NATIONAL CHOLERA CONTROL PLAN (NCCP)

FOR
BANGLADESH

2019 - 2030

Communicable Disease Control

Directorate General of Health Services
Health Service Division, MOH&FW
Bangladesh

1
FOREWORD

Cholera has now become a global public health threat with its resurgence as it continues to affect 47
countries with an estimated 2.9 million cases and 95,000 deaths globally each year. The disease is
endemic in Bangladesh, causing outbreaks and epidemics. It is however now believed that the disease
can be controlled in a multi-sectoral approach using oral cholera vaccine (OCV) and implementation
of improved water, sanitation and hygiene (WASH) practices.

The Global Task Force on Cholera Control (GTFCC), WHO has launched ‘Ending Cholera: A Global
Roadmap to 2030’ aiming for at least 90% mortality reduction in 47 endemic countries. With the
commitment of cholera affected countries, technical partners and donors as many as 20 countries
could eliminate the disease transmission in this timeline. This goal can be achieved by strengthening
preparedness, early case detection and quick response to contain cholera outbreaks using OCV as well
as by having an implementation plan for improving WASH services. OCV can also be used to control
endemic situation.

The Government of Bangladesh affirms its commitment to eliminate cholera in a well-coordinated

effort by mobilizing all concerned sectors towards a good planning for effective interventions
facilitated by the Ministry of Health and Family Welfare (MOHFW). This will result in implementing
the National Cholera Control Plan (NCCP) for Bangladesh prepared with the technical and financial
support of WHO, which will be used as guiding document to ensure that oral cholera vaccine is
delivered to the target population putting in place effective surveillance system and cholera case
management, social mobilization and community engagement with improved WASH services.

With committed leadership and adequate funding from the government and partners, it is feasible to
eliminate cholera from Bangladesh.

Working in combination with related ministries, development partners, donors and other stakeholders
from relevant sectors to commit for achieving the implementation of the multisectoral cholera
elimination plan for Bangladesh will be executed in order to stop transmission of cholera in the
country with no further public health threat by 2030.

…………………………………………

(Name of the signatory)

2
 List of Contributors

Advisors:

1. Professor (Dr.) Abul Kalam Azad, Director General, DGHS

2. Professor (Dr.) Nasima Sultana, Additional Director General (Admin), DGHS

Coordinator:

Professor (Dr.) Sanya Tahmina, Director, Disease Control, and Line Director, Communicable
Disease Control (CDC), DGHS

Members:

1. Dr. S.M. Golam Kaisar, Deputy Program Manager, ARC, VH & Diarrheal Disease Control,
CDC, DGHS
2. Dr. S.M. Shahriar Rizvi, Microbiologist, CDC, DGHS
3. Dr. Mustufa Mahmud, Evaluator, CDC, DGHS
4. Dr. Iqbal Ansary Khan, Principal Scientific Officer, IEDCR, DGHS
5. Dr. Jubayer Ahmed, Medical Officer, EPI-HQ, DGHS
6. Israfil Hossain Akanda, Executive Engineer, MODS Zone
7. AHM Khalequr Rahman, Executive Engineer, , Department of Public Health Engineering
8. Dr. Sanjida Islam, Assistant Health Officer, Dhaka South City Corporation
9. Dr. Mahmuda Ali, Assistant Health Officer, Dhaka North City Corporation
10. Dr. Firdausi Qadri, Senior Scientist, icddr,b
11. Dr. Ashraful Islam Khan, Scientist, icddr,b
12. Dr. Muhammad Shariful Islam, Project Coordinator, icddr,b
13. Dr. Fahima Chowdhury, Project Coordinator, icddr,b
14. Dr. Md. Mahbubur Rashid, Assistant Scientist, icddr,b
15. Dr. Tajul Islam A Bari, Consultant, IDD, icddr,b
16. Md. Shofiqul Alam, WASH Specialist, UNICEF
17. Dr. Nurullah Awal, Health Advisor, WaterAid
18. Dr. Hasan Mohiuddin Ahmed, NPO, Surveillance, WHO
19. Dr. Shamsul Gafur Mahmud, NPO, WASH & Environmental Health, WHO
20. Dr. Md. Tazul Islam, National Consultant-Cholera Control, WHO

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 Contents
Glossary .................................................................................................................................................. 7
Executive Summary ................................................................................................................................ 8
1. Introduction .................................................................................................................................... 14
The Goals and Objectives of NCCP ..................................................................................................... 15
1. 1 Situation analysis ....................................................................................................................... 16
1.1.1. Cholera surveillance in Bangladesh .................................................................................... 16
1.1.2 Water, Sanitation & Hygiene (WASH) Status ..................................................................... 19
1.1.3 Health Care System .............................................................................................................. 20
1.1.4. Health Care Delivery .......................................................................................................... 21
1.1.5 Current Cholera Containment Situation in Bangladesh ....................................................... 21
1.2 Strength, Weakness, Opportunity and Threat (SWOT) Analysis ............................................... 22
2. Strategies for Cholera Elimination .................................................................................................... 23
2.1 Key Strategic Activities (2019- 2030) .................................................................................. 23
2.1.1 Short term activities (2019-2021) ........................................................................................ 23
2.1.2 Midterm Activities (2022– 2025) ........................................................................................ 24
2.1.3 Long term activities (2025- 2030): ...................................................................................... 25
3. The strategic approaches for NCCP .................................................................................................. 25
3.1 Strategic approach 1: Sustainable cholera surveillance system .................................................. 25
3.2 Strategic approach 2: Cholera case management ........................................................................ 36
3.3 Strategic approach 3: Oral Cholera Vaccination......................................................................... 37
3.4. Strategic approach 4: Increase the access to safe Water, sanitation and Hygiene intervention . 40
3.5. Strategic approach 5: Coordination and monitoring through multi-sectoral approach .............. 47
3.6. Strategic approach 6: Advocacy Communication and Social Mobilization (ACSM)................ 54
4. Implementation of National Cholera Control Plan for Bangladesh (NCCP) .................................... 56
4.1. Inclusion in Sector Wide Plan .................................................................................................... 56
4.2. Implementation Framework ....................................................................................................... 56
4.3. Implementation Targets and Activities for cholera control ....................................................... 57
4.4. Potential risk and mitigation plan .............................................................................................. 59
4.5 Monitoring Framework ............................................................................................................... 60
4.6 Implementation Timeline ............................................................................................................ 61
4.8. Program Evaluation ................................................................................................................... 62
5. References ......................................................................................................................................... 63

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 ACRONYMS AND ABBREVIATIONS

AMR : Antimicrobial Resistance

AWD : Acute Watery Diarrhea
BCC : Behavior Change Communication
BDHS : Bangladesh Demography and Health Survey
BHE : Bureau of Health Education
CC : Community Clinic
C4D : Communication for Development
CDC : Communicable Disease Control
CFR : Case Fatality Rate
CSFP : Cholera Surveillance Focal Person
CS : Civil Surgeon
DC : Disease Control/Divisional Coordinator
DCC : Dhaka City Corporation
DSCC : Dhaka South City Corporation
DNCC : Dhaka North City Corporation
DGFP : Directorate General of Family Planning
DGHS : Directorate General of Health services
DHIS : District Health Information System
DPHE : Department of Public Health Engineering
EPI : Expanded program on Immunization
EWARS : Early Warning, Alert and Response System
FDMNs : Forcibly Displaced Myanmar Nationals
FWA : Family Welfare Assistant
GoB : Government of Bangladesh
GTFCC : Global Task Force for Cholera Control
HA : Health Assistant
HED : Health Engineering Department
HPNSDP : Health Population Nutrition Sector Development Program
HSO : Hospital Surveillance Officer
icddr,b : international Centre for Diarrheal Disease Research, Bangladesh
IEDCR : Institute of Epidemiology, Disease Control and Research
IMCI : Integrated Management of Childhood Illness
JMP : Joint Monitoring Program for Water, Sanitation and Hygiene
LSO : Local Surveillance Officers
M&E : Monitoring and Evaluation
MODC : Medical Officer- Disease Control
MOHFW : Ministry of Health and Family Welfare
MOLGRD&C : Ministry of Local Government, Rural Development and Co-operatives
MIS : Management Information System
NCCP : National Cholera Control Plan
NCTF : National Cholera Task Force
NGO : Non-governmental organizations
OCV : Oral Cholera Vaccine
OP : Operation Plan
ORT : Oral Rehydration Therapy
PCR : Polymerase Chain Reaction
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RDT : Rapid Diagnostic Test
RFW : Result Frame Work
RMO : Residential Medical Officer
SBCC : Social and Behavior Change Communication
SFP : Surveillance Focal Point
SIMO : Surveillance and Immunization Medical Officer
SOP : Standard Operating Procedure
UHC : Upazila Health Complex
UH&FPO : Upazila Health & Family Planning Officer
UHFWC : Union Health & Family Welfare Center
UNICEF : United Nations International Children Fund
UNO : Upazila Nirbahi Officer
USC : Union sub-center
VPDs : Vaccine Preventable Diseases
WASH : Water, Sanitation and Hygiene
WASH FIT : Water and Sanitation for Health Facility Improvement Tool
WASA : Water Supply & Sewerage Authority
WHO : World Health Organization

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Glossary
Acute watery diarrhea (AWD): Acute watery diarrhea is an illness characterized by 3 or more loose
or watery (non bloody) stools within a 24-hour period.

Cholera Control: A reduction in the incidence, prevalence, morbidity or mortality of cholera cases to
a locally acceptable level (according to NCCP), and no longer considered as a public health problems
and continued intervention is required to maintain controlled situation.

Cholera elimination: Any country that reports no confirmed cases with evidence of local
transmission for at least three consecutive years and has a well-functioning epidemiological and
laboratory surveillance system able to detect and confirm cases.

Cholera-endemic area: An area where confirmed cholera cases, resulting from local transmission,
have been detected in the last 3 years. An area can be defined as any sub-national administrative unit
including state, district or smaller localities.

Cholera hotspot: A geographically limited area (e.g. city, administrative level 2 or health district
catchment area) where environmental, cultural and/or socioeconomic conditions facilitate the
transmission of the disease and where cholera persists or re-appears regularly. Hotspots play a central
role in the spread of the disease to other areas.

Cholera confirmed case: A suspected case with V. cholerae O1 or O139 confirmed by culture or
PCR.

Cholera suspected case: In areas where a cholera outbreak has not been declared, a suspected case is
any patient who has acute watery diarrhea and severe dehydration or Rapid Diagnostic Test (RDT)
positive case or died from acute watery diarrhea. In areas where a cholera outbreak is declared, a
suspected case is any person presenting with or dying from acute watery diarrhea.

Cholera Outbreak: A cholera outbreak is defined by the occurrence of at least one confirmed case
of cholera by culture or PCR and evidence of local transmission. Outbreaks can also occur in areas
with sustained year-round transmission. These outbreaks are defined by an unexpected increase in the
magnitude or timing of suspected cases over two consecutive weeks, with some cases being
confirmed by the laboratory. Investigate and respond to such increases appropriately through
additional outbreak response and control measure are required.

Hygiene: Hygiene refers to the conditions and practices that help maintain health and prevent spread
of disease including hand washing, menstrual hygiene management and food hygiene (JMP WASH)

Safely managed drinking water services: Improved water source located on premises, available
when needed, and free from microbiological and priority chemical contamination.

Safely managed sanitation services:

Use of improved facilities that are not shared with other households and where excreta are safely
disposed of in situ or transported and treated off site ( JMP report 2017)

Upazila (Sub-district): The upazilas are the second lowest tier of regional administration in
Bangladesh.

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Executive Summary
Bangladesh has made significant progress over the years in reducing diarrhea related deaths. Much of
it is due to the Government of Bangladesh’s political commitment, well established health nationwide
infrastructure, improved WASH services, well-trained health and WASH manpower, widespread
public awareness on cholera, cooperation from public representatives and key persons of the society.
Moreover, the International Centre for Diarrheal Disease Research, Bangladesh (icddr,b) in Dhaka has
a long history of carrying out research on diarrheal diseases with emphasis on cholera, and is playing
major role in reducing morbidity and mortality due to diarrhea. There is widespread awareness among
all segments of the population in the country on the use of oral rehydration solution (ORS) for
preventing dehydration in diarrheal disease in children and adults. Cholera disproportionately affects
populations who have poor access to WASH as well as those who are living in poverty. Nevertheless,
Bangladesh is one of the World Health Organization (WHO) recognized cholera endemic countries. In
more recent years, growing problems of climate change, urbanization, and population growth are
likely to increase the risk of cholera in high risk areas and susceptible populations in the country.

The Global Task Force on Cholera Control (GTFCC) has launched in 2017, a new strategy “Ending
Cholera-A Global Roadmap to 2030”2. The overall objective is to reduce the mortality resulting from
cholera by 90% by 2030. With the commitment of the cholera prone countries, technical partners, and
donors, as many as 20 countries including Bangladesh will need to make plans to eliminate cholera in
their settings by 20302, 7.

A long term multi-sectoral prevention and control strategy ensuring adequate access to cholera
vaccine, water and sanitation, social mobilization for health and hygiene promotion, surveillance, and
rapid appropriate case management are essential for reducing the morbidity and mortality of cholera
in endemic and epidemic contexts.

The National Cholera Control Plan (NCCP) for Bangladesh 2019-2030 is a cholera control strategy,
prepared to reach the cholera elimination goal in the stipulated time. However, system of cholera
surveillance is limited in Bangladesh. The plans for the reduction of mortality and morbidity of
cholera mentioned below have been set based on available surveillance data of IEDCR (Institute of
Epidemiology, Disease Control and Research) and icddr,b.

Bangladesh is an endemic country with one of the world’s highest burdens of cholera, with an
estimated 109,052 cholera cases annually while a population of 66,495,209 is at risk with an annual
incidence rate of 1.64/1,000 population5. The cholera cases in high-risk populations and cholera prone
areas may exceed 2/1,000 population (ranges 1-5) suggesting that an occurrence of 450,000
hospitalized cases and >1 million infections per year5. On the other hand, 56% population covered
with safely managed drinking water services, 47% covered with basic sanitation services while 40%

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people wash hands with soap8. Several studies have shown strong link between quality of WASH
services with cholera prevalence.

