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Cholera
Prevention
10 Key factors
UNICEF West and Central
Africa
OBJECTIVE OF NORWAY
INITIATIVE
• Develop systems for cholera
prevention and outbreak response
and to extend the benefits over a
longer time frame to reduce
diarrhoeal disease incidence.
1. What are the symptoms?
• Very rapid onset of vomiting and diarrhoea with
large volumes of very watery (rice water type)
stools (>3 times a day)
• Severe de-hydration, = low pulse, undetectable
blood pressure, sunken eyes, wrinkled hands
and feet
• Slow recovery of shape after depression of skin
• No urine output
• Laboratory confirmation but count all suspected
cases and treat
2. How is it transmitted?
It is caused by a bacterium (Vibrio cholerae) which
lives naturally in brackish/freshwater amoeba,
and is transmitted through -:
• Unsafe water (7/8 investigations in Latin America
identified this as a major route)
• Unwashed fruit and veg (or washed in bad
water), left over rice not re-heated (3
investigations +Lusaka 2004),
• Lack of handwashing (food preparation, hand
shaking, childcare)
• Cooked and uncooked sea food – vibrio survives
light cooking (2 investigations)
3. Who is most at risk?
• Those living near lagoons / low lying areas
with fresh/ brackish water/ fishing populations
• With unsafe water sources
• With poor faecal disposal practices
• With poor personal hygiene
• With poor food hygiene (esp. moist food of
neutral acidity)
• Close to cholera patients in early stages
(hyper-infectivity) and dealing with bodies
4. When does cholera become
epidemic?
• After heavy period of rainfall
• When water temperatures rise
• When normal diarrhoeal incidence
increases
• Endemic cholera with good sanitation
needs permanent source of vibrio, but with
poor sanitation higher secondary
transmission can maintain endemic status
5. How long does it take?
• Incubation period 2hrs-5 days
• Infection 7-14 days, but most people do not
become ill or show any symptoms
• Only about 10-20% of infected people show
moderate or severe symptoms.
• Moderate symptoms difficult to differentiate
from other types of acute diarrhoea
• Group O blood group highest risk
6. How is it treated?
• Greatest risk in first 24 hours, so re-hydrate as
soon as possible
• Normally ORS (rice- rather than glucose-based
reduces purge rate,- sodium = or > 75mmol/l)
• If vomiting, give intravenous fluid replacement
(eg Ringer’s lactate) –extreme cases.
• Give food as soon as patient can take it
• Extreme cases only should have 1-3 days
antibiotic (esp doxycycline single dose) to
shorten illness, when vomiting stops
7. How is it prevented?
• Blocking routes of transmission – water
disinfection (source and /or household),
hand washing, sanitation, good food
hygiene and well-cooked
• Cholera vibrio doesn’t like acid
environment (block with acidic water eg.
With citrus juice, healthy stomach acid
levels, acid food)
• Oral vaccine (Dukoral) only for IDP setting
8. What proportion will die?
• Most people who die, do so within the first day of
symptoms appearing
• Without any treatment about 50% of people
survive
• With adequate re-hydration less than 2% will die
• With good surveillance, rapid establishment of re-
hydration, and anti-biotics for worst cases, almost
all deaths can be avoided (<0.2% die)
9.Risky cultural practices/
beliefs
The following beliefs about causes of cholera may
reduce effectiveness of key messages -:
• Witchcraft, eye, wind, climatic change cause the
sickness
• Children’s stools are not dangerous
• Soap is believed to wash away luck
The following practices increase risks
• Anal washing is often not followed by hand-washing
• Handshaking transfers bacteria directly from one
person to the next
• Burial ceremonies may spread disease
10. What are Key Messages?
• Bad water is one source of cholera (disinfect
source or stored water) but others, especially
contaminated food (clean and cook well) and
associated lack of hand washing (essential times
and methods for handwashing) should also be
highlighted
• Rapid transfer to clinics or use of ORT corners
speeds up treatment and reduces cross infection.
• Re-hydration as early as possible saves the most
lives- water quality in OR is of little importance
• Good surveillance systems can identify causes and
reduce infection rates
Africa's percentage of Global cholera
0%
20%
40%
60%
80%
100%
120%
1996 1998 2000 2002 2004 2006
Africa’s global dominance?
West Africa
League
Table
Country Total cases Incidence/1000Mortality Incidence/1
(sorted on mortality) 1997-2004 Ranking Average
Central African Republic 785 18 15.189 0.206579
Congo 8,319 5 11.285 2.291736
Cameroon 16,556 9 9.639 1.051175
Guinea 3,974 14 9.269 0.475359
Mali 6,276 12 8.530 0.497188
Mauritania 576 19 8.348 0.200697
Togo 8,536 6 6.985 1.778333
DR Congo 137,349 4 6.743 2.682598
Chad 23,943 3 6.467 2.867425
Niger 4,457 16 5.968 0.386088
Côte d'Ivoire 11,239 10 5.495 0.686771
Nigeria 46,803 15 5.409 0.387086
Burkina Faso 2,224 20 4.071 0.180813
Sierra Leone 3,472 11 3.829 0.590175
Ghana 26,280 7 2.431 1.283767
Benin 7,614 8 2.290 1.189688
Senegal 1,598 21 1.890 0.15104
Guinea-Bissau 21,968 1 1.866 16.15294
Equatorial Guinea 59 22 1.695 0.122661
Cape Verde 133 17 0.752 0.3325
Liberia 42,497 2 0.474 12.81188
Gabon 635 13 0.000 0.488462
TOTAL 375,293
Endemic 1. Cholera
reservoir, constant or
sporadic few cases
Epidemic. Triggered by
factors in 4. reaches
peak and then preventive
measures dominate
Endemic 2. Continued
levels higher than
endemic 1 while person
to person infection
continues
Typical cholera curve

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07-UNICEF_Cholera_Prevention.ppt

  • 2. OBJECTIVE OF NORWAY INITIATIVE • Develop systems for cholera prevention and outbreak response and to extend the benefits over a longer time frame to reduce diarrhoeal disease incidence.
