Cholera Treatment Facilities and IPC

Ethiopian Public Health Institute

Public Health Emergency Management
Bacterial Diseases Surveillance and
Response

April 10/ 2023

Jima, Oromia, Ethiopia
2

Ethiopian Public Health Institute

CHOLERA
TREATMENT
FACILITIES
AND IPC
MEASURES
Ethiopian Public Health Institute 3
Chapter Outlines

• Overview of Cholera treatment facilities

• Location of Cholera treatment facilities
• Organization and Design of CTC/CTU’s
• IPC measures at a CTU/CTC

Cholera Outbreak surveillance and response Training 4

Enabling Objectives
• By the end of this chapter, the participants will be able to:
• Identify the available cholera treatment facilities and their Roles
• Describe the criteria’s for selecting proper location of Cholera
Treatment Facilities
• Explain the various functions of Cholera Treatment Facilities
• Describe the organization and design of Cholera treatment centers

Cholera Outbreak surveillance and response Training 5

Cont…
• Construct different treatment facilities in response to cholera
outbreak
• Implement proper infection prevention and control measures to
control further spread of the disease
• Describe the various Infection Prevention Control measures to
control further infection and spread

Cholera Outbreak surveillance and response Training 6

Cholera Treatment Facilities & IPC
Activity 5.1 . Self-reflection Time: 5 minutes

Instruction: Think for 2 minute and reflect your ideas for 3

minutes

Question: Based on your experience, where did you treat

cholera cases?

Cholera Outbreak surveillance and response Training 7

Overview of Cholera Treatment Facilities

• Rapid access to rehydration therapy is the primary treatment for the full clinical
spectrum of patients with cholera.

• During outbreaks of cholera, identification of cholera treatment facilities is a

major problem especially in resource-limited areas. The purpose of these
facilities is to have strict infection control, to ensure close follow-up of the cases
and to minimize cross contamination.

Cholera Outbreak surveillance and response Training 8

Cont…
• Based on the varying degrees of Dehydration, patients can be managed in
different levels of care starting from the household level, in the community by
setting up several oral rehydration points(ORPs) up to the highest level of care
in Cholera treatment centers(CTCs/CTUs).

Cholera Outbreak surveillance and response Training 9

Oral Rehydration Points(ORPs)

• Oral rehydration points (ORPs) provide first line, community-level rehydration and
at the very lowest level of health care delivery such as health centers and posts and
must be decentralized and widespread for the rapid management of cases.

• The main objectives of decentralization of ORPs are:-

• To treat patients promptly

• To screen severely dehydrated patients for referral to CTC

• They reduce pressure on overburdened CTCs

• At least one CTC with several ORPs is required

Cholera Outbreak surveillance and response Training 10

Cholera Treatment Center/Unit
• Cholera treatment centers(CTCs) and smaller cholera treatment units(CTUs) are
in-patient health-care structures set up during outbreaks to isolate and treat
patients. It operates 24 hours a day and provide oral and IV rehydration.

• The purpose of CTC is;-

• to have strict infection control,
• to ensure close follow-up of the cases,
• to minimize cross contamination.

Cholera Outbreak surveillance and response Training 11

Cont…
• A CTC can be located and established inside the existing hospital or health
centers as separate structures using tents or other materials and must be
clearly separated and isolated from other departments.

• In rural settings when affected areas are too far from the CTC, access can
become a problem. Ambulances can be provided for referral, or consider the
establishment of other CTC close to the affected area.

Cholera Outbreak surveillance and response Training 12

Activity
Activity 5.2 . Self-reflection Time: 5 minutes

Instruction: Think for 2 minute and reflect your ideas for 3

minutes

Question: Have you ever been involved in site selection of

cholera treatment facilities? If Yes, what factors did
you consider?

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Organization and Location of CTC/CTUs

• The organization of CTC, their location, and staffing are based on principles that help
to reduce mortality rate. Treatments of cholera can be decentralized to the community
level where ORS is provided to the patient by community health worker or health
extension workers through establishing ORPs.

• Traditionally, CTUs have a smaller capacity and are attached to existing health facilities,
and CTCs are independent structures with larger capacity. However, there is no strict
definition of a CTU or CTC, and the names are sometimes used interchangeably.

Cholera Outbreak surveillance and response Training 14

Cont…
• CTUs/CTCs can be established in isolated wards in hospitals or health centres, in
a tent on the grounds of a health centre or in special units in community
buildings.

• If in health facilities, it must be clearly separated and isolated from the other
departments, to avoid contamination of non-cholera patients.

