assessments should include CHW supervision, supervision in health care facilities and supervision of cholera-specific treatment structures during emergencies. Prioritize supervision before and during known cholera seasons Supervision should include:
• Protocols and supplies available.
• Timely access to appropriate rehydration methods.
• Quality of treatment provided.
• Identifying and correcting any delays of supplies arriving to the facilities, or delays to receiving treatments .
• Availability and implementation of basic WASH and IPC.
• Implement feedback sessions and refresher trainings, considering the results of supervision.

5. Scale-up community engagement and access to treatment during outbreaks

• At the community level, reinforce messaging on cholera prevention and identification, including the importance of seeking care rapidly when symptoms appear. Messages should also include the location of treatment centres/facilities and information on all services put in place to respond to the outbreak.
• Prioritize capacity building in health care facilities where CHWs are trained on triage, diagnosis, case management supplies, IPC and reporting (as described above).
• Use surveillance data to identify areas to establish and maintain Cholera Treatment Centres (CTC) and Oral Rehydration Points (ORP) that are accessible to the most affected populations; organize appropriate patient flow in health care facilities and CTCs.⁽¹⁰,¹¹⁾
• Distribute treatment protocols, job aids, job descriptions and SOPs to all treatment facilities.
• Identify and support means of transport for patients in accessing care.
• Estimate and regularly reassess supply and infrastructure needs at all levels, including provision of adequate safe water and food, material for sanitation to cover the needs of patients, caregivers and staff.
• Identify, determine availability and train additional surge staff, including for WASH and IPC measures.
• Establish a plan for management of treatment facilities, including rotation of staff to ensure that all facilities are functional 24/7 during outbreaks.

6. Establish coordination mechanisms between health care providers

• Verify that treatment strategies and protocols are consistent and coherent at all levels of care provision and between all actors (state and non-state); this may be a sub­group of a broader coordination mechanism.
• Disseminate information on the location of different structures at all levels to facilitate referral of patients.
• Coordinate ambulance services for all health care providers/structures.

C. Use of Oral Cholera Vaccine

OCVs should be used in selected cholera hotspots and during cholera outbreaks .The vaccines should always be used in conjunction with other cholera prevention and control strategies (e.g., case management, emergency WASH, etc.) . In addition, in order to increase visibility of OCV and to have more efficient OCV campaigns, it is important to actively engage/collaborate with the Expanded Programme on Immunization (EPI) and to use/adapt relevant existing tools, such as for monitoring and evaluation, Knowledge, Attitudes and Practices (KAP) studies, risk communication strategies, etc.

Detailed guidance to support countries in implementing and monitoring OCV campaigns has been developed by the Global Task Force on Cholera Control.⁽¹²⁾

Strategic objectives:

• To implement preventive OCV campaigns in selected cholera hotspots and reach high coverage of target populations.
• To implement reactive OCV campaigns (when appropriate) in case of emergency and reach a high coverage of target population.

Proposed interventions to be included in an NCP:

1. Develop a request for preventive vaccination in selected hotpots

• Identify and set up a cross-disciplinary OCV planning team, including immunization, surveillance, case management, WASH and community engagement.
• Select hotspots that will be targeted for preventive OCV campaigns.
• Develop medium-term vaccination plans (phases for the duration of the NCP).
• Develop timelines of activities and identify key responsible parties, including identification of dates for each campaign, training of frontline workers, identify community networks to be mobilized, evaluate touchpoints to debrief on lessons learned, etc.
• Develop contingency plans for vaccination campaigns in unexpected locations, including identifying decision pathways for determining the use of OCV, preparation of readily available data for applications, etc.
• Submit requests (per phase) to the GTFCC Secretariat .The request should also include a detailed plan of WASH interventions.

2. Develop a request for a reactive vaccination campaign

Emergency requests can be initiated when a culture-confirmed cholera outbreak is reported in any given area, or in humanitarian crises where there are no cases but a high risk of cholera outbreak The next steps are:

• Submit an International Coordinating Group (ICG) request form - duly filled and accompanied with annexes - to the ICG Secretariat.
• Develop and submit a vaccination plan and a map of areas to be vaccinated, including adjacent areas.
• Verify and confirm that an OCV campaign has not been conducted in the previous 3 years in the same area (with consideration for the quality of implementation of the campaign, vaccination coverage and population movement).

