The global burden of diarrhea

Learning ObjectivesLearning Objectives
At the end of this session, students willAt the end of this session, students will
learn:learn:
 Common causes of diarrheaCommon causes of diarrhea
 Mode of transmission of diarrheaMode of transmission of diarrhea
 Sign and symptoms of common diarrheal illnessesSign and symptoms of common diarrheal illnesses
 Simple management tools for diarrheaSimple management tools for diarrhea

Diarrheal DiseasesDiarrheal Diseases
The BasicsThe Basics
 DiarrheaDiarrhea describes bowel movementsdescribes bowel movements
(stools) that are loose and watery.(stools) that are loose and watery.
It is very common and usually notIt is very common and usually not
serious. Many people will have diarrheaserious. Many people will have diarrhea
once or twice each year. It typically lastsonce or twice each year. It typically lasts
two to three days and can be treated withtwo to three days and can be treated with
over-the-counter (OTC) medicines. Someover-the-counter (OTC) medicines. Some
people have diarrhea often as part ofpeople have diarrhea often as part of
irritable bowel syndromeirritable bowel syndrome or other chronicor other chronic
diseases of the large intestine.diseases of the large intestine.

What are the main forms of diarrhea?What are the main forms of diarrhea?
There are three main forms of diarrhea, all of which
are Potentially life-threatening and require different
treatment courses:
Acute watery diarrhea includes cholera and is associated with
significant fluid loss and rapid dehydration in an infected
individual. It usually lasts for several hours or days.
The pathogens that generally cause acute watery diarrhea
include V. cholerae or E. coli bacteria, as well as rotavirus.
1. Acute watery diarrhea

Bloody diarrhea, often referred to as dysentery, is marked by visible blood in
the stools. It is associated with intestinal damage and nutrient losses in an
infected individual. The most common cause of bloody diarrhea is Shigella, a
bacterial agent that is also the most common cause of severe cases.
Persistent diarrhea is an episode of diarrhea, with or without blood, that lasts
at least 14 days. Undernourished children and those with other illnesses,
such as AIDS, are more likely to develop persistent diarrhea. Diarrhea, in
turn, tends to worsen their condition.
3. Persistent diarrhea
2. Bloody diarrhea

Signs & Symptoms ofSigns & Symptoms of
DiarrheaDiarrhea

Signs & Symptoms of DiarrheaSigns & Symptoms of Diarrhea
Symptoms of diarrhea can be brokenSymptoms of diarrhea can be broken
down into uncomplicated (or non-down into uncomplicated (or non-
serious) diarrhea and complicatedserious) diarrhea and complicated
diarrhea.diarrhea.
Complicated diarrhea may be a signComplicated diarrhea may be a sign
of a more serious illness.of a more serious illness.

Symptoms of uncomplicated diarrhea include:
 Abdominal bloating or crampsAbdominal bloating or cramps
 Thin or loose stoolsThin or loose stools
 Watery stoolWatery stool
 Sense of urgency to have a bowelSense of urgency to have a bowel
movementmovement
 Nausea and vomitingNausea and vomiting

 Blood, mucus, or undigested food in the stoolBlood, mucus, or undigested food in the stool
 Weight lossWeight loss
 FeverFever
The symptoms of complicated diarrhea include:

Causes Of DiarrheaCauses Of Diarrhea
 Infection by bacteria (the cause of most types of food poisoning)Infection by bacteria (the cause of most types of food poisoning)
 Infections by other organismsInfections by other organisms
 Eating foods that upset the digestive systemEating foods that upset the digestive system
 Diseases of the intestines (Crohn's disease, ulcerative colitis)Diseases of the intestines (Crohn's disease, ulcerative colitis)
 Malabsorption (where the body is unable to adequately absorb certainMalabsorption (where the body is unable to adequately absorb certain
nutrients from the diet.nutrients from the diet.
 HyperthyroidismHyperthyroidism
The most common cause of diarrhea is a virus that infects the gut.
The infection usually lasts for two days and is sometimes called
"intestinal flu" or “stomach flu." Diarrhea may also be caused by:

COMMON CAUSES OF DIARRHEA- BACTERIACOMMON CAUSES OF DIARRHEA- BACTERIA
 Vibrio choleraVibrio cholera
 ShigellaShigella
 Escherichia coliEscherichia coli
 SalmonellaSalmonella
 Campylobacter jejuniCampylobacter jejuni
 Yersinia enterocoliticaYersinia enterocolitica
 StaphylococcusStaphylococcus
 Vibrio parahemolyticusVibrio parahemolyticus
 Clostridium difficileClostridium difficile