The burden of cholera in Bangladesh is estimated to be high based on information of hospitalization

due to acute watery diarrhea from the facility based surveillance data from the DGHS (Directorate
General of Health services). Limited culture confirmed data is available. Bangladesh started endemic
diseases surveillance including cholera with collaboration of IEDCR and icddr,b in 22 surveillance
sites covering overall administrative divisions of Bangladesh and the report showed highest burden in
Chittagong, Narayanganj, Comilla and Cox’s Bazar (7-14%) and the burden was low in Narsingdi,
Thakurgaon, Satkhira, Netrokona, Sunamganj and Chapai Nawabganj (1-2%).

Systematic surveillance of diarrheal patients in the Dhaka hospital of icddr,b was initiated from 1979
and the data shows high rates of cholera for the last 40 years with bi-annual peaks3, 4 during April to
May and August to September with lower rates in the winter months from November to January. This
surveillance shows 18-20% of culture confirmed cholera among admitted patients. More recently
surveillance in 22 sentinel sites of the country in the last four years (2014- 2018) by IEDCR & icddr,b
covering all administrative divisions has shown existence of culture confirmed cholera all over
Bangladesh.

Oral cholera vaccine (OCV) is considered as an important public health tool to control both epidemic
and endemic cholera globally. The OCVs is available in the World Health Organization (WHO)
stockpile from 2013 and over 30 million doses have been administered to control cholera in countries
in Africa, Asia as well as Latin America13. More recently, between 2017- 2018 large campaigns have
been carried out in Cox’s Bazar, Bangladesh among the Forcibly Displaced Myanmar Nationals
(FDMNs).

Cholera vaccine as outlined by the GTFCC should be used in a multi-sectoral cholera manner in
complement with Water, Sanitation and Hygiene (WASH), reinforced surveillance, social
mobilization and case management. These have been implicated as the most significant factors in the
causal pathway of cholera infection and transmission which also incur a remarkable economic loss. In
order to decrease the burden of cholera, multi-sectoral approach involving Ministry of Health and
Family Welfare (MOHFW), local government, WASH, and education will be integrated together to
attain the broader national goal of reducing cholera morbidity and mortality by 90% by 2030. To
practically achieve this objective, an aggressive vaccination scheme together with an implementation
plan for improved WASH interventions will remain a high-level policy priority.

Effective coordination among concerned government agencies, national multi-sectoral partners and
global partners is needed for achieving the elimination goal by 2030. Based on the NCCP strategy
document, the national control plan will proceed under the guidance of the MOHFW and will be
initiated by the Communicable Disease Control (CDC) unit of DGHS. Cooperation from the Ministry
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of Local Government, Rural Development and Co-operatives (MOLGRD&C) as well as the Ministry
of Education (MOE) and other related ministries, Water Supply & Sewerage Authority (WASA),
Department of Public Health Engineering (DPHE), Dhaka North City Corporation (DNCC) and
Dhaka South City Corporation (DSCC) are essential. The technical support of concerned
partners/donors, such as World Health Organization (WHO), The United Nations International
Children Fund (UNICEF), icddr,b, WaterAid and other Non-governmental organizations (NGOs) are
required for implementation of this plan.

To address these challenges and achieve the goals, the MOHFW and stakeholders have developed a
multi-year plan, “National Cholera Control Plan (NCCP)” for implementation between 2019 and
2030.

The goals and objectives:

Goal: The goal is to reduce cholera morbidity and mortality by 90% within 2030 through early case
detection and quick response to cholera outbreaks, improved case management and controlling
endemic situation. A number of development activities particularly OCV vaccination in
hotspots/high-risk areas with water, sanitation & hygiene interventions and surveillance for impact
evaluation throughout Bangladesh will contribute to this achievement.

Objectives:
1. Conduct sustained and efficient surveillance system that is able to predict, detect, and respond
to cholera outbreaks in a timely manner.
2. Ensure appropriate cholera case management in all health facilities
3. OCV vaccination in conjunction with WASH in cholera hotspots to complete interruption of
transmission, and any new outbreaks.
4. Improve nationwide WASH Services as a long-term solution.

This multi-sectoral and multi-year plan will be implemented phase by phase in a period of 12 years
with the MOHFW as the lead Ministry and other government sectors and stakeholders supporting and
coordinating the implementation. The NCCP for Bangladesh has a demonstration plan as well a short,
mid and long term objectives. The short term activities will include sustainable laboratory supported
surveillance system, along with early warning and alert response systems (EWARS), improved case
management and use of OCV and WASH activities to adopt integrated approach in controlling
cholera transmission in the hotspots, In the midterm and the long term activities, the interventions of
the short time activities will be strengthened. As a specific long term activity, WASH facilities will be
gradually expanded nationwide. To reach Global Roadmap by 2030, following procedures are
outlined:

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Table 1: Cholera control strategies at a glance.

Agenda Major Activities Outcome Indicators Lead

institute.
1. Establishment of 1. Strengthening of laboratory 1. RDT based V. cholerae
national supported Cholera surveillance. detection system
surveillance and 2. Strengthening IEDCR laboratory developed in all health
outbreak as referral center and public facilities by 2023
detection and medical college hospitals as 2. Lab based confirmatory
response system sentinel centers for V. cholerae test facilities strengthened
for V. cholerae detection (confirmatory capacity) at IEDCR by 2020 and all
public medical colleges
3. Training on cholera detection at
by 2023
all health facilities
3. Detection of new high
4. Maintenance of regular cholera risk areas/ population by
surveillance at all sentinel sites IEDCR,
2025
CDC,DGHS
5. Training of rapid response teams 4. At least 90% outbreaks
at all levels. are diagnosed/confirmed
6. Development of early warning and addressed by 2023
and response system 5. Trained emergency
response team equipped
7. Regular supply of required
with all logistics in all
reagents and other logistics
hotspot districts by 2025
6. Early warning system in
action in all hot spots by
2023
1. Countrywide establishment 1. By 2030, universal
2. Nationwide of safely managed drinking coverage of safely managed
improvement of water source especially in drinking water services.
safely managed hard to reach areas
water and including urban slums, 2. By 2025, 50% and by
sanitation hilly areas, coastal zones 2030, universal coverage of
services as long- etc. safely managed sanitation
term solution 2. Establishment of safely services.Environmental
managed sanitation laboratory is established at
services with emphasis on central and divisional level
rural areas, char areas, by 2025.
floating communities.
3. By 2025, 80% people
3. Establishment of DPHE,
can recall slandered critical
environmental laboratory WASA,
times of hand washing with
based monitoring system at MOLGRD&C,
demonstration
the central and divisional CDC, DGHS,
level for quality and safety IEDCR, BHE,
4. By 2030, 100% people
of WASH operations MoHFW.
can recall slandered critical
countrywide
times of hand washing with
4. Raising awareness on demonstration
importance of hand
washing with running 5. 90% reduction of cholera
water and soap at critical hospitalization by 2030
times.
5. Increase hand washing
practice with special focus
on pregnant women,
mother of under five
children and adolescents.

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 1. OCV campaign in City
1. Immunization campaigns with
3. Immunization Corporations from 2019
OCV in high risk areas through
with OCV with followed by other high EPI, CDC,
national EPI network in
WASH facilities risk areas in phase wise DGHS,
collaboration with MOLGRD&C
in hotspots manner DPHE,
for strengthened WASH facilities
and/or high 2. Maintain 90% OCV WASA,
by 2025.
burden/ risk areas coverage in all identified MOLGRD&C,
by Expanded high burden districts by
2. Prevent and respond to cholera
Program of 2024.
outbreaks with OCV
Immunization 3. Cholera outbreaks are
immunization & emergency
(EPI) to control addressed with both the
WASH package services
endemic situation WASH and OCV
3. OCV procurement, planning and
and outbreaks as intervention.
execution through national EPI
short term 4. 90% reduction of
4. Training and logistics supply
measures hospitalization due to V.
through national EPI
cholerae by 2030
4. Establishment of 1. Development/customization of 1. Trained service providers
appropriate case case management protocol are managing cases in all
management 2. Training of service providers on facilities by 2025
protocol for case management.
2. Morbidity due to cholera
diarrheal diseases 3. Equitable distribution of drugs
is reduced by 90%in all
including cholera and saline to the public health
districts and City
at all health facilities
Corporations by 2030. CDC, DGHS
facilities in
3. CFR for cholera and & IEDCR,
accordance with
other diarrheal diseases DGHS
WHO Guidelines
stayed well below 1% in
(preferably by
all districts and City
using the
Corporations by 2030
mHealth
platform)

5. Complete
interruption of V.
cholerae
transmission, and CDC,
rapid detection IEDCR, ,
and interruption 1. Regular surveillance to identify 1. All V. cholerae EPI,
of any new cases along with appropriate case transmission stopped by DPHE,
outbreaks. management and timely 2030 WASA
6. Control intervention with WASH and with
certification of V. OCV to contain V. cholerae technical
cholerae transmission in the communities 2. Country cholera control support of
transmission by certified by end of 2030 icddr,b &
the end of 2030 WaterAid,
so that cholera is , WHO,
no more a public UNICEF
health problem in
Bangladesh

DGHS under the MOHFW will coordinate and guide all activities; Activity leads will implement the relevant activities with technical
support of icddr,b, WaterAid, UNICEF and WHO

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Estimated Budget Requirement for implementation of NCCP

The NCCP outlines development activities from 2019 -30 with a total estimated budget of US$ 3.58
billion. Out of this, OCV budget will be $ 0.43 billion; the WASH budget will be US$ 3.13 billion;
for improved water $0.68 billion; sanitation $1.35 billion and hygiene promotion around $1.1 billion.
The surveillance budget is estimated to $ 0.02 billion.

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1. Introduction
Cholera is a major public health problem in many countries in Asia, Africa and Latin America 1.
Globally 47 countries are recognized as cholera endemic and is a cause of major concern 2. Cholera is
responsible for an estimated 2.9 million cases and 95,000 deaths per year worldwide1. Bangladesh is
one of the endemic countries with highest burdens of cholera with bi-annual peaks in certain areas of
the country3, 4. An estimated 109,052 cholera cases annually while a population of 66,495,209 is at
risk with an annual incidence rate of 1.64/1,0005. The cholera cases in high-risk populations and
cholera prone areas may exceed 2/1,000 population (ranges 2-5) suggesting that an occurrence of
450,000 hospitalized cases and >1 million infections per year5.

According to World Population Review (2019), Bangladesh is a large and densely populated country
in South Asia, bordering Myanmar, India and the Bay of Bengal. Bangladesh has an estimated
population of 168.07 million (2019), up from the 2013 estimate of 156.5 million. This makes
Bangladesh the 8th most populous country in the world. The country has a population density of
1,115.62 people per square kilometer (2,889.45/square mile), which ranks 10th in the world. The
surface area in Bangladesh is currently at 147,570 km² (or 56,977 square miles). The capital and
largest city of Bangladesh is Dhaka, which has a population of 14.4 million and a density of 19,447
people per square mile (50,368/square mile). With an estimated population growth rate 0.98%, by
2025, the projected population in Bangladesh will be 178 million with male 50.3% and female 49.7%.
With the estimated population growth rate 0.81%, by 2030, the projected population in Bangladesh
will be 185 million with male: female ratio 50.2: 49.8 and population density will be 1257.61 per
square kilometer6.
Ninety eight percent of the Bangladeshi populations are ethnic Bengali with the remaining 2% made
up from other ethnic tribes. Minorities in Bangladesh include indigenous people in northern
Bangladesh and the Chittagong Hill Tracts, which have 11 ethnic tribal groups such as the Chakma,
Tanchangya, Kuki, Bawm and Marma. The Mymensingh region is home to a large Garo population,
while North Bengal has a large population of aboriginal Santals.6
Life expectancy in Bangladesh is currently at 73.4 years of age. According to JMP 2017 report,
56% of total population has access to safely managed drinking water while 47% have access
to basic services for sanitation. 72.8% of the population over 15 years of age is literate6.
Bangladesh is vulnerable to environmental disasters due to combined effects of climate change,
population growth, population density and urban migration. Drinking water sources are contaminated
during frequent disaster such as floods, landslides and cyclones. Latrines overflow and contaminate
water sources during these extreme events. Water quality in Bangladesh is affected by environmental
pollution from industrial effluents, over-obstruction for irrigation and saltwater intrusion. Barriers to

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safe drinking water, alongside sanitation, have significant impact on health, nutrition, education,
protection and other outcomes for population as a whole.

WASH services in Bangladesh is close to optimum, but the problem is that the country is prone to
natural catastrophe like cyclone, flood, tornado, etc. that poses a threat and causing damage to WASH
infrastructure with cholera appearance in the population at risk.

This could be successfully overcome with prior OCV vaccination of at-risk population for developing
herd immunity against cholera threat. The topography, population density, climate, and environment-
all these factors justify large scale OCV vaccination in the country.

The Global Task Force on Cholera Control (GTFCC) has launched in 2017, a new global strategy
“Ending Cholera-A Global Roadmap to 2030”2. The overall objective is to reduce the mortality
resulting from cholera by 90% by 2030. With the commitment of the cholera prone countries,
technical partners, and donors, as many as 20 countries including Bangladesh will need to make plans
to eliminate cholera in their settings by 20302, 7.

For long-term sustainable solution of cholera elimination, services with WASH are important.
According to Joint Monitoring Program (JMP) for Water, Sanitation and Hygiene, the current status
of the population all over the country covered by safely managed drinking water supply is 56% 8 and
has plan to increase >85% by 2025, and 100% by 2030. The accessibility to basic sanitation services
has a plan to be increased from current level of 47%8 to > 70% by 2025 and > 100% by 2030. The
hygiene practice will be increased from current level of 40%8 to > 80% by 2025 and >100% by 2030.
All these factors are projected in the NCCP 2019 - 2030.

The Goals and Objectives of NCCP

Goal: The goal is to reduce cholera morbidity and mortality by 90% within 2030 through early case
detection and quick response to cholera outbreaks, improved case management and controlling
endemic situation.

Objectives:

1. Conduct sustained and efficient surveillance system that is able to predict, detect, and respond
to cholera outbreaks in a timely manner.
2. Ensure appropriate cholera case management in all health facilities
3. OCV vaccination in conjunction with WASH in cholera hotspots to complete interruption of
transmission, and any new outbreaks.
4. Improve nationwide WASH Services as a long-term solution.

