Prevention and control of cholera with household and community water, sanitation and hygiene (WASH) interventions: A scoping review of current international guidelines.

Introduction

Cholera remains a frequent cause of outbreaks globally, particularly in areas with inade- quate water, sanitation and hygiene (WASH) services. Cholera is spread through faecal- oral routes, and studies demonstrate that ingestion of Vibrio cholerae occurs from consum- ing contaminated food and water, contact with cholera cases and transmission from contam- inated environmental point sources. WASH guidelines recommending interventions for the prevention and control of cholera are numerous and vary considerably in their recommenda- tions. To date, there has been no review of practice guidelines used in cholera prevention and control programmes.

Methods

We systematically searched international agency websites to identify WASH intervention guidelines used in cholera programmes in endemic and epidemic settings. Recommendations listed in the guidelines were extracted, categorised and analysed. Analysis was based on consistency, concordance and recommendations were classified on the basis of whether the interventions targeted within-household or community-level transmission.

Results

Eight international guidelines were included in this review: three by non-governmental organi- sations (NGOs), one from a non-profit organisation (NPO), three from multilateral organisations and one from a research institution. There were 95 distinct recommendations identified, and concordance among guidelines was poor to fair. All categories of WASH interventions were featured in the guidelines. The majority of recommendations targeted community-level trans- mission (45%), 35% targeted within-household transmission and 20% both.

Conclusions

Recent evidence suggests that interventions for effective cholera control and response to epidemics should focus on case-centred approaches and within-household transmission. Guidelines did consistently propose interventions targeting transmission within households. However, the majority of recommendations listed in guidelines targeted community-level transmission and tended to be more focused on preventing contamination of the environment by cases or recurrent outbreaks, and the level of service required to interrupt commu- nity-level transmission was often not specified. The guidelines in current use were varied and interpretation may be difficult when conflicting recommendations are provided. Future editions of guidelines should reflect on the inclusion of evidence-based approaches, cholera transmission models and resource-efficient strategies.

Cholera is a diarrhoeal disease caused by ingestion of the pathogenic bacteria Vibrio cholerae. Cholera is spread to susceptible individuals via the faecal-oral routes of transmission from consuming contaminated water and food, contact with cholera cases and from a contaminated environment. Water, sanitation and hygiene (WASH) interventions such as improved water sources, sanitation and hygiene measures can prevent and control the disease. While this is widely accepted, and demonstrated in Europe and the Americas which have been cholera free for decades after sanitary improvements, there is a paucity of evidence to support which WASH interventions are most relevant in cholera-affected populations today.

Guidelines for the implementation of WASH interventions in cholera epidemic and endemic settings have been written by numerous organisations and vary considerably. Whilst appropriate cholera response will be specific to geographical and social context, it is important that the guidelines are informed by the best possible and available evidence.

A total of eight guidelines were identified and 95 recommendations extracted from the guidelines. These were categorised and analysed for their consistency, concordance and according to current cholera transmission models. This paper details the included recommendations from guidelines and recommended actions to improve future guideline development by international organisations.

It may encourage change to guidelines or use of evidence in future cholera WASH guidelines