Lactate or Hartmann's solution are preferred over normal saline  Rate of administration

1. Cholera Prevention and Control
WHO Iraq Epidemiologist
+ Lancet 2012
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2. Introduction:
 Cholera is an acute, secretory diarrhoea caused by infection with Vibrio
choleraeof the O1 or O139 serogroup.
 It is endemic in more than 50 countries &causes large epidemics.
 Since 1817, seven cholera pandemics have spread from Asia to much of the
world.
 The seventh pandemic began in 1961 &affects 3–5 million people each year,
killing 120 000.
 Although mild cholera can be indistinguishable from other diarrhoeal
illnesses, the presentation of severe cholera is distinct, with pronounced
diarrhoeal purging.
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3. Introduction:
 Management of patients with cholera involves aggressive fl uid replacement;
eff ective therapy can decrease mortality from more than 50% to less than
0·2%.
 Antibiotic treatment decreases volume & duration of diarrhoea by 50%
&recommended for patients with moderate to severe dehydration.
 Prevention of cholera depends on access to safe water & sanitation.
 Two oral cholera vaccines are available&the most eff ective use of these in
integrated prevention programmes is being actively assessed.
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4. History of Cholera
Cholera Epidemics in England
– 1831-1832: 22 000 deaths
– 1848-1849 : 54 000 deaths
– 1853-1854 : John Snow’s work
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5. EPIDEMIOLOGY
 Cholera continues to be an important public health problem
among many communities
 It is one of the oldest diseases affecting humans.
 It is caused by the gram-negative bacteria Vibrio cholerae.
 About 20% of those who are infected develop acute, watery
diarrhoea – 10–20% of these individuals develop severe watery
diarrhoea with vomiting
 Can cause as high as 20 to 50% mortality if case management
is not adequate.
 Conversely, the death rate can be low (<1%) if well treated .
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6. Cholera: Causal agent
 While over 100 vibrio species have been isolated, only
the “cholerae” species are responsible for cholera
epidemics.
 Vibrio cholerae species are divided into 2 serogroups:
1. V. cholerae O1, subdivided into Classical and El Tor biotypes, (Is
the causal agent for 7th pandemic)
2. V. cholerae O139 sero– group, was first identified in 1992 in India
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7. Cholera : Causal Agent
.
 Both El Tor and Classic biotypes are divided into 3 serotypes:
Ogawa, Inaba and Hikojima
 The three serotypes can co-exist during an epidemic because the
bacteria can mutate between serotypes
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8. Cholera : Causal Agent
 Species: Vibrio Cholerae
 Serogroup: O139 & O1
 Biotypes :EL Tor Classic
 Serotypes Hikojima, Ogawa& Inaba
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9. Reservoir
Humans are the main reservoir of Vibrio
cholerae. Other potential reservoirs are water,
Vibrios grow easily in saline water and alkaline
media. They survive at low temperatures but
do not survive in acid media;
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10. Carriers and transmission
The reservoir is mainly human, asymptomatic
(healthy) carriers and patients carry huge
quantities of vibrio in faeces and in vomit; up
to 108 bacteria can be found in 1 ml of cholera
liquid.
The infective dose depends upon individual
susceptibility, but in general a 10 8 doses is
needed.
Cholera is transmitted by a faecal-oral route
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11. TRANSMISION
 Cholera is transmitted by the fecal –oral route through contaminated
water & food
 Person to person infection is rare
 The infection dose of bacteria required to cause clinical disease
varies with the source
 If ingested with water the infective dose should be higher;
 When ingested with food fewer organism are required to cause the
disease
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12. RISK FACTORS
 Poor social and economic environment, precarious living conditions
associated with Insufficient water supply (quantity and quality)
 Poor sanitation and hygiene practices
 High population density: camps and slum populations are highly
vulnerable.
 Underlying diseases such as malnutrition, chronic diseases and
AIDS are thought to increase susceptibility to cholera, but this has
not been proven.
 Environmental and seasonal factors
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13. Period of communicability
 Infected persons (symptomatic or not) can carry and
transmit vibrios during 1-4 weeks
 A small number of individuals can remain healthy carriers
for several months.
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14. PATHOGENESIS
 V.cholerae cause clinical disease by producing an
enterotoxin that promotes the secretion of fluid and
electrolytes into the lumen of the gut
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17. Case Definitions for Cholera
Suspected
 In an area where the disease is not known to be present:
severe dehydration or death from acute watery diarrhoea
in a patient aged 5 years or more;
 In an area where there is cholera endemic: acute watery
diarrhoea, with or without vomiting in a patient aged 5
years or more
 Epidemic ongoing: acute watery diarrhoea with or without
vomitting
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18. Case definition for cholera
Confirmed
 A suspected case that is laboratory-confirmed.( Isolation
of Vibrio cholerae O1 or O139 from stools in any patient
with diarrhoea is the laboratory criteria for diagnosis)
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19. CLINICAL FEATURE
 Cholera is an acute enteric disease characterized by the sudden
onset of profuse painless watery diarrhoea or rice-water like
diarrhoea, often accompanied by vomiting;
 Can rapidly lead to severe dehydration and cardiovascular collapse
 Clinical features are the same whatever the strain. Regardless the
strain, the response is the same
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20. Clinical features
 No fever
 Dehydration appears within 12 to 24 hours.
 Asymptomatic and/or minor forms: in more than 80% of the cases,
infection is asymptomatic or causes simple diarrhoea
 In moderate forms there are frequent watery stools, however, fluid
loss and dehydration are moderate.
 In severe forms there is intense diarrhoea and vomiting with
significant fluid loss
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2