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1. 1 Situation analysis
Cholera remains in Bangladesh sometimes throughout the years from the ancient period. First six, out
of seven pandemics, originated from this region. Mortality due to cholera has been reduced
dramatically but morbidity still remains as a threat for the health system of the country. Surveillance
in icddr,b Dhaka hospital, 22 sentinel sites and outbreak response surveillance reveal continued
existence of cholera all over the country round the year. Bangladesh has passive reporting and
monitoring system for diarrheal diseases from health facilities, but there is provision of active
surveillance system for cholera by IEDCR only during outbreak. Limited ongoing cholera
surveillance that currently exists in Bangladesh are-

1.1.1. Cholera surveillance in Bangladesh

a. Surveillance on enteric infections including cholera in 22 sentinel sites of the country jointly
by IEDCR & icddr,b covering all administrative divisions
b. Surveillance in Dhaka cholera hospital of icddr,b among admitted patients and
c. Investigation of reported/suspected cholera outbreaks by IEDCR.

a. Cholera surveillance in sentinel sites:

Bangladesh has started hospital-based enteric

disease surveillance for cholera, Salmonella,
Shigella and ETEC since May, 2014, in 10
district level hospitals under the cooperation of
IEDCR and icddr,b. In 2016, the surveillance has
been extended to more 12 health facilities only
for cholera covering all geographical areas from
overall Bangladesh. The health facilities
included 6 sub-district Hospitals, 13 district
hospitals, 2 tertiary level hospitals and one
institute named Bangladesh Institute of tropical
and Infectious Disease (BITID) in Chittagong.
The surveillance sites were Thakurgaon,
Naogoan, Habiganj, Narshingdi, Satkhira,

Patuakhali, Cox’s Bazar, Tangail, Narayanganj,

Figure 1: Twenty two nationwide surveillance
Chuadanga, Meherpur, Comilla, Kushtia district sites for cholera in Bangladesh, May, 2014-
hospitals and Sub-district hospitals were December 2018.
Chaugacha (Jessore), Madan (Netrokona), Chhatak (Sunamganj), Bakerganj (Barisal), Mathbaria
(Pirojpur) and Shibganj (Chapai Nawabganj) (Figure:1).

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Table 2: Cholera scenario in 22 surveillance sites in Bangladesh (2016- 2018)

Total
stool Culture
Surveillance Sites
sample Positive, n (%)
tested
Narsingdi 796 8 (1.0)
Habiganj 1,917 97 (5.1)
Cox's Bazar 1,975 144 (7.3)
Naogaon 1,469 53 (3.6)
Patuakhali 1,548 73 (4.7)
Thakurgaon 1,381 18 (1.3)
Satkhira 1,265 24 (1.9)
Dhaka Medical College Hospital, Dhaka 701 23 (3.3)
Uttara Adhunik Medical College & Hospital (UAMC&H), Dhaka 555 27 (4.9)
Bangladesh Institute of Tropical & Infectious Diseases (BITID), Chittagong 1,535 213 (13.9)
Tangail 2,220 110 (5.0)
Narayanganj 1,850 253 (13.7)
Chuadanga 1,525 80 (5.2)
Meherpur 1,711 39 (2.3)
Comilla 871 68 (7.8)
Chowgacha, Jessore 395 15 (3.8)
Kushtia 1,873 79 (4.2)
Madan, Netrokona 366 8 (2.2)
Chhatak, Sunamganj 615 13 (2.1)
Mathbaria, Pirojpur 959 53 (5.5)
Bakerganj, Barishal 265 35 (13.2)
Shibganj, Chapai Nawabganj 673 15 (2.2)
Total 26,465 1448 (5.5)

b. Cholera surveillance in icddr,b, Dhaka Hospital

The icddr,b Dhaka hospital, publicly known as cholera hospital,

has well established surveillance system for cholera including
other enteric infections. It has been conducting hospital based
systemic surveillance since 1979. People in and around Dhaka
city suffering from diarrhea prefer getting treatment from
icddr,b. Surveillance data revealed that the most common
organism causing diarrheal diseases are: Rotavirus, cholera,

Figure 2: Enteric pathogens isolation ETEC, shigella and others. Among the isolated pathogens, 18-
rate of diarrhea patients in icddr,b 20% of the total diarrheal cases are due to cholera (Figure: 2)
Dhaka hospital during 2014- 2018
which can increase up to 40% during the two seasonal peaks, in
3, 4
the autumn and spring . Among the existing 50 thanas in Dhaka city most of the cholera cases

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comes from Mohammadpur, Kotwali, Khilkhet, DakshinKhan, Tejgaon, Turag, Jatrabari, Badda,
Uttara, Kamrangirchar, Sabujbagh, Lalbagh and Mirpur, (Table: 3).

Table 3: Population based hospitalization rate (per thousand) of cholera cases in Dhaka City at
icddr,b hospital (2014-2018).

Name of Thana in Hospitalization Rate (per thousand)

Dhaka city
2014 2015 2016 2017 2018 (2014-18)
Mohammadpur 2.8 2.5 2.0 2.9 3.9 2.8
Kotwali 2.3 3.8 1.5 3.8 2.2 2.7
Khilkhet 10.0 1.8 0.7 0.0 1.1 2.7
Dakshinkhan 1.1 1.9 1.1 2.6 5.4 2.4
Tejgaon 3.3 2.6 1.9 1.9 2.2 2.4
Turag 2.8 3.3 1.5 0.9 3.2 2.3
Jatrabari 1.1 1.5 1.1 2.7 2.6 1.8
New Market 1.0 0.0 1.0 1.9 3.7 1.5
Sabujbagh 1.9 0.9 1.1 1.6 1.5 1.4
Lalbagh 2.1 0.8 1.0 1.5 1.5 1.4
Kamrangirchar 1.0 1.0 2.5 0.5 1.5 1.3
Khilgaon 0.6 0.9 2.3 1.7 0.8 1.3
Motijheel 1.1 0.7 0.2 0.9 2.9 1.2
Sutrapur 0.7 2.0 0.0 1.3 1.8 1.2
Mirpur 1.1 0.4 0.3 0.7 3.1 1.1
Shah Ali 1.7 2.1 0.0 0.8 0.8 1.1
Sher-e-Bangla Nagar 1.8 0.7 1.7 1.0 0.0 1.0
Adabor 0.9 0.9 0.5 0.5 2.3 1.0
Kadamtali 0.7 1.2 0.9 0.8 1.5 1.0
Gulshan 1.9 0.0 0.2 1.3 1.3 0.9
Darus Salam 1.8 1.5 0.3 0.3 0.0 0.8
Hazaribagh 0.0 1.3 0.0 1.5 1.0 0.8
Rampura 0.0 0.6 0.6 1.3 1.2 0.8
Badda 2.4 0.4 0.2 0.4 0.3 0.8
Gendaria 1.1 1.0 1.0 0.3 0.3 0.8
Uttara 0.3 0.3 0.3 0.8 1.8 0.7
Demra 0.6 0.4 0.2 1.0 1.0 0.7
Kafrul 0.6 0.8 0.2 0.2 0.7 0.5
Cantonment 0.0 0.7 0.4 0.0 0.4 0.3
Pallabi 0.4 0.1 0.2 0.1 0.2 0.2
Tejgaon Industrial Area 0.0 0.3 0.0 0.0 0.0 0.1
* Population is adjusted yearly with Census 2011, Bangladesh (Source: icddr,b)

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c. Cholera surveillance in suspected/reported outbreaks in the country

From February 2011 to August 2014, IEDCR conducted total 10 outbreak investigations in nine
districts of Bangladesh. A total 6,670 AWD cases had been reported and investigated. Rectal swab
collected from 192 AWD patients; culture confirmed cholera were isolated from 85 collected samples.
Average percentage of cholera detection rate was 44.3%; the range of isolation rate varied from as
low as 21.1% to as high as 80% in the areas of collected samples. The district in which outbreaks
investigation were done: (1) Bogra, (2) Kishoreganj, (3) Tangail, (4) Dhaka City Corporation (in two
thanas), (5) Netrokona (outbreaks persisted for as long as 70 days), (6) Mymensingh, (7)
Narayanganj, (8) Chuadanga, (9) Kushtia. In those 10 outbreak investigations, total 10 deaths were
reported from 6,670 AWD cases with a CFR of 0.1%, the range was from 0.1% to 0.3% indicating
effective management of outbreaks and AWD cases had increased accessibility and availability of
treatment facilities for cholera and diarrhea. The following table shows the results:

Table 4: Outbreaks of cholera (culture confirmed) in Bangladesh reported by IEDCR (2011- 14).
% of V. Death
Duration Rectal cholerae
Place Date Case # CFR
(days) Swab positive, #
n (%) %
Bogra Sadar 11-14 Feb 2011 4 22 17 5 (29) 0 0
Kishoreganj Sadar 15-19 Apr 2011 5 84 20 8 (40) 0 0
Tangail Sadar 14-25 Sep 2011 12 314 24 8 (33.3) 0 0
Kalayanpur, DCC Oct 2011 10 644 65 24 (37) 2 0.3
Maddah Badda, DCC 8-15 Apr 2012 7 1500 0 0
Netrokona 15 Aug - 25 Oct 2013 70 1568 41 33 (80) 5 0.3
Mymensingh A. M. 27 Aug- 2 Sep 2013 7 64 0 0
College
Narayanganj 6 Oct 2013 7 645 6 3 (50) 2 0.3
Chuadanga Sadar 1-11 Aug 2014 11 1323 36 1 0.1
Kushtia Sadar 21-25 Aug 2014 5 506 19 4 (21.1) 0 0
Total/Average 6670 192 85 (44.3) 10 0.1

1.1.2 Water, Sanitation & Hygiene (WASH) Status

Cholera is generally transmitted through faecal contaminated water or food which has short
incubation period (2 hours to 5 days) and the number of cases rise exponentially leaving a high
number of deaths. Environmental factors such as climate variability, temperature, and rainfall play an
important role in cholera transmission. Population density, urbanization, force displacement and
overcrowding influence cholera transmission. It is also closely associated with the social and
behavioral aspects of individuals as well as communities.

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Bangladesh has moderate access to WASH services. WASH services significantly alters the spread of
cholera, and is one of the most important tools for long-term sustainable cholera control and
elimination program. Following table shows the current status of ongoing WASH activities in
Bangladesh.

Table 5: Situation of Water, Sanitation and Hygiene (WASH) in Bangladesh (According to JMP
report, 2017).

Access & Practice National Rural Urban

Population covered with safely managed drinking water services 56% 61% 45%
Population covered with at least basic drinking water services 97% 97% 98%
Population covered with basic sanitation services 47% 43% 54%
Open defecation <1% <1% 0%
Availability of a hand washing facility on premises with soap and 40% 31% 58%
water
(Source: JMP 2017)

1.1.3 Health Care System

Bangladesh is administratively divided in to 8 divisions, 12 city Corporation, 64 districts, 492 upazilas
(sub-district), 328 municipalities, 4,554 unions and 40,986 wards9. The health care delivery follows
the administrative tiers in the country. The health system of Bangladesh follows the administrative
tiers of the country, and is built on six “building blocks” that make up the system. These are: (i)
Service delivery; (ii) Health workforce; (iii) Information; (iv) Medical products, vaccines and
technologies; (v) Financing; and (vi) leadership and governance (stewardship).

Figure 3: Level of Health Care in Bangladesh.

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The health care services delivered through primary, secondary and tertiary level health care facilities
(Figure: 3). At national level there are Medical College Hospitals and Specialized Hospitals; at
divisional level Medical College Hospitals and district hospitals, at district level district hospitals with
Medical College Hospital in some districts. At upazila (sub-district) level there is Upazila Health
Complex (UHC), at union level Union Health & Family Welfare Center (UHFWC). Union sub-center
(USC) and 20 bedded hospitals (Rural dispensaries) in some unions. At village levels there are
Community Clinics (CC) for every 6 thousand populations. EPI Service is delivered through outreach
sites located in public houses, UHFWCs, USC and CCs EPI service is also available in primary,
secondary and tertiary level health care facilities. CC provides only out-patients services. In-patient
bed facilities are available at UHC and above-level facilities.

1.1.4. Health Care Delivery

Health care services, including immunization, in Bangladesh are provided by the wings of two
ministries; MOHFW and MOLGRD&C. MOHFW is responsible for providing health care services
mainly in rural areas through primary health care centers (UHC, UHFWC, USC and 20-bed urban
health centers). At urban areas MOHFW provide health services through secondary and tertiary level
hospitals (Upazila health complexes, urban dispensaries, district sadar hospitals and medical college
hospitals and specialized hospitals). Local Government division of the MOLGRD&C is responsible
for providing Primary Health Care services in urban areas e.g. municipalities and city corporations.
The urban health services are provided by NGOs supported by two projects (Urban Health Care
Service Delivery Project (UHCSDP) and NGO Health Service Delivery Project (NHSDP)). Each of
the city corporations and municipalities are individual units who have separate health division
responsible for supervision and monitoring of health care services in its jurisdictions.

Rural immunization services are delivered by Health Assistant (HA) and Family Welfare Assistant
(FWA) of MOHFW and urban immunization services are delivered by government and Non-
government Organizations (NGOs). Health Assistant (HA) and Family Welfare Assistant (FWA) of
MOHFW maintain close contact with household members by door-to-door visit and develop health
service related awareness.

Health Engineering Department (HED), a wing of MOHFW has the responsibility of construction,
renovation and maintenance of toilets and for ensuring WASH services at upazila and below level
health facilities- UHC, UHFWC and CC.

1.1.5 Current Cholera Containment Situation in Bangladesh

Bangladesh has well-established diarrheal diseases recording and reporting system at all government
health facilities but due to absence of diagnostic facilities, cholera is not reported separately from
those health facilities. Bangladesh is the pioneer of using oral rehydration solution (ORS) in diarrheal

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diseases and almost all the people in this country know its use to prevent dehydration and deaths from
diarrhea. There is oral rehydration therapy (ORT) corner in each of the primary, secondary and
tertiary level health care hospitals, which plays a vital role for correcting dehydration and averting
diarrheal deaths including cholera. Moreover, diarrheal treatment is provided to the under five years
children through Integrated Management of Childhood Illness (IMCI), which is established in almost
all health facilities. As a result, diarrheal deaths have come down significantly. There have been
notable achievements in combating diarrheal diseases; these efforts have rendered positive impact on
preventing cholera deaths as well. The activities for cholera control to be strengthen during the
planned period.
OCV vaccination experience: Bangladesh has experience of using OCV through very limited
campaigns in Mirpur, Keraniganj and Kamrangirchar of Dhaka district10. From October 2017 to end
of 2018, Bangladesh conducted four rounds of OCV campaign for FDMNs in Rohingya camps at
Cox’s Bazar. Approximately 700,487 doses of OCV used during 1st round in October 10-18, 2017. In
that campaign icddr,b provided technical assistance along with other national and international
partners.
Second round of OCV was delivered to 200,000 children aged 1-5 years along with OPV from 4-9
November 2017. The 3rd round of OCV campaign was done from 6-13 May 2018 for the newly
arrived FDMNs and the host community and a total of 879,273 FDMNs received OCV. In the fourth
round, total 428,556 doses of OCV delivered with routine EPI vaccines from 17 November 2018 for a
target population of 328,556 of which 224,788 were FDMNs, and 103,768 were surrounding host
community.

