Annex 6E – Suggested logical framework for cholera preparedness and response
Goal: To reduce the spread and limit mortality from cholera through an integrated approach
CO-ORDINATION, INSTITUTIONAL FRAMEWORK, INFORMATION MANAGEMENT
Objective: To improve leadership and coordination of cholera preparedness and response, ensuring a cholera risk reduction focus and including all related
sectors, levels and stakeholders/partners.
Expected result: Effective coordination mechanisms are established and provide guidance for all sectors and stakeholders/partners on common approaches
and standards for cholera preparedness and response, ensure all gaps and vulnerabilities are covered without duplication.
Outcome
Multi-sectoral coordination
framework for cholera
preparedness and
response (including
taskforce and technical
working groups, subnational coordination
structures) is established
and functional
Suggested indicators
Suggested activities
-
-
-
-
1
Terms of reference for the cholera taskforce with
defined coordination arrangements and
structures including technical (sub) working
groups and sub-national coordination platforms
with clear functions, roles and responsibilities
# and % of meetings 1held by the multi-sectoral
national taskforce per identified time period (daily
or weekly during an outbreak, quarterly interoutbreak periods)
# and % of meetings held by the sub-national
taskforces (daily or weekly during an outbreak,
quarterly inter-outbreak periods)
# and % of cross border coordination meetings
held (daily or weekly during an outbreak,
quarterly inter-outbreak periods)
Who does what where matrix document
-
-
Reference
(in the
toolkit)
Establish a cholera taskforce (or similar overall coordination mechanism)
at national level, integrating all related sectors and stakeholders.
Support coordination functions and regular meetings (to analyse
epidemiologic data, conduct risk assessments, preparedness and
response planning, reporting, information management, definition of
technical standards, resource gap analysis and mobilization, etc.).
Identify and define technical (sub) working groups (i.e. surveillance, case Chapter 5
management, WASH, community mobilization) as necessary for
Annex 5A
coordinating cholera preparedness and response activities.
Identify and define coordination structures and leads at sub-national level,
and promote their engagement into national activities.
Set up cross-border coordination mechanisms among Ministries of Health
and/or responsible authorities/stakeholders at local level.
Develop a who does what where and when (4W) document and keep it
updated on a regular basis.
The denominator will depend on the time frame, if it is weekly, daily and over time in X # of months.
UNICEF Cholera Toolkit v. 1.0 - Annexes
Outcome
Preparedness and
response plans are
developed with all key
sectors and stakeholders
Suggested indicators
Suggested activities
-
Preparedness plan document
Response plan document
Preparedness and response checklist filled out
by key responsible
# and % of at risk districts/provinces have a
cholera preparedness and response plan
# of simulation exercises conducted on
preparedness and response plans
-
# and % of health facilities or outreach staff that
have technical standards and guidance available
# and % or partners involved in cholera control
have technical standards and guidance and are
using them for control measures
-
-
Cholera related sectors
and actors receive
technical support and
guidance from the cholera
taskforce/technical (sub)
working groups
-
-
-
Cholera risk and capacity
assessment identifies
areas and communities at
risk and capacity to
prevent, prepare and
respond to an outbreak
Cholera related needs are
identified based on a gap
analysis and actions are
defined to address the
gaps
-
-
Risk and capacity assessment document for
preparedness
Risk and capacity assessment during response
Needs and gap assessment document
(preparedness and response)
Capacity and resource map document with
actions against it to fill gaps
Chapter 6 – Cholera preparedness
-
-
Reference
(in the
toolkit)
Conduct a national workshop with all key sectors and stakeholders to
review the epidemiologic situation and risk assessment and produce a
Chapter 6
preparedness and response plan with wide input
Produce a preparedness plan with all key sectors and levels of service
Annex 6A and
delivery
6D
Produce a response plan with all key sectors and levels of service delivery
Conduct a national and sub-national simulation exercise to test plans
Define and agree technical standards, standard operational procedures,
and other technical guidance in all related sectors and levels
Distribute key technical guidance, standards and tools to all partners and
direct service providers including community health workers
Chapter 6
Annex 6B
Conduct a multi-sectoral risk and capacity assessment (preparedness and
response)
Identify areas for interventions for case management, WASH, enhanced
Chapter 6
surveillance and early warning and communications (preparedness and
response)
Annex 6C
Identify capacities gaps and what is required to be strengthened for
cholera preparedness and response
Conduct a needs and gap analysis with all key stakeholders to identify
gaps in resources such as supplies, human resources, training and
funding (preparedness and response)
Based on needs and gap assessment identify a plan and responsible
parties to fill gaps (preparedness and response)
Chapter 6
Annex 6F and
6G
Outcome
Suggested indicators
-
Information on cholera
preparedness and
response activities is
collected and analysed in
a timely manner. Sector
and partners receive it for
guiding their
implementation.