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24. Role of laboratory test
 Bacteriological confirmation is compulsory on the first
suspected cases, in order to:
Confirm cholera
 Identify the strain, biotype and serotype
 Assess antibiotic sensitivity
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25. Laboratory Test
 Confirmation on 10 to 20 stool samples is sufficient. Samples can
be taken using different methods : filter paper, Cary Blair medium
or rapid tests
 Rapid tests can give a quick confirmation of a cholera diagnosis,
however, rapid tests
 Do not provide information on antibiotic sensitivity nor can
they be used for biotyping,and therefore must always be
followed by sampling.
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26. Selection of cases for bacteriologic sampling
 For confirmation of an outbreak, stool samples should be
collected from up to 10-20 previously “untreated” cases
who meet all of the following criteria:
– onset of illness less than four days before sampling;
– currently having watery diarrhoea;
– have not received antibiotic treatment for this illness;
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27. Selection of transport media
 The most reliable, currently available transport medium is
Carry-Blair. The CB transport medium should be
refrigerated for one hour before collecting the stool
specimen. (It can be used for 18 months or longer under
proper conditions of storage, provided there is no loss of
volume and no evidence of contamination or colour
change)
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28. Collection of specimens
 Stool should be collected either by:
 Collecting a swab from a freshly passed stool specimen
(fresh stool should be less than 1 hour old) or from
 A swab of the rectal contents (rectal swab)
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29. CASE MANAGEMENT
 The main stay of case management of correction of
dehydration status
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30. Clinical Management of Cholera
 Aim for case fatality ratio of 1% or less
 80-90% of patients can be treated with ORS
 Initiate treatment promptly
 intravenous therapy (Ringers/Hartmann's) only for
severely dehydrated
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33. What type of Dehydration is this ?
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36. Severe Dehydration
 Loss of at least 10% of body weight
 Hypovolemic shock
 Low blood pressure
 Rapid, weak, or undetectable peripheral pulse
 Skin has lost normal turgor (“tenting”)
 Mouth is very dry
 Thinking is dulled
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37. What type of Dehydration is this ?
.
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38. 38 | Cholera | 3 October 2012

39. What type of dehydration is this ?
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41. Moderate Dehydration
 Loss of 5-10% of body weight
 Normal blood pressure
 Normal or rapid pulse
 Increased thirst, drinks eagerly
 Mucosal membranes are dry
 Restless, irritable
 Skin goes back slowly after skin pinch
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43. Step-2: Maintenance of hydration and monitoring the
hydration status
 Reassess the patient for signs of dehydration for first 6
hours
– Number and quantity of stool and vomit in order to compensate
for the body fluids;
– Radial pulse: If remains weak, rehydration should be continued;
Provide frequent small meals with familiar foods during the first
two days
Provide food orally as soon as the patient is able to swallow
Breastfeeding infants and children should continue
43 | Cholera | 3 October 2012

