Protocol No 7 – Hygiene, sanitation and isolation aspects of CTCs
Risks of not implementing hygiene, sanitation & isolation aspects
It is VERY important that basic hygiene, sanitation and isolation procedures are followed at ALL TIMES in
health facilities where patients with AWD are being treated. Failure to follow these procedures could lead to
cross-infection of other patients or infect people who come to the health centre who did not in fact have AWD.
Helping staff to improve their health facilities
Helping the staff to improve their facilities:

Observing another well set up CTC centres / improved hygiene centre.
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Discussing what they saw and suggesting any improvements.
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Providing required equipment where not already available.
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Providing additional operational costs for guards, cleaners and medical helpers.
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Working with the staff to discuss and suggest and make the improvements together.
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Follow up visits after a few days to see how the procedures are being followed.
Minimum hygiene, sanitation and isolation activities
Essential principles that all health facilities and CTCs must follow:
1. Isolate severe cases
2. Contain all excreta (faeces and vomit)
3. Only one carer per patient
4. Wash hands with chlorinated water
5. Disinfect feet when leaving the centre
6. Disinfect clothes of infected people before leaving the centre
7. Provide hygienic and with privacy
8. Toilets and bathing areas for patients and carers
9. Follow up on the families and relatives of the patient, ensure there are no other cases and disinfect
the house, give hygiene information.
10. If people arrive by public transport the cars should be disinfected.
Cards for hygiene actions to be taken in the treatment centre:
Laminated cards in different colors should also be prepared for the following:
Patients
When they
arrive
During their
stay
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Before they
leave
In case of death

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Their skin is disinfected with a 0.05% solution (with a sponge or by spray)
Their waste (body liquids like vomit and faeces) will be collected in bedpans or buckets
Do not allow people to vomit on the bare earth
Their waste must be left for 10 minutes in a strong 2% solution (pour this solution in the bed
pans before empting them)
Their waste must be emptied in a specific pit.
Their clothes are sterilized in boiling water or dipped in a 0.2% solution for 10 minutes and then
rinsed (ATTENTION the chlorine might bleach the clothes)
Their skin is disinfected with a 0.05% solution (with a sponge or by spray)
Their shoes (especially the bottom) or feet are sprayed with 0.2% solution or they walk
through a foot bath
Their body needs to be disinfected with a strong 2% solution
All body openings must be closed with cotton dipped in the same 2% solution
The body is wrapped in a plastic bag
Relatives
When they
arrive
During their
stay
Before they
leave
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When possible, try to provide separate latrines and washing facilities for the relatives
Every time they use the toilet they should wash their hands with a 0.05% disinfected water
The relatives should try to minimize contacts with the patient’s waste
Every time they leave the camp they have to wash their hands in a 0.05% solution
The sole of their shoes (especially the bottom) must be sprayed with a 0.2% solution or
walk through a footbath
If food has come from outside, the plates and everything should be washed in a 0.05%
solution before being allowed from the camp
If dirty, their clothes are sterilized in boiling water or dipped in a 0.2% solution for 10 minutes
and then rinsed with clean water
The relatives should be advised that funeral ceremonies are a risky practice
All the people handling the dead body should wash their hands and not handle food
Hygiene education should be given to the relatives before returning to the center
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Staff should use gloves when treating patients
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Staff should try to use separate latrines and washing facilities, ideally in neutral area
Staff should use gloves when treating patients
Staff should wear gowns and special outfits which will be disinfected in the center
After treating the patient the staff member should wash their hands with disinfected 0.05%
solution (and their gloves if they are reusable )
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In case of death
Only 1 relative allowed (unless the others are also sick)
Staff
When they arrive
During their stay
What to do with dead bodies / instructions for funerals:
Keep the body separate from the patients.

Disinfection of corpses and plugging of orifices with cotton in a 2% chlorine solution (note – only
effective for a short period). Bury as soon as possible.

Wrap the body in a plastic sheet when transporting to catch any body fluids.
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Discourage funeral feasts until the end of the outbreak (or limit size).

