An effective response to cholera involves engaging on several different fronts at the same time—and as fast as possible—to treat sick patients and to stop transmission within communities. The key pillars of this strategy rely on MSF's medical staff working alongside epidemiologists, water and sanitation experts, logistics managers and community health promoters. If patients receive the care they need, deaths can be reduced from as high as 50% to below 2%. Since an effective oral vaccine became available within the past decade, we have also incorporated large-scale vaccination campaigns into our response.
A big part of MSF’s ability to respond quickly is our standardized, pre-positioned cholera treatment kits that come equipped with rehydration salts, antibiotics, and IVs, along with buckets, boots, chlorine, and plastic sheeting—in short, everything needed to hit the ground running after an outbreak is confirmed.
Once cholera is confirmed, MSF conducts an outbreak investigation, or supports others to do so. This involves mapping where patients are coming from so that responders can prioritize the most affected areas. Throughout the epidemic epidemiologists continue looking into new cases in other areas.
Treatment facilities for patient care
When an outbreak is reported, MSF sets up dedicated cholera treatment centers at central locations. These centers are specialized isolation wards for rapidly treating large numbers of patients while preventing disease spread beyond the facility—patients, caregivers, and medical staff have controlled entrances, exits, and decontamination areas, where they are sprayed with chlorine. In some situations, patients with mild cases are treated at simpler facilities called oral rehydration points, set up within or close to affected communities. This is especially important in settings where sick patients otherwise face a long journey to reach treatment, since cholera can cause death very quickly.
Water and sanitation improvements
MSF water and sanitation staff work to ensure availability of sufficient latrines and adequate supplies of clean water from safe sources, at both the home and communal levels. This typically involves activities ranging from distributing soap, clean buckets, and water disinfection tablets for home use, to providing bucket chlorination at water sources before water is carried home. In response to the Rohingya refugee crisis in Bangladesh, MSF set up water distribution systems in Cox's Bazar, drilled boreholes and tube wells, rehabilitated and constructed latrines, and distributed domestic water filters.
Community health promotion
During outbreaks, health promoters visit schools, churches, markets, and homes to help people implement measures to protect themselves against cholera and know what to do if they develop diarrhea. For example, in 2016 during the cholera outbreak in Democratic Republic of Congo, health promoters visited villages to encourage people to wash their hands, to safely dispose of waste, and to get help as soon as symptoms of cholera begin.
MSF is increasingly using vaccination to help curb cholera outbreaks that are predicted to start soon or have just begun. A big advantage of the cholera vaccine is that it is oral, so it’s very simple to administer—people simply drink it. But globally there is a shortage of vaccines available, so vaccination can't be used nearly as widely as it should be. MSF conducts vaccination campaigns both in response to cholera outbreaks and to prevent future ones. In one recent example, MSF vaccinated nearly 200,000 people as a prevention strategy in Juba, South Sudan, where cholera is endemic.
Our advocacy work focuses on the urgent need to expand global supplies of vaccine and to develop and confirm the effectiveness of simpler strategies for conducting mass vaccination campaigns. We participated in establishing the Global OCV Stockpile, maintained by the World Health Organization and supported by Gavi, the Vaccine Alliance, that helps provide cholera vaccine for emergency use in outbreaks. As vaccine supplies gradually increase, we will continue advocating for more widespread use, including in routine vaccination rather than just to stop outbreaks once they’ve begun.
Finding ways to optimize strategies for using cholera vaccines is an important part of our response. For example, in 2016 we showed that although the vaccine is usually given in two doses that confer 3-5 year protection, one dose still curbs transmission effectively in the short term. MSF used this one-dose strategy in Lusaka, the densely populated capital of Zambia, to vaccinate over half a million people in just two weeks. We are also assessing simpler two-dose vaccination campaign strategies for use when enough vaccine is available, based on recent findings that the cholera vaccine remains effective for at least four weeks without refrigeration. We have also researched more efficient ways to conduct mass vaccination campaigns like using mapping and surveillance techniques to help determine priority areas for immunization.