COMMON CAUSES OF DIARRHEA- VIRUSCOMMON CAUSES OF DIARRHEA- VIRUS
 RotavirusRotavirus
 AdenovirusesAdenoviruses
 CalicivirusesCaliciviruses
 AstrovirusesAstroviruses
 Norwalk agents and Norwalk-likeNorwalk agents and Norwalk-like
virusesviruses

COMMON CAUSES OF DIARRHEA - PARASITECOMMON CAUSES OF DIARRHEA - PARASITE
 Entameba histolyticaEntameba histolytica
 Giardia lambliaGiardia lamblia
 CryptosporidiumCryptosporidium
 IsosporaIsospora

Common DiarrheasCommon Diarrheas
 Age <2 years: RotavirusAge <2 years: Rotavirus
 Age 2-5 years: Cholera; E. coli;Age 2-5 years: Cholera; E. coli;
ShigellosisShigellosis
 All ages: E. coli; CampylobacterAll ages: E. coli; Campylobacter
 Immunocompromized: Amebiasis;Immunocompromized: Amebiasis;
CryptosporidiumCryptosporidium

How are diarrhea pathogensHow are diarrhea pathogens
transmitted?transmitted?
 Most pathogens that cause diarrhea share a similar mode
of transmission – from the stool of one person to the
mouth of another.
 This is known as faecal-oral transmission.
 There may be differences, however, in the number of
organisms needed to cause clinical illness, or in the route
the pathogen takes while travelling between individuals
(for example, from the stool to food or water,
which is then ingested).

Mechanism Of DiarrheaMechanism Of Diarrhea
 Firstly, the basic principles of absorption and secretion in the intestine ofFirstly, the basic principles of absorption and secretion in the intestine of
healthy animals are described. The etiology and the pathophysiologichealthy animals are described. The etiology and the pathophysiologic
mechanisms of neonatal diarrhea in the calf due to E. coli andmechanisms of neonatal diarrhea in the calf due to E. coli and
rota-/coronavirus are discussed. Enterotoxins of E. coli stimulate primarilyrota-/coronavirus are discussed. Enterotoxins of E. coli stimulate primarily
the secretion of chloride (and thereby water) in the small intestine withoutthe secretion of chloride (and thereby water) in the small intestine without
damaging the intestinal mucosa.damaging the intestinal mucosa.
 The sodium-dependent transport systems for the absorption of glucose andThe sodium-dependent transport systems for the absorption of glucose and
amino acids remain intact. In contrast, infections with rota- or coronavirusamino acids remain intact. In contrast, infections with rota- or coronavirus
lead primarily to a disturbance of absorption processes in the intestine duelead primarily to a disturbance of absorption processes in the intestine due
to villous atrophy. Crypt cells are indirectly affected by inflammationto villous atrophy. Crypt cells are indirectly affected by inflammation
mediators. Intestinal motility is inhibited during most diarrheic episodes; themediators. Intestinal motility is inhibited during most diarrheic episodes; the
application of para-sympatholytics in therefore not favourable.application of para-sympatholytics in therefore not favourable.

Laboratory DiagnosisLaboratory Diagnosis
Etiologic diagnosis of diarrhea is valuable for public health interventions and case
management.
Microbiological culture and microscopy remain the standard, despite their limited
sensitivity.
Simple microscopy for protozoa or helminths can be quick and effective when the
proper sample is obtained and a well-trained technician is available to examine a
fresh specimen, but these prerequisites are often not available in developing
countries.
Newer immunological and nucleic acid–based tests to detect pathogen-specific
factors hold great promise for all diarrhea agents, but they are too expensive or
require specialized instrumentation and trained technicians.

TREATMENTTREATMENT
 Supportive therapy—fluid and electrolyte replacement.Supportive therapy—fluid and electrolyte replacement.
 Antidiarrhoeal symptomatic treatment to reduce stoolAntidiarrhoeal symptomatic treatment to reduce stool
frequency and any other symptoms such as abdominal pain.frequency and any other symptoms such as abdominal pain.
 Antisecretory drug therapy aimed at reducing faecal losses.Antisecretory drug therapy aimed at reducing faecal losses.
 Specific therapy such as antimicrobial chemotherapy toSpecific therapy such as antimicrobial chemotherapy to
reduce duration and severity of the illness.reduce duration and severity of the illness.

