18 Water, sanitation and hygiene (WASH) in cholera treatment centres in emergencies

18
TECHNICAL NOTES ON DRINKING-WATER, SANITATION AND HYGIENE IN EMERGENCIES
Water, sanitation and hygiene (WASH) in
cholera treatment centres in emergencies
Cholera Treatment Centres (CTCs) or smaller Cholera
Treatment Units (CTUs) may be established during outbreaks
of cholera or other severe diarrhoeal diseases to isolate and
treat patients and help control the spread of disease. CTCs
and CTUs are environments with a high concentration of
pathogens and a full range of WASH interventions is required
to limit the spread the spread of disease within the facility and
to the surrounding environment.
The importance of WASH in
CTCs and CTUs
During outbreaks of cholera, or other
diarrhoeal diseases, health-care
facilities may quickly become
overcrowded and insanitary as a
result of rises in patients. A quick
response is required to strengthen
standards of WASH in order to
protect staff, carers, and patients,
and to avoid contaminating
communities around the facility.
General principles
The following principles are based on
the WHO publication WASH in
health-care facilities in emergencies
(2012). All the interventions should
be carried out to an acceptable
standard so infection routes in the
health-care setting are blocked.

Organise space and activities,
and control movement. The layout
of the CTC should be planned
around the pathway taken by the
patient through the facility.

Movement between each section
in the CTC should be controlled to
reduce the spread of contamination.
The main strategies for restricting
movement include:
 Providing drinking-water,
handwashing points, toilets and
showers in each section.
 Providing clear information, with
repeated explanation to all new
patients and carers.
 Posting guards at key locations,
particularly the entrances, exits
and central passage between
the sections.
Manage entrances and exits.
Ensure that entrances and exits to
the CTC have functional foot baths
or chlorine solution sprayers,
handwashing stations and
permanent guards. This may
involve providing basic equipment
(chlorinated handwashing stations,
soap, backpack sprayers, chlorine,
buckets, mixing spoons, bowls)
and training guards to limit the
number of people entering the
area in addition to ensuring
anyone entering or leaving
disinfects their feet and washes
their hands with soap.

 Establish a dedicated CTC with
its own WASH services. During
outbreaks of highly infectious
diseases, it is recommended that
patients are managed in CTCs
and CTUs. These isolated centres
should ideally be located away
from the rest of the rest of the
health-care facility. Ensure that
CTCs or CTUs are fully fenced
and have their own dedicated,
functional and safe toilets,
showers, laundry, changing area,
and health-care waste disposal
facilities.
TECHNICAL NOTES ON DRINKING-WATER, SANITATION AND HYGIENE IN EMERGENCIES
18.1
WASH in cholera treatment centres in emergencies
Ensure all water supplies are
chlorinated regardless of use.
All water supplies during times or
risk of diarrhoeal disease
epidemics must be chlorinated so
there is a free chlorine residual
level of at least 1.0 mg/l at the
point of consumption. This is
higher than normal and provides
additional protection in a
contaminated environment. For
effective chlorination, the turbidity
should be less than 5NTU.
Residual free chlorine levels

should be checked daily with a
colour comparator (e.g. pool
tester) and it may be necessary to
re-chlorinate if levels drop during
storage. It may also be necessary
to re-chlorinate municipal (piped)
water supplies if they are not
adequately chlorinated.
out using simple equipment, such 
as a drum of water equipped with
a tap, a basin for wastewater and
soap. Wastewater should be
collected and disposed of in a
soakaway that does not
contaminate the groundwater. If
available, healthcare workers may
use an alcohol-based hand-rub
instead of soap to routinely clean
their hands between patient
contacts, if hands are not visibly
dirty.

Provide sufficient quantities of
safe water. A large quantity of
water is required in a CTC, for
handwashing, cleaning,
disinfecting, bathing and
laundering. In most cases, plan for
60 litres per patient per day and 15
litres per carer per day. It is very
important there is never a
shortage of water. Ensuring there
is sufficient water may require
interventions to repair the water
supply (or power or fuel supply if
the water system requires power
or fuel to function), install basic
emergency water treatment units,
or organise water tankering. It may
also involve the installation of
temporary water storage facilities
such as demountable steel water
tanks, bladder tanks or
polyethylene tanks. There should
be at least three days quantity of
water stored in a closed tank in
case of a break in supply.
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
Handwashing facilities.
Handwashing with soap and
chlorinated water (see table 18.1
below) is an effective barrier to
cholera transmission. Ensure that
there are sufficient numbers of
functional handwashing facilities
with chlorinated water, soap and
safe wastewater disposal next to
toilets and at every entrance and
exit. Handwashing may be carried