1.2 Strength, Weakness, Opportunity and Threat (SWOT) Analysis

Table 6: SWOT Analysis

Strength Weakness Opportunity Threat

1. Strong political 1. Surveillance and 1. IEDCR strengthen 1. Timely receipt of
commitment by GoB reporting of cholera for improving adequate funding from
2. Functional Upazila case is not optimum as surveillance GTFCC
Health System (UHS) not separately done 2. icddr,b for technical 2. OCV supply (OCV
3. Extensive network 2. No lab facility at support global supply is
of primary care level district & upazila level limited)
2. GTFCC for fund
health facilities for cholera diagnosis 3. Cross boarder
raising and technical
4. Strong Community 3. No routine reporting transmission of cholera
support
Based Health Program of cholera case from cases
3. Development
5. IEDCR for disease peripheral health
Partners (DPs) support
surveillance facilities
for technical assistance
6. Strong EPI network 4. WASH services is
and oversight
7. Availability and yet to be optimum
extensive practice of 5. Frequent destruction
ORS (Bangladesh is by natural calamities of
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house of ORS WASH infrastructure
8. No open defecation
9. Acute Watery
Diarrhea (AWD) case
fatality rate (CFR) is in
grip
10. Established and
functional reporting
system of AWD
11. Cholera cases and
CFR can be estimated
from AWD report
12. Cholera diagnostic
facility available
centrally at IEDCR and
icddr,b
13. Moderately
accessible WASH
services

2. Strategies for Cholera Elimination

Considering the country’s existing capacity and available information, cholera elimination strategies
have been designed as short, mid and long term activities. Interventions, such as, mass vaccination
campaign with OCV, timely and appropriately case management, establish and strengthen nationwide
cholera surveillance system and wide access to WASH resources are the key approaches have been
included in this strategic plan to be achieved through an integrated multi-sectoral approach.

2.1 Key Strategic Activities (2019- 2030)

2.1.1 Short term activities (2019-2021)

Target: 25% reduction of cholera burden

• Multi-sectoral coordination mechanism among stakeholders and quarterly meeting on a
regular basis. .

• OCV demonstration campaign at cholera prone areas in Dhaka city along with strengthened
WASH intervention.
• Initiate Rapid Diagnostic Test (RDT) based passive surveillance system for cholera at
primary, secondary and tertiary level health facilities.
• Capacity development for cholera detection at all level of health facilities.
• Strengthen culture and Polymerase Chain Reaction (PCR) lab capacity at IEDCR as referral
center.
• Identify hotspots/ high risk areas/ populations

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 • Strengthen case management for cholera as per WHO guideline preferably through mHealth
platform in all health facilities.
• Establish epidemiological unit with Surveillance Focal Point (SFP) at all level of health
facilities.
• Establish Early Warning and Response System (EWARS)
• Ensure early detection, reporting and quick response system for cholera outbreaks. Routinely
report surveillance data to global partners for monitoring regional and global cholera
transmission patterns.
• Develop SOP for emergency outbreak response
• Develop SOP to provide/strengthen WASH services

• Ensure safe water, sanitation and hygiene practices.

• Establish supervision and monitoring system

• Ensure vaccine and logistics supply

• Strengthen water surveillance system to prevent the use of cholera contaminated water

• Establish awareness development program for all communities through appropriate

communication mechanism
• Program evaluation after the end of the short term activities

2.1.2 Midterm Activities (2022– 2025)

Target: 50% reduction of cholera burden

• Multi-sectoral coordination mechanism among stakeholders and quarterly meeting on a

regular basis.
• Revise strategy as per evaluation report after short term activities.
• OCV campaign along with WASH intervention in all identified cholera prone areas will be
continued in phase wise manner.
• RDT based passive cholera surveillance system at primary, secondary and tertiary level health
facilities.
• Establish/ strengthen culture facilities and PCR lab capacity at all the public Medical College
Hospitals.
• Establish/ strengthen environmental laboratory at central and divisional level.
• Identify hotspots/ high risk areas/ populations.
• Strengthen appropriate case management in all health facilities.
• Establish/Strengthen epidemiological unit with Surveillance Focal Point (SFP) at all level of
health facilities.
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 • Continue early detection, reporting and quick response system. Routinely report surveillance
data to global partners for monitoring regional and global cholera transmission patterns.
• Strengthen safe water, sanitation and hygiene practices.
• Strengthen supervision and monitoring system.
• Ensure vaccine and logistics supply.
• Strengthen routine water surveillance system to prevent the use of cholera
contaminated water.
• Strengthen awareness development program for all communities through appropriate
communication mechanism.
• Strengthen evaluation after the end of the midterm activities.
2.1.3 Long term activities (2025- 2030):
Target: 90% reduction of cholera burden

• Multi-sectoral coordination mechanism among stakeholders and quarterly meeting on a

regular basis.
• Revise strategy as per evaluation report after midterm activities.
• Expand appropriate WASH services gradually in all districts.
• OCV campaign along with WASH intervention in the newly identified hotspots and outbreak
area.
• Sustainable surveillance system.
• Strengthen advocacy on safe water, sanitation and hygiene practices.
• Evaluation after the end of the Long term.

3. The strategic approaches for NCCP

• Strategic approach 1: Sustainable cholera surveillance system
• Strategic approach 2: Cholera case management
• Strategic approach 3: Oral cholera vaccination
• Strategic approach 4: Increase the access to safe Water, Sanitation and Hygiene intervention.
• Strategic approach 5: Coordination and monitoring through multi-sectoral approach.
• Strategic approach 6: Advocacy Communication and Social Mobilization (ACSM)

3.1 Strategic approach 1: Sustainable cholera surveillance system

3.1.1. Overall gaps in cholera surveillance

• Sustainability of surveillance system- Project based passive sentinel surveillance system
including RDT exist for cholera, but sustainability is in question.
• Limited capacity available for cholera diagnosis at central level; no diagnostics facility for
cholera at district and sub-district level health facilities.
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3.1.2 Activities to strengthen cholera surveillance

1. Establishment of Rapid Diagnostic Test (RDT) for cholera identification to aid proper and
timely case management in all public health facilities in Bangladesh and strengthen regular
routine reporting.
2. Strengthened Laboratory Facilities
2.1. Strengthen laboratory in all Public Medical College Hospitals with culture capacity.
2.2. Strengthen capacity of IEDCR as National Cholera Surveillance Centre and establish
Cholera reference laboratory at IEDCR.
3. Review the sentinel surveillance sites for proper geographical representation of the country
and to identify new hotspots.
4. Enhancing Surveillance Capabilities
4.1. Capacity development at all level of health facilities for cholera to ensure early detection,
reporting and quick response, including establishment of Early Warning, Alert and
Response System (EWARS) at all levels.
4.2. Establishment of epidemiological unit with Surveillance Focal Point (SFP) at all level of
health facilities.
5. Ensure regular need based supply of logistics and other resources to support early diagnosis
and timely management of cases to stop transmission of cholera in the community.

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Table 7: Mechanism for developing nationwide cholera surveillance system.

Source of
Indicator Comment
information
Axis 1: Early detection and quick response to contain outbreaks at an early stage
Decentralized culture * Not available in the country
capacity for early detection * RDT available now in sentinel sites; but
IEDCR, icddr,b,
of cholera in all sentinel sustainability is uncertain as IEDCR currently
surveillance sites have no fund
* Both RDT & Cary Blair media temporarily
available in sentinel surveillance sites, but may
Preposition of RDT & not continue if fund is not available further
appropriate transport media * Samples transported to central labs (IEDCR,
IEDCR & icddr,b,
(Cary Blair) in all sentinel icddr,b) using Cary Blair media.
surveillance sites * Except for the sentinel sites RDT is not
available in all the districts, not even
incorporated in the Operational Plan (OP)
Culture and PCR * Available at IEDCR and icddr,b lab in
characterization of isolated Dhaka; this may serve the purpose. IEDCR & icddr,b,
V. cholerae
No EWARS in existence.
AWD reporting system exists in all districts &
Early Warning/Surveillance sub-districts of Bangladesh; CDC, DGHS,
system (EWARS) * Cholera surveillance is ongoing in 22 sentinel IEDCR & icddr,b
sites. Sustainability depends on availability of
fund if not supported by OP.
Axis 2: Multi-sectoral approach to prevent cholera in hotspots
Identification of cholera * Data of cholera/diarrhea surveillance aims to
IEDCR & icddr,b
hotspots identify cholera hotspots
National Cholera Control
Plan aligned with the * Under process CDC, DGHS
GTFCC roadmap
* National mechanism exists; funding
Financing mechanism &
reflection in respective OP is required for CDC, DGHS
availability of funds
availability of funds in Operational Plan.
Axis 3: Effective mechanism of coordination for technical support, resource mobilization and
partnership at national level
Existence of cholera focal *Director, Disease Control (DC) functions as
point, in-charge of national focal point;
implementing NCCP & CDC, DGHS
appointed by a high * IEDCR & other partners like icddr,b, DPs &
authority NGOs collaborate together

NCCP integrated into * Such mechanism exists for National Program

regular program, cross- on Diarrheal Diseases Prevention, Management CDC, DGHS
sectoral collaboration and & Control. Cholera to be integrated in this
activities are projected in mechanism under National Surveillance
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Operational Plan (OP) of System
CDC, EPI DGHS
* NCCP alignment with regular surveillance
reporting system under consideration

3.1.2.1. Establishment of Rapid Diagnostic Test (RDT) for cholera identification to aid proper and
timely case management in all public health facilities in Bangladesh and strengthen regular routine
reporting
Currently there isn’t any provision of identifying cholera at the health facilities at different level.
NCCP aims to establish RDT based routine diagnostic facilities at all the public health facilities for
immediate diagnosis for the sake of appropriate and timely case management of cholera cases
presenting at the facilities. Each year, following the operational definition of cholera case, after the
first identified case, every 10th case will be tested with RDT. Based on clinical, and/or RDT findings
case management will be initiated immediately. All RDT positive samples will be sent to the nearest
public medical college hospital (when established with the facilities) for confirmation by culture and
sensitivity testing. SoPs with standard tools for data collection and reporting (e.g., patient line lists,
reporting formats etc.) will be developed, concerned personnel will be trained on the use of RDTs,
specimen collection, transport, and storage, data collection, reporting procedures, data analysis,
logistics management etc. After implementation in the facilities, the activities will be regularly
supervised and monitored.

3.1.2.2. Strengthened Laboratory Facilities

2.1 Strengthen laboratory in all Public Medical College Hospitals with culture capacity.
2.2 Strengthen capacity of IEDCR as National Cholera Surveillance Centre and establish Cholera
reference laboratory at IEDCR,
All public medical college hospitals will be gradually strengthened with resources for culture capacity
to diagnose cholera. This will help the nearest health facilities at district and upazilas. Gradually they
will be upgareded with better facilities, initial preference will be on the divisional level hospitals.

In the referral center at IEDCR capacity will be strengthened to conduct PCR for the referred samples
from sentinel sites, outbreaks and, if required, even for routine activities as well. IEDCR will
participate in external quality assessment program and act as internal quality assessment referral
center for medical colleges.

3.1.2.3. Review the sentinel surveillance sites for proper geographical representation of the country
and to identify new hotspots.
The existing sentinel sites will be reviewed by IEDCR to identify new hotspot area/population and to
have representative surveillance data for action and sharing with all concerned stakeholders.
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The RDT based diagnostic facilities at the sentinel sites will continue for the first four suspected cases
each day for five days in each week and the sample of the positive cases will be sent to the referral
laboratory at IEDCR for confirmation. Where on the basis of culture, sensitivity, and PCR findings
data will be generated and shared with all concerned. Regular feedbacks to the professionals for case
management and containment will be provided to the sentinel sites.

3.1.2.4 Enhancing Surveillance Capabilities

3.1.2.4.1 Capacity development at all level of health facilities for cholera to ensure early
detection, reporting and quick response, including establishment of Early
Warning and Response System (EWARS) at all levels.
To strengthen the surveillance system in the country, IEDCR will conduct annual review and
implementation of guidelines, protocols, and processes, identify potential barriers and implement
solutions to effective management of cholera surveillance. IEDCR will ensure logistics for the
surveillance system, train the laboratory technicians and surveillance personnel on laboratory
techniques, data collection, analysis and reporting.
Rapid response teams at national, district, upazila, district municipalities and City Corporations levels
will be strengthened, trained for investigation and containment of outbreaks. At all levels response
team members will be trained and emergency preparedness plan will be in place, so that within three
hours of notification of any outbreak teams will be in action. All outbreaks are to be notified to
IEDCR, so that national team could be always in communication with the local investigating team,
and when required can go and intervene in the field.
All cases of an outbreak will be tested with RDT and positive samples will be sent to IEDCR for
confirmation and further diagnostic processes.
IEDCR will also establish Early Warning, Alert and Response System (EWARS) for cholera and
other infectious diseases of public health importance. EWARS is designed to improve disease
outbreak detection in emergency settings. It is essential to detect disease outbreaks quickly before
they spread, cost lives and become difficult to control.

3.1.2.4.2. Establish epidemiological unit with Surveillance Focal Point (SFP) at all level of
health facilities.

a. Cholera Surveillance Focal Person: The CSFP is responsible for managing all surveillance
activities for cholera in his/her assigned geographical area. The surveillance activities include:

• Monitoring and ensuring surveillance for cholera.

• Ensuring timely investigation of and respond to cholera case/s and suspected outbreaks.