• During large epidemics, tent-based structures designed to accommodate large

numbers of cholera patients may be easier to manage than other options.

Cholera Outbreak surveillance and response Training 15

Cont…

• In rural settings when affected areas are too far from the CTC, access can become a
problem. Ambulances can be provided for referral, or consider the establishment of
other CTC close to the affected area.

• Factors to be considered in site selection:

 Areas with high incidence rates, large number of patients, high CFR
or many deaths reported in the community;
 Areas with poor access to health care for geographic, economic or
social reasons.

Cholera Outbreak surveillance and response Training 16

List of criteria's in selecting a site
Facility Character List of criteria

Position  Avoid low ground or depressions.

 High ground with good drainage is the best option.
 Consult local leaders about the most appropriate spot

Distance  To market = 100 m

 To water source = 40m on sandy soil, 15m if clay
 To other buildings and especially dwellings = 100m

Floor and Walls  Concrete floor, or, if temporary structure, a plastic sheeting cover to facilitate
cleaning
Ventilation  Well Ventilated

Access  Trucks are needed for water, food, etc. ,therefore a good road is important

Cholera Outbreak surveillance and response Training 17

Cont…

Space and Surface  The space should be adequate for future expansion if required
 Ward capacity = 2.5 m2 per patient + 1 attendant
 A 29m2 tent can accommodate 10 patients + attendants
 A 82m2 tent can accommodate 30 patients + attendants

Light  Hospitalization wards need good light (placing an IV line with a flashlight is
not easy!)
 All available light sources are needed: kerosene lamps, solar lamps, generator,
etc and ensure regular supplies of kerosene, fuel, etc.
 For a CTC a generator is advised as a backup, even if there is local electricity.

Cholera Outbreak surveillance and response Training 18

Activity
Activity 5.3. Self-reflection Time: 5 minutes

Instruction: Think for 2 minute and reflect your ideas for 3

minutes

Question: From your experience(if you were involved in the

construction of one), how did you organize cholera
treatment facilities?

Cholera Outbreak surveillance and response Training 19

Organization and Design of CTC/CTU’s

• There are principles and general requirements for a standard CTC that we
need to implement in all CTCs. These include:
• Good design of CTC hygiene, sanitation and isolation

• Adequate staff and appropriate job description

• Safe and Adequate Water Supply

• Waste and environmental management

• Health education

Cholera Outbreak surveillance and response Training 20

Cont…
• The organization of CTUs/CTCs should facilitate caring for patients with cholera while
minimizing the risk of becoming a source of infection.
 The different areas of the structure (such as patient treatment

areas and areas for staff only) must be clearly delineated.

 Patient flow is one-directional and follows strict rules.

 Only one caregiver should be present with each patient.

 There are clear entry and exit points.

 Separate latrines and baths/showers for patient use only. If

possible, staff should have separate facilities.

Cholera Outbreak surveillance and response Training 21

Cont…
 Patient care areas should be gender segregated whenever possible.

 Special considerations should be made for vulnerable groups, such

as persons with disabilities, elderly people and pregnant women,
when constructing latrines and showers/bathing units.

Cholera Outbreak surveillance and response Training 22

Design & Layout of a CTU/CTC
• Organize the CTUs/CTCs into the following areas:

• Entrance and exit (screening of patients and hand washing area)

• Observation area for patients with no or some dehydration (plan A

and B)
• Hospitalization area for patients with severe dehydration (plan C)

• Staff area for supplies, offices, etc.

• Recovery area for patients with no remaining signs of dehydration

• Waste area (laundry, waste pits, etc.)

• Morgue

Cholera Outbreak surveillance and response Training 23

Cholera Outbreak surveillance and response Training 24
Cont…
• Foot Bath
• Feet, shoes, and boots need to be systematically disinfected in the compulsory foot
bath. At the first two entrances (staff entry and patient entry) as well as at the exit.
• Put a wide tray or other material at the gates and place a piece of blanket or sponge
(same size as the tray) soaked with 0.2% chlorine solution. Every person entering or
exiting the CTC should soak his feet in the foot bath.

• Latrine
• The latrine should be located 15-30m away from any groundwater source and 5 to 10m
from tents and the latrine pit should be as deep as possible.

Cholera Outbreak surveillance and response Training 25

Cont…
• Latrines should also be away from any channels where water flows during heavy
rains. Floor areas of the latrines should be cleanable.

• Bathing or Shower unit

• Two bath (shower) rooms are required per CTC (one for females and the other for
males). The room should be big enough for two persons (patient and caregiver).

