this presentation was prepared and presented 4 years back for federal police crime prevention health main department staffs, to warm up them about AWD out break and its possible mangemnt
1. Over view of
AWD/cholera
Mikru taye
Insp.
Crime prevention health
service division
Disease prevention & health
promotion coordination office
2. Learning objectives:
By the end of the session the participants will be
able to:
• Describe key characteristics of cholera as a disease
• List the characteristics of cholera causing agent “Vibrio cholerae”
Describe It’s risk factors and mode of transmission
• Mention the case definition for cholera (suspected and
confirmed)
• Describe pathogenesis , Incubation period ,clinical presentation of
AWD/cholera
• Clinical management, prevention and control of AWD/cholera
4. What is cholera?
Cholera is -characterised by a sudden
onset of profuse painless watery
diarrhoea or rice-water like
diarrhoea, often accompanied by
vomiting
5. Causal agent - Vibrio cholerae
Vibrios are one of the most
common organisms in the
surface water around the
world.
There are over 100 different
Vibrio species but only vibrio
cholerae causes cholera.
6. - clinical features are the same, whatever the strain
– regardless the strain, the response is the same.
7. • The three serotypes can co-exist during an
epidemic because the bacteria can mutate
between serotypes This does not affect the
epidemic pattern:
• Clinical features are similar, whatever the
strain
• Regardless of the strain, the response is the
same.
9. Mode of transmission
Most epidemics have started
from a single source and
spread rapidly.
The reservoir is mainly
human: asymptomatic
(healthy) carriers and
patients carry huge
quantities of Vibrio cholerae
in faeces and in vomit.
12. Transmission…
Corpses of cholera
patients
are highly
infectious through
their excreta.
Physical contact and
food preparation
during funerals can lead
to ingestion of
contaminated food and
beverages.
20. Most bacteria is destroyed by
Surviving bacteria will move to the surface of
intestinal cells where they produce enterotoxins. It
is the enterotoxin that generates fluid loss and
diarrhoea.
gastric acids
21. Incubation
• From few hours to 5 days, most commonly
2-3 days
• A small number of individuals can remain
healthy carriers for several weeks.
Period of communicability: Infected
persons (symptomatic or not) can carry
and transmit vibrios during 1 to 4 weeks
22. The typical presentation of cholera is
• A sudden onset
• Profuse painless watery
stools, sometimes
rice-water like
often accompanied by
vomiting
• There is no fever
• Dehydration
appears within hours.
• Cause 20-50% death if not
managed well
23. Clinical presentation…
Patients with severe cholera often complain of
cramps in the arms, or legs
Patients become thirsty stop urinating, and quickly
become weak and dehydrated.
Patients develop acute renal failure.
24.
25. Cholera Case Definition
• Suspected case:
In an area where the disease is not known:-
a patient aged 5 years or more develops severe
dehydration or dies from acute watery diarrhoea
In an area where there is a cholera epidemic:-
a patient aged 5 years or more develops acute watery
diarrhoea, with or without vomiting
At the health post and at community levels Def.-Any
person 5 years of age or more with profuse acute watery diarrhea
and vomiting
26. Cholera Case Definition…
• Confirmed case: A suspected case in which
Vibrio cholerae O1 or O139 has been isolated
from their stool
27. OUTBREAK INVESTIGATION
• Upon receipt of a report of a suspected outbreak,
activate the multidisciplinary outbreak investigation
team (rapid response team) and initiate outbreak
investigation within 3 hours.
• Before departure to the field, the team needs to
secure relevant supplies:……….
• Required formats
• Guideline
• Supplies
• Laboratory equipment
• IEC
• Data analysis tools (laptop, etc.)
28. The main objectives of the field assessment
1. Verification
2. Determine magnitude and characteristics
3. Collect specimens (5-10 rectal swabs)
4. Assessing the local capacity
5. Create an investigation register (LL)
6. Identify high-risk groups and possible contaminated
sources
7. Implement simple, on-site control measures
8. Provide emergency treatment supplies
9. communicate findings to decision makers.