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 • Ensuring that all data from cases and outbreaks are properly collected, compiled, analyzed and
interpreted for appropriate local action.
• Ensuring that data of passive surveillance, case investigation and outbreak investigation are
forwarded timely to IEDCR.
Local Surveillance Officer (LSO): To assist CSFP in carrying out his/her surveillance
responsibilities in implementing surveillance activities including case investigation, outbreak
investigations, case or outbreak response intervention immunization and report to CSFP and
IEDCR. The following table lists the CSFPs and LSOs for districts, City Corporations,
Upazilas and Municipalities. The surveillance officer will ensure that data of surveillance,
case investigation and outbreak investigation are forwarded timely to respective CSFP and
IEDCR. The Municipal Medical Officer reports to respective Upazila Health & Family
Planning Officer (UH&FPO)/ Civil Surgeon (CS).
b. Hospital Surveillance Officer (HSO): To facilitate and coordinate passive reporting of
cholera cases and carry out investigation and other surveillance activities in Hospitals, Residential
Medical Officer (RMO) is the hospital surveillance officer in the hospital. HSO is responsible for
managing hospital surveillance system and for preparing and submitting cholera ‘Weekly Line Listing
Form for Hospitals and UHCs’ to CSFP. For case-based surveillance HSO is responsible for
notification, initiate case investigation, ensure sample collection, storage and sending of specimen to
district/ national cholera laboratory (NCL).

c. Cholera Surveillance Medical Officer (CSMO)

In every district, one medical doctor will be posted/assigned to provide all cholera surveillance,
supervision and monitoring support in his assigned area/areas. He may be freshly recruited by WHO
or existing WHO Bangladesh recruited Surveillance and Immunization Medical Officer (SIMO) will
take this responsibility. He will closely work with District and upazila managers. National
Professional Officer- Divisional Coordinator (NPO-DC) will coordinate his activities as usual. His
responsibilities will be-
• Technical assistance to local health authorities in coordinating cholera surveillance activities
• Ensure passive and active surveillance
• Technical assistance to ensure timeliness and completeness of reporting
• Facilitate activities for investigation and reinvestigation of cholera cases
• Necessary orientation/training to relevant personnel to establish/strengthen surveillance
network
• Coordinate activities for collection and transportation of specimens
• Technical assistance in case/outbreak response activities
• Analysis surveillance data and provide feedback in district and upazila meetings

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Table 8: List of Cholera Surveillance Focal Person (CSFP) and Local Surveillance Officers (LSO),
Hospital Surveillance Officers (HSO) for cholera surveillance.

Location CSFP LSO HSO

District Civil Surgeon Medical Officer- Cs (MOCS),
Medical College Resident Physician (RP) MO RP
Hospital/ Specialized
Hospital
District Sadar Superintendent/ CS RMO Medical
Hospital Officer-
Disease
Control
(MODC)
City Corporation Chief Health Officer Health Officer/Assistant Health RMO
Officers/Zonal Medical Officer
Upazila UH&FPO MO-DC RMO
Municipalities with Municipal Medical Officer Municipal Medical Officer MODC
Medical Officers
Other Municipalities Respective UH&FPO MO-DC of UHC MODC
where MMO post
vacant

3.1.2.5. Ensure regular need based supply of logistics and other resources to support early diagnosis
and timely management of cases to stop transmission of cholera in the community.
Current sentinel surveillance is running in collaboration with funds from icddr,b, and isn’t sustainable.
All activities in this NCCP document will be projected in the operational plan of the concerned
directors (DC, CDC, IEDCR, EPI, HEB) under DGHS to ensure adequate fund allocation for smooth
conduction of all the activities at different level with regular supply of the required logistics.

3.1.3 Timeline of Activities of surveillance system development

Table 9: Timeline of activities for surveillance system development

Activity Timeline
1. RDT based Cholera surveillance sites will be 60% by 2021,100% by 2023
established and functional at upazila, districts
and medical college hospitals
2. Number of Cholera outbreaks will be covered 90% by 2023 and 100% by 2030
3. Routine RDT based diagnostic facility is 100% by 2023
established in all districts
4. Establish cholera culture based lab at all 100 % by 2023
Medical College Hospitals
5. Cholera reference lab strengthened/established By 2020 at one in IEDCR (strengthen) and one in
at national level icddr,b (established)

3.1.4 Surveillance Performance indicators

Regular monitoring of surveillance indicators will identify cholera prone areas where intervention is
needed. Surveillance indicators to monitor routinely the cholera situation are listed in the table below.
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Table 10: Cholera Surveillance Performance Indicators

No. Indicators Target

1. RDT supply and use in routine & outbreak investigation 100%
2. Completeness of passive reporting from all facilities ≥ 90%
3. Timeliness of passive web based reporting ≥ 90%
4. Suspected cholera cases investigation within 3 hours of notification at local level ≥ 80%
5. Operationally defined cholera stool samples are collected immediately after > 80%
presenting with symptom
6. Stool specimens arriving at laboratory in “good” condition > 90%
7. Stool samples arriving at laboratory within 2 days after collection > 80%
8. Stool culture result available within 4 days after specimen received at laboratory ≥ 80%
9. Cholera alert reported to higher level health authority within 1 hour of ≥ 80%
verification

3.1.5 Special consideration for cholera surveillance

Environmental Surveillance:

Cholera is primarily a waterborne disease and monitoring the presence of Vibrio cholerae in specific
environmental water sources may identify sources or vehicles of infection and aid with the early
detection of cholera transmission in some areas. Considering the presence of cholera in environment,
a surveillance system for cholera in environmental samples will be developed with laboratory
facilities at national and divisional level.

3.1.6 Estimated Budget for Cholera Surveillance Development

a. Surveillance system development
b. Diagnostic facility establishment cost

Table 11: Diagnostic Facility (RDT & PCR) establishment cost.

Remarks
Estimated
Total Total cost in Total cost in USD
Health Facility Number RDT/Year/
RDT/year USD for 10 years
Institute

Upazila Health 491 250 122750 245,500 2,455,000 For

Complex isolation
District Hospital 64 450 28800 57,600 576,000 and for
Medical College 64 150 9600 19,200 192,000 culture &
Hospital sensitivit
Total 619 850 526150 1,052,300 10,523,000 y test.
*RDT unit Cost- 2 USD
PCR unit
Health Facility Number Total PCR cost ($) Remark
cost ($)
PCR unit Total PCR Cost ($) One time
cost ($)
cost for
Medical College Hospital at 8 8000 64,000.00
Division launchin

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IEDCR & icddrb 5 8000 40,000.00 g
Total 13 104,000.00
$ 140,684.00
Grand Total 18,355
BDT 1,18,17,456/-
c. Capacity building/Training cost:
a. Total surveillance manpower needed @2/peripheral health facility: 18,342 x 2 = 36,684
b. Total surveillance manpower at MCH & IEDCR, icddr,b @5/facility: 65
c. Total surveillance manpower needed for identification: 36,749
d. Manpower surveillance training cost (for RDT) @2/health facility: 18,342 @ $300.00 x 2
= $ 11,005,200.00
e. Manpower surveillance training cost (for CS & PCR)@5/facility: 8 + 5 = 13 @ $ 500.00
x 5 = $ 32,500.00
f. Total manpower training cost for surveillance system development (d + e) =
$ 11,005,200.00 + $ 32,500.00 = $ 11,037,700.00; BDT 927,166,800/-
g. Operational cost for training: $ 919,000.00; BDT- 77,196,000.00

Grand Total for Training: $ 11,956,700.00; BDT 1,004,362,800/-

Total cost for surveillance system development for cholera control: $ 24,046,700

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3.1.8 Implementation Framework: Cholera Surveillance Monitoring and Evaluation

Table 12: Cholera surveillance monitoring and evaluation

Pillar Input Activities Output Outcome Impact

1. Surveillance system will be established from central to

1. Designated surveillance
peripheral level under IEDCR with collaboration of
officer, statistician will be
Disease Control (DC), CDC, MIS, icddr,b & other Proposal approval in nine
employed/ filled in up at Cholera cases
partners for all diseases with emphasis on cholera and months by Nov 2019. Relevant National disease
upazila level. reduced by 75%
AWD. Disease Control unit of DGHS will prepare staffs recruited and placed by surveillance system for
2. Statistician will be posted by 2025, and
proposal in six months by August 2019. another six months- August, cholera is in place
in all tertiary care level 90% by 2030.
2. Proposal submitted to appropriate authority for 2020.
hospitals.
approval in Sep 2019.
3. IT programmer will be
3. Fund placed within twelve months by Feb 2020.
employed at central level.
4. HR Recruitment process initiated by March 2020.
Guidelines for National Guidelines on
surveillance and Emergency Surveillance system,
Preparedness, Rapid Response Outbreak investigation,
Reference manuals on and outbreak investigation is and Emergency
National surveillance guidelines, manual/SOP, and developed by CDC with support Preparedness and Rapid
surveillance and reporting
reporting formats including emergency preparedness, from other stakeholders, Response are in use at
formats including emergency
Surveillance rapid response and outbreak investigation guideline including IEDCR, icddr,b, all levels for cholera
preparedness, rapid response
development WHO and UNICEF by 2019 and and other diarrheal
and outbreak investigation
disseminated within 2019 to all diseases.
stakeholders. Data are entered in
DHIS2 according to
plan
Training on disease
Outbreak investigation and Rapid Response team at all In addition to the surveillance
surveillance including
levels will be strengthened staffs, relevant Doctor, Nurses,
Emergency Preparedness and
Training of all relevant staffs in all Health facilities is Medical Technologist (MT) , all
Rapid Response, outbreak
planned and imparted field staffs are trained
investigation
Reports are generated and
communicated,
Field investigation occurred within 24 hours of Outbreaks are
Outbreak investigation appropriate preventive measures
notification of suspected cases contained
identified and implemented,
future guidelines are
communicated
Regular supply of logistics for outbreak investigation and Logistics will be ensured at
Logistics
Rapid Response activities designated endemic sites

34
 Surveillance data are timely
Data will be entered from the peripheral levels through disseminated to all stakeholders Regular follow up of
Data entry and Reporting DHIS2 and reports will be disseminated to the concerned Reporting of results within 72 cholera activities at all
stakeholders in time hours of receipt of specimens to endemic sites
health facilities and health
district office.
EWARS will be developed Immediate alert system is
EWARS will be incorporated in the DHIS2
and established functioning
Suspected cases are
Community Based Community based screening for cholera cases will be SOPs for screening and referral screened at CC and
Surveillance established at community clinic will be prepared for CC referred immediately to
UHC for further
management
1. Establishment of reference lab for disease surveillance 1. Suspected cases will be tested
at IEDCR. with RDT at local level and
2. National lab guidelines/SOP/training manual systematic samples are collected
developed and disseminated. and transported to laboratory
3. Laboratory personnel are trained on appropriate (initially centrally, later to
laboratory techniques (collection, transportation, culture divisional labs when
Screening and
Reference laboratory for and sensitivity and/or PCR) established)
confirmation for
cholera at IEDCR 4. Systemic collection of specimen for culture or PCR, 2. Cholera Cases will be
cholera is established
results available within 72 hours. confirmed by culture/PCR at
5. Availability of national referral laboratory of national and divisional level
necessary technology for PCR characterization of 3. Logistics will be available at
isolated V. cholerae and cholera RDT at local level. health facilities
6. Availability of health facilities of RDTs and Cary 4. Reports are generated and
Blair transport medium, other logistics disseminated
1.Case management of cholera cases following WHO
Nationwide proper
guideline All staffs dealing with patient
Management of cholera cases management of cholera
Management of 2. Development of uniform guidelines and training care will be trained with regular
following WHO guideline cases at all levels of
cholera cases manual for all endemic sites. supply of necessary logistics
health facilities
3. Conduction of training for relevant staffs at all sites.
4. Regular adequate supply of relevant logistics.

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3.2 Strategic approach 2: Cholera case management

The case management of cholera patients will be usually undertaken in all health facilities following
WHO guidelines. Routine RDT based testing facility for all public health facilities will be established
and will be used in detecting cholera at all levels with laboratory support at all public health facilities
and also at the central referral laboratory at IEDCR. Based on clinical, and/or RDT findings case
management will be initiated immediately and modified after receiving the test result from laboratory.
Use of the mobile platform for managing cholera cases will be explored. 3. Regular assessment of
antimicrobial resistance (AMR) pattern will be utilized for patient’s care. Uniform guidelines and
training manual will be developed. All concerned will be trained and the activities will be
implemented with regular supply of adequate logistics at all level.

3.2.1 Budget for cholera case management

a. Guideline/Training Manual/Module Development
b. Training of service providers
c. Supply chain management

36
3.3 Strategic approach 3: Oral Cholera Vaccination

3.3.1 Implementation Strategy for OCV Deployment

Table 13: Deployment and implementation strategy for OCV

Input Activities Output Outcome

1. Development of strategic plan for OCV

deployment. 1. Country
2. OCV deployment integrated in national registered
OCV plan. OCV will be Nationwide
deployment in 3. National guidelines/SOP/training manual available. OCV
conjunction developed and disseminated to health vaccination
with WASH facilities. 2. Capacity
according to
services 4. OCV training workshop conducted prior to building of
risk
according to campaign implementation. vaccinators.
assessment.
risk assessment 5. Rapidity of reactive OCV deployment 3. Increased
during outbreaks. OCV coverage
6. Proportion of cholera high-risk areas where
OCV pre-emptive campaign implemented.

3.3.2. OCV Vaccination Campaign Plan

a. Oral cholera vaccine (OCV) Demonstration Campaign: A large OCV demonstration along
with WASH facilities will be carried out in Dhaka targeting 1.2 million population to gather evidence
for targeted mass vaccination which will follow in other hotspot areas of the country in phase wise
manner.

Table 14: OCV Campaign plan in high risk districts.

OCV Campaign plan in high risk districts

1 2 3 4 5 6 Total
Year
2019 2020 2021 2022 2023 2024
District # DCC DCC 4 6 6 5
(Demonstration) (part) (includi (Year 4 (Year 5 (Year 6
ng +Year + Year +Year 3)
DCC) 1) 2)
Population 1.2 5.45 13.30 21.15 25.40 19.95 86.45
in Million

b. First phase (Urban Dhaka ) campaign:

High risk Dhaka urban population will be targeted for vaccination in the 1 st phase that will be the
testimony for conduction of nationwide campaign. Surveillance report of last five years indicate that
maximum number of the patients seek treatment in icddr,b, are from the catchment area of Badda,
Mirpur, Gulshan, Tejgaon, Mohammadpur, Jatrabari, Dakshin Khan, Sabujbag thana. Data reveals
Page | 37
that overall annual incidence of cholera among the population in these areas ranges from 0.8 to 3.2 per
1000 population. Considering incidence rate, geographical location, effective communication, human
resource and proper logistics management and based on previous OCV vaccination experience, Dhaka
city would be convenient. The campaign will be organized in the rest of Dhaka city consecutively
based on cholera incidence rate. About 5.45 million high risk populations will be targeted to vaccinate
in the 1st phase.

c. Second phase campaign: Outside Dhaka (Target Population- 13.30 million)

After conducting 1st phase vaccination in Dhaka urban area, the high risk population of the whole
country will be taken under consideration for vaccination with OCV in a phase wise manner. Priority
areas will be selected based on district category risk assessment. Based on current nationwide
surveillance in 22 sites’ data, hospital burden due to cholera is highest in Chittagong (14%),
Narayanganj (12.5%) and Comilla (9%). Estimated population of those districts are over 15 million as
8.4 million people in Chittagong, 6.0 million people in Comilla and 3.2 million people reside in
Narayanganj district.