• The floor should be washable and on a slight slope falling in a direction towards a
pit filled with stones to take the wastewater.(as the water might be contaminated)

Cholera Outbreak surveillance and response Training 26

Cont…
• Washing area or Laundry
• An isolated and safe area with good drainage is required in the compound of
CTC for washing equipment and laundry.
• Materials should be immersed and disinfected first in 0.2% chlorine solution for
10 minutes, then washed as usual and hung to dry.
• Waste management
• Solid waste must be properly disposed to prevent the transmission of cholera
and other diseases related to medical waste (e.g. hepatitis B tetanus, HIV).
• Waste can be divided for segregation and disposal purposes into 3 categories: Soft
items(cottons, gauze), Organic(food residues, human tissues) & sharp objects.

Cholera Outbreak surveillance and response Training 27

Cont…
• Morgue
• The morgue should be located in the CTC compound. A closed tent (plastic,
material) should be used for corpses to prevent access to the body.
• The mortuary structure should enable effective cleaning inside, with drainage canals
that flow into a soak-away pit (body fluids are likely to be highly contaminated). It
should have an entrance from inside the CTC and a separate exit to allow collection
of the body.
• If a CTC does not have the possibility to build a morgue, rapid burial should be
promoted.

Cholera Outbreak surveillance and response Training 28

Cont…
• Safe and adequate water supply
• The adequate amount of water, at least for three days, should be stored in CTC;

• Water for consumption (for drinking and for ORS) should be chlorinated by using
chlorine products;
• Make sure 60 liter/person /day water stock is prepared.
• Fence
• A fence must surround a CTC with a guard at the entrance / exit. It serves as a physical
barrier and restricts everyone from entering the CTC.

Cholera Outbreak surveillance and response Training 29

Staff and supplies at CTUs/CTCs
• Staffing of CTC
• At CTC level at least six health workers and four support staff should be assigned.
• Senior nurse or medical doctor to serve as head

• Four nurses run the CTC (2 per 12 hours), but might depend on the number of
patients
• IPC personnel( preferable Environmental Health professional or IPC trained
professional)
• 1 cleaner / sprayer per shift– who deals with all of the cleaning and disinfecting
of people’s clothes, disposal of waste etc.

Cholera Outbreak surveillance and response Training 30

Cont…

• 1 guard per shift – to make sure that people follow the hand and foot washing
procedures and that the isolation rules are followed.
• 1 Medical Helper per shift that assists the nurse and prepares ORS (if possible).

• Sufficient supplies must be provided at every healthcare facility and ORP that might
have to treat cases of cholera. Supplies should not be limited to IV fluids; most
patients can be treated with ORS alone.

Cholera Outbreak surveillance and response Training 31

Cont…
• Adequate provision of WaSH supplies, including chlorine, residual chlorine testers,
cleaning materials, buckets for chlorine solution preparation, protective gear, hand
washing stations, waste bins and trolleys/wheelbarrows, body bags, etc. should be
organized.

• Stock management is a key part of running CTUs/CTCs and ORPs. The rate of use of
supplies can vary greatly during the course of an epidemic.

• A minimum supply to cover 3 days or longer should be kept on site, depending on

reliability and regularity of supply delivery. There should be dedicated staff to manage
supplies, if possible.

Cholera Outbreak surveillance and response Training 32

Activity
Activity 5.3- Case study
Objective: To able the participants in selecting, organizing, designing
and constructing Treatment centers or units.

Instruction:
• Be in a group of 4-6 people
• Select lead and rapporteur
• Read and analyze the scenario and discuss the questions
• Summarize discussion points in the flip chart and present
them to the plenary

Time: 15 min (5 minutes for discussion and 10 min for

reporting)

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Scenario: A family of 4 presented to your health post with history
of profuse diarrhea and vomiting of 2 days duration. When you
assessed the dehydration level, two of them had severe
dehydration the rest had no dehydration. The neighboring woreda
had reported a cholera outbreak. You wanted to refer the cases to
next level of care as the health post was not adequate for the
treatment of cholera cases.
Discussion question:
1. For this scenario which treatment facility is appropriate?
2. Organize and select proper location to treatment centers?
3. Organize and design treatment centers?

Cholera Outbreak surveillance and response Training 34

IPC measures at a CTU/CTC

• Infection Prevention and Control (IPC) refers to scientifically sound practices aimed at
preventing harm caused by infection to patients, health workers and the community. It
is a systematic effort or process of placing barriers between a susceptible host (person
lacking effective natural or acquired protection) and infectious agents.

