Role of WASH in Management of cholera / AWD

1. Session 3.4 WASH Cholera / AWD EP&R training Role of WASH in Management of cholera / AWD WASH cholera/AWD EP&R training

2. Learning objectives By the end of the session the participants will be able to • identify criteria for opening, relocating and closing cholera/AWD treatment facilities. • describe water, hygiene and sanitation requirements within cholera/AWD treatment facilities and identify appropriate technology choices and approaches. • list standard chlorine solutions and their uses for disinfection within cholera/AWD treatment facilities WASH cholera/AWD EP&R training

3. Management of Cholera - Reducing Mortality • Interventions to reduce mortality aim at providing early rehydration treatment and the organisation of cholera treatment facilities, their location and staffing are all based on this principle. • Cholera is an emergency – treatment facilities must be set up rapidly. • Flexibility is key as the epidemic progresses – facilities must be rapidly multiplied or relocated as the situation evolves. • Cholera is highly contagious – patients must be isolated and infection control procedures put in place. WASH cholera/AWD EP&R training

4. Cholera Treatment Facilities- Definitions • Cholera Treatment Centres (CTC) and Units (CTU) are inpatient structures where severe cases are isolated and receive specialised care, including IV rehydration. • Oral Rehydration Points (ORP) or ORS Corners are simple structures that provide oral rehydration to moderate cases and refer severely dehydrated patients to CTC/CTU. WASH cholera/AWD EP&R training

5. Locating Cholera Treatment Facilities • The number of cases per location will determine priority areas where treatment facilities will be set up. • CTC are placed at central level while CTU are smaller, decentralised facilities. • ORP are decentralised and widespread to provide early rehydration for moderate cases and identify severe cases for quick referral to CTC/CTU. WASH cholera/AWD EP&R training

6. In rural settings multiple, decentralised CTUs are recommended to increase coverage and access. WASH cholera/AWD EP&R training

7. In urban settings & refugee camps it is preferable to have one single CTC and several ORPs. WASH cholera/AWD EP&R training

8. ORPs can be decentralised to the community level. WASH cholera/AWD EP&R training

9. Estimating the Capacity of Cholera Treatment Facilities Rough ‘standard’ figures are used at the beginning of an epidemic in planning interventions [MSF]: These first estimates are based on high AR and high proportion of severe cases and must then be adapted to each specific situation. WASH cholera/AWD EP&R training

10. Using Existing Building for CTC/CTUs WASH cholera/AWD EP&R training

11. Structures for Cholera Treatment Facilities Source: MSF WASH cholera/AWD EP&R training

12. Structures for Cholera Treatment Facilities Source: MSF WASH cholera/AWD EP&R training

13. Criteria for Site Selection Health Authorities & communities should be actively involved in site selection and the following criteria considered: • Position – look for high ground with good drainage • Distances – other buildings 100m, water sources 40m, markets 100m • Access – vehicle access for materials delivery • Space – consider needs for future expansion, • Floor - concrete preferable, if a temporary structure can use plastic sheeting • Ventilation & Light WASH cholera/AWD EP&R training

14. Design of Cholera Treatment Facilities Organisation & design of treatment facilities are based on two key principles: • Isolation of the entire facility from other public structures such as schools, health services and markets. • Separation of patients (contaminated area) from the ‘neutral area’ (not contaminated). WASH cholera/AWD EP&R training

15. Simplified Design of CT Facilities WASH cholera/AWD EP&R training

16. Group Work In your groups consider the given scenario and design the layout of a CTU of the specified capacity, considering isolation & patient flow. Draw a plan of the layout. Indicate the type of building selected. 15 min WASH cholera/AWD EP&R training

17. Water Supply Principles & Standards Water Quantity • CTC/CTU – 60 litres/patient/day + 15 litres/carer/day • ORP – 10 litres/patient/day Water Storage • Ideally, sufficient for 3 days, but as a minimum 1 day Water Quality (for consumption) • Residual chlorine 0.5 mg/l (pH<8) • Turbidity <5 NTU (up to 20 NTU in initial emergency phase) WASH cholera/AWD EP&R training