In this manner, the projected districts with high risk of cholera will be covered by OCV vaccination;
in addition WASH interventions will be continued in those districts for long term sustainability.

Recurrent campaign: After each phase of OCV vaccination in one area, it will be repeated at 3 years
interval for containment of transmission (Table: 14).

In each of the phases, 1st dose of OCV will be given to the target population and second dose will be
given to the same target population at least 2 weeks apart. Since the timelines of the cholera control
planning is important, depending upon availability, WHO prequalified or domestically licensed OCV
will be used. The vaccine will be deployed following Controlled Temperature Chain (CTC).

3.3.3 Program indicators and targets for OCV

Table 15: OCV Program Indicators and targets

OCV Indicators
Indicators Targets
OCV deployment integrated in national plan OCV integrated in national plan by 2019
Generic Monitoring and Evaluation (M&E) Protocols developed by 2019
protocol developed
OCV training workshop conducted prior to Training workshop occur prior to OCV
campaign implementation campaign 100% of time
Rapidity of reactive OCV deployment during Initiation of OCV reactive campaigns within 1
outbreaks week following vaccine arrival
Proportion of cholera high risk areas where OCV OCV pre-emptive campaign implemented in
pre-emptive campaign implemented all high-risk areas by 2024
Proportion of campaigns during which all logistics 100%
support are available in a timely manner

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3.3.4 Budget for OCV

Table 16: Phase wise OCV vaccination implementation plan including budget from 2019 to 2024

No. of
% of high No. of at OCV
risk risk doses
Coverage of Total cost in Total Cost in
Year populatio populatio required
vaccination USD BDT
n be n be (2
covered covered dose/perso
n)

OCV
Year
2019 Demonstratio 1200000 2400000 6,000,000 504,000,000
1
n in Dhaka
10
Year Regular in
2020 5450000 10900000 27,250,000 2,289,000,000
2 Dhaka
Year
2021 20 13300000 26600000 66,500,000 5,586,000,000
3
Year 30 (Year
2022 Cholera 21150000 42300000 105,750,000 8,883,000,000
4 4+ Year 1)
endemic
Year 30 (Year
2023 areas 25400000 50800000 127,000,000 10,668,000,000
5 5+ Year 2)
Year 10 (Year
2024 19950000 39900000 99,750,000 8,379,000,000
6 6+ Year 3)
6
Tota
year 100 86450000 172900000 432,250,000 36,309,000,000
l
s
* OCV cost in USD/ dose= 1.85
Operational Cost in USD/ per dose= 0.65
OCV total cost USD/Dose= 2.5

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3.4. Strategic approach 4: Increase the access to safe Water, sanitation and
Hygiene intervention

Bangladesh has performed well in achieving MDG targets for access to basic water and sanitation
services. . However, it is a big challenge for the country to achieve SDG targets by 2030, when we
have to ensure access to safely managed water and sanitation services. Maintaining quality of services
is the big challenge for achieving SDG targets. Water, Sanitation & Hygiene (WASH) service
significantly alters the spread of cholera and is one of the most important tools for long-term
sustainable cholera control and elimination program. The target is tracked with the indicator of “safely
managed drinking water services”- the drinking water from an improved water source that is located
in premises, available when needed, and free from contamination. Water chlorination with safe
storage vessels testing showed that incidence of cholera infection was reduced by 75% and 58% in the
storage container and chlorination groups respectively when compared to the control group. Some
examples of water, sanitation & hygiene (WASH) activities that are ongoing in Dhaka City
Corporation are:

• Through Dhaka WASA, installation of 5,635 metered pipe water connections covering
643,735 poor people living in the low income community/ slum.
• Through community contracting under the supervision of DNCC, installation of 100 toilets
cubicles covering 3000 urban poor.
• Through DNCC, formation and activation of community groups in zone-2 for solid waste
management and awareness for faecal sludge management.
• Through DPHE and DNCC, dissemination of hygiene message (hand washing, MHM, safe
excreta disposal, safe water handling) to poor communities targeting 100,000 unban poor of
zone-2.
• Through DPHE, installation of safe water supply options like shallow and deep tube well,
protected ring well, Pond Sand Filter, Gravity Flow System, Infiltration Gallery, Rain Water
harvesting etc. are going on in rural areas of Bangladesh. Through DPHE, installation of
water supply system including production tube well, pipeline, treatment plant, house
connection etc. are going on in municipality and urban areas of Bangladesh.
• Dhaka WASA is constructing District Metered Area (DMA) to provide potable water to the
city dwellers. Construction of 47 DMAs have completed and remaining DMAs will be
completed by 2021.
• Dhaka WASA prepared the Sewerage Master Plan. Under Sewerage Master Plan 5 Sewerage
treatment plan will be constructed in and around Dhaka city to bring all city dwellers under
sewerage network

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The current status of the population all over the country covered by safely managed drinking water
supply is 56%8 and is expected to increase >85% by 2025, and 100% by 2030. The accessibility to
improved sanitation is expected to increase from current level of 47%8 to > 70% by 2025 and > 100%
by 2030. We have to ensure 100% safely managed sanitation by 2030 to achieve SDG targets. The
hygiene practice will be increased from current level of 40%8 to > 80% by 2025 and >100% by 2030.
All these factors are projected in the NCCP 2019 - 2030.

Climate change, urbanization, population growth, migration and force displacement will likely to
increase the risk of cholera in the years to come since living in urban areas is steadily increasing with
economic growth of the country as a consequence of industrialization, notably garment sector that has
an impact on WASH services. The pressure on infrastructure in urban areas will therefore continue to
increase, worsening access to safe water and basic sanitation. The basic WASH package with safe
water is minimum requirement to reduce burden of cholera. BHE will take initiatives for an effective
countrywide hygiene promotion.

3.4.1 Scheme for safe drinking water

The aim of the scheme is to ensure safe water to protect users from the pathogen that causes cholera
and to strengthen policy, regulatory, and monitoring mechanisms at the national level to support
appropriate targeting with consistent and correct use of water. WHO/UNICEF jointly developed tool-
WASH FIT (Water and Sanitation for Health Facility Improvement Tool), an adaptation of the water
safety plan approach. WASH FIT aims to guide small, primary health care facilities in low- and
middle-income settings through a continuous cycle of improvement through assessments,
prioritization of risk, and definition of specific, targeted actions.

The WHO/UNICEF JMP reported progress on drinking water, sanitation and hygiene update and
baselines in 2017. The report introduces and defines the new indicators of safely managed drinking
water and sanitation services.

3.4.2 Status on Water, Sanitation and Hygiene in Bangladesh.

Table 17: Water, Sanitation and Hygiene (WASH) progress in Bangladesh (According to JMP
Report, 2017)

Access & Practice National Rural Urban

Population covered wth safely managed drinking water supply 56% 61% 45%
Population covered with at least basic drinking water services 97% 97% 98%
Population covered with basic sanitation services 47% 43% 54%
Availability of a hand washing facility on premises with soap 40% 31% 58%
and water
Source: JMP 2017

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3.4.3 Result Frame Work (RFW) goal level WASH indicators
Table 18: RFW Goal Level WASH indicators

Means of verification Baseline & Target

SL. No. Indicator
and timing source 2025 2030

1 2 3 4 5 6
Population covered by
56%, JMP
Goal 1 safely managed JMP/BDHS, every 3 years 80% 100%
2017
drinking water services
Improved drinking 97%, JMP
Goal 2 JMP/BDHS, every 3 years 80% 100%
water supply available 2017
Improved Sanitation
47%, JMP
Goal 3 available and JMP/BDHS every 3 years 70% 100%
2017
accessible
01%, JMP
Goal 4 Rate of open defecation JMP/BDHS, every 3 years 0% 0%
2017
At least basic hygiene 40%, JMP
Goal 5 JMP/BDHS, every 3 years 80% 100%
practice exists 2017

3.4.4. Targets for WASH intervention

For long-term sustainable solution of cholera elimination, services with Water, Sanitation & Hygiene
is important. The current status of the population covered by safely managed drinking water supply is
56%8 that should be increased to >85% by 2025, and >100% by 2030. The accessibility to improved
sanitation should be increased from current level of 47%8 to > 70% by 2025 and > 100% by 2030.
The hygiene practice should be increased from current level of 40%8 to > 80% by 2025 and >100% by
2030.

The highlights of WASH services for implementation during the period of NCCP are:

• Preparedness for implementation of WASH response through strengthening of chlorination of

community water supplies and monitoring water quality in piped network.
• Improved health care facility infrastructure, including WASH in facilities, availability of
supplies, infection prevention and control, medical technologies, and decentralized access to
health care (Oral Rehydration Points (ORP), in Bangladesh it is called Oral Rehydration
Therapy (ORT) corner that is already well established under running IMCI program)),
together with better community awareness and mobilization. Early detection and timely and
effective case management of cholera reduce the case fatality rate to less than 1%.
• Establishment of WASH and Health Rapid Response Teams as separate entity for field
interventions, risk evaluation, and immediate response.

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 • Maintenance of stocks of WASH supplies (rapid microbial test kits, chlorine tests, water
disinfection technologies including chlorine, water tanks, and hygiene kits), and monitoring
and enforcing food safety and water quality standards at all levels.
• Specific WASH interventions to prevent disease spread, such as increased use of safe water
and effective water treatment at point of use, implemented effectively at large scale without
delay.
• Community engagement and community-based interventions promoting hygiene practices.
• Implementation of reactive large-scale mass vaccination campaigns with OCV, to be initiated
as soon as cases are confirmed for maximum impact.
• Establishing contingency agreements with governments, agencies and supplies to ensure
efficient planning and coordination for effective supply management, including rapid
procurement, importation, warehousing and prompt distribution of equipment and other
resources for immediate response.
To reach goal of global roadmap to 2030 for cholera control and elimination, the strategic approaches
are:
3.4.5. Make Water, Sanitation and Hygiene activities more ‘Cholera-Sensitive’.
1. Improve quality of water and sanitation facilities

It is crucial to improve the quality of water at source, in storage, and at point of consumption- and
sanitation facilities to limit transmission of infection. There is also a need to ensure that households
that have a piped water supply also have water that is safe for drinking. Awareness campaigns along
with social drivers can be effective in meeting these needs.

2. Strengthen implementation of hygiene-related activities.

Hygiene remains the weakest link in the water and sanitation sector. At the strategic level, the 2014
draft National Water Supply and Sanitation Strategy adequately addressed this issue. It is now critical
to finalize the draft 2014 Strategy and implement the action plan. The GoB will need to monitor
progress of the implementation of the action plan through a high-level inter-sectoral committee.
Particular emphasis should be placed on increasing the availability of hand washing stations and
ensuring that these are used.

3. Strengthen the health sector response, but also build a non-health, multisectoral response for
addressing cholera

Operationally, this involves identifying interventions within sectors that have the potential to
significantly improve WASH services for addressing cholera.

4. Align efforts of the various sectors with the overall goal of reducing cholera deaths

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Individual efforts by MOHFW and other ministries have the desired impact on cholera deaths. The
relevant sectors such as health, local government, water and sanitation, education need to act in an
integrated way to attain the broader national goal of reducing cholera deaths by 90% by 2030. To
enable this, improving WASH services must remain a high-level policy priority. Promoting
interventions with cross-sectoral involvement will be useful. There is now mounting global evidence
from diverse sources- including biological, epidemiological, and economic analysis- of a strong
linkage between contaminated water and poor sanitation and hygiene with cholera. Over the years,
poor water quality with poor sanitation and hygiene has been implicated as the most significant factor
in the causal pathway of cholera that incur a significant economic loss.

3.4.6. WASH indicators and improvement target by year in %

Table 19: WASH: Water supply and water quality indicators and improvement target by year in %

WASH: Water supply and water quality indicator Benchmark Target (%) by year
(%)
2025 2030
Proportion of people accessing and using improved and safely 56%
85% 100%
managed sources of drinking water. JMP 2017
Proportion of water supply sources that have regular (every NA
alternate year) water quality testing for bacteriological 85% 100%
contamination
Proportion of families adapted water safety plan in managing NA
85% 100%
safe drinking water
Percentage of health facilities with an improved and safely NA
85% 100%
managed water accessible to all users at all times
Percentage of schools with an improved and safely managed NA
85% 100%
water sources accessible to all users at all times

Table 20: WASH: Sanitation indicator indicators and improvement target by year in %

Benchmark Target
WASH: Sanitation indicator
(%) 2025 2030
56% (JMP
Percentage of household members using safely managed 2017)
70% 100%
sanitation facilities which are not shared 61%
(JMP 2015)
Percentage of population not practicing Open Defecation 99% (JMP
100% by 2020
2017)
Percentage of child feces management safely (Under 5
40% 70% 100%
years)
Percentage of schools having safely managed sanitation 24% (with
facilities with running water inside the toilets, gender- running
segregated and at least one toilet for every 50 students. It water, but 70% 100%
must be disabled friendly. disable
friendly)
Page | 44
 WS- WS-
**WS-96%, 100%, 100%,
Schools having water supply with functional water source
*FWS-25% FWS- FWS-
60% 100%
**WS: Water supply; *FWS: Functional water supply
WASH Indicator (Hygiene) target by year in %
Table 21: WASH: Hygiene indicators and improvement target by year in %

Benchmark Target
WASH: Hygiene indicator
(%) 2025 2030
Percentage of households with a specific place for hand
washing where water and soap or other cleansing agent are NA 80% 100%
present
Percentage of households with a specific place for hand
washing where water and soap or other cleansing agent are NA 80% 100%
present
Percentage of health facilities with a specific place for hand
washing where water and soap or other cleansing agent NA 80% 100%
present
3.4.7. Costing and Financing Estimates (Budget) for WASH
Total upazila: 491
Hotspots: 120 upazila
Average population per upazila: 270,000
Total population in hot spots: 120 x 270,000 = 32,400,000 People= 6,480,000 Family
Water cost:
Target: 100% water coverage
56% already covered by safe water; rest 44% of 32,400,000 = 14,256,000 people= 2,851,200 Family
1 water source covers 500 people (100 families) through piped water supply system on premises
# of water supply system required= 28,512
Fund required per water supply system = BDT 2,000,000/- (US$ 23,800)
Total fund required: BDT 57,024,000,000/-; USD$ 678,857,142 = US$ 0.68 Billion
Sanitation cost: Hardware
Total Family = 6,480,000
30% covered already; rest 70% to cover = 4,536,000;
@ BDT 25,000/- per unit cost = BDT 113,400,000,000/- = US$ 1,350,000,000= US$ 1.3 Billion

