About this guidance
This document, compiled in response to recent increases in the number of cholera cases in the Eastern Mediterranean Region, provides recommendations on risk communication and community engagement (RCCE) interventions for cholera outbreak mitigation and response.
Background
The Eastern Mediterranean Region has experienced a significant upsurge in cholera cases and outbreaks, including in countries where cholera is not endemic and has not occurred in the past decade. The rise in cholera cases can be attributed to a range of factors affecting countries, from protracted civil unrest, mass migration and displacement of populations to the impact of the COVID-19 pandemic on socioeconomic conditions.
Cholera outbreaks have far-reaching consequences. They threaten the lives of at-risk populations and impact economies and industries, particularly in the food production and agricultural sectors.
About cholera
Cholera is an acute diarrhoeal disease caused by the highly infectious bacterium Vibrio cholerae. Transmission occurs when a person drinks or eats food contaminated with the bacterium. Outbreaks typically occur when the faeces of an infected person contaminates food or water.
The bacterium spreads rapidly in areas with inadequate sewage treatment and limited access to clean water and sanitation facilities. Cholera outbreaks are common in peri-urban slums, flood areas, unplanned settlements and camps for internally displaced persons (IDPs) and refugees.
Symptoms typically appear between 12 hours and 5 days after ingesting contaminated food or water. Most infected individuals will have no or mild symptoms. If symptomatic, oral rehydration solution (ORS) is an effective treatment. However, some individuals may develop acute watery diarrhoea with severe dehydration, requiring rapid treatment with intravenous fluids and antibiotics. Without prompt and adequate treatment to replace lost fluids, cholera can lead to severe dehydration and death within hours.
RCCE objectives in the response to cholera outbreaks
A multifaceted approach is key to preventing and controlling cholera and reducing deaths. Effectively managing cholera outbreaks requires a combination of surveillance, water, sanitation and hygiene (WASH) interventions, treatment and oral cholera vaccines, and RCCE.
Efforts to engage and empower affected populations and provide people with the knowledge, skills and resources they need to reduce individual, household and community risk are central to any effective cholera outbreak response.
RCCE supports all pillars of the cholera outbreak response by engaging and empowering affected populations with knowledge, skills and resources.
Community surveillance and reporting increases community knowledge and awareness of cholera and supports the early detection and reporting of suspected cases.
Diagnostics and treatment reduces mortality by increasing household awareness of, and access to, ORS. RCCE should ensure caregivers and household members promptly administer ORS and that severe cases are referred to health services or cholera treatment centres.
Water, sanitation and hygiene (WASH) interventions engage and empower communities to design and implement enhanced WASH facilities at both the household level and over the longer term. They include immediate household interventions such as water filtration, chemical or solar disinfection of water and safe water storage practices. Longer-term WASH interventions should actively involve the community in designing and implementing solutions, including infrastructure development and the relocation of water sources.
Behavioural change promotes the adoption of appropriate hygiene practices, such as handwashing with soap, safe preparation and storage of food and safe disposal of children's faeces.
Oral cholera vaccine builds community confidence in the oral cholera vaccine (OCV) during mass vaccination campaigns.
Recommended RCCE actions and interventions
RCCE response plans should involve 4 key actions to ensure a coordinated, evidence-informed and community-led approach.
- Coordinate (internally and externally), including with multisectoral partners.
- Collect and apply social and behavioural data.
- Communicate risks and appropriate actions to affected populations.
- Engage and empower communities in the design and implementation of interventions.
The following list of recommended RCCE actions and interventions reflects the role of RCCE as a cross-cutting pillar in any cholera response. RCCE focal points in ministries of health and partner organizations should work closely with their counterparts in other operational areas to ensure that RCCE is embedded into all aspects of the response.
Coordination
Activate the RCCE pillar in cholera incident management structures
Embedding the RCCE role across different operational response pillars/functions ensures RCCE is integrated into all aspects of the response, facilitating a cohesive and comprehensive approach.
Activate/establish a multisectoral RCCE coordination mechanism
Include representatives and partners working in WASH, community representatives, NGOs and civil society to foster collaboration and ensure multiple perspectives are considered in RCCE strategies.
Establish/activate subnational coordination mechanisms
Leverage existing community health committees and structures to support coordinated community engagement and outreach in affected areas. This strengthens local ownership and facilitates targeted interventions.
Develop an RCCE response plan with partners
Ensure harmonization of interventions and leverage the respective capacities of partners, including networks, resources, funding and trusted relationships. This optimizes resource utilization and ensures a synergistic approach.
Coordinate with other response pillars (case management, surveillance, WASH) to develop joint initiatives
Ensure that RCCE interventions are embedded into activities such as community mobilization, the design of interventions and health education. This promotes a unified response and maximizes the impact of interventions.
Collect and apply social and behavioural insights
Gather baseline social and behavioural data to inform risk perception and response planning. Consider data such as:
demographics, including population size, ethnicity, religion, education level, local languages and economic activity to tailor communication to specific audiences and address potential barriers to accessing information and services;
access to health services, level of health service delivery and access to health resources and treatment to identify gaps in service provision and inform strategies to improve access to care;
community infrastructure, including water, sanitation and hygiene infrastructure at the community and household level and identify areas for improvement to prevent further transmission;
preferred methods of engagement, including formal and informal networks and trusted sources, to ensure effective communication channels are utilized and messages reach the intended audience; and
specific risk behaviours, including health-seeking and -giving behaviours, beliefs and cultural practices, including the use of traditional healers for treatment. This helps address potentially harmful practices and promotes appropriate health-seeking behaviours.