Undertake hygiene promotion at funerals.
Minimum key staff and job descriptions
Minimum key staff:
As a minimum the CTCs or health centres which are dealing with AWD infected people, must have the
following staff:
1. Medical and support staff (cleaners, guards etc) should work ONLY with the AWD infected patients –
they must not switch between different groups as this will lead to infection.
2. There should be one nurse per shift, as the center has to be open 24 hours a day.
3. There should be 1 medical helper per shift that assists the nurse and prepares ORS if possible.
4. 1 Cleaner / sprayer per shift– who deal with all of the cleaning and disinfecting of people’s clothes,
disposal of waste etc.
5. 1 guard per shift – to make sure that people follow the hand and foot washing procedures and
ensuring that the isolation rules are followed. They need to be very strict about these rules!
6. Cook – to cook for the patients, carer, health and other staff who remain in the centres (where
possible).
Job descriptions for staff:
The following simplified job descriptions have been developed from the MSF cholera guidelines. They have
been simplified so that they can be realistically followed in all health posts and small CTCs run by any
organisation.
The cards should be prepared in different colors and laminated and in both the local language and English.
They will be hung up in the centers for use by the staff on a daily basis.
Nurses / Medical helper
Actions
Remarks
Case Management
Follow training instructions
Differentiate non AWD from AWD and severe cases
from mild
The ‘differentiation area’ should be separated from the centre.
Only patients with AWD can enter the contagious area
Preparing ORS every day
(This could be done by a medical helper if available)
Follow training instructions
Supervise cleaners and ensure hygiene and
sanitation rules are followed
Be familiar with their tasks and do some inspections
Use personal hygiene
Use separate toilets.
Wear gloves and boots in the center area.
Wash hands after treating patients even when wearing gloves.
Hygiene education when patients and relatives
leave or die
Focus on hand washing, safe water and funeral practice
Hygiene education for community members
When giving community education from the centre site, hold the
training outside the centre itself.
Put syringes / needles into syringe box
Syringe box should be used until full and given to RHB for disposal
Cleaners
Actions
Remarks
Cleaning bed pans every hour (soaking them in
chlorine and emptying them into the pit)
Pour a 2% solution for 10 minutes, then empty in a covered pit
latrines
Clean toilets and showers 2 to 4 times per day
Use 0.2% solution
Cleaning beds and floors 2 times a day or when they
become dirty
Clean or spray using 0.2% solution
Disinfecting patients when they arrive
(or this can be done by the guard)
Spray them or use sponge with 0.05% solution
Prepare every day 2 types of disinfecting solutions
(0.2% and 0.05% solutions)
(This could be done by the Medical helper if available)
Follow solution table
Prepare every week the 2% solution
Follow solution table
Disinfecting patients when they leave
Spray them or use sponge with 0.05% solution
Cleaning clothes when people leave (patients,
relatives and staffs)
Boil them or soak them in 0.2% solution for 10 minutes then rinse
with clean water
Refill hand washing containers when empty
Use 0.05% solution
Refill drinking water containers
Use PUR or WaterMaker prepared by the nurses
Refill sprayers and foot bath
Use 0.2% solution
Collect waste in bins with lids
Burn in an open pit
Dispose buckets with excreta
Put half a cup 2% chlorine solution in the empty buckets
Use personal hygiene
Use separate toilets.
Wear gloves, apron or overall and boots in the center area.
Wash hands and gloves after work.
Guard
Actions
Remarks
Admitting only patients and 1 relative
If relatives are sick then they can be admitted
Making whoever exits the camp (patient, relatives,
staff) wash their hands every time
Make sure there is chlorinated water in the container
Making whoever enters or exits the camp (patient,
relatives, staff) disinfect feet or shoes
Spray the bottom of the shoes
Make sure there is chlorine solution (0,2%) in the sprayer or foot
wash
Use personal hygiene
Use separate toilets.
Wear gloves and boots in the center area.
Wash hands and gloves after work.
Making chlorine mixes
Disinfecting solutions:
Depending on the chlorine available, choose the table appropriate and provide this table only for making up
the disinfectants:

5% liquid - local Birkina yellow bottle

10% liquid - provided by UNICEF
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65-70% HTH powder – imported
Yellow bottle
5% solution
Blue container
10% solution
2% solution
0.2% solution
0.05% solution
Waste and
Excreta
Dead Bodies
Floor
Objects / Beds
Footbaths
Clothes
1 lt. chlorine
19 lt. water
(1:25)
0.5 lt. chlorine
19.5 lt. water
(1:50)
Hands
Skin
10 lt. chlorine
10 lt. water
(1:1)
5 lt. Chlorine
15 lt. water
(1:4)
Drinking water
0.2 lt. chlorine
19.8 lt. water
(1:100)
0.1 lt. chlorine
20 lt. water
(1:200)
1 cap
(only transparent
water)
1 sachet
Waterguard
Watermaker
2 sachets
PUR
NB: The solutions should be freshly prepared every day, since light and heat weaken the solution
If there is no chlorine available, use normal bleach that is locally on the market available (5%).
HTH powder 6570%
2% solution
0.2% solution
0.05% solution
Waste and
Excreta
Dead Bodies
Floor
Objects / Beds
Footbaths
Clothes
3g for 1 liter
30g for 10 liter
Hands
Skin
30g for 1 liter
300g for 10 liter
0.75g for 1 liter
7.5g for 10 liter
Never mix the solution with detergent!
Disinfecting transport and the houses of the infected people
When people are transported to a health facility they may leave traces of AWD in the vehicle which may infect
others. This needs to be disinfected to prevent cross-contamination. Disinfecting people’s houses can also
lead to opportunities for undertaking hygiene promotion or surveillance activities where new cases are
identified.
1. Disinfect immediately the car in which the patient was transported in (Ambulance or Taxi) on arrival before it
leaves again. Use a 0.05 % Chlorine solution for the car.
2. It is important to go immediately to the house of the patient instead of waiting until the patient is discharged
and going home.
3. Explain to the household that spraying of chlorine is done to disinfect and that is not poison.
4. Use a 0.2 Chlorine Solution to do house spraying.
5. Ask in which places the patient was vomiting and where has been stool.
6. Spray also latrine (if there is), clothes and kitchen area (after removing food items).
7. The visit of the affected household is a good opportunity to give extra Hygiene Promotion to the family
members and the neighbors.
8. At the same time it is a way of surveillance, as you can detect new cases in the neighborhood.
Layouts of CTC / isolation areas in health facilities
a) A simplified arrangement which can be used at a small health centre
The above layout is for a reasonably large CTC / treatment centre, but the principle of patient flow and
isolation is the same for smaller centres. The patients under observations should not be mixed with the
patients who are severely affected and except for the patient, staff and one carer, no other people should be
allowed to be in the centre.
Simple design guidelines for latrines for the CTCs
Siting:
1. The latrine should be between 5 to 10m from the tents where people are staying. This will hopefully
be far enough away to prevent the smell becoming a problem and near enough that people can reach
them for use.
2. Care must be taken that these latrines are a minimum 30m from any groundwater source. The safe
distance is shorter than this but this allows for a margin of error.
3. The latrine should not be located in any channels where water flows during heavy rains. If it is in this
location, then there is a risk of it flooding or collapsing from water entering down the sides of the pit.
4. Ideally therefore should be separate latrines for women and men which are located a small distance
away from each other or separated by a screen. In the smaller centres a joint latrine for men and
women can be considered after checking the local customs.
5. The patients and the staff should have different latrines. The carers will probably need to use the
same latrines as the patients depending on the size of the centre. Particular effort will need to be
focused on keeping the latrines clean for all users.
6. The entrance to the latrine should be facing away from the centre so that people are not seen entering
or leaving the latrine for the privacy of the user.
Design:
1. All floor areas in the latrines should be cleanable and the cleaning water must be washed into the pit.
2. The walls of the latrine should ideally be close up to the sides of the latrine slab so that vomit or
feaces are more likely to hit the plastic slab. Alternatively the space inside the latrine can be bigger,
but all floor areas must be covered with plastic sheeting.
3. As some people using the latrine may need a carer the latrines could be made of double size (ie one
plastic slab and an equivalent size area with plastic sheet for the carer to stand on) to allow the carer
to also enter at the same time. This can be discussed by the team on site with the users and CTC
staff.
4. The slab should be slightly above the ground level (i.e. should sit on the ground level or be slightly
raised) so that rain water from the ground will not run into the latrine through the central hole.