Faecal sludge/ solid waste management

Unit cost = 25, 00,000 BDT required unit = 50
Total cost = BDT 125,000,000, USD 1,488,095
Therefore total cost for sanitation =

Page | 45
 BDT 113,400,000,000 + BDT 125,000,000, = BDT 113,525, 000,000 = US$ 1,351,488,095
=USD 1.35 Billion
Hygiene cost: Hygiene activities will be continued till 2030 in two phases, intensive and
continuation phase.
Intensive phase: 4 Years
Total population to be covered: 32,400,000 @ US$ 4/person/year = 4x4 = US$ 16/person for 4 years
= US$ 518,400,000
Continuation phase: 7 Years
Total population to be covered = 32,400,000 @ US$ 2/person/year = 2x7 = US$ 14/person = USD
453,600,000+30% increase (market price adjustment and population increase) = USD 589,680,000
Total cost for hygiene promotion =USD (518,400,000+589,680,000) =USD 1,108,080,000= USD 1.1
Billion
Total projected cost for implementation of WASH component: US$ 3.13 Billion (0.68 + 1.35 + 1.1)
Exchange rate: Rate of US$ and Date: US$ 1 = 84 BDT, Date: April 03, 2019

Page | 46
3.5. Strategic approach 5: Coordination and monitoring through multi-sectoral
approach
Lead will be taken by the MOHFW with support and assistance from other stakeholders including
DPHE, WASA, City Corporations & municipalities under MOLGRD&C with involvement of icddr,d,
WHO, UNICEF, and other sectors/agencies outside health like Ministry of Education (MOE),
WaterAid & other NGOs for planning and implementation. District Coordination Committee will be
headed by Deputy Commissioner, and Upazila Coordination Committee by Upazila Nirbahi Officer
(UNO).

Figure 4: NCCP Government Structure

Page | 47
3.5.1. Leadership and Coordination
Under the leadership of MOHFW, the leadership and coordination will ensure the multi-sectoral task
is established and program implementation is affected. The coordination framework for cholera
control is mentioned below:

Table 22: Coordination Framework for NCCP

Coordination
Headed by Minister of Health & Family Welfare. Secretary
of Health Division will work as Member Secretary with all
National Task Force for Cholera
inter-sectoral stakeholders including health, local
Control
government, CDC, IEDCR, EPI, DPHE, WASA, WHO,
UNICEF, icddr,b, WaterAid.
Headed by Director General of Health Services with all
Planning and Implementation inter-sectoral stakeholders including health, local
Committee government, CDC, IEDCR, EPI, DPHE, WASA, WHO,
UNICEF, icddr,b, WaterAid
Headed by Director, Disease Control (DC) with all technical
Technical Committee
specialists from all relevant organization and partners.
The committee will work with specific TOR at regular
Terms of Reference
interval, may need to sit more frequently.
Headed by Chairman, Zila Parishad of the district. Civil
Surgeon will act as Member Secretary. Other members will
be Executive Engineer of DPHE, City Corporations and
District Coordination Committee
Municipalities, District Education Officer (DEO), UNOs,
UH&FPOs, Sis and co-opt members from relevant
department
Headed by Chairman, Upazila Parishad. UH&FPO will act
as Member Secretary. Members will be from LGED
Upazila Coordination Committee
Engineer, UEO, UP Chairman, local elites and co-opt
members from relevant department.

Interventions:
i. Establish a inter-ministerial task force and develop terms of reference for the task force.
ii. Establish legislative framework, communication and implementation strategy, inter-ministrial
and inter-sectoral collaboration for healthy environment towards cholera control.
iii. Improve the activities for implementation of health education and promotion at individual and
community level.
iv. Identify different target audience and to address cholera control issue.
v. Establish linkage with other Operational Plan (OP) of DGHS for implementation of respective
Social & Behavior Change Communication (SBCC).

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 vi. Establish linkage with print, electronic and social media for community engagement for SBCC

Legislative framework

Activities:

1. Evidence based advocacy with policy makers for enforcement of legislation for cholera control
2. Conduct advocacy workshop with the Parliamentarian Caucus group
3. Awareness building for legislation on pollution and controls in industrial areas

4. Establish inter-sectoral collaboration that influence cholera control and elimination

Collaboration for cholera control and elimination: Important stakeholders & key output areas:

Table 23: Collaboration for cholera control and elimination: Important stakeholders & key output
areas
Stakeholders Key strategic areas
MOHFW Provide overall policy directions, financial commitment, support to the
Ministers and stakeholders, and review and monitor Bangladesh’s national
and global commitments in cholera elimination.
Provide national coordination with other sectors to facilitate cholera
elimination, regulate standards of health services, facilitate cholera
prevention, early case detection and quick response, treatment services,
conduct cholera surveillance, mass media campaigns.
Ministry of Local Lead initiatives to promote Healthy Settings Programs through Healthy City
Government, Rural Projects which holistically address establishing city dwellers friendly
Development and Co- environment, enforce food safety, support Healthy Schools and Healthy work
operatives place initiatives; and integrate healthy lifestyle education and cholera
(MOLGRD&C) screening in urban primary health care facilities.
Ministry of Education Support for curricular inclusion on healthy lifestyle, food safety, WASH
(MOE) promotion, participate in scaling up of preventing water borne diseases.
NGOs Participate in policy lobby, provide cholera control and elimination support
services, and engage in prevention of specific risk factors and prevention
programs such as projects related to promotion of WASH intervention.

Advocacy and Coordination

Advocacy and coordination is essential to have SBCC activities aligning with cholera elimination
policies and guidelines, promoting linkage with different health care services.

Activities:
1. Collaborate with relevant sectors and organizations for comprehensive planning and
implementation of Lifestyle and Health Education and Promotion programs
2. Conduct workshops with stakeholders at National, Divisional, District and Upazila levels to
facilitate smooth implementation of activities of cholera control and elimination.
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3. Coordinate interventions with other National and Sectoral interventions conducted by other
departments and organizations.
4. Advocate to reduce cholera high risk behaviors
5. Procurement of Service Package to conduct advocacy meeting, seminars and other awareness
raising activities on Cholera and Water borne diseases.
6. Inter-sectoral & Multisectoral advocacy and coordination meeting with other OP’s
7. Promotion of quality essential health-care services at public hospitals to achieve the Universal
Health Coverage (UHC).

3.5.2. Program indicators and targets for leadership and coordination

Table 24: Leadership and Coordination Indicators for NCCP

Leadership and Coordination Indicators

Indicators Targets
National Plan for Cholera Control developed Plan developed by 2019, disseminated by 2019
and disseminated
Resources: funds receive versus those request Funding available for 100% components of the
(breakdown by donor and by sector) plan
Functional National Cholera Task Force Terms of Reference (TOR) of NCTF finalize
(NCTF) in place and 1st meeting of NCTF by 2019
Number of meetings held by coordination Quarterly and/or need based
bodies (NCTF, subcommittees and technical
working groups, etc)
Proportion of sectors (Health Sectors, WASH At least 90%
authorities, etc.) engage in coordination bodies
meetings

Planning and Coordination

Prevention and containment of cholera requires integrated and well-coordinated efforts among
stakeholders at different levels of both public and private sectors. For planning and coordination of
activities, the following committees are being developed with their respective terms of reference
(TOR):

• National Task Force for cholera control

• Emergency Response Committee (ERC) for cholera at all level
• National level
• Divisional level
• District level
• Upazila level

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National Cholera Task Force (NCTF)

It is the highest policy formulation body at national level comprising Hon'ble Ministers of MOHFW,
Secretaries and high officials of Ministry of Health and Family Welfare and related Ministries. It also
includes top executives of concerned UN bodies, professional bodies and different stakeholders.

Chairperson
Hon'ble Minister, Ministry of Health & Family Welfare

Co-chairperson
Hon'ble State Minister, Ministry of Health & Family Welfare

Member Secretary
Secretary, Health Service Division, Ministry of Health & Family Welfare

Members
(Not according to warrant of precedence):
1. Joint Secretary- Planning Wing, MOHFW
2. Joint Secretary (WHO & Public Health)
3. Joint Secretary, LGRD&C
4. Joint Secretary, Finance
5. Joint Secretary, MOE
6. Director General, Directorate General of Health Services
7. Director General of Family Planning
8. Director General, Department of Environment
9. Director (Disease Control) and Line Director, Communicable Disease Control (CDC), DGHS
10. Chairman, Bangladesh Food Safety Authority
11. Managing Director, Dhaka Water Supply and Sewerage Authority (WASA)
12. Chief Engineer, Department of Public Health Engineering (DPHE)
13. Chief Health Officer, Dhaka North City Corporation
14. Chief Health Officer, Dhaka South City Corporation
15. President/Secretary General, Bangladesh Medical Association
16. Public Health Specialist (by name)
17. Immunization and Vaccine Management Specialist (WHO GTN Trained) (by name)
18. Executive Director, icddr,b and Dr. Firdausi Qadri, icddr,b
19. Country Representative, World Health Organization (WHO)
20. Country Representative, UNICEF
21. Country Representative, Water Aid

22. Co-opt member

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Terms of reference
• Approval of the Strategy, Action Plans and Guidelines for prevention and control of cholera.
• Decision/Approval on proposals/recommendations sent by National Technical Committee.
• Oversee implementation status of National Strategy Action Plans and Guidelines for prevention
and control of Cholera.
• Review and approve budgets for the different activities outlined in Action Plan.
• Meet every six month and at shorter intervals if required.
• Co-opt member(s) if and when necessary.

Emergency Response Committee (ERC) for cholera control

It is the highest multi-sectoral and multidisciplinary executive technical body at Directorate level
headed by Director General of Health Service (DGHS) and Director, Communicable Disease Control,
DGHS as Member Secretary. Representatives from relevant stakeholders, leaders of professional body
and executives of UN organizations have been included in this committee. This committee has
incorporated eminent personality(s) from different sectors.

Chairperson
• Director General of Health Services

Co-chairperson
• Additional Director General (Planning and Research) of Health Services

Member-Secretary
• Director (Disease Control) and Line Director, Communicable Disease Control (CDC), DGHS

Members (not according to warrant of precedence)

• Director (Hospitals), DGHS
• Line Director, MNC&AH, DGHS
• Director, Institute of Epidemiology, Disease Control & Research (IEDCR)
• Director, Institute of Public Health (IPH)
• Director, National Institute of Preventive and Social Medicine (NIPSOM)
• Director, Primary Health Care
• Representative from World Health Organization (WHO)
• Representative, UNICEF
• Representative from icddr,b
• Coordinator, Core Working Group
• Co-opt member

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Terms of Reference
• Develop and periodical review of Strategy, Action Plans and Guidelines for prevention and
control of cholera in case of outbreak for consideration of NTF
• Propose budgets for the different activities outlined in Action Plan
• Monitor and evaluate implementation status of Strategy, Action Plans and Guidelines
• Coordinate with other Directorates and sectors involved in the Action Plan;
• Meet every 3 month and when the country situation requires
• Co-opt member(s) if and when necessary

Core Working Group (CWG) for Cholera Control

Coordinator
• Director, Disease Control & Line Director, Communicable Disease Control, DGHS

Members (not according to warrant of precedence)

• DPM, AMR, Viral Hepatitis & Diarrhea, CDC, DGHS
• PSO, Department of Microbiology, IEDCR
• Assistant Professor/ Representative, Department of Microbiology, IPH & NIPSOM
• DPM/Representative from Hospital Management Service, DGHS
• NPO (Epidemiology), WHO/ Representative
• Representative, IDD, icddr,b
• Assistant Professor/ Representative, Dept. of Microbiology BSMMU
• Assistant Professor/ Representative, Dept. Microbiology, DMC
• Representative, Dhaka- WASA
• Competent Representative, Water AID
• Competent Representative, UNICEF

• Co-opt member

Terms of Reference
• Develop and periodical review of Strategy, Action Plans and Guidelines for prevention and
control of Cholera for consideration to NTF
• Monitor and evaluate implementation status of Strategy, Action Plans and Guidelines
• Coordinate with other Directorates and sectors involved in the Action Plan
• Meet every month and when the country situation requires
• Secretarial support of the NTF will be provided by this committee
• Co-opt member(s) if and when necessary

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3.6. Strategic approach 6: Advocacy Communication and Social Mobilization
(ACSM)

3.6.1. Communication: A Core Communication Committee will be formed under the leadership of
the Director, Disease Control. Bureau of Health Education, UNICEF, BTV, Bangladesh Betar and
other Stakeholders, engaged in developing health related IEC materials, will be included in this
committee. The committee will develop need based different types of IEC materials on cholera during
outbreaks and also during OCV vaccination campaigns. The committee will develop public
awareness regarding WASH intervention. The committee will take initiative to include cholera and
WASH in primary/secondary education curriculum. All IEC materials will be used after approval of
IEC Technical Committee of MOHFW.
3.6.2 Advocacy and social mobilization
Bangladesh has made commendable success in health sector. Strong political commitment from the
government, effective service delivery, multi-sectoral SBCC, supply chain, collaboration with
government and non-government organizations (NGOs) have contributed in this achievement. Almost
all the people of the country are well aware of the use of ORS during diarrhea and more than 99%
children have access to first vaccine i.e. BCG. As a result, infant and under five and maternal
mortality reduced significantly. Bangladesh has achieved most of the health related MDG goals
before its time limit. In the process of cholera control program, comprehensive advocacy and social
mobilization program will be taken to develop awareness among all populations. The process
includes:
a. Community engagement: The key access of child immunization and other health
intervention is related to engagement of community people. Community key persons like public
representatives, religious leaders, youth club, school teachers, local journalists and community leaders
played a vital role in developing public awareness and success of the programs. Currently community
people have been engaged in Community Based Health Care (CBHC) programs through Community
Clinic (CC). Each CC has one community group and three community sub-group. During last HNP
sector program (HPNSDP: 2011-2016)11 number of positive lessons have been learned in
implementing different SBCC activities which can be used to control cholera. These experiences will
be applied to control cholera.
b. Media Engagement: Previous experience reveals that media (both print and electronic
media) media plays important role in widespread public awareness development on health programs.
Mass media campaign, using radio and TV including government and private channels have been
proved to be an effective approach to disseminate messages to the maximum number of population.
This approach will be used for cholera control.
c. Coordination: To strengthen the SBCC activities a strong platform can be formed through
closer interactions with different professional groups and committees like BCC Working Group, the
HPN Coordination Committee which help integrating and harmonizing different SBCC initiatives
across health and beyond health sector. Establishing linkages with all relevant factors including
NGOs, and the private sectors to increase service coverage would be effective way for use in cholera
control activities.
d. Advocacy: Intensive communication campaigns can break religious conservatism and
negative barriers on health related issues. Repeated dissemination of messages through workshops and
campaigns to targeted stakeholders could increase the service demand. As part of policy advocacy
IEM unit can take initiatives to update current communication strategy in line with the

Page | 54
Comprehensive Social and Behavior Change Communication Strategy (CSBCCS) prepared by
MOHFW.
The Operational Plan (OP) of CDC with cholera control activities to be revised align with Global
Roadmap. Accordingly, in light with recently developed and approved Comprehensive Social and
Behavioral Change Communication Strategy 2016 by MOHFW, bringing positive changes in people’s
lifestyle to improve health in cholera free environment would be the key strategic focus of the IEC OP
that can be used also for reaching Global Roadmap targets of cholera deaths reduction by 90% by
2030.