Hygiene promotion. Ensure that
hygiene educator inform patients,
and carers of essential hygiene
behaviours repeatedly, starting
within 30 minutes of arrival and
then continuously throughout their
visit. Staff, patients and carers
should be reminded to wash their
hands at these critical times:
When entering/leaving the CTC.
Before preparing food.
Before eating.
After going to the toilet.
After cholera patient contact.
After handling stools and vomit.
After cleaning and disinfecting
contaminated surfaces/objects.
TECHNICAL NOTES ON DRINKING-WATER, SANITATION AND HYGIENE IN EMERGENCIES
Containment and disposal of
excreta. An average of 1 toilet per
20 people should be provided
separated for men and women
with separate toilets for staff. All
toilets should be regularly cleaned
and disinfected. Wastes from
patients with uncontrollable
diarrhoea and vomiting should be
collected in graduated basins
under the bed (to be monitored by
medical staff). These recipients
should be emptied and rinsed
regularly with half a cup of 2%
chlorine solution added before
reuse. The waste should be
disposed of in a specific toilet used
only for this purpose. All latrines
and waste pits must be located at
least 10m downhill of water
sources and so there is at least
2m between the bottom of the pit
and highest seasonal groundwater
level. If this is not possible seek
specialist advice. If the facility
uses septic tanks, check that the
effluent does not contaminate
groundwater or flow out of the
facility. If septic tanks are emptied,
ensure that the sludge is handled
and disposed of safely. Seek
specialist advice on this.
18.2
WASH in cholera treatment centres in emergencies

Cleaning and disinfecting.
Regular cleaning and disinfection
of contaminated surfaces and
objects in the CTC is an essential
barrier to the spread of
contamination. Ensure that the
CTC has separate cleaning
equipment (detergent, mops,
buckets, sprayers, chlorine) for
each section. Consider installing
plastic sheeting to facilitate
cleaning in temporary facilities.
Table 18.1 shows the chlorine
solutions used for disinfection and
the quantities of chlorine products
to make them. The procedures for
cleaning and disinfection in the
CTC are as follows:
 Floors: mop with 0.2% chlorine
solution twice per day.
 Beds: wipe with 0.2% chlorine
solution daily and between
patients.
 Spills of stools and vomit:
mop up and disinfect with 2%
chlorine solution.
 Clothes and sheets: soak in
0.2% chlorine solution for 10
minutes then rinse, wash as
normal and dry on a line.
 Cooking and eating utensils:
rinse in 0.05% chlorine solution 
then wash and dry on racks.
 Shoes and feet: disinfect by
spraying or walking through a
footbath containing 0.2%
chlorine solution when moving
between sections or when
entering and leaving the CTC.
Change footbaths twice a day
as chlorine loses its disinfection
properties in muddy water.
 Hands: wash with soap and
chlorinated water or spray with
0.05% chlorine solution on
entering and leaving the CTC.
 Dead bodies: wash with 2%
chlorine solution, and block
orifices with cotton wool soaked
in the same solution.
CTC Health-care waste
management. Ensure that all
infectious wastes, sharps, excreta
and body fluids created in the
isolation area are disinfected with
2% chlorine solution and disposed
safely within the isolation area.
Ensure safe segregation,
collection, transport, treatment and
disposal of all CTC health-care
waste. Consider providing
sufficient numbers of durable and
safe colour-coded containers in all
parts of the CTC where healthcare wastes are generated,
creating a dedicated waste
disposal zone within the CTC, and
ensuring staff have appropriate
personal protective equipment and
are trained in waste management.
Train guards to ensure that no
material acting as a potential
cholera pathogenic reservoir is
carried out of the CTC e.g. food,
food containers, or soiled clothing.
Table 18.1 Preparation of 2%, 0.2%, and 0.05% chlorine solutions
Use the following table to calculate the quantity of various chlorine generating products required to prepare
the three main disinfecting solutions for a Cholera Treatment Centre or Cholera Treatment Unit.
Solution ‘A’
2% Chlorine
Solution ‘B’
0.2% Chlorine
Solution ‘C’
0.05% Chlorine
(Use to disinfect vomit,
feaces, corpses)
(Use to disinfect floors,
walls, beds, feet, clothes)
(Use for handwashing and
disinfecting eating utensils)
Calcium hypochlorite (HTH)
at 70% active chlorine
30g per litre
(2 level dessert
spoons per litre)
3g per litre
(2 level dessert
spoons per 10 litres)
0.7g per litre
(1/2 level dessert
spoon per 10 litres)
Chlorinate lime
at 30% active chlorine
60g per litre
(4 level dessert
spoons per litre)
6g per litre
(4 level dessert
spoons per 10 litres)
1.4g per litre
(1 level dessert
spoon per 10 litres)
20 tablets per litre
2 tablets per litre
5 tablets per 10 litres
166ml per litre
16ml per litre
4ml per litre
500ml per litre
50ml per litre
12ml per litre
NaDCC Tablets
at 1g active chlorine per tablet
Sodium hypochlorite concentrate
at 15% active chlorine
Sodium hypochlorite (bleach)
at 5% active chlorine
TECHNICAL NOTES ON DRINKING-WATER, SANITATION AND HYGIENE IN EMERGENCIES
18.3
WASH in cholera treatment centres in emergencies