• It is very important that basic hygiene, sanitation and isolation procedures are followed
at all times in health facilities where patients with cholera are being treated.

Cholera Outbreak surveillance and response Training 35

Cont…
• Essential principles that all health facilities and CTCs must follow:
• Isolation: Isolate cholera cases from other cases and in CTC severe cases from
non- severe cases.
• Hand Hygiene: Avoids the transmission of Vibrio cholerae and other
pathogenic micro-organisms in the CTC. There are critical times to wash hands
for health workers and patients while providing treatment for cholera patients.

Cholera Outbreak surveillance and response Training 36

Staff
On entering the CTC On leaving the CTC
And before: And after:
• An aseptic procedure (e.g. inserting • Contact with stool, vomit, blood or other
a catheter, intra-osseous needle). body fluids.
• Preparing ORS solution or food. • Visiting/using the toilet.
• Feeding a patient. • Preparing a corpse.
• Giving a patient ORS to drink. • Handling soiled laundry, waste or
• Eating emptying excreta buckets, etc.

Patients/Attendants
On entering the CTC On leaving the CTC
• And before: And after:
• Feeding a patient. • Contact with stools, vomit.
• Giving ORS to drink. • Visiting/using the toilet.
• Eating
• Preparing food for a patient, Breast • Handling soiled laundry.
feeding a child

Cholera Outbreak surveillance and response Training 37

Cont…

• Hand washing facilities with soap and safe water should be available and

maintained in the CTU/CTC for health professionals and patients’ caregivers in

each ward and at the entrance and exit.

• Soapy water should be used in hand-washing stations for bare hands and skin. If

soap is not available, use alcohol-based hand rubs (ABHR). If soap and ABHR are

not available, use 0.05% chlorine solution.

Cholera Outbreak surveillance and response Training 38

Personal Protective Equipment
• Use glove, apron, medical mask, boots and gown while providing care for all

cholera patients. Utility or Heavy-Duty Household Gloves should be worn when

processing instruments, equipment and other items, for handling and disposing
contaminated waste, and when cleaning contaminated surfaces.

• Donning PPE upon room entry and discarding before exiting the patient room.

• Caretakers who are providing care (e.g., feeding, holding) should use PPE correctly,
wear gloves whenever touching the patient’s intact skin or surfaces and articles in
close proximity to the patient (e.g., medical equipment, bed rails).
Cholera Outbreak surveillance and response Training 39
Infection Prevention and Control critical points in CTC

• At the Entry/Exit Point

• A footbath or preferably a guard with sprayer will be employed for spraying and
disinfecting feet. The spraying or footbath also has the objective to make staff and
visitors aware of the contamination they are potentially bringing into the different
areas.
• If footbaths are installed, they should be trays with cloth or sponge soaked in 0.2 %
chlorine solution and changed twice per day or when the cloth appears dirty. Plastic
sprayers adapted to resist strong concentrations of chlorine should be used

Cholera Outbreak surveillance and response Training 40

Cont…
• At Admission
• Patients and caregivers should enter through the patient entrance area where their
feet and shoes will be disinfected with a 0.2 % chlorine solution by a sprayer
preferably, or footbath.
• All people entering or leaving will need to wash their hands with a 0.05% chlorine
solution.
• Disinfect the patient’s transportation: 0.05% solution for stretchers and beds or
0.2% for vehicles. Patient and Caretaker clothes should be washed in a 0.05%
solution for 30 minutes, then rinsed with clean water and dried on the sun.
• Restrict and control movements into and within the wards as much as possible.
Restrict admission and care to one caretaker per patient.
Cholera Outbreak surveillance and response Training 41
Cont…
• During Hospitalization
• Wash hands with soap or 0.05% chlorine solution before and after examining each
patient. Gloves should also be made available for those touching blood, chlorine and
chlorinated solutions.
• Disinfect the shelters, beds, and floor at least twice daily and also showers and latrines
with the 0.2% solution.
• Buckets should be placed under the hole in the CTC beds and at the bedside for vomit.
The bucket can be raised on a block to prevent splashing of the surrounding area. A 2%
chlorine solution should be put into the bucket before placement. Do not allow people
to spit and vomit on the ground/floor.

Cholera Outbreak surveillance and response Training 42

Cont…

• Dispose stools of patients collected in buckets with 1cm of 2% chlorine solution in

latrines.