18. Calculation exercise in plenary Let’s estimate the water supply & storage requirements for your given scenario. WASH cholera/AWD EP&R training

19. Hygiene Principles • Movement through the facility should be strictly controlled. • Disinfection of shoes/feet and hand washing should take place on all entry and exit points to the facility and between different areas. • Strict disinfection procedures should be followed throughout the facility. WASH cholera/AWD EP&R training

20. Entry to a CTU WASH cholera/AWD EP&R training

21. Chlorine Solutions & Cleaning Equipment WASH cholera/AWD EP&R training

22. Spraying at CTC Entrance Source: MSF and OGB WASH cholera/AWD EP&R training

23. Sprayers & Footbaths • Sprayers or footbaths are compulsory on the entry-and-exit route between the different areas of the CT facility to ensure disinfection of shoe soles & feet. • Footbaths are rather inefficient as they become dirty very quickly • Sprayers or footbaths can also be an important psychological barrier between the facility and outside. • Both use a 0.2% chlorine solution. • Staff should be equipped with boots to avoid the irritation caused by repeated contract with chlorine. WASH cholera/AWD EP&R training

24. A word about spraying of patient’s houses To spray or not to spray? No scientific proof either way + Can be used as an access to further investigate the epidemic e.g. common causes / risks among the households affected / sprayed - Logistically challenging - Can increase stigma WASH cholera/AWD EP&R training

25. Guard and hand washing facility at exit Hand-washing facilities should be available throughout the CT facility, in all patient treatment areas, and at latrines, footbaths, the kitchen, mortuary and waste area. Hand-washing should be done with a 0.05% chlorine solution WASH cholera/AWD EP&R training

26. Bathing WASH cholera/AWD EP&R training

27. Bathing Areas • Patient showers should be big enough for 2 persons – carer & patient • A concrete slab or plastic sheeting floor covering are more functional than a layer of gravel as they are easier to clean & disinfect • Showers should drain to a soakaway within the CT facility. WASH cholera/AWD EP&R training

28. Laundry Areas WASH cholera/AWD EP&R training

29. Laundry • A laundry should be set up to wash all soiled items from the facility, including blankets, gowns and protective clothing. • Where sinks are not available, large plastic tubs can be used. • Laundry should be immersed and disinfected first in a 0.2% chlorine solution for 10 min, then washed as usual and hung to dry. WASH cholera/AWD EP&R training

30. Ideally floors should be made of concrete, or covered in plastic sheeting, for ease of cleaning. Floors in the wards should be mopped with a 0.2% chlorine solution up to 4 times a day. Cholera beds should be sprayed with a 0.2% solution as appropriate and between each occupancy. Latrines should be cleaned several times a day with a 0.2% solution, either mopped or sprayed. Cleaning the CT Facility WASH cholera/AWD EP&R training

31. Chlorine Solutions Standard chlorine solutions used for disinfection within cholera treatment facilities: WASH cholera/AWD EP&R training

32. Protective Clothing • Staff should be provided with protective clothing, including boots and overalls. • Gloves should be available for those in contact with blood, chlorine or chlorine solutions. • Gowns or clothes should be made available to patients on hospitalisation, after bathing. WASH cholera/AWD EP&R training

33. Promotion of Hygiene in the CTC or CTU The organisation of a CT facility is based on a set of actions (disinfection of hands, feet, stools, etc.), that are simple, but often new for patients and carers who just stay for a short time. These new actions need to be assimilated and put into practice quickly by new arrivals. Hence it is recommended to: • Equip the facility in such a way to make actions automatic or compulsory • Inform staff, patients & carers of the reason for, and nature of, the actions • Monitor and make actions compulsory WASH cholera/AWD EP&R training

34. Groups 1 & 3: consider the important hygiene practises which should be promoted to staff, patients & carers regarding activities within the CTU. How could this be done? Group Work Groups 2 & 4: consider the important hygiene practises which should be promoted to patients and carers, just prior to discharge. How could this be done? WASH cholera/AWD EP&R training

35. Sanitation Principles & Standards Excreta Disposal In addition, provide buckets for all cholera beds & some in observation. Contents should be disinfected prior to disposal. Either place 1 cm of 2% solution in the bucket before use and then empty into the toilet or latrine, or construct an excreta disposal facility specifically for the disinfection & emptying of buckets. WASH cholera/AWD EP&R training