-
Communication plan document outlining the
communication system and information
management tools for operational response (all
sectors) for preparedness and response
# of cross border communication systems are
established (where relevant)
# and % of partners reporting to the cholera
taskforce using pre-defined information
management tools during response
# and % of information bulletins published for
partners and key stakeholders for cholera related
activities (will vary if during preparedness and
response)
Reference
(in the
toolkit)
Suggested activities
- Define and implement information management tools/systems for cholera
prevention and response (including epidemiological data, information on
reported cases, information on CTC/CTU, information on community
focused interventions)
- Develop cross border communication channels where relevant
- Train relevant staff on communications and information management
- Analyse information from partners to identify needs and gaps in cholera
response
- Produce regular information bulletins outlining cholera preparedness and
response activities
Chapter 6
UNICEF Cholera Toolkit v. 1.0 - Annexes
SURVEILLANCE AND EARLY WARNING AND MONITORING DISEASE TRENDS
Objective: To improve early detection and consistent monitoring of disease trends
Expected result: Cholera is detected early and monitored on a routine basis to inform action and adjust programs accordingly
Outcome
Suggested indicators
Suggested activities
-
Early warning, alert and
response network
(EWARN) is set up in
affected areas and those
at high risk including
across borders
-
# and % of alerts verified in the first 24 hours
# and % of verified alerts responded to by
partners within 48 hours
-
-
Case-based surveillance
for cholera is in place and
functioning in affected
areas and those at high
risk for cholera
-
# and % health facilities meeting reporting
deadlines (target 85%)
# and % laboratories with no stock out of
reagents
# and % of weekly (daily) epidemiologic
analyses completed
# and % monthly summary reports
-
-
Chapter 6 – Cholera preparedness
Reference
(in the
toolkit)
Set up and EWARN system using standard case definition with direct
linkages to response from the health and WASH sectors (daily or
weekly), including verification of rumours
Train health staff and rapid response teams at all levels including the
community on EWARN system
Provide supplies and resources to manage the EWARN system
Implement rapid field investigation and response to reported cases or
alerts
Chapter 3
Annexes 3A,
3D, 3E
Set up or strengthen a case-based surveillance system in all health
facilities, CTC/CTU and communities in affected areas or at risk areas
and provide standard case definition
Train health staff to use a uniform case definition for reporting of all
suspected cases, and how to register using a line-listing that meets the
case definition
Collect stool specimens from 10-20 suspected cases for laboratory
confirmation at the beginning of the outbreak, periodically throughout
and to determine the end
Where needed improve laboratory capacity through training, provision
of laboratory supplies and periodic quality checks
Map all cases to identify areas where cases are concentrated to better
target areas for cholera control activities
Analysis of and publication of a weekly (daily) surveillance data
Analysis and publication of monthly summary reports
Analyse data to identify and understand transmission routes and
epidemiological trends
Chapter 3
Annex 3C, 3F,
3G, 3H and 3I
REDUCING / CONTAINING CHOLERA TRANSMISSION / SPREAD
Objective: To prevent and control transmission of cholera among affected and at risk populations.
Expected result: Transmission of cholera is eliminated/contained
Reference
(in the
toolkit)
Suggested indicators2
Suggested activities
People access and use
safe water supply for all
purposes but specially for
drinking and cooking
- % of people accessing and using safe water (from
chlorinated sources/by using household water
treatment methods) for drinking and other
purposes.
