Now I want to talk a little bit about how we would manage outbreaks of communicable diseases. And here I've selected one particular disease, and we'll talk about that in a minute. But before we get there, let's look at this cycle. The cycle starts with preparedness. It starts with a realization that we may have a potential epidemic in this population. Now, if a population has been displaced from one place to another, we have to remember that many diseases that are present in the destination location are likely to reappear for this population who've entered this area. So if this is an area that's likely to have cholera, that's an area that's malarious, if it's an area with leishmaniasis traditionally, we should be prepared to see these diseases in the displaced population as well. In creating our surveillance system, this surveillance system should be tuned to be able to detect these diseases at the first appearance. And that surveillance system would be our alert system so we can find information that we're dealing with the consequence. And I like to just use the illustration of meningitis here. Because once that we have an alert that meningococcal meningitis is present in a community, we have only a very narrow window to decide whether we will do mass immunization against meningitis or not. And if we don't take that step to do mass immunization at the appropriate time, then that epidemic is going to escape us. And no amount of immunization is really going to change that epidemic curve. And then we have an approach of collecting data, what kind of data do we need? Who, where, when, why, that typical group of epidemic and epidemiological criteria. Then we analyze the data, and we have to be able to analyze these data and turn them around very quickly to determine what our response should be in this kind of outbreak. And once that we're into the response, then the monitoring and documentation, the monitoring and evaluation is critical to tell us. Are we really doing the right kind of thing, or are we missing something? Is there a population, is there a risk factor that somehow we have not addressed? And all of this should feed back into our preparedness, again so that we'll be better set next time we have an outbreak to deal with these conditions. I want to use this example of cholera. Now, cholera is a waterborne disease except where there's a high density of populations. And then it can become a person-to-person condition. There are not many times that this has happened. But we've seen this to some extent with the flooding in Pakistan, which is now becoming a fairly regular event. And we certainly saw this with the outbreak of cholera in Goma after the disasters and genocide in Rwanda. There can be major loss of life, particularly if the health system is not prepared. Now, the most prepared health system in the world to cholera is in Bangladesh. And the rest of the world has very well benefited and profited from what they've learned from the experience of Bangladesh in being able to manage cholera outbreaks in a community. Cholera is endemic in an area, then we'll see it in the displaced population. There's also some seasonal variations. In much of the world, cholera is a disease of the rainy season. In which infection can be spread by standing water and by latrines that have been flooded and overcome. We have a photograph on this slide of a cholera ward with the intravenous fluids. And this is a cholera ward run by the International Committee of the Red Cross. So knowing that, you can pretty well assume that this is in some conflict-related situation. Since the International Committee of the Red Cross is focused very much on providing assistance in conflict situations. Now, on the next slide, we'll talk about the response and how a health system can manage this. And there's a photograph on this slide of a cholera treatment unit in Haiti. And this is a pretty standard-looking cholera unit. Many cholera patients can be managed just with oral rehydration solutions. And they can do this as outpatients alone. Do not even need to be admitted to the health facility. This was a major system that was used in Haiti. And this is something that was developed to its current high level of sophistication by the various groups in Bangladesh who are working with cholera, which is a constant condition there. Now, the attack rate for cholera is only 5%. So that means, of people susceptible, only 5% will develop cholera. Or we should say, will develop clinical cholera. There can be a large number of people. And there most certainly are a large number of people with cholera who do not have major symptoms. So you can see immediately, this is a major risk for spreading it into the population, exactly what happened in Haiti. The duration of a major outbreak is generally about a month. And this is interesting because in a month's time, nearly everybody who is susceptible to cholera is likely to be infected. Or at least the number of people that are needed to sustain an epidemic will have been infected within a month. And after that period of time, although cholera doesn't produce a lot of immunity, it does produce some short-term immunity. And that cholera outbreak will be broken in a month's period of time. There are those that require inpatient care of cholera. And those are the people that are really badly dehydrated. But these people can be hydrated fairly quickly, and the condition can be reversed. So these data from East Africa remind us that you can have a facility like this. But on average, people need to stay here only three days on average. Because after that period of time, they'll be well enough hydrated to be managed outside the facility. On average, people will need to have 10 to 15 liters of oral rehydration solution. That's a lot of fluid, so you need to have plenty of good supply of water and plenty of oral rehydration salts to compose these fluids. On average, the people who are admitted to hospitals will require 8 liters per person of intravenous fluids. In this picture, we see the diagram of a typical cholera treatment unit. And this comes from Doctors Without Borders, or MSF. And this organization has probably had the greatest experience of anyone in treating outbreaks of cholera. So they have reduced this process to a very standardized procedure. And one that has been responsible for saving lots of lives. So if we look at these numbers, number 1 shows a tent with some cots in that tent. This tent is for people who do not require intravenous fluids, can be managed with oral rehydration fluid. Yet somebody needs to be there pushing the fluids all the time, encouraging people to take it. Tent number 2 has people who require intravenous fluids. And you can see a typical cholera cot there with a hole in it and a bucket underneath to measure the output from cholera. And number 3 emphasizes the importance of ORS, of the salts that are necessary to compose the oral rehydration fluid. And the source of water on item number 4, the tank there, critically important. And then, of course, having adequate latrines so the cholera can be contained and not be spread person to person. Now, you might not think that cholera is easy to spread person to person in a health facility. But I could tell you of a major teaching hospital in East Africa where cholera was being brought in by visitors to the hospital ward and being spread around to patients in this tertiary healthcare facility. So don't discount its ability to infect within the health facility. Number 6 are the incinerators to burn infectious materials. And you can imagine a lot of infectious materials are going to be created. From sheets to other kinds of materials here that have to be burned. And number 7 is the entrance, actually. And there's somebody with a spray with chlorine to try to disinfect people coming in. And a shower on the right-hand side for health workers to shower before they leave the facility.
