Cholera outbreaks primarily occur in areas lacking adequate water, sanitation, and hygiene (WASH), and infection can cause severe dehydration and death. As individuals living near cholera cases are more likely to contract cholera, case-area targeted interventions (CATI), where a response team visits case and neighbor households and conducts WASH and/or epidemiological interventions, are increasingly implemented to interrupt cholera transmission. As part of a multi-pronged evaluation on whether CATIs reduce cholera transmission, we compared two organizations’ standard operating procedures (SOPs) with information from key informant interviews with 26 staff at national/headquarters and field levels who implemented CATIs in Nigeria in 2021. While organizations generally adhered to SOPs during implementation, deviations related to accessing case household and neighbor household selection were made due to incomplete line lists, high population density, and insufficient staffing and materials. We recommend reducing the CATI radius, providing more explicit context-specific guidance in SOPs, adopting more measures to ensure sufficient staffing and supplies, improving surveillance and data management, and strengthening risk communication and community engagement. The qualitative results herein will inform future quantitative analysis to provide recommendations for overall CATI implementation in future cholera responses in fragile contexts.

Monitoring water, sanitation, and hygiene programs in cholera outbreaks is critical to improve humanitarian response. The objective of this research was to evaluate, and improve, WASH in cholera monitoring tools currently used in northeast Nigeria. We collected 723 forms from 2019 from three form types, combined them into one database of 980 activities, and stratified data by form type, response, implementing organization, activity, month/day, and geographical area. We conducted seven key informant interviews (KIIs) with monitoring tool users and decision-makers. Data irregularities (including in design, collection, and entry) led to an inability to meaningfully analyze monitoring forms. In KIIs, eight themes emerged: ease of use of current tools, improvement in monitoring over time, lack of access to data, need for training, inconsistent reporting practices, need for modification of current questions, need for the addition of new questions, and connectivity issues. Although informants reported monitoring helped organizations identify gaps during the response, the scarcity and inconsistency of the reported data make it difficult to draw any conclusions about program effectiveness, accountability in humanitarian response, or to make recommendations for improving programming. To improve monitoring, we recommend refining data collection by increasing the quantity of data reported, data consistency, and data relevancy.