Cholera Rapid Response Teams: Effective and Targeted Cholera Alert Intervention

1. Cholera rapid response teamsGeneric description of RRTs work organization Zimbabwe RRT activation case studyHaiti CATI’s impact study published with description of the Haitian mechanismMozambique currently

2. RRT : What is that ? Mechanism that allows to deliver a targeted and rapid response to cholera alerts consisting in a complete WASH package to: • Each suspected case and his/her immediate neighbors, ideally the same day of the case admission at a CTC • A cluster of cases and the affected neighborhood

3. RRT : is it new ? • Not really… in 1971, an article written by Dr J. Voelkel, a French military doctor, mentions the need to have “multipurpose mobile teams” for surveillance (in-between outbreaks), diagnosis and care of patients, hygiene, sanitation and other prevention actions (disinfection, vaccination, contacts chemoprophylaxis) Voelkel Med Trop 1971

4. RRTs : who are they ? NB: A RRT is a team whose staff can move together to reach the intervention area, i.e. each team has its own means of transportation. GVT teams (depends on line ministry): 1 team leader (experiencied water or environmental officer, or nurse) 1 water officer, nurse, or environmental-health staff 1 hygiene promoter 1 driver Mixed NGO-GVT teams: 1 GVT team leader 2 water officer, nurse, or environmental-health staff 1 NGO driver NGO teams: 1 team leader 1 hygiene promoter 1 water officer 1 driver If chemoprophylaxis or OCV (ring vaccination) to contact is part of MoH strategy, a nurse needs to be included in the team. Mixed NGO-GVT teams: NGO usually supporting logistic component in countries where technical capacities are available within line ministries.

5. RRTs : when do they intervene? • Alert thresholds: • 1 case = 1 alert = 1 response OR • Cluster of cases in a given geographical area over a period of time = 1 response

6. RRTs : when can they be activated? • Outbreak onset, when no. of cases per team per day < 5 in average Whether a progressive or sudden spike is notified in a cholera-prone area, we want to avoid a disease expansion, 5-6 teams may be activated immediately, adding more if cases increase after the initial response. In such case, teams are already prepared.

7. An sudden massive outbreak is reported, quickly resulting in hundreds of new cases per day (eg. Zimbabwe last year, Mozambique this year). It would take too long to activate 50-60 teams if they are not already prepared, so the first response needs to be blanket type with massive WASH interventions in the affected area. However, RRT activation can be planned below a certain incidence threshold, or when the outbreak has reached a plateau situation (eg. Zimbabwe), leaving about 3-4 weeks to secure funds and prepare them. • Second phase of response • Hotspots and endemic settings Depending on how ambitious the national cholera plan is (targeting elimination or control), RRT type mechanism can be implemented in known hotspots aiming to progressively cut the transmission, as immediate initial measures while preparing long-term WASH improvements.

8. RRTs : what do they implement ? • Case-Area Targeted Interventions consisting in: WASH RRT implementing first response in and around cases’ house within 48 hours • Immediate households level response: • Active search of cases • Quick investigation • House disinfection • Hygiene awareness • Household water chlorination level spot-check • Cholera kit delivery • Immediate community level response: • Bucket chlorination • Preventive and corrective chlorination of local water systems, quick fixes • Hygiene awareness in gathering places • Mass risk communication campaign • Food hygiene awareness and control in markets Completed by a package of intervention at community level depending of the quick investigation results:

9. RRTs : why are they useful ? Close contacts (in time and space) of a cholera case have a much higher risk of being infected. • 36 times risk within 50m (in first 3 days) • 6 times risk within 51 – 100m (in first 3 days) • 5 times risk within 101 – 150m (in first 3 days) • > 2 relative risk within 150 m (after 23 days) Transitory increased cholera risk among neighbors of cholera cases (DebesInt J Epidemiol 2016; Azman JID 2018) • But also: • frequent household transmission of V. cholerae O1 (Weil CID 2009; Taylor PLoS one 2015; DommanNat Genet 2018) • significant protection of household contacts of cases by promoting hand washing with soap and treatment of water (Georges EID 2016)