Personal Protective Equipment 
(PPE). Personal protective
equipment should be provided to
all staff who may be exposed to
contamination in the CTC. Medical
staff should have the correct PPE
for their activities. WASH staff
carrying out specific tasks such as
cleaning or health-care waste
management should also have
appropriate PPE such as gloves,
masks, overalls and boots.

Overcrowding. CTCs may quickly
become overcrowded due to an
unanticipated rise in admission.

Ensure that wards are not
overcrowded and there is at least
1-2m between beds to reduce
transmission risks. Ensure that
there is a maximum of one carer
per patient. Work with the facility
to identify and establish new
locations for temporary CTC
overflow such as car parks,
courtyards, or spare wards.

Wastewater disposal.
Wastewater from handwashing,
laundry, cooking and cleaning
should be disposed in soakaway
pits. It may be easier to build small 
soakaway pits to serve individual
points. Contaminated wastewater
should not be allowed to mix with
rainwater and run-off and should
not be allowed to flow out of the
CTC. If working in or next to an
existing health facility, the
wastewater disposal system may
be used if it is functioning
correctly.
Rainfall and run-off. The CTC
should not be located in an area
that is exposed to flooding. A
drainage channel should be dug
around the upper edge of the site
to divert rainwater away from the
site and provide extra protection.
Ensure that rainwater is prevented
from entering any areas of the
CTC, and does not carry
potentially infectious material away
from the CTC into the rest of the
health-care facility or the
community.
Disease vector control. Flies,
mosquitoes and rats may become
a nuisance to patients and staff,
and a source of infection in the
CTC, and should be carefully
controlled. Various species of

mosquito favour the shady and
humid conditions often found in
cholera-treatment wards and
cholera patients are vulnerable to
infection by malaria, dengue fever
and other mosquito-borne
diseases. If there are problems
with disease vectors seek
specialist advice.
Food safety. In some cases, food
may be prepared at the healthcare facility. In all cases, it is
essential that all food that is
stored, prepared, and consumed
by patients, staff and carers is
safe. Ensure proper handwashing,
food handling is carried out with
utmost cleanliness, food is
thoroughly cooked, and safe water
is used in food preparation.
Human resources. Managing
WASH in a CTC is a very intensive
activity, requiring a number of
specialist roles and overall
supervision. The following posts
need to be permanently (24 hours)
filled in a typical CTC:
 1 x WASH supervisor / officer
 3 x Cleaners
 2 x Laundry workers
 6 x Sprayers / guards
 2 x Water carriers
 1 x Chlorine-solution makers
 1 x Waste technician
 1 x Hygiene promoter
Recruitment and training needs to
be organised very quickly at the
start of an outbreak, and refresher
training is important, to develop
skills and improve the quality of
work.
Further information
WHO (2012) WASH in health-care facilities in
emergencies. World Health Organization, Geneva.
MSF (2004). Cholera Guidelines. Second Edition.
Médecins Sans Frontières, Paris.
WHO (2004). Standard precautions in health-care: aide
memoire. World Health Organization, Geneva.
Water, Sanitation,
Hygiene and Health Unit
Avenue Appia 20
1211 Geneva 27
Switzerland
WHO (2004). Cholera outbreak: assessing the outbreak
response and improving preparedness. World Health
Organization, Geneva.
ACF (2005). Water, sanitation and hygiene for populations
at risk. Action Contre la Faim, Paris.
Telephone:
Telephone (direct):
Fax (direct):
Email Coordinator:
URL:
+41 22 791 2111
+41 22 791 3555/3590
+41 22 791 4159
bosr@who.int
www.who.int/water_sanitation_health
Prepared for WHO by Ben Harvey
Editorial contributions by John Adams, Dominique Maison, and Jean McCluskey
Line illustrations by Chandan Dhoj Rana Magar
© World Health Organization 2012 All rights reserved. All reasonable precautions have been taken by the World Health Organization to verify the information contai ned in
this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and
use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.
18.4