36. Excreta Disposal Methods • Excreta Disposal Pit – specifically for the emptying of buckets. First disinfect stools and vomit in a 2% solution for 20-30 minutes in a plastic barrel prior to emptying in the pit. • Temporary Simple Latrines – for staff, carers and patients in the convalescent phase. • Existing Facilities – not ideal but sometimes necessary. Patients’ stool should be disinfected prior to emptying into toilets. Toilets connected to a sewer network should never be used directly by patients. WASH cholera/AWD EP&R training

37. Temporary Latrines WASH cholera/AWD EP&R training

38. Sanitation (cont) Waste Water • All waste water from showers, laundry, kitchen, etc can be considered contaminated and should treated in CTC. • Rainfall run-off may contain some contamination but is considered low risk, so may therefore be collected and, where possible, drain out to an existing drainage system. WASH cholera/AWD EP&R training

39. Sanitation (cont) Vector Control In areas where vector transmitted diseases exist and are of concern, appropriate vector control measures may include: • general hygiene measures (e.g. cleanliness, washing & exposure of bedding to direct sunlight) • prevention of breeding or elimination of breeding sites (e.g. effective excreta disposal, solid waste management, waste water management) • other methods such as indoor residual spraying or flytraps. Note: the use of bed nets is not appropriate in CTC & CTUs WASH cholera/AWD EP&R training

40. Mortuary • In CTCs a mortuary should be constructed near to the waste zone. It should have an entrance from inside the CTC and access from outside to collect the body. • A closed tent can be set up as a temporary mortuary. Whatever structure is used it should enable effective cleaning inside, with drainage channels that flow into a soakaway pit (body fluids are likely to be highly contaminated). • In CTUs, there may not be the possibility to build a mortuary, in which case rapid burial should be promoted. WASH cholera/AWD EP&R training

41. Management of Dead Bodies • The body should be moved to the mortuary as soon as possible as fluids will start to evacuate the body • Disinfection of the body should be done inside the mortuary, with 2% chlorine solution • Where body bags are available, they should be used to transport the body for burial. If not available, the body can be wrapped in a sheet soaked in 2% chlorine • Where many bodies must be stored, quicklime (calcium oxide, CaO) can be used to neutralise liquids and reduce odours. WASH cholera/AWD EP&R training

42. Group Work Locate sanitation, waste management and mortuary facilities on your existing CTU layout. WASH cholera/AWD EP&R training

43. Sanitary Staff • Sanitary staff include supervisor, cleaners, sprayers/watchmen, chlorinator, laundry workers and mortuary workers. • Staffing levels depend on the size of the facility but can be significant – e.g. CTC with 300 patient capacity with 67 sanitary staff on start up and 118 at epidemic peak. [ACF] • Even if there has been cholera preparedness in recent months, training will need to be conducted for all staff. WASH cholera/AWD EP&R training

44. Closing Cholera Treatment Facilities • The key indicator is when the number of patients is small enough that patients can be treated in separate wards within the existing health structures. Managerial factors to consider include: • possibility of integration of remaining cholera patients into a regular health structure, • possibility to isolate patients, • adequate staffing in the health structure. WASH cholera/AWD EP&R training

45. Water, Hygiene & Sanitation in Cholera Treatment Facilities Sources of Information: • National Standards or Guidelines • MSF – Cholera Guidelines, 2004 • ACF – Water, Sanitation & Hygiene for Populations at Risk, 2005 • SPHERE – Humanitarian Charter & Minimum Standards in Disaster Response, 2004 • WHO – Guidelines for Drinking Water Quality, 2004 WASH cholera/AWD EP&R training

46. Learning objectives By the end of the session the participants will be able to • identify criteria for opening, relocating and closing cholera/AWD treatment facilities. • describe water, hygiene and sanitation requirements within cholera/AWD treatment facilities and identify appropriate technology choices and approaches. • list standard chlorine solutions and their uses for disinfection within cholera/AWD treatment facilities WASH cholera/AWD EP&R training