The use of WHO Guidelines for Cholera Control must be promoted, with training sessions where necessary for local health professionals, and unaffected islands. Simple fact sheets for health professionals can help to improve surveillance and control activities, including patient management.

There must be a technical public health professional responsible for the coordination of communicable disease surveillance at the State level—with clearly defined responsibilities for surveillance and control activities, including epidemiological investigation and interpretation of the outbreak.

The Department of Health should collect data about persons affected by the outbreak—the traditional epidemiological triad of "time, place and person". Data should include clear information about personal identification (including father’s and mother’s names), place of residence, and date of presentation. It may be useful to collect additional data for evaluation purposes, such as secondary attack rates, dates of chemoprophylaxis, etc.

For the purpose of a more specific monitoring of the epidemic, the WHO case definition "acute watery diarrhoea with or without vomiting in patient aged five year or more" should be used. This definition is for surveillance purposes only, and should not impact clinical management of patients under five years of age.

The Department of Health may want to collect additional information about the magnitude of the outbreak, such as numbers of cases identified through active case finding. To quantify the impact of this epidemic, details of people suspected to have died from cholera should be recorded in a case series.

Once the diagnosis is confirmed the Department of Health should share surveillance data, every week, with other Islands through PACNET.

The Department of Health should confirm the biotype of V. cholerae responsible for this outbreak with the World Health Organization Philippines Regional Office (WPRO) and Secretariat for the Pacific Commission (SPC). The biotype is likely to be El Tor, meaning that many infections will be sub-clinical.

The local or national Hospital should be able to monitor antibiotic resistance of V. cholerae, until the end of the epidemic. Once diagnosis is established, during the epidemic, clinicians should only collect faecal swabs every 2-3 weeks on a series of patients (20-30) aged 5 years and older presenting to health facilities to verify the diagnosis and monitor V. cholerae antibiotic sensitivity. All samples should be placed in Cary-Blaire media to ensure the best conditions for transportation.

As the end of the epidemic approaches, the local or national Hospital should systematically test every specimen from patient aged five years and over who present to inpatient and outpatient/emergency departments with acute watery diarrhoea. The end of the epidemic may be defined as, when the laboratory has not identified V. cholerae from any stools specimens or rectal swabs over 10 consecutive days (two incubation periods).

The Department of Health and local and national Hospitals needs to remain vigilant about following-up cases of acute watery diarrhoea following the end of the outbreak, as point source outbreaks due to cholera may still to occur.

The Health Department should insure that a proper professional agency (e.g., EPA) monitors local foods and environmental samples for V. cholerae in the months following the outbreak.

Clear patient management guidelines must be present and used at all levels of health services susceptible to deal with cholera (see Guidelines).

Use of ORS (or equivalent) should be encouraged, as it is the most effective treatment for cholera and other diarrhoeal diseases.

Severely dehydrated cases should be treated with IV fluids (Ringer Lactate solution is the first choice). The use of antibiotics should only be restricted to severe cases, as misuse of antibiotics can easily lead to the emergence of resistance.

It is important to strengthen the outbreak control efforts by establishing "primary care teams" to actively find cases of suspected cholera in the population. This can improve early case detection, the implementation of appropriate control measures, limit the transmission of disease, and improve case-fatality by early treatment of those cases.

Selective chemoprophylaxis (e.g., for household contacts of cholera cases) should not be recommended. In cases where selective chemoprophylaxis may be presented as potentially useful [when the probability of secondary transmission is high, i.e. where the main household carer is affected, or there is a high secondary attack rate (>1:5 cases following index case)] the situation still needs to be carefully assessed before deciding to use chemoprophylaxis.

Chemoprophylaxis, altogether, should not be recommended, in any situation.

Health education about cholera must include information on disease transmission and prevention (avoiding raw food, food handling, and water treatment), personal hygiene, symptoms and measures to be applied at home, such as rehydration with ORS.

Schools are an important vehicle for health education, even where sanitary conditions or facilities are not ideal. Conditions at school may reflect conditions at home and are an appropriate environment to teach about hygiene. Students should be discouraged from sharing food at school. In outbreak settings, schools should only be closed where there is a strong epidemiological association between school attendance and infection.

Community leaders must be consulted and involved in all activities to control the outbreak, particularly for provision of appropriate health education.

To control waterborne transmission of cholera, it is important to improve aggressive house-to-house training about treating drinking water with chlorine and boiling.

Community water supplies should be disinfected, first with hyperchlorination, then with regular or continuous chlorination. It may be useful to investigate disinfection of shallow wells using slow-release chlorine.

Water supplies should be tested for traditional bacteriological indicators on a more frequent basis.

Culturally appropriate toilets should be installed where possible to take into account local preference for squatting, as opposed to sitting.

Travel restrictions to neighboring islands should not be introduced in the acute phase of a cholera outbreak. They may, however, be useful for small islands where there are no appropriate health services to deal with cholera, or where food and water supplies are susceptible to contamination. Health services, hygiene and sanitation on these islands must be improved in order to be able to prevent and control cholera.

Passengers should not carry non-commercial food out of cholera-infected areas, as these can cause point source outbreaks. These outbreaks can severely impact exports from the originating country. The National and Local Authorities need to seriously consider ways to minimize passengers transporting non-commercial food from island-to-island.

National and International trade should not be restricted during cholera outbreaks. National and State governments should follow the World Health Organization Guidelines for Cholera Control.

The Health Department should encourage every district/province/states to conduct active surveillance for diarrhoeal diseases, and be prepared to implement control activities as soon as cholera is suspected. Clinicians should immediately report and any case of acute watery diarrhoea suspected as cholera. These cases must be properly and urgently investigated. States should monitor, at least weekly, acute diarrhoea cases of any type with appropriate case investigation.

It is important that other unaffected areas prepare by:

1. securing stocks of ORS and IV fluids and equipment for rehydration, antibiotics active against cholera, chlorine and disinfectant,
2. reminding clinicians that ALL patients with moderate dehydration should primarily be given ORS rather that IV fluids,
3. chlorinating water for domestic use or advising people to boil water vigorously for one minute, and assessing water supply systems,
4. providing suitable facilities for sanitary human waste disposal in the communities,
5. training health personnel in clinical and lab investigation, case management, and preventive measures,
6. providing health education/awareness activities to the communities, starting with the basic advice—"Cook it, peel it or leave it !",
7. identifying a laboratory that can rapidly confirm the organism at the beginning of the epidemic, either at national or regional level through the Pacific Public Health Surveillance Network public health laboratory network (PPHSN LabNet), and
8. ensure that proper stocks of Cary-Blaire media are available for laboratory samples transportation.

All cholera control measures must be continued until the epidemic is over. Immunization against cholera helps only if the other measures are in place.

Where multiple households use water from common shallow wells and tanks, it is important that these are chlorinated at the local community level.

If relevant, it is important to determine the reasons why cholera is stigmatised by many people, as it will assist in responding to future emergencies. It would also be useful to evaluate the Health Education provided during the outbreak, versus commonly held beliefs in the community.

There should be environmental "sentinel" surveillance for Vibrio cholerae established, where these organisms are likely to be found, e.g. estuaries with sewage overflows.

The responsibilities of the "Notifiable Disease Surveillance Coordinator" at National and sub-national levels should be clearly defined, especially in case of an epidemic, in order to maximize the benefits of rapid, evidence-based decision making. It is suggested this person becomes the leader of the investigation and response team(s), and the technical reference person during epidemics or outbreaks.

5 Further information and emergency contacts

 Dr Tom Kiedrzynski at SPC Noumea

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