3. Implement vaccination campaigns in line with the approved request

a) Provide supplies and vaccines at all relevant levels⁽¹²⁾

• Calculate the quantities of vaccines and supplies needed by site, according to a calendar of implementation.
• Develop distribution plans for supplies and vaccines to reach health care facilities five days prior to planned vaccination dates .
• Ensure appropriate cold chain available when campaigns are conducted.
• Identify a process for reporting and requesting additional supplies and vaccines when stocks are running low.

b) Establish and train vaccination teams⁽¹³⁻¹⁴⁾

• Determine the composition and number of vaccination teams . Calculate:
  • The number of persons to be vaccinated per team and per day; and
  • The number of teams needed to cover target populations and for how many days these teams are needed .
• Develop a training plan for vaccination teams .
• Develop a plan for supervising and monitoring of OCV campaigns.
• Ensure that standardized tools for data collection are available at peripheral health care facilities and that the vaccination team is trained on reporting requirements.
• Identify and engage implementing institutions to assist in the roll-out of the OCV campaigns; assign roles and responsibilities.

c) Engage communities

• Before OCV campaigns, identify social, cultural, economic and other barriers to immunization; adapt vaccination strategies accordingly.
• Develop risk communication and community engagement micro-plans and materials that cover OCV characteristics; address vaccine hesitancy and the timing and locations of campaigns.
• Work with local media to ensure that misinformation and disinformation are not disseminated to the local population.
• Develop and conduct communications around the timing of vaccination campaigns and delivery strategies. Ensure that community engagement activities precede the roll-out of vaccinations and ensure that these activities continue during and after the vaccination period.

4. Conduct monitoring & evaluation activities⁽¹³⁾

• Ensure that vaccination teams are equipped and trained on vaccination data recording and reporting requirements during the campaign.
• Ensure formal planning and budgeting for post-campaign evaluations (e.g., coverage surveys, etc).
• Collect and report³ all campaign data to national surveillance officers for further compilation at national level.
• Ensure that the standardized tools for Adverse Event Following Immunization (AEFI) action and reporting are available and that staff are trained on how to use them appropriately.
• Prepare contingency communication plan and materials in case of occurrence of AEFI or other negative reactions to the OCV campaign.
• Conduct a coverage survey that includes data collection on WASH conditions in communities targeted by the vaccination campaign.
• Conduct any other relevant M&E activities (e.g., effectiveness of alternative delivery strategies, cost-effectiveness studies, etc), as needed.

D. Water, Sanitation and Hygiene (WASH)

WASH is the key intervention to long-term cholera control .The Global Roadmap contributes directly to SDG 6 (Water and sanitation for all), SDG 3 (Good health and well-being), SDG 2 (Zero hunger) and SDG 10 (Reduced inequalities) by targeting investments in WASH in cholera hotspots, which are indicators of poor WASH and sanitary conditions .

The WASH interventions to be implemented in cholera hotspots should be defined based on a baseline assessment of water, sanitation and hygiene conditions in the area .

Interventions and messages should be evidence-based, adapted to the local context and adapted to cultural practices of the population. Once interventions are identified, cost recovery and operation and maintenance (O&M) plans should be developed.

This section provides a set of interventions that can be considered by countries, depending on the prevailing situation in the hotspots .This section also provides a set of interventions that can be undertaken to prepare for and respond to cholera outbreaks, if necessary.

Strategic objective:

• Increase (to 80%) the portion of the population with access to basic plus⁴  water and basic sanitation services and hygiene promotion in all cholera hotspots.