Drugs Used in Treatment of DiarrheaDrugs Used in Treatment of Diarrhea
(Monogastric)(Monogastric)
 Therapy for diarrhea includes fluids, electrolyteTherapy for diarrhea includes fluids, electrolyte
replacement, maintenance of acid/base balance, andreplacement, maintenance of acid/base balance, and
control of discomfort.control of discomfort.
 Antiparasitic drugs or dietary therapy can also play anAntiparasitic drugs or dietary therapy can also play an
important role in the treatment of some types of diarrhea.important role in the treatment of some types of diarrhea.
 Additional therapy may include intestinal protectants,Additional therapy may include intestinal protectants,
motility modifiers, antimicrobials, anti-inflammatory drugs,motility modifiers, antimicrobials, anti-inflammatory drugs,
and antitoxinsand antitoxins

Why are children more vulnerable?Why are children more vulnerable?
Children with poor nutritional status and overall health, as
well as those exposed to poor environmental conditions, are
more susceptible to severe diarrhea and dehydration than
healthy children.
Children are also at greater risk than adults of life-
threatening dehydration since water constitutes a greater
proportion of children’s bodyweight.
Young children use more water over the course of a day
given their higher metabolic rates, and their kidneys are less
able to conserve water compared to older children and
adults.

The Global Burden Of Diarrhea
 More than one in ten child deaths – about 800 000 each year – is due toMore than one in ten child deaths – about 800 000 each year – is due to
diarrhea.diarrhea.
 Today, only 44% of children with diarrhea in low-income countriesToday, only 44% of children with diarrhea in low-income countries
receive the recommended treatment.receive the recommended treatment.
 Each year, an estimated 2.5 billion cases of diarrhea occur amongEach year, an estimated 2.5 billion cases of diarrhea occur among
children under five years of age.children under five years of age.
 Diarrhea is a leading cause of malnutrition in children under five yearsDiarrhea is a leading cause of malnutrition in children under five years
old.old.

Diarrheal disease is a leading cause of child mortality and morbidity in the
world, and mostly results from contaminated food and water sources.
Worldwide, 780 million individuals lack access to improved drinking-water
and 2.5 billion lack improved sanitation.
Diarrhea due to infection is widespread throughout developing countries.
In developing countries, children under three years old experience on
average three episodes of diarrhea every year.
Each episode deprives the child of the nutrition necessary for growth. As a
result, diarrhea is a major cause of malnutrition, and malnourished children
are more likely to fall ill from diarrhea.

SAVE THE CHILDREN: EVERY ONESAVE THE CHILDREN: EVERY ONE
CAMPAIGNCAMPAIGN
To help end this injustice, the Unilever Foundation has made a
three-year €15 million commitment to Save the Children’s biggest-
ever global campaign, EVERY ONE. As a lead global partner
Unilever is working with Save the Children to stop the needless
deaths of millions of children and their mothers.
Together we have identified four priority countries – Bangladesh,
China, Nigeria and Pakistan to improve access to health workers,
ensure that children in need are reached with transformational
health and nutrition programmes and life-saving vaccines.

Population ServicesPopulation Services
InternationalInternational
PSI headquarter is in Washington D.C,,,(U.S) and Amsterdam.
The Organization provides clinical services and life saving
drugs for major diseases like H.I.V, Malaria, Diarrhea and child
survival
PSI currently manages diarrhea control programs in more than
30 countries across Africa, Asia and the Caribbean.

 Together, pneumonia and diarrhea account for an estimated 40 %
of all child deaths around the world each year.

PrevalencePrevalence
Of Diarrhea InOf Diarrhea In
PakistanPakistan

Prevalence Of Diarrhea InPrevalence Of Diarrhea In
PakistanPakistan
 According to World Health Organization (WHO),According to World Health Organization (WHO),
worldwide. In Pakistan diarrhea is rated as theworldwide. In Pakistan diarrhea is rated as the
number one killer of children accounting for aboutnumber one killer of children accounting for about
250,000 deaths and unimaginable morbidity.250,000 deaths and unimaginable morbidity.
 Estimated number of diarrhea episodes in the countryEstimated number of diarrhea episodes in the country
is more than 20 million annually.is more than 20 million annually.
 Diarrhea (15%): There were around 4,500,000Diarrhea (15%): There were around 4,500,000
reported cases in 2006, 14% of which were childrenreported cases in 2006, 14% of which were children
under the age of fiveunder the age of five

A study in Pakistan found that hand washing condensed the number of Diarrhea
related infections in children under the age of five by more than 50 %
According WHO and UNICEF Moreover, each year approximately 91,000 and
53,000 children die from pneumonia and diarrhea respectively, accounting for
more than 30 % of the current under-five mortality burden,” he added.
23 % of children under age 5 had diarrhea in the two weeks before the survey.
The proportion of children with diarrhea taken to a health care provider for advice
or treatment has increased over time, from 48 % in 1990-91 to 61 % in 2012-13.
The use of ORS among children with diarrhea is not popular; only 38 % of
children who had diarrhea in the two weeks preceding the survey received ORS.