- % of samples from water sources reporting more
than 0.5 mg/l of FRC
- % of people treating water for drinking at
household level and having a FRC of 0.2 mg/l.
- % of people recognising/indicating household
water treatment and storage practices in
FGD/household interviews and observation.
- [Especially in high risk area and when there is indication of contamination
of the water source] repair/ improve water points and undertake
shock/emergency chlorination before they reinitiate their operation.
- Undertake bucket chlorination in centralised water points (boreholes, wells,
hand pumps).
- [In areas where water supply systems are not available] Provide safe
drinking water through water trucking, centralised treatment and
distribution, etc. Train water vendors in safe water production and handling
and in certain contexts in point of use/ household water treatment and [as
appropriate] provide the required supplies for undertaking it.
- Distribute supplies for household water treatment [including water
containers, as per necessary].
- Monitor water quality at water distribution points and household level; and
undertake follow up actions when problems are reported.
Households, communities,
institutions and food
outlets practice safe food
hygiene and follow
national food safety
standards (when existent)
- % of inspections on institutions/outlets reporting
good hygiene conditions
- % of people recognising/indicating safe food
hygiene practices in FGD/household interviews.
- Train food providers on environmental health and food safety.
- Communicate and undertake community mobilization to promote safe food
practices among households.
- Conduct regular inspections on institutions and food outlets to monitor
Infants are given safe
fluids and food
- % of children under 6 months being exclusively
breastfed
- % of mothers using safe water in food production
when they introduce solid food to infants
-Provide health and hygiene education messages into all interventions at the
community and facility level on how to ensure safe infant and young child feeding
Outcome
Chapter 9
Chapter 9
Chapter 7
and 9
2
The table presents suggested indicators for monitoring the accomplishment of the indicated outcomes. The list of activities aims to be as comprehensive as possible and should be selected
depending on the specific context in which they are applied.
UNICEF Cholera Toolkit v. 1.0 - Annexes
Suggested indicators2
Outcome
Risk of cholera
transmission through
excreta (faeces and vomit)
is reduced because they
are properly disposed
People wash their hands
with water and soap (or
ash) at critical times
Environmental hygiene is
adhered to in markets and
other public places
3
Suggested activities
Reference
(in the
toolkit)
- Undertake communication and community mobilization activities focused
on behaviour/social-norms change, towards stop open defecation.
- [When community facilities exist] support operation, maintenance and final
disposal of excreta
- [When other options are limited and the practice already exists] promote
the use of flying toilets as a temporary measure, with special attention on
effective collection, safe transport and disposal.
- Communicate/train on appropriate procedures for disinfecting areas and
materials soiled with faeces and vomit.
- Distribute disinfectant (and sometimes tools for disinfection) at community
level.
- Household spraying is not recommended in all situations given its high
resource/time consuming nature, lack of evidence on its effectiveness and
issues around the risk of increased stigmatization of cholera patients and
households.
Chapter 7
and 9
- % of people washing their hands with soap (or
ash) at critical times3.
- % of households where soap [or ash] is available
specifically for handwashing
- % of public sanitation facilities where
handwashing stations are available with soap (or
ash) available for use
- Undertake communication and community mobilization activities to
promote handwashing with soap or ash [in cholera epidemics, use of sand
is not recommended due the risk of it to be contaminated].
- Provide and maintain handwashing stations (ensuring soap is always
available) as a complement of communal/public sanitation facilities (at
markets, schools, and other institutions) and next to food preparation and
serving / eating areas.
- Distribute soap at household level [targeted for vulnerable groups, such as
cholera patients’ families at CTC level], as part of non-food item kits.
Chapter 7
and 9
- # of communal/public solid waste disposal sites
created and in use
- health risks around solid waste are contained,
especially where contaminated with human faeces
- Support activities on solid waste management, collection and disposal, with
particular attention to markets and other public spaces
- Establish solid waste management and disposal system and; with special
emphasis on management and disposal of faeces in plastic bags (flying
toilets), collected as part of the regular system.
