Prevention and control of cholera in complex emergencies in Sub-Saharan Africa: evaluating the effectiveness of water, sanitation and hygiene interventions used by Médecins Sans Frontières

Across Sub-Saharan Africa, an estimated 430 million people are at risk of cholera. Cholera will continue to challenge health systems in affected regions until access to safely managed water, sanitation and hygiene (WASH) services is expanded. Populations in many African countries experience concurrent humanitarian crises including natural disasters, civil conflict or war, malnutrition and food insecurity and economic crises or chronic poverty that further exacerbates the risk of both transmission and case-fatality of cholera. Efforts to control cholera across Sub-Saharan Africa have almost exclusively been reactive. Although essential, the variation in intervention strategies between epidemics and reliance on operational memory to implement emergency responses is not sufficient to guarantee success of a control programme. Controlling cholera comes with several disease-specific challenges due to its diverse transmission dynamics, the lack of specific symptoms and the insufficiency of any single intervention to sustainably control cholera. Case-area targeted interventions (CATI) are gaining traction on the premise that fast, localised response could significantly reduce transmission and control epidemics. Generation of evidence supporting the choice of interventions to include in CATI responses, and on interventions that could be systematically used by organisations for cholera preparedness and control in hotspots, is required. By integrating quantitative and qualitative methods for evaluating public health interventions, this thesis provides evidence on the effectiveness and implementation of a case-targeted WASH response to cholera in the Democratic Republic of Congo, working alongside Médecins Sans Frontières, UNICEF and the Ministry of Health, and reviews both normative guidelines for and previous experience of implementing cholera response programmes. After estimating the effect of a hygiene kit and health promotion distributed to cholera-case households, this thesis demonstrates how measuring and valuing the populations’ response to and the challenges among implementation bring new insights to the effectiveness and delivery of emergency, case-targeted cholera responses.