5. A raised mound of soil (can be taken from the excavation) should be placed around the three sides of
the latrine structure to prevent any run off from the ground to enter the pit or weaken the top of the pit
and cause it to collapse.
6. The pit should be as deep as possible depending on the soil strength / stability. As most centres will
be small the pits should not fill up too quickly.
7. The pit should be dug leaving 0.15-0.2m around all edges for the slab to rest on. As a minimum two
strong pieces of wood or logs should be dug into the ground which will extend longer than the pit
length or width, on which the slab will sit (or a frame constructed for the slab to sit on which has
extending arms to provide more stability / support).
8. Thick plastic sheeting should be used to surround the latrine and nailed to the upright poles. A loose
flap door should also be provided. A roof can also be added but will require additional bracings for the
walls of the latrine. If there is enough wood then bracing pieces can be added to stabilise the walls.
Maintenance:
1. The latrine should be cleaned regularly with 0.2% disinfectant.
2. Latrines which fill up to 0.5m to the surface should be closed and filled in. If the pit becomes too full
then it will be difficult to fill it in without spilling the contents on the surface. Another pit can be dug for
continuation of use.
Picture of a latrine to be inserted – side view and slab – provided by MSF
Simple guidance for bathing units for the CTCs
Siting
1. The bathing units for men and women should ideally be located some distance apart from each other
to allow for privacy.
2. They can also be located relatively near to the latrine but care must be made to ensure that the waste
water flows away from the latrine pit, so as not to damage the pit.
Design
1. The bathing unit is simply a screened unit which allows people privacy for washing / bathing. The door
should be away from the CTC and should be formed using a flap of plastic.
2. It should allow enough space for both a patient and carer and for the person to move around while
bathing.
3. The floor should be washable and on a slight slope falling in a direction towards a pit filled with stones
to take the waste water (remember that the waste water will be contaminated and hence is
dangerous). The slope can be formed either by digging slightly into the ground or using wood to raise
up the base of the unit.
4. If wooden planks are used to form the floor of the bathing unit, then they should be covered with thick
plastic sheeting nailed down to the wooden planks.
Maintenance:
1. The floor of the bathing unit should be washed regularly with 0.2% chlorine solution.
List of minimum requirements for equipment for hygiene, sanitation & isolation of
the CTCs (small centre at health centre)
Quantity
required for 1
CTC
Unit cost
(USD)
Cost for
1CTC
Cost for
40 CTCs
1
1400
1400
56,000
Tents 24 sq meter
2
700
1400
56,000
CTC beds
10
50
500
20,000
Plastic mattresses – for staffs
10
18.2
182
7,280
Fencing rope (bright colours if possible) of 200m
200m
46
46
1,840
Plastic sheets 4 x 6 m (or equivalent)
20 pc
10
200
8,000
Blankets
15
8
120
4,800
Pillows
15
3
45
1,800
Bed pans
12
0.5
6
240
Safety box (syringes)
20
0.8
16
640
Hand torch (flash light)
5
1.2
6
240
Dry cell batteries (for hand torch)
20
0.3
6
240
Stretchers
2
110
220
8,800
No.
Item description
Tents for patients 72 sq meter (10 patients, 10
carers, space between beds)
Matches
1 pack of boxes
1
1
40
Candles
100
0.1
10
400
Large Dust bins with lids
5
15
75
3,000
Plastic buckets (with lids) – 10 L
10
1.5
7.5
300
Plastic buckets (with lids) – 30 L
5
1.75
7
280
Metal drum incinerator (or can use pit for burning)
1
25
25
1,000
4
1.50
6
240
1
10
400
Cleaning plastic brooms
Plastic apron (not disposable)
10
Medical gown/ Fabric
10
10
100
4,000
Sprayers – large (back pack type)
2
25
50
2,000
Trays for footbaths (large and wide)
2
1
2
80
Roto tanks, 2,000 litres
1
175
175
7,000
Blue water container (30-40litres) with tap for handwashing
5
5
15
600
Powdered soap – for washing dishes, cartons of
100g
20
0.2
4
160
Disinfectant – for cleaning, sterilizing etc (5%
chlorine solution, 1 litre bottles)
60 bottles
30
60
2,400
4,140
Disinfectant with HTH 70% (1 kg/day)
Tissue paper, rolls – 100 pieces pack
Heavy duty rubber gloves (not disposable)
Plastic table
30 kg
3
34.5
103.5
10 pr
1.8
18
720
3
42
126
5,040
Plastic chair
4
13
52
2,080
Plastic cup
50
0.3
15
600
Tea spoon
50
0.3
15
600
Plastic plates
50
0.3
15
600
Squatting slabs
4
Not available
in local market
-
-
Laundry soap
100
0.4
40
1,600
Body soap
100
0.25
25
1,000
10
2.9
29
1,160
Jerry cans of 20 liters
Gum boots – mixed sizes
10 pairs
Kerosene lantern for light
8
Blue overalls (coveralls)
6 pair
Cleaning items – 1 set to include – toilet brushes x
4, cloths x 20, mop & bucket x 3
1 set
Large plastic containers / baths for soaking clothes
3
Funds for buying wood poles for fences and
structures and minor local costs
$100
Total cost (USD)