There are visible variations in the prevalence
of diarrhea by region.
The highest prevalence of Diarrhea at Khyber
Pakhtunkhwa 28%, followed by Sindh 23 % and
Punjab 22 %; the lowest proportion is in Balochistan
12 %.

In the 2012-13 PDHS, information on diarrhea was
gathered by asking mothers whether their child had
experienced any episode of diarrhea in the two weeks
before the survey.
If the child had had diarrhea, the mother was asked
about feeding practices during diarrhea, types of
treatment, and her knowledge and use of ORS.

Table 10.8 shows data on the treatment of recent episodes of diarrhea
among children under age 5, as reported by their mothers.
Overall, 61 % of children with diarrhea were taken to a medically trained
health provider for advice or treatment.
Children age 12-23 months, male children, children with bloody diarrhea,
children living in urban areas and Sindh, children of mothers with a middle
level of education, and children from households in the highest wealth
quintile are more likely than other children to visit a health professional or
a health facility for diarrhea treatment.

Table 10.7 shows that 23 % of children under age 5 suffered from diarrhea in the two
weeks preceding the survey. .
Diarrhea with blood was reported for only a very small proportion of children (2 %).
The prevalence of diarrhea was reported to be 15 % in 1990-91 and 22 % in 2006-07.
Although diarrhea prevalence varies seasonally, the three PDHS surveys were
conducted in more or less the same period, and thus the diarrhea episodes reported in
the three surveys depict a realistic trend.
The prevalence of diarrhea is highest among children age 6-11 months (35 %), a span
during which solid foods are first introduced into the child’s diet.
Diarrhea prevalence is higher among households using a non-improved source of
drinking water than among households using an improved source.

DIARRHEA TREATMENT INDIARRHEA TREATMENT IN
PAKISTANPAKISTAN
The MNCH program focuses on the management of diarrheal diseases
among children under age 5.
Pakistan is one of the first countries in the region to include zinc in the
diarrhea treatment protocol along with low osmolality ORS and oral
rehydration therapy.
Treatment with zinc is not a substitute for ORT, but, when taken in addition to
ORT, it can reduce the severity and duration of diarrhea.
This improved treatment, recommended by WHO, has lower amounts of
sodium and glucose and, thus, lower osmolality (WHO, 2006d).
Pakistan initiated the protocol in 2005, and this newer version of ORS therapy
is now available on the market.

The government’s standard diarrhea case management strategy includes
ORT, counseling on continued feeding, and zinc tablets provided through
health service outlets.
ORT services have been established in all hospitals, primary health care
centers, lady health worker programs, and nongovernment health centers
throughout the country.
Health facilities and community health volunteers are the primary health
providers with responsibility for treating diarrhea with ORS and zinc
supplementation.

Table 10.8 shows data on the treatment of recent episodes of diarrhea
among children under age 5, as reported by their mothers.
Overall, 61 % of children with diarrhea were taken to a medically trained
health provider for advice or treatment.
Children age 12-23 months, male children, children with bloody diarrhea,
children living in urban areas and Sindh, children of mothers with a middle
level of education, and children from households in the highest wealth
quintile are more likely than other children to visit a health professional or a
health facility for diarrhea treatment

46 % of children with diarrhea were given ORT or increased fluids.
38 % of children with diarrhea received ORS packets, while
9 % were given a recommended homemade fluid. Overall,
42 % were given either ORS or a recommended homemade fluid.
9 %of children were given increased liquids.

After increasing from 39% in 1990-91 to 41% in 2006-07, the use of commercially
available ORS packets stabilized to 38% in 2012-13.
The percentage of children receiving homemade fluids increased from 12 % in 1990-
91 to 16 % in 2006-07 and then decreased to 9 % in 2012-13.
The percentage of children receiving increased fluids has not changed substantially
over the past two decades.
Only 2 % of children were treated with zinc.
Although not a preferred treatment, 5 % of children were treated with antimotility
drugs. 33 % of children with diarrhea were given antibiotic drugs.
It is also vital to note that 11 % of children did receive any form of treatment.

