Humanitarian and conflict · WHO, GTFCC and Sphere guidance
Cholera, measles and other outbreaks in camps
Crowding, poor water and sanitation, low vaccination coverage and malnutrition make camps and informal settlements ideal for outbreaks. Cholera and measles can both kill quickly, and both are largely preventable and treatable at first-level care if you act early.
- For clinicians, nurses and community health workers in camps and crowded settings
- Reviewed October 2026
Why outbreaks spread in camps
- Crowding and poor ventilation: measles, respiratory infections, meningitis.
- Unsafe water and poor sanitation: cholera, other watery and bloody diarrhoea, hepatitis E, typhoid.
- Low vaccination coverage: measles, diphtheria, pertussis.
- Malnutrition and vitamin A deficiency: more severe disease and more deaths.
- Disrupted services: late treatment, no surveillance.
Young children, pregnant women, older people, people with HIV and acutely malnourished children are at highest risk.
Source: Sphere Handbook 2018, communicable diseases standards
Suspect an outbreak: act the same day
- Apply the case definition and report the alert immediately through the agreed early warning route (target: within 24 hours).
- Start treatment; do not wait for test results.
- Isolate or separate patients as the disease requires.
- Record standard information on every suspected case: age, sex, place, date of onset, outcome.
- Take samples if you are part of the testing plan.
- Tell water, sanitation and hygiene partners and the community health workers.
Source: Sphere Handbook 2018, communicable diseases standard 2.1.2
Cholera: recognise and assess dehydration
Suspected cholera (GTFCC)No outbreak declared: anyone aged 2 years or more with acute watery diarrhoea and severe dehydration, or who dies of acute watery diarrhoea.
Outbreak declared: anyone with, or who dies of, acute watery diarrhoea (3 or more loose, watery, non-bloody stools in 24 hours, lasting less than 7 days).
Outbreak declared: anyone with, or who dies of, acute watery diarrhoea (3 or more loose, watery, non-bloody stools in 24 hours, lasting less than 7 days).
Treatment depends on the degree of dehydration, not on the test result. A rapid diagnostic test helps to choose samples for the laboratory but cannot confirm cholera.
| Signs | Classify | Plan |
|---|---|---|
| One or more danger signs: lethargic or unconscious; absent or weak pulse; breathing difficulty. Or two or more of: not able to drink or drinks poorly; skin pinch goes back very slowly; sunken eyes | Severe dehydration or shock | Plan C: IV fluids now |
| Two or more of: irritable or restless; sunken eyes; rapid pulse; thirsty, drinks eagerly; skin pinch goes back slowly | Some dehydration | Plan B: ORS in the clinic |
| Awake and alert, normal pulse and thirst, eyes not sunken, skin pinch normal | No dehydration | Plan A: ORS at home |
Source: GTFCC cholera patient treatment flowchart, version 1.0, 2024
Cholera: treat
| Plan | What to give | Reassess |
|---|---|---|
| Plan C (severe) | IV Ringer's lactate. Under 1 year: 30 mL/kg in 60 minutes, then 70 mL/kg over the next 5 hours. 1 year and over: 30 mL/kg in 30 minutes, then 70 mL/kg over the next 2½ hours. Watch for low blood glucose and treat it quickly with IV dextrose. | Every 15 to 30 minutes until awake, able to drink and the pulse is stronger; then continue with ORS. |
| Plan B (some) | ORS 75 mL/kg over 4 hours in the clinic. | At least every hour. Move to Plan C if severe dehydration or severe vomiting develops. |
| Plan A (none) | ORS by age, as on the GTFCC flowchart: under 2 years 50 to 100 mL, 2 to 9 years 100 to 200 mL, 10 years and over as much as wanted. Show the family how to make up and give ORS at home. | Discharge when no dehydration, drinking ORS without vomiting, no watery stool for 4 hours, walking unaided and passing urine. |
Antibiotics (GTFCC)
Give a single dose to everyone with severe dehydration, and to pregnant women and older people: doxycycline is preferred (200 mg under 12 years; 300 mg for older children and adults); azithromycin is the alternative (20 mg/kg under 12 years; 1 g for older children and adults). Antibiotics shorten the illness but rehydration is what saves lives.
