The protocol has six steps that form a loop, since the last step feeds the preparedness plan against which the next response will be reviewed. Figure 1 shows the sequence. The review is intended to be led by the district health office, with a facilitator from outside the district where one can be found, and to be completed within a few weeks.
The six steps of the proposed after-action review, shown as a cycle that returns to preparedness
The review begins by stating which event is under examination, between which dates and within which administrative boundaries. A single timeline is then built from the line list, laboratory register, alert log, situation reports and meeting minutes. It should record at least the onset of symptoms in the earliest known case, the first alert received by the health system, laboratory confirmation, notification to the next level, the first response actions, the peak, and the last case.
Intervals on this timeline are compared with explicit targets. The 7-1-7 metric offers a ready set: detection within seven days of emergence, notification within one day of detection, and completion of early response actions within seven days of notification (Frieden et al., 2021). Delay in detecting cholera has been shown to be the main determinant of how large an outbreak becomes in fragile settings (Ratnayake et al., 2020), so the review should give this interval most attention. The intervals that miss their targets become the critical moments around which the remaining steps are organised.
Evidence is gathered before anyone is asked for an opinion. The protocol sorts it under six pillars that correspond to the main lines of a cholera response. Table 1 lists them with the central review question and the records to be collected for each. The questions are framed against published standards so that the discussion starts from a shared reference and not from personal impressions.
Response pillars, central review question and records to assemble in the proposed protocol
| Pillar | Central review question | Records to assemble |
|---|---|---|
| Surveillance and alert | How long from first case to alert, and what delayed it? | Line list, alert log, community reports |
| Laboratory confirmation | Were rapid tests and culture available when needed? | Laboratory register, stock cards, transport log |
| Case management | Could patients reach rehydration quickly and safely? | Treatment unit registers, referral notes, supply records |
| Water, sanitation and hygiene | Was safe water restored where cases clustered? | Water quality tests, distribution lists, maps |
| Oral cholera vaccination | Was a campaign requested, and was timing useful? | Request forms, campaign reports |
| Coordination and communication | Who decided what, and did communities receive clear advice? | Minutes, situation reports, messages issued |
The technical yardsticks come from the literature. For case management, the Sphere standards and the cholera field manual expect the case fatality ratio in treatment facilities to be kept below one per cent (Sphere Association, 2018; GTFCC, 2019). For water and sanitation, reviews of the evidence find that the commonly used interventions are plausible but have rarely been evaluated rigorously during outbreaks (Taylor et al., 2015), and that household chlorination and filtration work when households use them consistently, which depends on supply and follow-up (Lantagne and Yates, 2018). For vaccination, killed whole-cell oral vaccines give substantial protection for several years after two doses (Bi et al., 2017), so the question for the review is one of timing and targeting.
Participants are drawn from every level that acted: community health workers, facility staff, the district rapid response team, the laboratory, water and sanitation officers, local government, partner organisations and, where possible, community representatives from affected villages. The working-group format in the World Health Organization guidance suits a district, with one group per pillar and a plenary to bring the findings together (WHO, 2019).
The facilitator presents the timeline and asks each group four questions about its critical moments: what was supposed to happen according to the plan, what did happen, what accounted for the difference, and what should be kept or changed. Ground rules state that the purpose is learning and not the attribution of blame, and that statements will not be linked to named individuals in the report. Junior staff and community members often hold the most relevant knowledge and are the least likely to speak in front of superiors, so groups should be arranged, and some views collected separately, with that in mind.
Each important gap is examined by asking repeatedly why it occurred until an answer is reached that someone in the room, or at the level above, has the authority to change. A late alert, for example, might be traced through an unrecognised case definition to training that reached only facility staff. Reason's account of organisational accidents is a helpful guide here: failures at the front line usually rest on latent conditions set earlier by decisions about staffing, supply and procedure (Reason, 1997). The protocol asks reviewers to record for each finding both the immediate cause and the latent condition behind it, and to do the same for things that went well, since strengths that depended on one individual or one donor are also vulnerabilities.
Flood-related causes deserve a separate pass. Access roads cut by water, cold chain and sample transport interrupted, treatment units sited on ground that later flooded, and water points contaminated by saline or faecal intrusion are specific to the setting and are easily filed under general logistics. Recording them as their own category lets the district see which parts of its cholera plan assumed dry conditions.
Findings are converted into actions in the plenary. Each action has one owner, a completion date, a statement of the resources required and an indicator by which its completion can be checked. The protocol limits the plan to the handful of actions judged most likely to shorten the critical intervals identified in Step 1, because a long list disperses effort and is rarely completed. Where modelling and field experience suggest that rapid, localised action around early cases can curb transmission (Finger et al., 2018), actions that pre-position supplies and authority for such targeted interventions merit priority. Actions beyond the district's power are written as requests to the province or ministry and recorded separately.
The report is short, is shared with all participants and with the next administrative level, and is attached to the district cholera preparedness plan. Progress on actions is reviewed at a fixed interval by the district health management team. Before the next flood season a table-top or simulation exercise tests whether the changes hold, using a scenario drawn from the reconstructed timeline. This closes the loop: the exercise shows whether a lesson has been learned or merely written down.