Use of ORT or increased fluids varies by age, from a low of 34 % among
children less than age 6 months to a high of 51 % among children age 12-
23 months. Use of ORT or increased fluids is more common among male
than female children.
In addition, there are differences in the use of this treatment by residence
(51 % in urban areas and 44 % in rural areas) and region (43 % in Punjab
and 77% in Gilgit Baltistan).
The proportion of children receiving ORT or increased fluids varies by
mother’s education as well, ranging from 43 % of children whose mothers
have no education to 59 % of those whose mothers have a secondary
education. Use of ORT or increased fluids is much higher among children in
the highest wealth quintile (55 %).

Relief Camps provideRelief Camps provide temporary homes for those displaced bytemporary homes for those displaced by
Pakistan's flood of 2010.Pakistan's flood of 2010.
Aitemaad Relief camp
Muzaffarnagar Relief camp
Muzaffar-Garh Relief camp
 Badin relief camp
Larkana Relief camp
Dadu Relief camp
Swat Relief camp
Mithi, Tharparkar Relief Camps setup byMithi, Tharparkar Relief Camps setup by Pakistan ArmyPakistan Army
Pakistan's IDP Relief Camps: A Tenuous Sanctuary ... anti-
fungal creams, and anti-diarrhea medicine which are collected
through donations.
Diarrhea Relief Camps In Pakistan

10.9 FEEDING PRACTICES DURING10.9 FEEDING PRACTICES DURING
DIARRHEA IN PAKISTANDIARRHEA IN PAKISTAN
There are variations in feeding practices by other background characteristics as well.
Male children and children suffering from bloody diarrhea, children in urban areas,
children residing in Gilgit Baltistan, children of mothers with a secondary education,
and children from the highest wealth quintile are more likely than other children to
receive ORT and/or increased fluids with continued feeding.
The percentage of children with diarrhea given increased fluids and fed continually
has declined over the past six years, from 14 % to 8 %. Similarly, the practice of
giving ORT and/or increased fluids along with continued feeding has decreased over
this period, from 52 % to 36 %. The results outlined above clearly highlight the need
for health program managers to revisit their plans and strategies to improve the
health status of children in Pakistan.

Department of Pediatrics and Child Health,Department of Pediatrics and Child Health,
Karachi. That supported Diarrheal Patient.Karachi. That supported Diarrheal Patient.

Pakistan floodsPakistan floods
According to the National Disaster Management Authority, 1.3 million people have
been affected by the floods, 193 people have died and 31 355 people are living in
512 relief camps in the flood-affected districts.
WHO has provided essential medicines support to 165 693 people through
customized kits, including emergency health kits, diarrheal disease kits, hygiene kits,
and other supplies including anti-malarial drugs, anti-snake venom, and rapid
diagnostic kits. The medicines stock is depleting and need to be replenished.
In Sindh, the overall proportion of acute diarrhea is high as compared to the previous
year during the same reporting period. During the current monsoon season 15 acute
watery diarrhea outbreaks were identified and responded but the situation needs
continuous monitoring in the province.

Children with Diarrhea; By DistrictChildren with Diarrhea; By District
Hospital Dadu Sindh PakistanHospital Dadu Sindh Pakistan

http://www.aboutfamouspeople.com/article1095.html
3rd President Democratic-Republican Party
Born : April 13, 1743
Died : July 4, 1826 (aged 83)
Cause of Death: Diarrhea, age 83.
THOMAS JEFFERSONTHOMAS JEFFERSON

AriusArius
http://www.oddee.com/item_98665.aspx
Born : 256
Died : 336
Arius was walking across the imperial forum of Constantinople when he
suffered sudden diarrhea followed by hemorrhaging, which caused his
intestines to be expelled from his anus.
Many of his enemies implied that Arius's death was miraculous and a
consequence of his heretical views, while in reality it was nothing but the
result of poisoning.

ORIGINS OF CHOLERAORIGINS OF CHOLERA
The disease, however, is of ancient origins, having existed in
some form since the times of Lord Buddha and Hippocrates,
if not earlier.
The first recorded instance was in 1563 in an Indian medical
report but in more modern terms, the story of the disease
begins in 1817 when it spread from its ancient homeland of
the Ganges Delta in India to the rest of the world.
Since that time, untold millions have contracted and died from
this preventable infectious disease.