Undertake rapid data collection and analysis to inform the operational response
Use methods such as focus group discussions, community walk-throughs, key informant interviews and social media monitoring. This ensures timely and relevant data collection for informed decision-making.
Compile and share social and behavioural data with the incident management structure
This informs risk assessment and response planning for both RCCE interventions and the broader operational response. It includes understanding the source of contamination and community practices and behaviours that may contribute to transmission or control of the outbreak.
Regularly collect social and behavioural insights via social listening and community feedback mechanisms
Provide updates to the incident management structure to inform the ongoing operational response and adjust it based on expressed needs and emerging issues. This ensures the response remains dynamic and adaptive to the evolving situation.
Communicate community risks and appropriate actions
Communicate widely with affected populations
Ensure they are aware of the risks, address public concerns and provide information on how to respond and mitigate risk, including through vaccination. This empowers individuals and communities to take appropriate actions to protect themselves.
Provide clear information and guidance to affected populations on
Cholera disease information. Explain what cholera is, how it spreads and its potential consequences.
Sources of transmission. Clearly identify how cholera is transmitted in the specific context of the outbreak.
Signs and symptoms. Describe the signs and symptoms of cholera so individuals can recognize them early.
How to treat/respond if someone presents with symptoms. Provide clear instructions on administering ORS for home treatment and when to seek professional medical help.
Raise risk perception on severe cholera. Emphasize the dangers of severe dehydration and the need for immediate ORS administration and referral to a cholera treatment or health centre.
How to mitigate risks and prevent infection. Explain preventative measures at the individual, household and community levels, such as safe water practices, handwashing and proper sanitation.
Communicate through multiple channels and trusted messengers
Utilize media, social media, radio, direct community outreach and health education through other health outreach programmes. Consider language and educational levels, and use pictorials (flipcharts) and other accessible means whenever possible to ensure messages reach diverse audiences and are easily understood.
Continue to provide regular updates to affected populations
Include updates when new information becomes available, such as identifying the source of transmission. This keeps communities informed and fosters trust in response efforts.
Conduct regular social listening through media and social media monitoring
Analyse this information alongside community feedback, adapt communication responses as required and respond to rumours, misinformation and emerging issues. This ensures the communication strategy remains relevant and responsive as the situation evolves.
Engage and empower communities
Support community participation and consultation in problem identification and in designing solutions
Collaborate closely with other response pillars to ensure interventions are accepted, appropriate and understood by affected populations. For instance, work through existing community structures or with representatives to:
Identify the source of contamination. Involve the community in risk mapping to pinpoint potential transmission spaces/sources.
Support community-led management of water sources. Empower communities to conduct regular testing and treatment (chlorination) of communal water sources.
Provide health education in affected areas. Ensure households and caregivers can recognize cholera symptoms and understand the importance of early treatment and referral.
Distribute ORS and WASH supplies. Ensure access to ORS and essential WASH supplies like chlorination tablets.
Mobilize the community during mass vaccination campaigns. Encourage community ownership and participation in vaccination efforts.
Encourage and enable individual and household behaviour change. Promote good hygiene practices through health education, distribution of soaps and hygiene products and community-led interventions.
Undertake targeted interventions with key sectors. Work with schools/education providers, food vendors and water suppliers to increase early detection and reporting of cases and promote safe food, water and hygiene practices.
Collaborate with affected communities using existing community structures and mechanisms
Utilize community consultations or workshops to effectively involve affected populations in decision-making processes.
Establish community feedback mechanisms for iterative assessment and adjustment of the response
Gather community feedback through primary health workers, civil society and NGO partners and community representatives. This helps ensure the response remains aligned with community needs and priorities.
Available resources and materials
The following resources and materials have been compiled to support ministries of health and partners respond to cholera outbreaks. The list is not exhaustive.
Ministries of health and partners should coordinate closely to ensure that resources and messages are harmonized and avoid potential confusion in messaging, information and guidance. Adapt these resources to national contexts, using social and behavioural insights gained during the response. This ensures that information is responsive to community needs and issues.
Short animated video, Cholera – You Can Fight It Too
English: https://www.youtube.com/watch?v=8-sqticNg5o
Somali: https://www.youtube.com/watch?v=wnyc_6lRoOQ&t=170s
Cholera poster, animated video and infographics
English and Arabic: http://www.emro.who.int/health-topics/cholera-outbreak/information-resources.html
Community flipchart (pictorial) Protecting Ourselves from Cholera
English: https://www.unicef.org/zimbabwe/media/1776/file/Protecting%20Ourselves%20From%20Cholera%20(Cholera%20Flip%20Chart).pdf
Key messages and other information products and resources are available through the Global Task Force on Cholera Control (GTFCC) website
English: https://choleraoutbreak.org/book-page/appendix-8-key-messages-health-education
Sources
Cholera: introduction (Open WHO)
Country support platform: global task force on cholera control (CIFRC)
Cholera outbreak response field manual: global task force on cholera control
Water, sanitation and hygiene (CIFRC)
Reducing the spread of cholera in the community: global task force on cholera control