3.6.3. Program indicators and targets for social mobilization

Table 25: Social mobilization Indicators for NCCP

Social Mobilization Indicators

Indicators Targets
National social mobilization plan developed and Plan developed by 2019 & starts
disseminated implementing from early 2020
Availability of all necessary logistical support for Necessary logistical support available 80% of
social mobilization the time in high risk areas
Training programs takes place for health 100% of planned training occur by 2020 in
promotion personnel areas at increased risk of cholera
Implementation of social mobilization campaigns Evaluation occurs for 75% of social
in high risk areas before OCV and WASH mobilizations campaigns
interventions
Implementation of social mobilization campaigns 100% outbreaks supported by social
during outbreaks mobilization
Monitoring and evaluation surveys of social 100% outbreaks supported by social
mobilization campaigns conducted mobilization

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4. Implementation of National Cholera Control Plan for Bangladesh
(NCCP)
4.1. Inclusion in Sector Wide Plan

The program will be included in the revised OP 2017-2021 of Communicable Disease Control unit of
DGHS. WASH section will be included in budget of Local Government division of MOLGRD&C.

4.2. Implementation Framework

The following chart shows the implementation framework of national cholera control plan for
Bangladesh. The chart also shows the individual responsibility of the stakeholders. The CDC, DGHS
is the implementation focal point of the NCCP.

MOHFW Director General, DGHS

- Direction icddr,b
MOLGRD&C - Guidance - Technical Assistance
C - Surveillance support
MOE
- OCV Immunization
NRA/DDA - Operations Research
- Outbreak Investigation
WASA support

IEDCR
DPHE
- Surveillance
Director Disease Control, and
DCC- N&S - Information Collection
Line Director- CDC
- Data Analysis
- Planning
WHO - Outbreak Investigation
- Implementation
- Supervision
UNICEF
- Monitoring EPI
- OCV Immunization
WB
- Information Collection
Water Aid - Data Analysis
- Outbreak Investigation
NGO Implementation

WASH Monitoring Support Service Unit Technical Unit

- Safe Water - QA/QC - Capacity Building
- Basic Sanitation - MIS - Coordination
- Hygiene Promotion - Logistic Support - Networking
- Audit & Accounts - Communication
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4.3. Implementation Targets and Activities for cholera control

Table 26: Implementation Targets and Activities for cholera control

Area Targets Proposed Activities Lead Partners

* WASH promotional activities
* Cholera surveillance
* Using data on unvaccinated DPHE, CDC,
expansion
targets to drive decision WASA, BHE,
* WASH intervention * Lab facility at district level IEDCR and
promotion * Micro-planning, technology icddr,b, WHO,
platforms UNICEF,
* Use cholera expertise and
Water Aid
tools to identify high-risk
districts
* Enhance supportive supervision in
Cholera health care facilities
Surveillance, * Use cholera resources to * Channel SIMOs toward cholera
OCV specific surveillance system
help build capacity to
vaccination strengthening activity EPI, CDC,
vaccinate
and * Engaging in capacity building IEDCR,
WASH - unreached targets efforts focused on surveillance, icddr,b
Intervention - under- vaccinated targets OCV in trainings
* Align cholera response activities
in WASH with OCV immunization
coverage improvement
* Deliver other health * Broad applicability:
interventions in national * Harmonize cholera vaccination
immunization schedule to and guidance in the country IEDCR, CDC,
cholera affected * Joint micro-planning for EPI, icddr,b
districts/hotspots where integrated OCV campaign processes
vaccination is ongoing * Identify concrete
* Broad applicability:
* Harmonize WASH and OCV
campaign calendars at district level
* Micro-planning for OCV MOHFW,
* Collaborate for joint campaign processes and WASH MOLGRD&C,
planning of WASH & OCV promotion DGHS,
* Identify concrete activities from DPHE, CDC,
Joint
joint WASH activities and OCV EPI, IEDCR,
Planning
campaigns that will implement icddr,b, DCC,
decrease deaths WHO,
UNICEF,
* Maximize Joint Working * Ensure targeted agendas to plan, Water Aid
Group platforms to conduct prioritize, and monitor progress on
joint planning and agreed upon targets/milestones
commitments

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 * Ensure coherence of * Monitor performance
WASH promotion and * Track resources required
immunization outreach * Can be done in conjunction with
activities and accountability overall planning process including
framework campaign microplan development
* Ensure surge personnel have the
skills required
* Include national capacity building
into TORs of cholera surge staff
* Emergency WASH * Develop and disseminate
intervention messages and create effective
* Align processes to ensure demand generation strategies
DPHE, CDC,
Outbreaks cholera outbreak surge * Integrate specific EPI, IEDCR,
Response personnel systematically recommendations on WASH and icddr,b, DCC
build national capacity to OCV campaign plans
strengthen WASH and * Consider how to deliver other
immunization systems immunizations during outbreak
response activities
* Link integrated cholera outbreak
detection and response to
emergency WASH operations
* Involve cholera-funded staff in MOHFW,
identifying needs, HSS Global MOLGRD&C,
* Identify select districts Roadmap application process, DGHS,
Strengthening where cholera-funded staff supporting implementation, etc. Directorate
Health Care and resources can be used General of
* Identify how best to coordinate
Systems for targeted HSS Family
these activities through existing
interventions Planning
and/or new mechanisms
(DGFP), CDC,
IEDCR
* Ensure cholera supervision * Bring culture of using data and
Monitoring visits are linked with WASH evidence to drive decisions
CDC, IEDCR,
and promotion and immunization * Include government staff
icddr,b, DPHE
Supervision support plans, supportive counterparts in supervision /
supervision, and follow-up monitoring visits by cholera staff
* Integrate cholera elimination and
* Align advocacy efforts for immunization system strengthening
immunization strengthening message into GTFCC roadmap in
and cholera elimination country
* Ensure that cholera task force / MOHFW,
Political * Align cholera resources to MOLGRD&C,
executive committee meetings
advocacy facilitate broad ownership MOE, DPHE
include WASH and OCV
for WASH and OCV
immunization advocacy
immunization results and
accountability * Implement strategies for
engagement of community and
religious leaders, community-based
Page | 58
 organizations, and professional
organizations
* Ensure civil society and NGOs are
utilized to support cholera
elimination advocacy

4.4. Potential risk and mitigation plan

While Bangladesh remains optimistic in achieving a 100% reduction in cholera deaths, there are a few
risks that have been recognized. These risks and their mitigation strategies are discussed below:

Risk 1: Lack of Adequate Financing

Resource mobilization activities are available according to implementation plan. However, there
stands a risk of failing to raise adequate funds to implement the multi-sectoral plan. The realization of
this risk will lead to poor implementation of cholera control plan with other sectors having less funds
or nothing at all to execute their activities.

Mitigation Activities
Each sector will cost their activities within the GTFCC framework specifically indicating what is
required to implement their activities. These costing will be emphasized in the resource mobilization
meeting/s and the risks of raising less funds will be shown.

Risk 2: Insufficient Quantities of OCV vaccines

As countries jump on board to kick out cholera by 2030, the GTFCC highlight the need for an
estimated 44 million, 59 million and 76 million doses of OCV for 2018, 2019 and 2020 respectively.
The production capacity for OCV was only at 25 million doses in 2017. As Bangladesh plans to
introduce cholera as a preventive measure as opposed to a mitigation measure, the required number of
OCV doses will sky rocket. With the global picture, the country may not receive the desired number
of OCV doses and thus fail to reach their intended target.

OCV need of Bangladesh: Total 86.45 million from 2019 to 2024; 6.65 million in 2020, 13.30 million
in 2021, 21.15 million in 2022, 25.40 Million in 2023, 19.95 million in 2024.

Mitigation Activities
The OCV team will work closely with the GTFCC and partners like Gavi to plan ahead for the
number of vaccines required in a specific period of time. Based on this partnership, vaccine request
and distribution strategies will be developed to ensure 100% vaccine coverage.

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Risk 3: Cross Border Cholera Transmission

Bangladesh borders in three sides- west, north and east with India and a small side in South East with
Myanmar. Bay of Bengal is on south side of Bangladesh. These countries suffer from cholera and
pose a threat of cross contamination across borders.

Mitigation Activities
Collaboration and strengthening will be done with border security, communities and government
structures like health facilities. Yearly training will be held for cross border staff and regular OCV
vaccination will be given to populations around borders that pose a threat.

4.5 Monitoring Framework

In line with the GTFCC, the Bangladesh monitoring framework is designed under 3 axes. The
GTFCC has the aim of reducing cholera deaths by 90%, and Bangladesh cholera control plan runs
parallel to that of GTFCC. Being a state of good political atmosphere, the country is optimistic to
achieve the implementation targets it has set to eliminate cholera by 2030. Moreover, Bangladesh
does not face any crises and experiences relative peace and a safe political atmosphere. These
attributes are a prerequisite to the elimination of cholera.

Table 27: Overview of outcome indicators

Outcome indicators
Axis Indicators
Baseline 2021 2025 2030
Axis 1: Early Outbreaks NA Reduce Reduce Reduce
case detection severity outbreaks outbreaks outbreaks
and response to measured by deaths by deaths by deaths by
contain outbreaks number of 30% 50%
100%
cholera deaths
Axis 2: Number of 21 districts 30% districts 70% districts All 21
Prevention of currently remain eliminate eliminate districts
cholera endemic districts affected by cholera cholera eliminate
morbidity by that eliminate cholera
cholera
multi-sectoral cholera as a
interventions in threat to public
cholera hotspots health
Axis 3: An Number of fully Absence of Development Efficient All districts
effective funded multi- fully funded of implementati implemented
mechanism of sectoral cholera multisectoral multisectoral on of multisectoral
coordination for control plan cholera cholera multisectoral
plan
technical aligned to the elimination elimination plan
support, resource Global Roadmap plan plan with
mobilization secured fund
locally and
internationally
Impact: Reduction of NA Reduce Reduce Reduce
Reduction of cholera deaths outbreaks outbreaks outbreaks
cholera deaths deaths by deaths by deaths by
30% 50% 100%
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 In line with the implementation timeline, progress towards these indicators will be monitored every 3
years from 2022 t0 2030. Monitoring systems including activity logs and registers will be closely and
regularly reviewed and reported. Additionally, process evaluations and impact studies will provide
scientific accuracy in determining the effect of the multi-sectoral cholera control plan for Bangladesh.
4.6 Implementation Timeline

The commitment to eliminate cholera is shown by Bangladesh, and therefore the country has 10 years
to implement the multi-sectoral plan across the three axes of Global Roadmap. The efforts and
achievements made in the control of diarrheal diseases, measles control, polio eradication, and
Maternal and Neonatal Tetanus elimination (MNTE) and WASH implementation activities already set
a strong foundation to implement the activities to contain cholera as outlined in the multi-sectoral
strategy. The Bangladesh government remains committed in eliminating cholera and setting this
multi-sectoral plan in motion.

Table 28: Implementation timeline for NCCP

2029-
2019 2020 2021 2022 2023 2024 2025 2026 2027 2028
30
2019: Integrated Rollout: 1. Health systems strengthening
1.Preparatory activities and activities to improve surveillance
1. OCV + WASH campaign:
establishment of plan: and case management of cholera
initially in high burden
cases through regular supervision
2. Bangladesh commits to hotspots, and gradually
and monitoring activities
eliminate cholera by 2030 moving to medium to low
3. Launch multi-sectoral burden areas 2. Maintenance and repairs on
cholera elimination plan cold chain equipment and WASH
2.Strengthening cholera case
4. Resource mobilization infrastructure
management and its
meeting
implementation nationally 3. Reinforcement of BCC
5. Establishment of cholera
(Behavior Change
control focal point 3. Roll out of M&E tools in all
Communication) strategy
6. Revision & finalization of sectors
M&E tools for WASH, OCV, 4. Rigorous evaluation of the
4. Implementation of BCC
surveillance, social impact of the multi-sectoral plan
strategy
mobilization, and case in cholera incidence
management 5. Monitoring and evaluation
5. Dissemination meeting to the
7. OCV registration of cholera outbreaks
local and international audience
2020: 6. Improvement of WASH in
6. Development of process for
communities, schools, and
8. Surveillance system certification of cholera free
health facilities
establishment/implementation Bangladesh
9. Integrated demonstration 7. Process evaluation studies
project: OCV & WASH conducted
11. Gradual implementation of
OCV mass vaccination
12. Impact study of integrated
project
2021:
13. OCV campaigns gradual
expansion plan, other hotspot
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4.8. Program Evaluation

The progress of the cholera control plan will be evaluated after the end of short, mid and long term
activities i.e. 2023, 2026 and 2031 respectively. For this purpose, nationwide evaluation survey will
be carried out by third party as per WHO guideline. Result of the survey will be disseminated in high
level dissemination program. Based on the evaluation report, the program will be reviewed and
intervention will be applied for improvement, if needed. This evaluation will guide to reach the
elimination goal by 2030.

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5. References
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