4.5 Organization of curative services in rural settings

In rural settings, the affected population is scattered over a large geographical area in numerous small communities that are often hard to reach due to transportation challenges.
In addition, there are fewer health system resources (treatment facilities and staff) with which to provide treatment.
Difficult access to treatment is further exacerbated when the outbreak expands to areas beyond the reach of existing treatment facilities.

4.5.1 Facility-based approach

In an outbreak that affects a village and surrounding communities within a radius of around 5-10 kilometres, a central CTC or CTU with supporting ORPs is sufficient. A multi-disciplinary team can manage the setup of the necessary treatment facilities.

Some epidemics, however, are so rapidly evolving that a single CTC linked to surrounding ORPs and CTUs is insufficient to respond to the numerous alerts of newly affected populations.
Treatment facilities should be more numerous and less permanent. It is preferable to implement several CTUs (rather than a single CTC) and/or several ORPs with, when possible, the capacity to treat 1 or 2 severely dehydrated patients.
In such a setting, a different team deployment strategy should be considered with small mobile teams able to cover a large geographic area while maintaining reactivity to further cholera alerts.
Teams can be organized as follows:

• At least two mobile multi-disciplinary teams are available to respond to alerts, perform the initial on-site investigation, set up the site, train local staff, set up data collection, donate supplies and drugs, and treat the first patients. The team may remain on site (or return daily) for several days until the facility is functioning independently. Frequent supervision visits are required to reinforce training, assure adequate stock levels, and collect data.

or

• Task-specific teams are sent successively to a new site to perform defined tasks over a limited period before moving to the next location:
  • The investigation team (doctor or nurse plus logistician or water-sanitation specialist) responds to new alerts and assesses the situation and needs for a given location. This team should be capable of setting up a simple ORP if that is all that is required based on the assessment.
  • The implementation team (doctor or nurse, logistician and/or water-sanitation specialist, and if needed, one person for administrative support) is deployed to the site to set up a CTU or ORP, provide the necessary supplies and drugs, treat the first patients, manage and train staff, and set up a cholera register.
  • The supervision and supply team (nurse and logistician or water-sanitation specialist) circulates routinely among the sites to gather data, evaluate quality (of care, of water, etc.), reinforce training, and provide the required medications and material.

There are occasions when the scale of an outbreak is beyond the capacity of outbreak responders to provide access to treatment within reasonable reach of all affected populations. Patients have to spend considerable time trying to reach a treatment facility. “ORP relays” may be implemented at regular intervals a Citation a. ORP relays are positioned every 3-4 kilometres or at an hour’s walk from one to the next, for example.  along major travel routes to dispense ORS to patients traveling to a CTC or CTU. These are not full-scale ORP’s but less-formal sites where patients can drink ORS and take some to drink along the way (similar to water stations in endurance running races). In this way, incapacitating or life-threatening dehydration may be avoided during travel. The ORP relays are managed by local community workers or trained volunteers.

4.5.2 Home-based approach

Distribution of ORS sachets to isolated communities is another way to insure that treatment is available even in the absence of cholera treatment facilities. ORS distribution can be organized from a fixed site or door-to-door. A single person should be in charge, whether a community health worker or village chief.
Distribution should be accompanied by clear instructions on proper preparation, use, and storage.

Such distribution may also serve as a means to provide other prevention items, such as soap and water treatment products. However, if a chemical agent for water disinfection is distributed together with ORS, the risk of confusion between the two products at home should be taken into account.