Proposed interventions to be included in an NCP:

1. Improve access to water sources for all

• Assess and map existing water sources (i.e., availability, types, access, quantity of water, risk of contamination, etc.) in cholera hotspots .This should be done during the inception phase, but a more in-depth analysis could be required.
• Based on risk, it may be necessary to upgrade, rehabilitate existing or construct new water sources (e.g., boreholes, protected wells, protected hand pumps, protected springs, water tankers, water distribution systems [including taps in public institutions], communal or households, etc.) . Improvement of water sources should provide equitable access to safe drinking water and align with international and national standards for sufficient water quantities (depending on the context).
• Conduct water treatment of all rehabilitated or newly constructed water sources using the most appropriate technical solution based on an analysis of the water parameter (at the source or point of use) . Selection of the water treatment method can include filtration, disinfection or chlorination (bulk or batch chlorination).⁵ The use of pre-treatments such as sedimentation, flocculation and coagulation may be required to remove suspended particles and reduce turbidity before disinfection or chlorination . Combining treatments (used together, either simultaneously or sequentially) will increase the effectiveness.
• Consider household water treatment (HWT) methods (at point of use, at the tap, vessels or storage containers).⁶ These include boiling, disinfection, chlorination and filtration. Ensure safe transport and storage of the water that has been treated to avoid contamination.
• Implement water quality monitoring and surveillance to regularly measure free residual chlorine (FRC) . Consider putting in place Water Safety Plans (WSP) to support the water quality monitoring and surveillance.

2. Improve access to sanitation

• Support efforts to stop open defecation and work with communities to decrease the risk of contamination from open defecation .This can include cleaning and decommissioning of areas used for open defecation .
• Upgrade and rehabilitate existing and/or construct new sanitation and wastewater infrastructure (e.g., latrines, toilets, bathing units, sewage systems, etc.) .All sanitation infrastructure must be accompanied by hand washing facilities with soap and water. When upgrading, rehabilitating or constructing sanitation infrastructure, ensure that facilities are available for females and males, and that they are "disability friendly."
• Support desludging and safe disposal of excreta from existing latrines and toilets (e.g., in public institutions, communities and households).
• Provide hygiene equipment at local level.
• Plan community cleaning campaigns, including emptying of open drainages (particularly in urban areas) to promote and limit risks of vectors and stagnant water.

3. Improve health and hygiene practices

• Use formative research, including Knowledge, Attitudes and Practices (KAP) surveys and qualitative data to identify local risk, beliefs and practices.
• Conduct a behaviour analysis using appropriate guidance on behaviour change.
• Develop a hygiene promotion strategy defining key messages, target audience and communication channels. Participatory methods should be implemented to disseminate the hygiene promotion strategy. Key health and hygiene messages should be tailored to different target groups through a diverse range of communication channels and methods using local languages and visual aids .
• Promote access to hygienic items that support good hygiene practices such as soap, cleaning and disinfection materials.

Relevant to the all the interventions described above:

• Assess and review capacity development plans related to the WASH sector. This should identify training and learning opportunities required for the broad range of stakeholders supporting the WASH sector (e.g., national and local governments, international partners, service providers, communities etc).
• Consider Operation and Maintenance (O&M), proper management and cost recovery when developing plans for the WASH sector. This includes an analysis of financial viability and sustainability using tools (such as perception surveys) for willingness to pay and affordability.

4. Provide access to WASH infrastructure and promote good hygiene behaviours during outbreaks

• Provide temporary WASH infrastructure (e.g., water distribution systems, temporary bladders, water tanks and trucking, distribution of water treatment products, latrines or toilets, hand washing stations, etc.) in quality and quantity, per international standards .This should be accompanied by water quality monitoring and surveillance.
• Conduct mass communication campaigns (focused on key health and hygiene messages) to promote best practices using participatory methods .The messages should be tailored to different target groups, therefore use a diverse range of communication channels and methods and use local languages and visual aids. The key messages can include: the risks associated with the disease, disease transmission, importance of safe water, excreta disposal and handwashing at critical times .The mass communication campaigns should be conducted by trained personnel and community leaders.
• Promote or distribute hygienic items (adapted to the local context) that support good hygiene practices . These items should include soap, cleaning and disinfection materials (as needed). This should be accompanied by demonstrations performed by trained personnel and community leaders to illustrate the proper use of distributed items for households.
• Implement Post Intervention Monitoring (PIM) for all interventions conducted. A monitoring and reporting system should be put into place.