29. Verify the Diagnosis
• Several organisms, including some serogroups of V. cholerae,
can produce an acute, dehydrating diarrheal illness which is
clinically impossible to differentiate from cholera. These
organisms can occasionally cause a number of illnesses within a
community, but only V. cholerae O1 and O139 are capable of
causing widespread outbreak disease.
• Bacteriological confirmation is compulsory on the first
few suspected cases, in order to:
Confirm cholera
Identify the strain, biotype and serotype
Assess antibiotic sensitivity
• Confirmation of 5 to 10 stool or vomit samples is
sufficient per outbreak/woreda
30. Interpreting the data
• CFR is an indicator of adequate case management; WIR
indicates the extent of the epidemic and the rapidity of its
spread
By place :- high AR …..In densely populated scenarios
- In open situations –Rural
By time:- High CFR --- beginning & end of outbreak
32. General Principles of Clinical Management
is to rehydrate patients and replace electrolytes
lost in stool and vomitus.
80% - 90% of cholera patients can be rehydrated
with oral rehydration therapy alone.
34. Effective case management requires systematic and stepwise
approaches. These steps are.
1. Assessments for the level of dehydration
2. Decide the level of dehydration and Re-hydrating patients
accordingly
3. Monitoring the patient condition closely
4. Collect a rectal swab sample (the first 5 suspected)
5. Administration antibiotic only for severely dehydrated
patients
6. Identifying and treating complications
7. Continue feeding the patient
8. Advise the family on follow up and preventive actions from
cholera
9. Instruction to the patients and the families on discharge
35. STEP 1. Assessment for level of DHN
The severity of dehydration in patient with acute watery
diarrhea is detected by using the following Key
Signs:
I. General condition of the patient
A. Lethargic or unconscious OR
B. Restless and irritable OR
C. Alert/normal
II. Eye condition:
A. Very sunken
B. Sunken
C. Normal
36. Assessment…
III Drinking condition:
patient should be offered fluid and observed for one of
the following
A. Unable to drink or poorly drinking
B. Eager to drink/thirsty
C. Normally drinking
IV. Skin condition: When the abdominal skin is pinched
and released, observe for one of the following sign.
A. Skin pinch going back very slowly staying more than
2 seconds
B. Skin pinch going back slowly
C. Skin pinch going back immediately
41. STEP 2. Decide the level of dehydration
according to the following table
42. Status No Dehydration Some Dehydration Severe Dehydration
Check for pulse Present Rapid, weak None pulse
General condition
of the patient
Well, alert Restless, irritable‡
Lethargic or unconscious ‡
Eyes sunken? No Yes (sunken) Yes (very sunken and dry)
Mouth & tongue Moist Dry Very dry
Thirst* Drinks normally Thirsty, drinks eagerly‡ Drinks poorly or Not able
to drink‡
Skin pinch** Goes back quickly Goes back slowly‡ Goes back very slowly(> 2
seconds) ‡
Decide
The patient has no
signs of dehydration
If the patient has 2 or
more signs, including at
least 1 major sign, there is
some dehydration
If the patient has 2 or
more signs, including at
least 1 major sign, there is
severe dehydration
Treat
Maintain Hydration Oral Rehydration IV + ORS + Antibiotic
PLAN A PLAN B PLAN C
*Patient should be offered fluid to observe for this sign
** Abdominal skin has to pinched and released to observe for this sign
‡Major signs
43. Assessment…
Note:
For older children and adults pulse rate and blood
pressure are additional key signs to be check in
addition to the above signs. These include.