  • 3. 1. What are the symptoms? • Very rapid onset of vomiting and diarrhoea with large volumes of very watery (rice water type) stools (>3 times a day) • Severe de-hydration, = low pulse, undetectable blood pressure, sunken eyes, wrinkled hands and feet • Slow recovery of shape after depression of skin • No urine output • Laboratory confirmation but count all suspected cases and treat
  • 4. 2. How is it transmitted? It is caused by a bacterium (Vibrio cholerae) which lives naturally in brackish/freshwater amoeba, and is transmitted through -: • Unsafe water (7/8 investigations in Latin America identified this as a major route) • Unwashed fruit and veg (or washed in bad water), left over rice not re-heated (3 investigations +Lusaka 2004), • Lack of handwashing (food preparation, hand shaking, childcare) • Cooked and uncooked sea food – vibrio survives light cooking (2 investigations)
  • 5. 3. Who is most at risk? • Those living near lagoons / low lying areas with fresh/ brackish water/ fishing populations • With unsafe water sources • With poor faecal disposal practices • With poor personal hygiene • With poor food hygiene (esp. moist food of neutral acidity) • Close to cholera patients in early stages (hyper-infectivity) and dealing with bodies
  • 6. 4. When does cholera become epidemic? • After heavy period of rainfall • When water temperatures rise • When normal diarrhoeal incidence increases • Endemic cholera with good sanitation needs permanent source of vibrio, but with poor sanitation higher secondary transmission can maintain endemic status
  • 7. 5. How long does it take? • Incubation period 2hrs-5 days • Infection 7-14 days, but most people do not become ill or show any symptoms • Only about 10-20% of infected people show moderate or severe symptoms. • Moderate symptoms difficult to differentiate from other types of acute diarrhoea • Group O blood group highest risk
  • 8. 6. How is it treated? • Greatest risk in first 24 hours, so re-hydrate as soon as possible • Normally ORS (rice- rather than glucose-based reduces purge rate,- sodium = or > 75mmol/l) • If vomiting, give intravenous fluid replacement (eg Ringer’s lactate) –extreme cases. • Give food as soon as patient can take it • Extreme cases only should have 1-3 days antibiotic (esp doxycycline single dose) to shorten illness, when vomiting stops
  • 9. 7. How is it prevented? • Blocking routes of transmission – water disinfection (source and /or household), hand washing, sanitation, good food hygiene and well-cooked • Cholera vibrio doesn’t like acid environment (block with acidic water eg. With citrus juice, healthy stomach acid levels, acid food) • Oral vaccine (Dukoral) only for IDP setting
  • 10. 8. What proportion will die? • Most people who die, do so within the first day of symptoms appearing • Without any treatment about 50% of people survive • With adequate re-hydration less than 2% will die • With good surveillance, rapid establishment of re- hydration, and anti-biotics for worst cases, almost all deaths can be avoided (<0.2% die)
  • 11. 9.Risky cultural practices/ beliefs The following beliefs about causes of cholera may reduce effectiveness of key messages -: • Witchcraft, eye, wind, climatic change cause the sickness • Children’s stools are not dangerous • Soap is believed to wash away luck The following practices increase risks • Anal washing is often not followed by hand-washing • Handshaking transfers bacteria directly from one person to the next • Burial ceremonies may spread disease
  • 12. 10. What are Key Messages? • Bad water is one source of cholera (disinfect source or stored water) but others, especially contaminated food (clean and cook well) and associated lack of hand washing (essential times and methods for handwashing) should also be highlighted • Rapid transfer to clinics or use of ORT corners speeds up treatment and reduces cross infection. • Re-hydration as early as possible saves the most lives- water quality in OR is of little importance • Good surveillance systems can identify causes and reduce infection rates
  • 13. Africa's percentage of Global cholera 0% 20% 40% 60% 80% 100% 120% 1996 1998 2000 2002 2004 2006 Africa’s global dominance?
  • 14. West Africa League Table Country Total cases Incidence/1000Mortality Incidence/1 (sorted on mortality) 1997-2004 Ranking Average Central African Republic 785 18 15.189 0.206579 Congo 8,319 5 11.285 2.291736 Cameroon 16,556 9 9.639 1.051175 Guinea 3,974 14 9.269 0.475359 Mali 6,276 12 8.530 0.497188 Mauritania 576 19 8.348 0.200697 Togo 8,536 6 6.985 1.778333 DR Congo 137,349 4 6.743 2.682598 Chad 23,943 3 6.467 2.867425 Niger 4,457 16 5.968 0.386088 Côte d'Ivoire 11,239 10 5.495 0.686771 Nigeria 46,803 15 5.409 0.387086 Burkina Faso 2,224 20 4.071 0.180813 Sierra Leone 3,472 11 3.829 0.590175 Ghana 26,280 7 2.431 1.283767 Benin 7,614 8 2.290 1.189688 Senegal 1,598 21 1.890 0.15104 Guinea-Bissau 21,968 1 1.866 16.15294 Equatorial Guinea 59 22 1.695 0.122661 Cape Verde 133 17 0.752 0.3325 Liberia 42,497 2 0.474 12.81188 Gabon 635 13 0.000 0.488462 TOTAL 375,293
  • 15. Endemic 1. Cholera reservoir, constant or sporadic few cases Epidemic. Triggered by factors in 4. reaches peak and then preventive measures dominate Endemic 2. Continued levels higher than endemic 1 while person to person infection continues Typical cholera curve