role of wash in management of cholera / awd

WASH cholera/AWD EP&R training

Role of WASH in Management of cholera / AWD

Session 3.4WASH Cholera / AWD EP&R training


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


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.


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.


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.


In rural settings multiple, decentralised CTUs are recommended to increase coverage and access.


In urban settings & refugee camps it is preferable to have one single CTC and

several ORPs.


ORPs can be decentralised to the community level.


Estimating the Capacity of Cholera Treatment Facilities

Rough ‘standard’ figures are used at the beginning of an epidemic in planning interventions [MSF]:

Location Refugee Camp / Slum District Town / Rural Area

Estimated AR 5% 1%

Peak Week 3-4 Week 6-10

No. Cases During Peak 30% 10 -30%

Av. Length of Stay 2 days 3 days

% Severe Cases (of those coming to CTC)

75% 75%

These first estimates are based on high AR and high proportion of severe cases and must then be adapted to each specific situation.


Using Existing Building for CTC/CTUsBuilding Type Advantage Disadvantage

Existing Health Facility

Location is known by patients

Staff available

Concrete floor

Disruption to normal health service function

Isolation from other patients difficult or impossible

Temporary Structure (to construct)

Location is adapted to suit situation

Time to construct

Tents Location is adapted to suit situation – isolation possible

Easy to add extra capacity

Hot

No concrete floor

Hygiene can be difficult to maintain

School Large capacity

Easy to adapt, separate rooms

Education is blocked

Warehouse Large capacity

Easily adaptable & available

Poor ventilation – very hot

No partitions, no light

Private House Small

Close to other buildings

Last choice


Source: MSF

Structures for Cholera Treatment Facilities


Structures for Cholera Treatment Facilities

Source: MSF


Criteria for Site SelectionHealth 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


Design of Cholera Treatment Facilities

Organisation & design of treatment facilities are based on two key principles:

1. Isolation of the entire facility from other public structures such as schools, health services and markets.

2. Separation of patients (contaminated area) from the ‘neutral area’ (not contaminated).


Simplified Design of CT Facilities


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


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)


Calculation exercise in plenary

Let’s estimate the water supply & storage requirements for your given scenario.


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.


Entry to a CTU


Chlorine Solutions & Cleaning Equipment


Spraying at CTC Entrance

Source: MSF and OGB


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.


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


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


Bathing


Bathing Areas

Use Ratio Minimum

Patients / Carers 1:50 2 showers (m/f) in each area

(observation, wards, recovery)

Staff: Neutral Area - 2 showers (m/f)

• 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.


Laundry Areas


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.


Cleaning the CT Facility

• 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.


Chlorine SolutionsStandard chlorine solutions used for disinfection within cholera treatment facilities:

Solution Utilisation Storage Period

0.05% Disinfection of skin, mainly hand-washing One day

0.2% Disinfection of floors, walls, beds, stretchers, clothes, eating utensils, and vehicles (spray)

Spraying latrines

Foot sprayers & footbaths

One day

1.0% Mother/Stock Solution

For potable water treatment

One week

2.0% Disinfection of patient’s stools and vomit

Dead bodies

One week


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.


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:

1. Equip the facility in such a way to make actions automatic or compulsory

2. Inform staff, patients & carers of the reason for, and nature of, the actions

3. Monitor and make actions compulsory


Group WorkGroups 2 & 4: consider the

important hygiene practises which

should be promoted to patients and

carers, just prior to discharge. How

could this be done?

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?


Sanitation Principles & Standards

Excreta Disposal

Area Ratio Minimum

Patients: Observation, screening, recovery

1:20 2 toilets (m/f)

Patients: Wards 1:50 2 toilets (m/f)

Staff: Neutral Area - 2 toilets (m/f)

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.


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.


Temporary Latrines


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.


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


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.


• 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.

Management of Dead Bodies


Group Work

Locate sanitation, waste management and mortuary facilities on your existing

CTU layout.


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.


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.


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


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

role of wash in management of cholera / awd

Documents

emergency treatment

early rehydration treatment

moderate cases

epidemic progresses

single ctc

decentralised ctus

oral rehydration points

rural settings multiple