44. Step-3: Giving antibiotics if needed
 Why give antibiotic in cholera patients ?
– Reduces the volume and duration of cholera related diarrhoea
by half (50%); important adjunct to fluid treatment
 Benefits of giving antibiotics
– Shortens hospital stay and reduction of need for intravenous
fluid; Reduces the management cost
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45. Which Antibiotics ?
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46. ANTIBIOTICS
 Should be given only in severe cases to reduce the
duration of symptoms and carriage of the pathogen
 Selective chemoprophylaxis may be useful for
members of a household who share food and shelter
with cholera patient
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47. Use of Ciprofloxacin : Offers short course
for cholera treatment
 Offers short course for cholera treatment
– Ease of administration: Single dose
– Assurance of patients compliance;
– Reduction of cost of treatment;
 Evidence: Single dose Ciprofloxacin (500 mg) is shown to be
effective in both adults and children (Cure rate was 94% in adults
and 60% in children: Resolution of diarrhoea within 48 hours of the
start of treatment and no recurrence during 5 day stay in the
hospital (Ref: Lancet 1996; 348: 296-300 and Lancet 2005; 366:
1085-93)
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48. 48 | Cholera | 3 October 2012

49. Zinc Supplementation in Cholera : What is the
evidence ?
 Supplementation of zinc to the children with cholera
reduces both stool volume and duration of diarrhoea, an
effect that was more pronounced in malnourished
children (Ref: S.K. Roy, K E Islam, et al. Impact of Zinc on Children with
Cholera. Presented during 10th Annual Scientific Conferences (ASCON) of
ICDDR,B, Dhaka)
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50. WHO and UNICEF’s Recommendation for
Zinc Supplementation
Age group Dose Duration
Infants under 6 10 mg per day 10-14 days
months old
Children above 6 20 mg per day 10-14 days
months old
Ref: WHO/UNICEF Joint Statement on Clinical Management of Acute
Diarrhoea, May 2004
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52. Cholera Prevention Measures
Other Than Rehydration
 Antibiotics are not necessary for patient recovery, but
are used as a public health measure.
 Vaccination (mass chemoprophylaxis) and cordon
sanitaire are NOT effective in controlling epidemics.
 Selective chemoprophylaxis is rarely practical.
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54. Cholera Cot
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55. Complications
 Pulmonary edema if excessive IV fluid has been given
 Renal failure if too little IV fluid is given;
 Hypoglycaemia
 Hypokalaemia in children with malnutrition rehydrated
with Ringer lactate only
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56. IV Fluid Therapy
 Ringer’s lactate is the preferred IV fluid
 Normal 9% saline or half –normal saline with 5% glucose
can also be used
 ORS solution must be given at the same time to replace
the missing electrolytes
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57. 57 | Cholera | 3 October 2012

58. Composition of Standard and
Reduced Osmolarity ORS
Standard ORS Reduced
(mEq or mmol/l) Osmolarity ORS
Glucose 111 75
Sodium 90 75
Chloride 80 65
Potassium 20 20
Citrate 10 10
Osmolarity 311 245
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59. Proper preparation of ORS
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60. Home based ORS
.
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61. .
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62. CHOLERA TREATMENT CENTRE (CTC)
 The organization of the CTC is meant to offer the best
care to patients but also to protect other people from
contamination
 Fences around the CTC are often necessary to reduce
the number of visitors
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63. Cholera Treatment Centre
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64. Infection control
.
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65.  Assume infectious agent could be present in the
patient’s
– Blood
– Body fluids, secretions, excretions
– Non-intact skin
– Mucous membranes
 Hand hygiene and PPE are critical
Infection Prevention 2012
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66. Personal Protective Equipment (PPE)
 When used properly can
protect you from exposure to
infectious agents
 Know what type of PPE is
necessary for the duties you
perform and use it correctly
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67. Key Infection Control Points
 Minimize exposures
– Plan before entering room
– Minimize number of visitors
– Separation of Cholera patients
– Flow of patients
 Avoid adjusting PPE after patient contact
– Do not touch eyes, nose or mouth!
 Avoid spreading infection
– Limit surfaces and items touched
 Change torn gloves
– Wash hands before donning new gloves
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68. DISINFECTION OF PATIENT’S BEDDING AND
CLOTHING
Patient’s bedding and clothing can be disinfected
by stirring them for 5 minutes in boiling water
Bedding including mattresses can also be
disinfected by thorough drying in the sun
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69. Can we all now manage a cholera
patient ?
Yes?
Yes!