Globally, cholera continues to cause morbidity and mortality, and the Global Task Force on Cholera Control (GTFCC) works with countries affected by cholera to develop National Cholera Plans (NCPs). Water, sanitation, and hygiene (WASH) can prevent and/or control cholera. However, WASH program success varies, and is not necessarily replicable across contexts. Thus, guidance needs to be developed to assist countries in appropriately designing WASH programming in NCPs. The objective of this project was to develop guidelines for selecting context-specific WASH for cholera response. For that, a literature review of WASH interventions in cholera was completed, a Working Group was convened to collaboratively develop the guidelines, and we conducted key informant interviews (KII) with Working Group experts, representing international and national non-governmental organizations, donors, international organizations and health authorities. Inductive qualitative content analysis of KIIs was completed. KIIs were conducted with 18 informants, and data was coded into 26 subcategories, categorized under: 1) intervention objectives; 2) decision factors; 3) intervention circumstances; 4) influencing factors; and, 5) WASH activities. Based on these categories, we developed guidelines with the following steps: 1) define the disease objective (control, prevention, or elimination); 2) understand and define the broad context (including existing WASH infrastructure and population habits, available funding, outbreak sources and transmission pathways, stakeholder capacity, and access difficulties); and, 3) focus on monitoring of activities, multi-sectoral coordination (including WASH and health), and targeted approaches, both for implementation and future research. Overall, while building upon previous research and guidance, our results expand to include specific guidance for countries incorporating WASH into their NCPs, and highlight the necessity of a broad contextual understanding to select the most appropriate and successful WASH for cholera programming. These results have been used, with GTFCC, to develop a guidance document for including context-specific WASH in NCPs.
There are two common household disinfection interventions to prevent interhousehold transmission of cholera: household spraying, whereby a team disinfects cholera patients’ households, and household disinfection kits (HDKs), whereby cleaning materials are provided to cholera patients’ family members. Currently, both interventions lack evidence, and international agencies recommend HDK distribution; however, household spraying remains widely implemented. To understand this disconnect, we conducted 14 key informant interviews with international and national responders and a study in Haiti assessing HDK efficacy using two training modules including 20 household surveys and 327 surfaces samples before and after cleaning. During interviews, 80% of the international-level informants discussed evidence gaps for both interventions, and 60% preferred HDKs. Conversely, no national-level informants knew what an HDK was; therefore, they all preferred spraying. Informants discussed behavior changes, bleach perceptions, and implementation as facilitators and/or barriers to implementing both interventions. In households, training with demonstrations regarding the use of HDK led to increased reductions of Escherichia coli (P < 0.001) and Vibrio spp. (P < 0.001) on surfaces after participants cleaned the household compared with a hygiene promotion session only. These results emphasize the gap between the current international-level policy and the realities of cholera response programs, highlight the need for evidence to align household disinfection recommendations, and underscore the importance of the dissemination and training of responders and affected populations regarding methods to prevent intrahousehold cholera transmission.
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