10. RRTs: how do they intervene ? Joint coordination cell: MoH, Water & Sanitation authorities, WHO, UNICEF, relevant partners. Coordinate surveillance & response activities, ensure data are shared in a timely manner, produce regular progress report. Step 1: at the CTC Collect information on new cases (information on new cases may arrive by various means) Deliver prevention messages General principle: three key elements (C-S-IR) and four intervention steps Step 2: at patient’s house Active search of cases Quick investigation House disinfection Hygiene awareness Household water chlorination level control Cholera kit delivery Daily collection and reporting of new suspected and confirmed cases through shared line listing or MoH bulletins. Ensure adequate use of RDT and optimal utilization of laboratories with quick dissemination of results to ease response targeting. Regular analysis of disease trends, cases profiles, risks factors. Step 3: sanitary barrier - “cordon sanitaire” Active search of cases Hygiene awareness for each household Household water chlorination level control Cholera kit delivery Step 4: within the community Water sources investigation Emergency chlorination measures Quick fixes of water infrastructures Food hygiene and sanitation in public places Community engagement and hygiene awareness

11. Epidemiological surveillance, the cornerstone A rapid response mechanism has three surveillance prerequisites: • A definition of suspected cases of cholera with enough sensitivity to ensure a timely detection • A system to ensure a daily sharing of information to all involved partners • A weekly rapid analysis of the epidemic dynamics to guide the response teams in areas most in need In addition: • Wherever a laboratory surveillance can be implemented ensuring quick results feedback to response teams, it can further guide the response in areas with real cholera transmission, compared to areas with a majority of other AWD • A strong epidemiological surveillance system also allows for the identification of the main risks factors and the definition of hotspots, zones of persistence over several years, where more longer-term interventions can be planned

12. RRTs in Haiti : How does the surveillance system feed the RRT alert system in the Port au Prince metropolitan area (West dpt) • Stage 1: at the treatment center, a sentinel waits for new cases, starts the investigation by interrogating him/her or the caretaker, communicates the results to the response teams coordinator, regularly takes pictures of the register and send them to response teams, • Stage 2: response teams have established a Whatsapp surveillance group where they exchange information on the cases they follow • Stage 3: they use the same group to inform on the status on each case after the response • Stage 4: one NGO supports the health dpt directorate to consolidate the daily responses and compare them to the cases line listing (registers compilation) to assess the completeness and promptness of responses.

13. VIDEO RRTs in Haiti : a case example • https://bit.ly/2YgmiQM

14. RRTs : How much does it cost monthly? Highly depending on countries specific costs and RRT composition, but roughly:

15. RRTs: what are the needed supplies? Eg. Zimbabwe kit for 4 cases 4 cases x 20 L bucket = 4 buckets 15 HH x 4 cases x 3 strips = 180 strips 67mg ! Pool tester + DPD 1 per team member 15 HH x 4 cases x 1 bar = 60 bars 4 cases x 20 L jerrycan = 4 jerrycan 15 HH x 4 cases x IEC kit = 60 IEC kits 2 sprayers + PPE

16. RRTs : how are they monitored ? • Set of activities  expected to deliver a package of activities in a given timeframe = measurable • Set of indicators  online reporting tool in Haiti and Yemen (?), centralized daily excel data entry in Zimbabwe • Cases coverage (response completeness) and response promptness measured against official line listing • Field mentoring (≠ formal monitoring) • Regular teams/partners meetings

17. Eg. Harare EHRT weekly indicators

18. RRTs : are they sustainable? • Depends on local anchorage and funding mechanism: Is it a new extraneous mechanism? Does it build on existing structures and capacities? Is it included in a Government budget or depending on external assistance? • Potential wide scope of action: • can respond to more than cholera in many contexts, • reoriented toward surveillance activities when no cases are reported, • train community health volunteers or community-based organizations on surveillance-alert-first response, • support local authorities in hotspots identifying and helping to the implementation of key preventive programs etc.

