Implementation considerations in case-area targeted interventions to prevent cholera transmission in Northeast Nigeria: A qualitative analysis

Abstract

Cholera outbreaks primarily occur in areas lacking adequate water, sanitation, and hygiene (WASH), and infection can cause severe dehydration and death. As individuals living near cholera cases are more likely to contract cholera, case-area targeted interventions (CATI), where a response team visits case and neighbor households and conducts WASH and/or epidemiological interventions, are increasingly implemented to interrupt cholera transmission. As part of a multi-pronged evaluation on whether CATIs reduce cholera transmission, we compared two organizations’ standard operating procedures (SOPs) with information from key informant interviews with 26 staff at national/headquarters and field levels who implemented CATIs in Nigeria in 2021. While organizations generally adhered to SOPs during implementation, deviations related to accessing case household and neighbor household selection were made due to incomplete line lists, high population density, and insufficient staffing and materials. We recommend reducing the CATI radius, providing more explicit context-specific guidance in SOPs, adopting more measures to ensure sufficient staffing and supplies, improving surveillance and data management, and strengthening risk communication and community engagement. The qualitative results herein will inform future quantitative analysis to provide recommendations for overall CATI implementation in future cholera responses in fragile contexts.

A Quantitative and Qualitative Program Evaluation of a Case-Area Targeted Intervention to Reduce Cholera in Eastern Democratic Republic of the Congo

“…From interviews, we also learned that one CATI implementer encountered mistrust and hesitancy toward CATI activities in target areas, particularly at rural sites. This has been reported previously in CATI delivery in Nigeria [30]. Notably, while CATI implementers stated that they experienced distrust in communities regarding household disinfection, none of our CATI recipients discussed this.…”

“…Household spot checks and CATI recipient and implementer interviews indicated major challenges with the delivery of WASH intervention materials. Most studies of CATIs and other cholera rapid response delivery programs have reported a variety of challenges with the complete delivery of WASH materials, including logistical and financial constraints [30,33,49]. Incomplete delivery of WASH materials has the potential to both decrease the effectiveness of a CATI and to decrease trust between recipients and CATI teams, as has been reported previously [30].…”

“…Most studies of CATIs and other cholera rapid response delivery programs have reported a variety of challenges with the complete delivery of WASH materials, including logistical and financial constraints [30,33,49]. Incomplete delivery of WASH materials has the potential to both decrease the effectiveness of a CATI and to decrease trust between recipients and CATI teams, as has been reported previously [30]. Before cholera outbreaks, funding, implementation, and Ministry of Health partners should work together to source adequate funding and supplies.…”

“…Even though CATIs are recommended as a cholera control strategy globally, there are a limited number of published studies evaluating the effectiveness of this approach in increasing WASH behaviors [25,26,[30][31][32][33][34]. Additionally, only a few articles have utilized qualitative interviews with CATI recipients to tailor intervention design and delivery [33], and RCTs evaluating the impact of CATIs on cholera are rare [19,27].…”

Case-area targeted interventions during a large-scale cholera epidemic: A prospective cohort study in Northeast Nigeria

“…Previously published qualitative research from this study and reviews by UNICEF and Médecins Sans Frontières identified implementation challenges that may mediate CATI effectiveness such as high caseloads, incomplete line lists, stockouts, inadequate staffing, insufficient transportation, household refusals, security constraints, and high population density [ 14 , 52 , 53 ]. In Borno, the high population density resulted in cholera incidence that was 3 and 5 times greater than in Adamawa and Yobe, respectively, and translated into more households in a 150 m radius and increased travel time.…”