Identifying transferable lessons from cholera epidemic responses by Médecins Sans Frontières in Mozambique, Malawi and the Democratic Republic of Congo, 2015–2018: a scoping review

Abstract

Background Cholera epidemics occur frequently in low-income countries affected by concurrent humanitarian crises. Evaluations of these epidemic response remains largely unpublished and there is a need to generate evidence on response efforts to inform future programmes. This review of MSF cholera epidemic responses aimed to describe the main characteristics of the cholera epidemics and related responses in these three countries, to identify challenges to different intervention strategies based on available data; and to make recommendations for epidemic prevention and control practice and policy. Methods Case studies from the Democratic Republic of Congo, Malawi and Mozambique were purposively selected by MSF for this review due to the documented burden of cholera in each country, frequency of cholera outbreaks, and risk of humanitarian crises. Data were extracted on the characteristics of the epidemics; time between alert and response; and, the delivery of health and water, sanitation and hygiene interventions. A Theory of Change for cholera response programmes was built to assess factors that affected implementation of the responses. Results and conclusions 20 epidemic response reports were identified, 15 in DRC, one in Malawi and four in Mozambique. All contexts experienced concurrent humanitarian crises, either armed conflict or natural disasters. Across the settings, median time between the date of alert and date of the start of the response by MSF was 23 days (IQR 14–41). Almost all responses targeted interventions community-wide, and all responses implemented in-patient treatment of suspected cholera cases in either established health care facilities (HCFs) or temporary cholera treatment units (CTUs). In three responses, interventions were delivered as case-area targeted interventions (CATI) and four responses targeted households of admitted suspected cholera cases. CATI or delivery of interventions to households of admitted suspected cases occurred from 2017 onwards only. Overall, 74 factors affecting implementation were identified including delayed supplies of materials, insufficient quantities of materials and limited or lack of coordination with local government or other agencies. Based on this review, the following recommendations are made to improve cholera prevention and control efforts: explore improved models for epidemic preparedness, including rapid mobilisation of supplies and deployment of trained staff; invest in and strengthen partnerships with national and local government and other agencies; and to standardise reporting templates that allow for rigorous and structured evaluations within and across countries to provide consistent and accessible data.

Implementation considerations in case-area targeted interventions to prevent cholera transmission in Northeast Nigeria: A qualitative analysis

“…In particular, incomplete line lists, high population density, inadequate staffing for case load, and supply stock outs greatly hindered teams’ ability to access case households and appropriately target neighbor households according to the SOPs. Many of these key challenges identified herein align with other research on NGO-led cholera outbreak responses, including need for adequate staffing, supplies, staff training, mechanisms to enable reaching case households, and coordination [ 12 , 13 , 14 ].…”

A Quantitative and Qualitative Program Evaluation of a Case-Area Targeted Intervention to Reduce Cholera in Eastern Democratic Republic of the Congo

“…Household spot checks and CATI recipient and implementer interviews indicated major challenges with the delivery of WASH intervention materials. Most studies of CATIs and other cholera rapid response delivery programs have reported a variety of challenges with the complete delivery of WASH materials, including logistical and financial constraints [30,33,49]. Incomplete delivery of WASH materials has the potential to both decrease the effectiveness of a CATI and to decrease trust between recipients and CATI teams, as has been reported previously [30].…”

Case-area targeted interventions during a large-scale cholera epidemic: A prospective cohort study in Northeast Nigeria

“…Previously published qualitative research from this study and reviews by UNICEF and Médecins Sans Frontières identified implementation challenges that may mediate CATI effectiveness such as high caseloads, incomplete line lists, stockouts, inadequate staffing, insufficient transportation, household refusals, security constraints, and high population density [ 14 , 52 , 53 ]. In Borno, the high population density resulted in cholera incidence that was 3 and 5 times greater than in Adamawa and Yobe, respectively, and translated into more households in a 150 m radius and increased travel time.…”