Severe malnutritionChildren with severe acute malnutrition and dehydration need a different, slower rehydration approach. Use the GTFCC job aid on cholera with severe acute malnutrition and seek senior advice.
Source: GTFCC cholera patient treatment flowchart, version 1.0, 2024; Sphere Handbook 2018
Cholera: organise the response
- Oral rehydration points in the community so people start ORS early and close to home; plan about 10 litres of water per patient per day at each point.
- A treatment centre or unit with separate areas, handwashing, safe disposal of stools and vomit, and chlorinated water.
- Community health workers find cases, start ORS and refer.
- Aim for a case fatality rate under 1%. A higher rate means people are arriving late or care needs to improve.
- Oral cholera vaccine campaigns may be organised by the national authority with partners.
Source: Sphere Handbook 2018 (WASH and communicable diseases); GTFCC
Measles: recognise and treat
Suspected measlesFever with a maculopapular (non-blistering) rash, or any patient a health worker suspects has measles. Cough, runny nose and red eyes usually come first; the rash appears 3 to 5 days later, starting on the face and neck.
- Infectious from 4 days before the rash until 4 days after it appears: keep the person apart from others, especially unvaccinated children, pregnant women and malnourished children, for that time.
- Vitamin A: two doses for every suspected case in a child under 5, the first on the day of diagnosis and the second the next day. Give the dose for the child's age from your IMCI chart booklet or national protocol. A third dose 4 to 6 weeks later only for eye signs of vitamin A deficiency.
- Complications: pneumonia, ear and eye infections, diarrhoea and dehydration, malnutrition. Treat pneumonia, ear and eye infections with antibiotics as your protocol directs; replace fluids.
- Refer any child with danger signs, severe pneumonia, eye clouding or ulcers, severe dehydration or severe malnutrition.
Source: WHO measles fact sheet; WHO measles outbreak toolkit
Measles vaccination in a crisis
- If measles coverage is below 90% or unknown, run a mass campaign for all children 6 months to 15 years, whatever their vaccination history.
- Give vitamin A to children 6 to 59 months at the same time.
- Infants vaccinated between 6 and 9 months need another dose at 9 months.
- Vaccinate at least 95% of new arrivals aged 6 months to 15 years.
- Restart routine immunisation as soon as possible, at least 20 days a month, and check vaccination status at every visit.
Source: Sphere Handbook 2018, child health standard 2.2.1
Other outbreaks to watch for
| Disease | Clues | Acceptable case fatality rate (Sphere) |
|---|---|---|
| Meningitis | Fever with stiff neck, confusion or a non-blanching rash; bulging fontanelle in infants | Under 15% |
| Hepatitis E | Jaundice clusters where sanitation is poor; very dangerous in late pregnancy | Under 4% (10 to 50% in the third trimester) |
| Diphtheria | Sore throat with a grey membrane, swollen neck, in an under-vaccinated group | Under 5 to 10% |
| Dengue | Fever with severe body pain, bleeding or shock in a dengue area | Under 1% |
For any of these, report the alert and follow the national or WHO outbreak protocol.
Sources
- Global Task Force on Cholera Control (GTFCC). Cholera patient treatment flowchart, version 1.0. 2024.
- Global Task Force on Cholera Control (GTFCC). Cholera surveillance for health care workers, module 2. 2025.
- World Health Organization. Measles fact sheet (web page). 2026. Accessed October 2026.
- World Health Organization. Measles outbreak toolbox (based on Surveillance standards for vaccine-preventable diseases, 2nd edition). 2018.
- Sphere Association. The Sphere Handbook, fourth edition (communicable diseases and child health standards; WASH). 2018.
Adapted from WHO guidance; not endorsed by WHO. This page paraphrases and adapts the WHO publications listed under Sources, which are licensed CC BY-NC-SA 3.0 IGO; the adapted text is shared under the same licence for non-commercial education. Reasoning GP is not affiliated with WHO or any other organisation named here. Use it alongside your national guidelines, essential medicines list and formulary, and your clinical judgement. Doses are given only where they come from a WHO source; otherwise follow your national guideline or formulary.