Cholera Outbreak Training: Evaluation from Rural Zimbabwe and Next Steps

The Cholera Outbreak Training and Shigellosis program (COTS program) is a to-the-point guideline for the management of cholera outbreaks in resource-poor settings. The COTS program is an interactive eBook (www.cotsprogram.org) designed for rapid training during outbreaks, as well as a tool for public health educators. COTS is based on established protocols developed at the WHO and the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B). During the 2008-9 Zimbabwe cholera outbreak, COTS was successfully rolled-out by USAID and the WHO. Despite the strengths of the program, there were unique challenges in Zimbabwe that included a strain that equitably attacked all age groups, a population that proved to be immunologically naïve, and patients spread across an expansive, difficult geography. These factors, paired with the complete collapse of the healthcare system, likely contributed to the case fatality rate (CFR) of 5% -- a rate five times above the accepted CFR. Based on our clinical experience at a rural Zimbabwean clinic, we make recommendations herein to update COTS, improve NGO Aid Kits, and cater to the clinical needs of populations co-infected with HIV. In addition, we explore options for transferring this experience back to the laboratory to optimize the field application of current vaccine development.