4.4 Organization of curative services in urban settings

While cholera outbreaks in urban settings share several features with those occurring in refugee camps, several important distinctions affect how treatment services are organized.

Urban areas (including slums) are open settings, where the risk of cholera transmission can vary from one neighbourhood to another. Some are intense hotspots1  for transmission while others experience few or no cholera cases.
High risk neighbourhoods are often affected one after another as inhabitants circulate freely between affected and non-affected areas, and the outbreak and its response can shift from one area to another.
Travel distances may be relatively short in urban settings, but congestion and poor transportation infrastructure can significantly impact travel times.
The space necessary to set up cholera treatment facilities (with sufficient surface area, sufficient distance from private dwellings) is often limited in urban settings.
Furthermore, the population may not readily accept a cholera treatment facility where they live and negotiations may be required.

In urban settings, one or more CTCs located as close to the affected neighbourhood(s) as possible are usually required. Several ORPs are necessary to supplement the CTC(s) with at least one ORP in each of the affected neighbourhoods.
If site options are limited or the focus of high transmission shifts to another neighbourhood, several CTUs can be implemented in place of a CTC.
It is recommended to identify potential sites where additional CTCs or CTUs can be set up as the outbreak evolves.
A referral system should be set up to transport severe cases from ORPs or non-cholera facilities to the nearest CTC or CTU with provision of care during transport if transport time is long.

Ref Notes

A cholera hotspot is a geographically limited area (e.g. city, administrative level 2 or health district catchment area) where environmental, cultural and/or socioeconomic conditions facilitate the transmission of the disease and where cholera persists or re-appears regularly. Hotspots play a central role in the spread of the disease to other areas (WHO definition).