• At Discharge
• Ensure the person has basic knowledge on cholera and is aware of hygiene
measures to protect his/her family. (discharged patients might still be able to
transmit cholera for a small number of days if basic hygiene is not respected)
• Provide the person with soap and chlorine (discharge kit).

Cholera Outbreak surveillance and response Training 43

Preparation of Disinfectant at CTC
Activity 5.4 . Self-reflection Time: 5 minutes

Instruction: Think for 2 minute and reflect your ideas for 3

minutes

Question: From your experience, how did you prepare and

use disinfectants at CTC?

Cholera Outbreak surveillance and response Training 44

Cont…
• In addition to the isolation and treating patients with cholera, cross contamination at
the treatment center is prevented by using a proper concentration of chlorine
disinfectant during cleaning. The concentrations of disinfectant vary according to the
object to be disinfected.

• The WHO and CDC recommend cleaning objects, floors, surfaces, laundry with
detergent and water before applying chlorine solution. This helps prevent the
inactivation of chlorine. The solution also must be changed daily.

Cholera Outbreak surveillance and response Training 45

Available chlorine concentration and their use
.

0.05% solution 0.2% solution 2% solution

1% solution
-Hand washing -Floors, surfaces, -Preparation of
materials, corpses -Mother solution
-Disinfection of
for chlorinating
laundry aprons, boots, -Excreta and water
(after cleaning) dishes vomit buckets
(after cleaning)

Cholera Outbreak surveillance and response Training 46

Disinfecting Transport and the Houses of the Infected People

• When people are transported to a health facility they may leave traces of
cholera in the vehicle which may infect others. This needs to be disinfected to
prevent cross-contamination.
• Disinfect immediately the vehicle in which the patient was transported in
such as Ambulance, Taxi, materials like bed, stretcher etc. on arrival and
before it leaves again. Use a 0.25 % chlorine solution for the vehicle.

Cholera Outbreak surveillance and response Training 47

Cont…
• Go immediately to the house of each patient instead of waiting until the
patient is discharged. Use a 0.2% chlorine solution to do house spraying.

• The visit of the affected household is a good opportunity to give extra

hygiene promotion to the family members and the neighbors. At the
same time, household visits are a way of active case detection, as you
can detect new cases in the neighborhood.

Cholera Outbreak surveillance and response Training 48

Activity
Activity 5.5 . Self-reflection Time: 5 minutes

Instruction: Think for 2 minute and reflect your

ideas for 3 minutes
Question: What are the steps that need to be
followed to ensure dignified burial?(if possible
from your experience)

Cholera Outbreak surveillance and response Training 49

Safe and Dignified Burial

• In the community, the burial process is very sensitive for the family and the community
and can be the source of trouble or even open conflict. Before starting any procedure
the family must be fully informed about the dignified burial process and their religious
and personal rights must be respected.

• Ensure that the formal agreement of the family has been given before starting the
burial. No burial should begin until family agreement has been obtained

Cholera Outbreak surveillance and response Training 50

Cont…
• Funerals can contribute to the geographical spread of cholera, as people who
attend the ceremony may be infected and take the disease back to their
communities.
• A team (sprayer, dead body manger, supervisor and a person who discuss
with family) should be sent to the deceased house and discuss the burial
process.
• The funeral discussion should involve Edir, religious leaders and the family
representatives that can help to maintain safe dignified burial.
• The team should greet the family and offer condolences before starting any
work. Burial should take place as quickly as possible (preferably within 24
hours after death)
Cholera Outbreak surveillance and response Training 51
Cont…
• The body should be wrapped in a plastic sheet/bag before transporting the body. If not
available, a cloth soaked in 2% chlorine can be used. All body openings (mouth,
nostrils, ears, and anus) must be plugged with cotton dipped in a 2% chlorine solution
and sprayed with a 2% chlorine solution.

• If the death is in CTC, keep the body separate from the patients. The body must be
taken to the morgue immediately after death. The above procedures must be done
without delay as contagious fluids will start to evacuate from the body. However, family
consent must be well respected.

Cholera Outbreak surveillance and response Training 52

Activity 5.7 Think-pair-share Time: 10 minutes
Instruction: Read the scenario then think and pair to discuss the
following questions with your neighboring trainee for 5
minutes and share your ideas within 5 minutes.
Scenario: Imagine a 55 year old patient who was being treated
at your CTC died due to complications. You wanted to
prepare the body for safe burial.
Question:
1. Which disinfectant solution will you use and how will you
prepare it?
2. What steps will you follow to ensure safe and dignified
burial?

Cholera Outbreak surveillance and response Training 53

Cholera Outbreak surveillance and response Training 55