History Of CholeraHistory Of Cholera
During the 19th century, cholera spread across the world
from its original reservoir in the Ganges delta in India.
Six subsequent pandemics killed millions of people across all
continents. The current (seventh) pandemic started in South
Asia in 1961, and reached Africa in 1971 and the Americas in
1991. Cholera is now endemic in many countries.
Every year, there are an estimated 3–5 million cholera cases
and 100 000–120 000 deaths due to cholera in the world.

The disease is most common in places with poor
sanitation, crowding, war, and famine.
Common locations include parts of Africa, south
Asia, and Latin America.
If you are traveling to one of those areas, knowing
the following cholera facts can help protect you
and your family.

 About 75% of people infected with cholera do not developAbout 75% of people infected with cholera do not develop
any symptoms. However, the pathogens stay in their faecesany symptoms. However, the pathogens stay in their faeces
for 7 to 14 days and are shed back into the environment,for 7 to 14 days and are shed back into the environment,
possibly infecting other individualspossibly infecting other individuals
 Cholera is an extremely virulent disease that affects bothCholera is an extremely virulent disease that affects both
children and adults.children and adults.
 it can kill healthy adults within hours. Individuals with lowerit can kill healthy adults within hours. Individuals with lower
immunity, such as malnourished children or people living withimmunity, such as malnourished children or people living with
HIV, are at greater risk of death if infected by cholera.HIV, are at greater risk of death if infected by cholera.

Prevalence ofPrevalence of
Cholera InCholera In
PakistanPakistan

25 OCTOBER 2010 - On 12 October 2010, the Ministry of Health in
Pakistan reported laboratory confirmation of 99 cases
of Vibrio cholera 01 in the country.
These cases were laboratory-confirmed by the National Institute of
Health since the beginning of the flood until 30 September 2010.
These cases have been reported sporadically from a wide geographical
area in the flood-affected provinces of Sindh, Punjab and Khyber
Pakhtunkhwa.
Prevalence of Cholera In PakistanPrevalence of Cholera In Pakistan

The Ministry of Health in Pakistan supported by the (WHO) and other
Local and international partners are collaborating closely to prevent
outbreaks of any disease, including cholera, and treat people affected
by such illnesses.
More than 60 diarrheal treatment centres are either operating or are
soon to start functioning in the 46 most affected districts of the country.
Diarrhoeal diseases including cholera are among the most reported
health conditionsin many locations affected by the recent floods disaster
in the country.

In 2010, a surge in cholera cases seriously threatened public
health across Pakistan, where previously sporadic cases of
cholera had been reported.
In late July and August 2010, record monsoon rainfall and the
simultaneous glacier melt resulted in the worst flooding in the
recorded history of Pakistan, affecting an area of 61,776
square miles and displacing >20 million persons.
A cholera outbreak ensued, and the World Health
Organization (WHO) reported 164 laboratory-confirmed cases
with the help of National Institute of Health and other allied
departments in Pakistan

Latest update of cholera inLatest update of cholera in
PakistanPakistan
http://www.nathnac.org/DiseaseReport

Learning ObjectivesLearning Objectives
 Cholera is transmitted through contaminatedCholera is transmitted through contaminated
water or food.water or food.
 Cholera can rapidly lead to severe dehydrationCholera can rapidly lead to severe dehydration
and death if left untreated.and death if left untreated.
 Prevention and preparedness of cholera requirePrevention and preparedness of cholera require
a coordinated multidisciplinary approach.a coordinated multidisciplinary approach.

CHOLERACHOLERA
 Cholera is an infectious disease that causes severe wateryCholera is an infectious disease that causes severe watery
diarrhea, which can lead to dehydration and even death ifdiarrhea, which can lead to dehydration and even death if
untreated. It is caused by eating food or drinking wateruntreated. It is caused by eating food or drinking water
contaminated with a bacterium calledcontaminated with a bacterium called Vibrio choleraeVibrio cholerae..
 It has a short incubation period, from less than one day toIt has a short incubation period, from less than one day to
five days, and produces an enterotoxin that causes afive days, and produces an enterotoxin that causes a
copious, painless, watery diarrhea that can quickly lead tocopious, painless, watery diarrhea that can quickly lead to
severe dehydration and death if treatment is not promptlysevere dehydration and death if treatment is not promptly
given. Vomiting also occurs in most patients.given. Vomiting also occurs in most patients.
A young cholera patient is wheeled in a wheelbarrow
to a clinic in Harare's suburb of Budiriro Photo: EPA