E. Community engagement

The engagement of populations is critical for the prevention of cholera and to ensure quick response to outbreaks when they occur. Communities should be made aware of the best ways to protect themselves and their relatives, and an enabling environment should be put in place to allow those protective behaviours to emerge . Community engagement focuses on empowering communities and their social networks to reflect on and address a range of behaviours, cultural and contextual factors, and decisions that affect their lives and encourage proactive involvement in their development .This can be done through strategies that span across health promotion, social mobilization, risk communication and behaviour change communication. Furthermore, by identifying barriers that impede the uptake of interventions, teams can better tailor activities to the needs of each community . Community engagement should be embedded into all the pillars of the NCP. This section addresses specific activities related to social mobilization and communication. The strategic objective and proposed interventions to be included in the NCP for this pillar are as follows:

Strategic objective:

• To further engage communities in cholera prevention and control to stop community-level transmission.

Proposed interventions to be included in an NCP:

1. Identify at-risk and vulnerable groups and understand the community beliefs and behaviours in cholera hotpots

• Identify community stakeholders and key leaders to begin consulting and engaging as part of the development process.
• Engage with communities through participatory processes, including involving them in the design of preparedness and response activities .
• Develop an understanding of community beliefs and behaviours toward cholera through informant interviews and focus group discussions.
• Ensure that community engagement strategies include the most marginalized, disabled and at-risk people.

2. Engage communities, establish and maintain relationships

• Develop regular check-ins for community engagement focal points and key stakeholders - across all pillars - to avoid silos .
• Develop processes to ensure strong collaborations between CHWs and HCWs .
• Conduct assessments and revise community engagement messages and materials .
• Establish and manage a systematic community feedback mechanism, i.e., collect and analyse the views of communities to regularly adapt strategies and ways of working .

3. Develop and distribute materials communicating goals and objectives

• Identify key community engagement and communication entry points to promote cholera prevention using a variety of communication channels .
• Based on contextual analysis, develop an understanding of priority behaviours and groups at-risk, and foster harmonized approaches to communicate with and involve affected populations.
• Distribute suggested materials for local adoption by all stakeholders, including HCWs, CHWs and community leaders . It is critical that stakeholders use the same messages to avoid confusion and mistrust.
• Engage with the community to ensure that the burials of people who die of suspected cholera adhere to/respect local customs without being a potential source of transmission (safe and dignified burial).
• Ensure that the identification and targeting of cholera-affected populations does not generate stigma or discrimination . Use information and dispel myths and rumours to protect more vulnerable populations from harm.
• Develop suggested media (e.g., radio, TV and social media) and print materials.

4. Strengthen risk communication and community engagement during outbreaks

• Build on existing programmes to understand local knowledge and behaviours toward cholera of communities affected by the outbreak and adapt messages accordingly.
• Involve and engage the community in the outbreak response through community leaders and influencers identified as part of the NCP implementation. Consider setting up local task team(s) composed of community representatives and leaders to interact with response teams.
• Provide real time information to the communities at risk of cholera (based on a risk assessment) . Information should include how to reduce the risk of spreading the disease, how to take personal protective and preventive measures and how to proceed if someone gets sick. It should be easily understood, complete and free of misleading information .
• Communicate in a proactive and transparent manner to the public using a mix of preferred channels of populations affected by the outbreak (e.g., TV, radio, SMS, internet, social media, mass awareness initiatives and social mobilization). An open flow of information will avoid the spread of rumours.

² Logs of signals, weekly or monthly case counts, line-lists of suspected confirmed cases, health care facility and community death, demographic information, etc.

³ Minimum data requirements include collecting information on the number of doses received and delivered, number of doses wasted, target population vaccine registers, and tally sheets for the second round.

⁴ Access to basic plus water is defined as an improved facility within 30 minutes (round trip collection time) and low-cost water treatment to ensure safety.

⁵ Highly turbid water, at source, should not be chlorinated

⁶ HWTS product selection should be based on water source parameters, availability, skill level of users and ease of use, acceptability, O&M and cost.