4.2 Organization of the network of curative services

4.2.1 Access to care

Decentralization of care

Care should be decentralized to shorten the time between the onset of symptoms and the start of treatment.

Care is usually provided in cholera-specific treatment facilities (Section 3.2.2). These facilities should be distributed so that they are accessible to the entire population affected by the epidemic. The setting in which an epidemic occurs ‒ refugee camp, urban or rural area ‒ is key for deciding on the type, number, and location of treatment facilities (Section 4.3 and Section 4.4). Their number and location are not necessarily static. As the epidemic evolves, affecting new populations, treatment facilities, particularly cholera treatment units (CTUs) and oral rehydration points (ORPs), may be created or redeployed to provide adequate coverage.

In addition to cholera-specific treatment facilities ‒ or instead of, when such facilities cannot be implemented ‒ home-based care (distribution of sachets of oral rehydration salts (ORS) to the population) is a way to treat patients rapidly. Starting ORS therapy in the home at the first symptoms of cholera can prevent dehydration or reduce the risk of severe dehydration and hospitalization.

Prepositioning of treatment supplies

In areas at risk of cholera but not yet affected, basic treatment supplies, such as ORS and Ringer lactate (RL), should be prepositioned in health facilities so that proper therapy can be immediately provided to the first cases of an outbreak.

Referral system between facilities

Even in situations where ORS is widely available, some patients will need emergency care. An efficient referral system (ambulance or a vehicle adapted for this purpose) should be organized or reinforced so that severe or complicated cases can be readily transported to a facility where IV treatment can be given. When the transport time is longer than 15 minutes and for severe cases, treatment should be provided for the trip1 . Presence in the vehicle of an accompanying health worker is recommended for patients receiving an infusion.

Affordability of care

To guarantee access to care, diagnosis, treatment, transfer and hospitalisation must be free of charge.

Active case finding

In areas where community health workers are implicated in detecting and treating other common diseases (e.g. malaria), active case finding facilitates early treatment.

4.2.2 Quality of care

The benefits of improving access to care are limited if the quality of care is inadequate.
Standardized protocols must be used to ensure that case management follows accepted principles and practice. Adequate supply of treatment supplies must be maintained without interruption.
Healthcare workers, in sufficient number to give proper therapy, should be correctly trained and constantly supervised.

4.2.3 Organization of response teams

The setting up of cholera treatment facilities requires experience and knowledge across a range of domains: medical, logistics, water/sanitation, supply, surveillance, etc.

In most situations, the response team is multi-disciplinary, meaning that it is composed of all the specialists required to manage the entire range of activities in the specific location for the duration of the outbreak.

In large regional or country-wide outbreaks with a substantial rural component, different approaches can be considered.
For example, one or more multi-disciplinary team(s) can set up a fully-functioning treatment facility in a given area then, move to another affected area where another treatment facility is needed.
Alternatively, several task-specific teams can be deployed successively, each performing a dedicated task (i.e. investigation team, implementation team, supervision and supply team). See also Section 4.5.1.



Footnotes
Ref Notes
1

Always have 1-litre bottles of water to prepare ORS for transport.