[Formative supervision: the experience of treatment units during cholera epidemic in Douala, Cameroon]. / Supervision formative: i'expérience des unités de traitement du choléra au cours de l'epidémie de Douala, Cameroun.

Formative supervision is a quality and performance tool based on evaluation and adult training techniques. The 2004 cholera outbreak in Douala (Cameroon) presented a critical problem in terms of quality of care; formative supervision emerged as the choice of instrument developed as a key response and solution. After a chronological qualitative description of how the supervision team and system were constituted, established and organized, the results are presented: strengthening infrastructure, equipment and organisation; improving the quality of care, hygiene, communication, and management. The system requires capacity building for sustainability in order to also be eventually extended to other health districts and other health sector activities, on the condition that the necessary resources can be mobilized.

[Large-scale selective antibiotic prophylaxis during the 2004 cholera outbreak in Douala (Cameroon)]. / Antibioprophylaxie ciblée à large échelle au cours de l'épidémie de choléra de Douala en 2004.

INTRODUCTION: During the 2004 cholera outbreak in Douala, densely populated and poor suburban populations had very poor access to safe drinking water and were at high risk of transmission. The provincial task force thus decided to provide preventive antibiotic treatment of all patient contacts, that is, family members taking care of patients in the hospital and household members of patients or close neighbours living in houses directly adjacent to patients. METHODOLOGY: This retrospective report, based on data from hospitals, local cholera committees, and pharmacies, describes the course of the epidemic, bacteriological monitoring, and antibiotic distribution. RESULTS: Suddenly appearing in January 2004, the outbreak affected 5,020 patients in 8 months. V.cholerae, which was isolated in 111/187 samples, remained susceptible to doxycycline, amoxicillin, and fluoroquinolones. A total of 182,366 persons (35 contacts per patient) received antibiotic treatment. The rate of contacts among new patients fell from 30% to less than 0.2%. DISCUSSION: Antibiotic prophylaxis was a part of a comprehensive package of community interventions that included health education, disinfection of homes, latrines and wells in all affected households, and bacteriological monitoring. Although it reduces the risk of the disease, mass antibiotic prophylaxis is not recommended against cholera outbreaks, because it does not prevent contamination and is limited by contraindications, costs, and modes of administration. Moreover, it increases the risk of developing resistance. It is impossible to eradicate vibrio from the environment. The individual risk of contracting cholera is not known and it is difficult to assess the impact of a collective prevention strategy. Because the bacteria remains susceptible to antibiotic drugs, a well-targeted antibiotic prophylaxis made it possible to reduce direct human transmission of cholera. This reduction did not affect the overall epidemic, however, because of the massive environmental contamination. CONCLUSION: The role of chemoprophylaxis in limiting cholera epidemics is difficult to ascertain. Large-scale prophylaxis should be selective and limited to close contacts, in accordance with WHO recommendations, with rigorous application and monitoring of both integrated prevention procedures and antibiotic susceptibility.

[Service quality assurance by death analysis during the 2004 cholera outbreak in Douala]. / L'amélioration de la qualité par l'analyse des décès au cours de l'épidémie de choléra de 2004 à Douala.

Morbidity and mortality conferences (MMC) are used today in most medical departments as a tool for quality assurance as well as an educational tool. We introduced MMC with regard to cholera lethality during the 2004 cholera outbreak in Douala. The Delegation of Public Health (DPH) in Douala, coordinating body for the combat against the epidemic, decided to open cholera treatment units (CTU) in fourteen hospitals, equally distributed over the town. The CTUs' personnel was retrained on diagnostic and treatment protocols, procedures to follow and on management tools. To assure the quality of services, a provincial supervision team was constituted for the close follow-up of the CTUs. The supervision team had two main tasks, i.e. on-the-job training of the personnel involved in the care of cholera patients and systematic meetings whenever a cholera death occurred during hospital stay in order to analyse the reasons behind the death. We communicate our experience with these systematic meetings inspired by the MMC and aiming at the analysis of cholera deaths in the CTUs. Immediately after a cholera death in one of the CTUs, a meeting was organised by a member of the supervision team, assisted by the entire CTU team. During the meeting, the patient's file was re-examined as were the decisions token, the actions undertaken by the personnel, and the difficulties met. Alternative decisions and actions were discussed and conclusions based on the lessons learned formulated. Of all meetings minutes were kept. A monthly provincial meeting, joining all CTU teams, was organized for discussion of the minutes, exchange of experiences, and, eventually, adapting of protocols, procedures, and management tools. Five thousand and twenty cholera patients were notified during an 8-months-period (January-August 2004), 69 (1.4%) of the patients died, amongst them 8 before the declaration of the epidemic and 4 before hospital admission. Eleven CTUs out of a total of 14 organised 15 meetings concerning 39 (68%) of the 57 hospital based cholera deaths. Eight to eighteen CTU team members participated (with 2-5 physicians according to the CTU) and the meetings lasted between 1 and 2 hours. The meetings proceeded in a systematic way: after controlling for the presence of all CTU team members concerned, the patient's file was read together, team members were asked to elucidate what did not figure in the file, everybody was asked for commentaries and suggestions, the supervisor made a synthesis of the discussion, and, finally, conclusions and recommendations were formulated. The minutes of the meeting were sent to the DPH. The conclusions and recommendations aimed at the reception of the patients and his admission circuit, the diagnostic procedures, therapy, the case definition, the evaluation of the severity of the patient's status at the moment of admission, the surveillance during evolution of the patient, the respect of the therapeutical protocols, and the management of the CTU. In spite of the organisational, psychological, and socio-cultural difficulties, the meetings went off apparently without major reservations in the minds of the participants. These meetings analysing the reasons behind a case of cholera dying in a CTU gave the opportunity to discuss performance, to identify problems, and to search together for solutions. They were thought of as a tool for improving the quality of the service. Looking at the low over-all lethality rate during this major epidemic they seemed to have, at least partially succeeded.