Signs and symptoms ofSigns and symptoms of
dehydration includedehydration include
 Rice-watery stoolRice-watery stool
 Rapid heart rateRapid heart rate
 Loss of skin elasticity (the ability to return to original positionLoss of skin elasticity (the ability to return to original position
quickly if pinched)quickly if pinched)
 Dry mucous membranes, including the inside of the mouth,Dry mucous membranes, including the inside of the mouth,
throat, nose, and eyelidsthroat, nose, and eyelids
 Low blood pressureLow blood pressure
 ThirstThirst
 Muscle crampsMuscle cramps
 Marked dehydrationMarked dehydration
 Projectile vomitingProjectile vomiting
 No feverNo fever
 Shock, unconsciousnessShock, unconsciousness
 Scanty urineScanty urine

Cholera CausesCholera Causes
• Municipal water suppliesMunicipal water supplies
• Ice made from municipal waterIce made from municipal water
• Foods and drinks sold by street vendorsFoods and drinks sold by street vendors
• Vegetables grown with water containing human wastesVegetables grown with water containing human wastes
• Raw or undercooked fish & seafood caught in waters polluted with sewageRaw or undercooked fish & seafood caught in waters polluted with sewage
Vibrio cholerae, the bacterium that causes cholera, is usually found in food
or water contaminated by feces from a person with the infection. Common
sources include:
When a person consumes the contaminated food or water, the bacteria
release a toxin in the intestines that produces severe diarrhea.
It is not likely you will catch cholera just from casual contact with an infected
person.

Prevention and control of choleraPrevention and control of cholera
outbreaks: WHO policy andoutbreaks: WHO policy and
recommendationsrecommendations
Diagnosis
The presence of V. cholerae in stools is confirmed through
laboratory procedures. However, a new rapid diagnostic test (RDT),
now available, allows quick testing at the patient's bedside. WHO is
currently in the process of validating this RDT, to be able to include
it on the list of its pre-qualified products.
Once Vibrio cholerae has been confirmed, the WHO clinical case
definition is sufficient to diagnose cases. After that laboratory
testing is required for antimicrobial sensitivity testing and for
confirming the end of an outbreak.
Rapid diagnostic tests can facilitated early warning and detection of
first cases.

Provision of safe water, proper sanitation, and food
safety are critical for preventing occurrence of cholera.
Communities should be reminded of basic hygienic
behaviours, including the necessity of systematic hand-
washing with soap after defecation and before handling
food or eating, as well as safe preparation and
conservation of food.
Health education aims at communities adopting
preventive behaviour for averting contamination.
Prevention

Control of choleraControl of cholera
Among people developing symptoms, 80% of episodes
are of mild or moderate severity.
The remaining 10%-20% of cases develop severe watery
diarrhea with signs of dehydration.
Once an outbreak is detected, the usual intervention
strategy aims to reduce mortality - ideally below 1% - by
ensuring access to treatment and controlling the spread of
disease

The main tools for cholera controlThe main tools for cholera control
are:are:
proper and timely case management in cholera treatment centres;
specific training for proper case management, including avoidance
of nosocomial infections;
sufficient pre-positioned medical supplies for case management
(e.g. diarrheal disease kits);
improved access to water, effective sanitation, proper waste
management and vector control;
enhanced hygiene and food safety practices;
improved communication and public information.

Case management of choleraCase management of cholera
Efficient treatment resides in prompt rehydration through the
administration of oral rehydration salts (ORS) or intravenous fluids,
depending of the severity of cases. Up to 80% of patients can be
treated adequately through the administration of ORS
(WHO/UNICEF ORS standard sachet). Very severely dehydrated
patients are treated through the administration of intravenous fluids,
preferably Ringer lactate. Appropriate antibiotics can be given to
severe cases to diminish the duration of diarrhoea, reduce the
volume of rehydration fluids needed and shorten the duration of V.
cholerae excretion. For children up to five years, supplementary
administration of zinc2
has a proven effective in reducing duration of
diarrhoea as well as reduction in successive diarrhoea episodes. In
order to ensure timely access to treatment, cholera treatment centres
should be set up among the affected populations whenever feasible.

