Cholera: Management or Mitigation?
The blurred line between anticipation and response when alerting to cholera
The quarterly FOREWARN meeting in May 2021 focussed on epidemics in order to share recently-acquired learning on anticipating disease outbreaks and to apply them beyond the current pandemic.
For the Start Fund, cholera was the obvious choice to analyse because:
- Flooding is one of the alerts most frequently raised to the global Start Fund, accounting for 28% of alerts raised to date. While cholera is not a factor in all flooding alerts, it is mentioned in around 80% of them, so it is a frequent subject of interest to members who use the Start Fund.
- Cholera alerts account for nearly half of disease outbreak alerts (44%) raised to the Start Fund, suggesting that cholera cases are either more prevalent than other diseases, or that the Start Fund is considered more appropriate for cholera alerts by its members. The frequency of cholera in Start Fund work again indicated it as a priority disease to review.
- Encouraging early action and anticipation is a priority for Start Network. Disease outbreak and epidemic alerts are relevant here as Start Fund responses include a considerable element of preventative, mitigation and early management activities.
By reviewing the 20 alerts that have been activated with cholera as the primary cause, the diversity of the sample was clear. Alerts have been activated in ten countries, with funded projects reaching between 18,000 and 730,000 individuals, and with funding allocations between £50,000 and £400,000.
Another point of clear variance was the case numbers found in the community in the three months prior to the alert being raised. This swung widely between 21 and more than 10,000, with some focussed on small communities, and others addressing parts of populations in multiple regions.
Despite the breadth of information, we can extract three key lessons from the data available.
1) There is no minimum threshold for raising an alert where cholera is endemic
When looking at early action responses to cholera crises, if there is more than one case already present in the community, it is not really important whether the alert is raised as an anticipation alert or as a response alert. While the dichotomy of “anticipation” and “response” is a key focus for the Start Fund, a central aim of all cholera-driven alerts is to prevent cases spreading. This is true whether the semantics are around “anticipating further cases” or “responding to cases through mitigation”.
Alert 308 (anticipation of cholera) in Somalia was raised when 716 suspected cases had already been identified, while Alert 344 (response to cholera) in Cameroon was raised with only 61 local cases. Disease outbreak and epidemic alerts can be seen as those requiring a more flexible, mixed-method approach to seeking funding. Members should therefore not be deterred by waiting for a certain number of cases or put off by conceptions around needing to anticipate cases with zero cases present. The Start Fund’s flexibility can and should manage the combination of approaches that are needed in health crises. Furthermore, it can readily anticipate, alert and activate for situations where few or no cases are identified, whereas other mechanisms may need a threshold to be met before releasing funds.
2) Even when responding to cholera, an anticipatory approach that focusses on prevention and mitigation is often the most appropriate choice for NGO members
The WHO Joint Operational Framework’s (JOF) project on improving coordinated and integrated cholera preparedness and response emphasizes the need to have a coherent response involving elements of 1) Preparedness 2) Prevention and 3) Response.
However, they also note that “the overall leadership of cholera prevention, preparedness, and response…rests with government…tasks in the framework are thus for the humanitarian community to ‘support’ or ‘contribute to’…and support government authorities and other key stakeholders to ensure gaps are filled, and support the filling of those gaps as necessary.” (p.10).
When reviewing the Start Fund cholera responses, members have largely identified gaps in prevention activities: “Limited prevention activities are ongoing now – this is the major gap” (Alert 225, Nigeria) and “gaps mainly lie in the preventative aspects” (Alert 162, Yemen). This is apparent in the spend across activities, which is heavily skewed toward activities counted as preventative (including hygiene awareness, WASH kit distribution, communication, and dissemination). Response activities mostly include case surveillance, patient referral and supplies to cholera treatment centres, which could be considered more specialist activities than some NGOs can do.
The Start Fund experience of cholera activities really hits the intersection between 1) focussing on early action as it represents two-thirds of the recommended approach and 2) doing so because the gaps also happen to align with the activities most suited to the humanitarian community. Here, we see that the Start Fund has been used in an appropriate way by members to respond to and anticipate cholera crises to generate the best results for affected communities, regardless of whether the alert was presented as response or anticipation.
However, if we want the Start Fund to support ‘getting ahead’ of this blurred line, this could be explored through the expertise of anticipation experts.
3) Cholera is rarely a standalone crisis with no indication of risks. This could help render it forecastable.
While the Start Fund evidence threshold of cholera-specific alerts may be limited to 25 alerts, its experience with other crises (and specifically flooding) is much more extensive—and it is through these other crises that members might be able to get ahead of the ‘blurred line’.
When looking at the point of origin for the 25 cholera alerts that have been submitted, 20 of them explicitly mention the source of the outbreak as either a meteorological or seasonal crisis, or as a secondary impact of displacement (where there can be greater strain on health facilities).
When flooding is alerted to the Start Fund, the majority (roughly 80% based on sampling) contain references to cholera or water-borne diseases. When you look only at anticipation of flooding alerts, that increases to 90%. This suggests that the close link between cholera as a secondary impact of a forecastable crisis (for example, seasonal or annual flooding) may permit members to raise alerts specifically for the anticipation of cholera, either as a standalone alert or as part of a crisis anticipation alert that addresses the primary hazard (flooding, rains, storms, or dry season). There is an undeniabe link between contexts that are in other types of crisis and the prevalence of cholera. According to the JOF, “countries in humanitarian crisis represent both a significant proportion of the number of countries targeted [by the Global Task Force on Cholera Control], as well as of the global cholera burden” (p.4).
Therefore anticipating cholera ahead of case numbers increasing is possible, whether it is:
- raised as a component of a larger anticipation alert,
- understanding community resilience and the capacity of a healthcare system,
- through a Start Fund member identifying a gap in an early-action plan, or
- where a primary crisis might be managed within the community, but a cholera outbreak could not be.
By using expertise, technical forecasting skills and data, members and the community can act early for cholera and other vector-borne disease outbreaks that are frequently found as secondary impacts of other hazards. This has been demonstrated in the Malawi anticipation of cholera in the rainy season following a successful flood response alert.
“This anticipation alert draws on experience of implementing the flood response last year, including recommendations from the independent evaluation that was conducted at project end”. (Alert Note, Alert 221 Malawi)
The JOF states that “cholera preparedness is often implemented late or starts with the onset of the first cholera cases of an epidemic, which is then impossible to catch up on” (p.5) and while prevention and mitigation activities are still key once cases are in the community, the timeliness of cholera projects led by the membership can potentially be increased. To meet the needs of people in ways that are reliable, effective, and inclusive, we cannot rely on case numbers to begin in order to manage epidemics, or for clusters or coordination groups to be activated in response to a crisis.
Close coordination between Start Fund members, technical experts, and community leaders could result in moving to the early side of our currently blurred line. Using shared data, analysis, and expertise to respond to, contain, and even completely prevent cholera could certainly be a way to continue striving to make Start Fund responses as timely as possible.