- Undertake communication and community mobilization activities to
promote proper disposal of solid waste management at community level.
Chapter 7
and 9
- [for development/prevention phase] % of
communities reporting open defecation free status
- % of people using appropriate sanitation facilities
for excreta disposal [including disposal of
children’s and babies faeces’]
- % of people recognising/indicating practices for
disinfecting items contaminated with faeces/vomit
in FGD/household interviews.
Critical times: Before handling and preparing food, eating or feeding; after defecating, cleaning children or attending somebody with cholera; after touching dead bodies during funerals.
Chapter 6 – Cholera preparedness
Outcome
Precautions to prevent
cholera transmission are
taken at gatherings, with
specific focus on funerals
and when handling dead
bodies
[Especially in high risk
areas] People identify the
risk of cholera (and its
transmission routes) and
know how to prevent it.
Reference
(in the
toolkit)
Suggested indicators2
Suggested activities
Chapter 9
- % of gatherings4 where safe food and personal
hygiene practices are promoted and facilitated.
- Train religious and community leaders, community health workers on how
to keep people safe at gatherings (safe food and personal hygiene
practices, with special emphasis on safe handling of dead bodies.
- Provide/facilitate information and means for water treatment for drinking,
handwashing stations, handling/disinfection dead bodies.
- Undertake communication and community mobilization activities to
promote proper hygiene measures in gatherings.
- [With special emphasis on funerals] Identify risk practices for cholera
transmission on gatherings and other social practices and use them to
tailor communication/community mobilization activities.
- % of people recognising cholera transmission
routes and indicating measures for preventing it in
FGD/household interviews and through
observation
- # of trained community mobilizers per 1,000
affected people.
- Identify personal and community behaviours related to cholera [both, those
which may increase the risk of transmission or provide a protective factor]
and use it for developing IEC materials (printed, audiovisual, etc.).
- Train community mobilizers on communication techniques and the use of
IEC materials. Training should include information on case identification
and referral.
- Disseminate cholera preventive and response messages through various
communication channels (mass media, interpersonal communication,
through schools, etc.) [Each communication channel and type of messages
has advantages and disadvantages. A complementary combination of them
should be developed and used].
[Note: This must be linked with all other training/communication/
community mobilization-type of activities indicated before and should be
part of the same communication strategy].
Chapter 7
and
Annexes
and
chapter 9
This includes weddings, parties, funerals, religious/sports/political gatherings and any other congregation of people in which food might be sold/distributed and other “risky” hygiene practices are
present (especially during funerals) can pose as special risk for cholera transmission
4
UNICEF Cholera Toolkit v. 1.0 - Annexes
Outcome
Transmission of cholera
from CTC/CTU and other
cholera treatment centres
is eliminated through
appropriate infection
control measures
Suggested indicators2
Suggested activities
- # and % of CTC/CTU/health centres with
appropriate isolation systems and practices in
place
- # and % of CTC/CTU/health centres using safe
water supply.
- # and % of CTC/CTU health centres using
appropriate sanitation facilities, including disposal
of wastewater and medical waste.
- Train health staff on safe hygiene practices and handling of cholera
patients, excreta (faces and vomit and contaminated items) and medical
waste.
- Provide means for isolation of cholera cases/treatment rooms within health
facilities.
- Provide appropriate water supply, including monitoring of water quality at a
regular basis.
- Provide handwashing facilities with disinfected water and soap, making
them accessible for health staff, caregivers and patients.
- Provide and maintain of appropriate sanitation facilities, ensuring they are
easy to access and clean
- Dispose faeces/excreta and wastewater appropriately, as part of the
maintenance of the sanitation facilities (dislodging of latrines and final
sludge disposal, wastewater treatment on site, etc.)