 Stool microscopyStool microscopy
 Dark field microscopy of stool forDark field microscopy of stool for
choleracholera
 Stool culturesStool cultures
 ELISA for rotavirusELISA for rotavirus
 Immunoassays, bioassays or DNAImmunoassays, bioassays or DNA
probe tests to identifyprobe tests to identify E. coliE. coli strainsstrains
LABORATORY DIAGNOSISLABORATORY DIAGNOSIS

TREATMENT: 3 DsTREATMENT: 3 Ds
 DDehydration correctionehydration correction–– replace thereplace the
loss of fluid and electrolytesloss of fluid and electrolytes
 DDiet: Start food as soon as possibleiet: Start food as soon as possible
 DDrug:rug:
 Tetracycline/ ciprofloxacin for choleraTetracycline/ ciprofloxacin for cholera
 Selexid for shigellosisSelexid for shigellosis
 Metronidazole for amebiasisMetronidazole for amebiasis

Oral Cholera Vaccines (OCV)Oral Cholera Vaccines (OCV)
 The Gavi Alliance Board approved aThe Gavi Alliance Board approved a
contribution towards a global choleracontribution towards a global cholera
vaccine stockpile for the period 2014-vaccine stockpile for the period 2014-
2018 to increase access to oral2018 to increase access to oral
cholera vaccine in outbreak situationscholera vaccine in outbreak situations
and endemic settings.and endemic settings.

10 Facts on Cholera (WHO)10 Facts on Cholera (WHO)
Cholera is an acute infection of the gut, caused by
ingestion of food or water contaminated with the
bacterium Vibrio cholera O1 or O139, which can lead to
rapid dehydration if left untreated.
01 Cholera is an acute diarrhoeal disease that can kill
within hours if left untreated

02 There are 100 000–120 000 deaths due to cholera every year of
which only a small proportion are reported to WHO
There also are an estimated 3–5 million cholera cases
every year, contrasting with the 178 000–589 000 cases
reported annually to WHO over the past five years.

03 Up to 80% of cases can be successfully treated with oral
rehydration salts (ORS)
However, very severely dehydrated patients only
require administration of intravenous fluids. Such
patients also require appropriate antibiotics to diminish
the duration of diarrhea, reduce the volume of
rehydration fluids needed, and shorten the duration of
V. cholerae excretion.

04 About 75% of people infected with Vibrio cholerae O1 or
O139 do not develop any symptoms
Among the ones developing cholera, 80% have mild or
moderate diarrhoea.
Where sanitation facilities are not available bacteria are
shed back into the environment, which is a source of
further potential infection.

05 Typical at-risk areas of cholera include peri-urban slums with
limited access to safe drinking water and lack of proper
sanitation
Risk of cholera is highest in areas where basic infrastructure
is not available, as well as in camps for internally displaced
population or refugees, where minimum requirements of
clean water and sanitation are not met.

06 Surveillance is paramount to identify vulnerable populations
living in hotspots
Surveillance should guide interventions and lead to
timely prevention and preparedness activities. When
seasonal occurrence can be anticipated, prevention and
control must be enhanced and activities such as
preparedness plans, training of healthcare staff and pre-
positioning of supplies must take place.

07 Cholera is a preventable disease provided that safe water and
proper sanitation are made available
Cholera control depends on far more than the prompt
medical treatment of cases. The interplay of
prevention, preparedness and response focusing on
water safety and proper sanitation, together with an
efficient surveillance system are paramount for
mitigating outbreaks and diminishing case fatality
rates.

08 Once an outbreak is detected it is important to
focus on treatment and control measures
The usual intervention strategy, in an outbreak, is to reduce
deaths by ensuring prompt access to adequate treatment,
and to control the spread of the disease by providing safe
water, proper sanitation, and health education for improved
hygiene and safe food handling practices by the
community.

09 Safe and effective oral cholera vaccines are now
part of the cholera control package
Two types of vaccines are WHO-prequalified. They are
licensed in several countries and have shown to provide
sustained protection of >50% against cholera among all age
groups that lasts for two years in cholera endemic
populations. The vaccines should target vulnerable
populations living in high risk areas.
Vaccination should not disrupt the provision
of other proven interventions to control
or prevent cholera epidemics.

10 Today, no country requires proof of cholera
vaccination as a condition for entry
Past experience shows that quarantine measures and
embargoes on the movement of people and goods are
unnecessary.
http://www.who.int/features/factfiles/cholera/facts/en/index9.html

WATER, SANITATION AND HYGIENEWATER, SANITATION AND HYGIENE
A significant proportion of diarrhoeal disease can be prevented
through safe drinking-water and adequate sanitation and hygiene.
In fact, an estimated 88 % of diarrheal deaths worldwide are
attributable to unsafe water, inadequate sanitation and poor hygiene.
Water, sanitation and hygiene programmes typically include a number
of interventions that work to reduce the number of diarrhea cases.
These include: disposing of human excreta in a sanitary manner,
washing hands with soap, increasing access to safe water, improving
water quality at the source, and treating household water and storing it
safely.

The global burden of diarrhea

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