19. Zimbabwe RRTs example Rationale for introducing EHRTs in Harare in November 2018 Environmental Health Technicians from City of Harare doing case investigations, October 2018 • Second month of outbreak (October) saw reduction in daily number of cases from peak transmission • Number of cases had plateaued suggesting high likelihood of interpersonal transmission and need to prioritize households directly surrounding cases that may be at higher risk to transmission • City of Harare’s Environmental Health Division already tasked to conduct case investigations during initial stage of cholera outbreak (reason why RRT=EHRT)

20. UNICEF partners begin distributions of NFI kits; City of Harare begins sewer repairs, water quality testing, and case investigations at cholera-affected households 4 RRT teams activated in Glenview and Budiriro UNICEF-led Training workshop for City of Harare, NGOs on RRTs 2 additional RRT teams activated in Glenview and Budiriro 2 RRT teams activated at Beatrice Road Infectious Disease Hospital OCV Campaign in 9 additional suburbs Last case reported in Harare on 19 Dec 2018 OCV Campaign in 4 most affected suburbs

21. Performance Results of RRTs:Summary of Cholera and Typhoid Response

22. Lessons Learned from Zimbabwe • Activation of NGO-supported RRTs did not start until after number of cases had plateaued for multiple weeks. An earlier activation may have decreased overall number of cases and ended the outbreak earlier. • Building on local capacities/resources is key to facilitate RRT institutionalization; RRT are embedded within the Environmental Health Division of Harare city and have started to respond to typhoid cases after the last cholera case. • GPS data lacking for location of RRTs. With GPS data, we could better assess spread of cholera and typhoid, both spatially and over time.

23. RRTs: are they effective? Haiti - CATI effectiveness study in 2015-2017 in Centre dpt : • 456 outbreaks in 290 localities • 176 responded before the last case of the outbreak

24. Outbreak morbidity according to the response promptness • The sooner the first complete CATI was implemented, the fewer cholera suspected cases were recorded from the 4th day of outbreak • Adjusted effectiveness of a response in ≤1 day VS >7 days : 74% (58 - 84) P-value < 0.0001

25. Outbreak duration according to the response promptness • The sooner the first complete CATI was implemented, the shorter the duration of outbreaks • Adjusted effectiveness of a response in ≤1 day VS >7 days : 64% (42 to 78) P-value < 0.0001

26. Outbreak morbidity according to the response intensity • The higher the CATIs/week ratio, the fewer cholera suspected cases were recorded from the 4th day of outbreak • Adjusted effectiveness of a CATIs/weeks ratio ≥1 VS <0.25 : 76% (54 to 87) P-value < 0.0001

27. Outbreak duration according to the response intensity • The higher the CATIs/cases ratio, the shorter the duration of outbreaks • Adjusted effectiveness of a CATIs/cases ratio ≥1 VS <0.25 : 37% (-29 to 69) P-value = 0.21

28. Some lessons learned from Haiti • Monitored response coverage: RRTs responding to more than 80% of all cases have an impact Line listing with status of response, shared on a weekly basis, or higher frequency during spikes to ensure at least 80% of coverage and control response promptness.

29. Stable and greater number of teams allowed to intensify the response during specific periods and in specific locations Comparison of suspected cases in West dpt, national level, case mortality, rainfall and number of teams (2013-2019) – Sources: DELR/MSPP, NASA, UNICEF

30. Standardization and continuing improvement took time to optimize the mechanism • Community Engagement & Hygiene Awareness Teams: a necessary complement to RRTs to intensify risks communication and self-protection by communities • Funding predictability: would not have possible to sustain the cases decrease over the last 2,5 years without funding visibility

31. Ongoing RRTs activation -> Mozambique Phase 1 of the response: a massive WASH response in all affected area and an OCV campaign, from late March to early May Phase 2: introduction of RRTs decided around 20 April after a decrease of the daily incidence. The RRTs are managed by provincial health authorities with support from national surveillance institute and WASH partners. RRTs were effective on 8 May. Phase 1 Phase 2 OCV Campaign

32. Phase I of the response Outside of Beira, interventions at community level based on epi information available though field investigations In Beira, localized blanket distribution of WASH/Cholera minimum package 4 2 1 3

33. First results of phase 2 (RRTs) Objective: cost-effective way to maintain a control activity compared to blanket WASH strategies, with the aim of preventing further outbreaks during the upcoming rainy season. Results: as of 24 May, 24 household interventions were conducted, all of them within the target of the 48 hours window. Lessons learnt: earlier implementation of the RRTs may have enabled the intervention to have more impact. Ways forward: institutionalization of the RRTs. The RRTs are being led by DPS so the government can replicate the intervention in the next cholera outbreak (ongoing outbreak in the province of Cabo Delgado).