Chapter 6 – Cholera preparedness
Reference
(in the
toolkit)
Chapter 8
Annex 8E
and 8H,
Annex 6G
REDUCING CHOLERA MORBIDITY AND MORTALITY
Objective: To reduce cholera morbidity and mortality
Expected result: Early detection and appropriate case management of cholera to keep the CFR to < 1%
Outcome
Suggested indicators5
Establishment of a
network of prepared
Cholera Treatment
Centres including ORP’s
-
-
Children and adults who
have AWD/cholera are
effectively managed at
treatment centers with
quality services
-
-
-
# of CTC/CTU and ORP per population
according to the national standards
Map of all health facilities that have standards to
be a treatment center
Document outlining resource needs for treatment
facilities including materials for a stockpile of
supplies
Warehouse supply list for stockpile
# and % of health staff trained on case
management protocols
# and % of treatment facilities that have standard
treatment guidelines available
% no stockouts of supplies including ORS, zinc,
IVF, antibiotics according to level of care) in
CTC’s or other treatment facilities
# and % of treatment facilities that have
monitored quality of services in the last month
(using CTC/CTU evaluation form)
CFR for each treatment center
Suggested activities
Reference
(in the
toolkit)
- Identify and map health facilities and partners with capacity to run cholera
treatment centres.
- Establish standards for setting up CTC/CTU’s and ORPs
- Identify and train partners on how to establish treatment centers and
monitor quality
- Identify resource needs for the facilities including trained staff, supplies,
data collection materials, oversight and funding
- Stockpile heath, WASH and communications supplies and materials for
use in high risk areas
- Establish a database mapping all trainings completed by trainees and
trainers for cholera
- Establish a referral system
Chpater and
annexes 8
- Identify and train/refresh health staff including community health workers
on early detection/active case finding, case management, infection control
(see section above) in facilities and managing and reporting data
- Distribute standard treatment guidelines for health staff at all levels
- Provide health, WASH and communications supplies on a regular basis
- Supervise health staff providing treatment on a routine basis
- Monitor the quality of treatment centres on a regular basis
- Integrate management of cholera into standard training for diarrhoea
including IMCI and Integrated Community Case Management (iCCM)
Chapter 8
Annex 8H
5
The table presents suggested indicators for monitoring the accomplishment of the indicated outcomes. The list of activities aims to be as comprehensive as possible and should be selected
depending on the specific context in which they are applied.
UNICEF Cholera Toolkit v. 1.0 - Annexes
Cases in the community
are detected early and
adequately managed and
referred
-
Population at risk is
effectively vaccinated
against cholera
6
7
-
% of patients presenting at the health facility
within 24h of developing symptoms
# and % of community-based health works
trained
# trained community-based health workers/500
population
% stockouts of community-based health worker
supplies
% of caregivers recognising/indicating why and
how to access/use ORS, breastfeeding, proper
feeding, care seeking, through FGD or
household interviews.
- Identify and train community-based health workers in detection,
community-based surveillance, case management, hygiene and health
promotion and reporting
- Disseminate guidelines and standards to community-based health workers
- Provide materials such as ORS, zinc, aquatabs, IEC materials to
community-based health workers
- Establish ORP at community level and the associated supply chain.
- Especially in high risk areas, distribute ORS at household level and
disseminate information on how to access them at community level.
- Identify suitable home-made rehydration fluids and define – with the
responsible health authorities –endorsement/support for their use.
- Undertake communication and community mobilization activities for early
detection of dehydration, rehydration at household level (using ORS or
another government- supported rehydration fluid6) and early care seeking
for treatment7.
- Set up case referral systems and train/provide information to community
health workers on location of cholera treatment centres.
Chapter 9
% coverage of target population with 2 doses of
oral cholera vaccine (OCV)
- Undertake risk assessment to inform on areas and population at risk and
targeted for vaccination
- Prepare a strategy for OCV use for target populations with all
stakeholders
- Procure OCVs from UNICEF supply division
- Conduct a communications campaign for OCV with other key messages
such as health, hygiene and sanitation.
- Develop and carry out a vaccination campaign
- Evaluate and document campaign results including coverage, acceptance
and impact
Chapter 4
Annex 4A
They might be sugar-salt solution, rice-based ORS, among others, and their use should be approved and endorsed by the health authorities.
Main messages should include that household-based treatment is only an immediate measure, and must be followed by care by trained health staff.
Chapter 6 – Cholera preparedness