• Absent or weak and fast radial pulse
• Hypotension absent or very low blood pressure
44. Treatment of DHN
Plan C for severe dehydration
Action: Start IV line immediately
First choice: Ringer’s lactate
If ringer’s lactate is not available, use Normal saline
OR 5% glucose in N. saline
plain 5% glucose solution is not recommended
Give Ringer’s lactate a total of 100ml/kg divided in
to 2 as follows
45. STEP2: Re-hydrating patients according to level of
dehydration
Doses of IV fluid by age and by body weight of
patients
Age First give
30ml/kg in
Then give
70ml/kg in
Infants(<12mon
ths)
1 hour 5 hours
12 months and
above
30 minutes 2 ½ hours
Also give ORS 5ml/kg/hour if the patient
can drink
46. 3. Monitoring Patients condition closely
• Observe patient with severe dehydration very
frequently:
-Check patients condition
- Check that the IV is running well
After the first 30ml/kg have been given
-Radial pulse should be strong
-Blood pressure should be normal
• If pulse is not strong , repeat 30 ml/kg again
according the above table
47. Monitoring….
• Reassessment: Assess according to the above guide
- Infants, age<12 months: Assess after 6 hours
- Older children and adults: Assess after 3 hours
• If you find:
Severe dehydration = repeat PLAN-C
Some dehydration = Remove the IV if Vomiting is not
a problem => Give ORS according to PLAN-B
No dehydration = Remove IV
Give ORS according PLAN-A
Health -AWD/cholera training sesssion for
CTC staffs1.1
48. Monitoring….
If a patient is in severe Dehydration and you are not able
to give fluid through Intra Venous route, you must able to
give ORS through Naso-Gastric Tube (NGT).
The amount of ORS is 20ml/kg over 6 hours (Total
amount of 120ml/kg).
Reassess every 1-2 hours: if there is
repeated vomiting or increasing
abdominal distention give the fluid more
slowly
49. PLAN B for some dehydration
Cholera patients with some dehydration do not need IV
fluid replacement.
o Use ORS .
o The ORS required in 4 hours depends on the weight
of the patient (75ml/kg in 4 hours).
o If weight is not known, the age of patient can be
used as shown in the following table
50. Plan B: ORS for patients with some dehydration
Age* <4
months
4-11
months
12-23
months
2-4 years 5-14 years 15 years or
older
Weight < 5 kg 5-7.9 kg 8-10.9 kg 11-15.9 kg 16-29.9kg 30 kg or
more
ORS solution
in ml
200-400 400-600 600-800 800-1200 1200-2200 2200-4000
*Use age only when the patient's weight is not known. If the weight is known, calculate the
amount of ORS by multiplying the patient's weight in kg by 75
The amount of the ORS that should be given to a patient during the
first 4 hours.
51. Maintenance doses of ORS by age for cholera patients
who are treated for sever and some dehydration
For patients who are treated with Plan B or C
Age Amount of ORS
after each loose stool
< 24 months 100 ml
2-9 years 200 ml
10 years and over as much as wanted
Health -AWD/cholera training sesssion for
CTC staffs1.1
52. Plan A: Oral rehydration therapy for patients with
no dehydration (at home)
Age Amount of solution
to take after each
loose stool
ORS Sachets
needed
Less than 2
years
50 – 100 ml 1 sachet per day for 2
days
2 to 9 years 100 – 200 ml 1 sachet per day for 2
days
10 years and
above
As much as wanted 2 sachets per day for 2
days
53. STEP 4. Administration /use of antibiotics
• Antibiotics should be given only to patients with
severe dehydration.
• Most cholera patients are cured by rehydration and
do not need antibiotics.
• They are known to induce a false sense of security,
leading to underestimation of rehydration needs.
• On the other hand, if not correctly rehydrated,
patients will die even if antibiotics are given.
• Mass chemoprophylaxis is not effective in controlling a
cholera outbreak
54. Suggested Antibiotic regimen for out break Management
Age*
< 4
mon
4-11
months
12-23
months
2-4 years 5-14 years
15 years and
above
Weight < 5 kg 5-7.9 kg 8-10.9 kg 11-15.9 kg 16-29.9kg
30 kg and
above
Doxycycline 100mg
cap. single dose
½ capsule 1capsule 2 capsules 3 capsules
Tetracycline 250mg
caps QID for 3 days
For age >= 8
years 250 mg
each time
500 mg each
time
Amoxicillin
250mg/5ml TID for
3 days
1 TSP 1 ½ TSP 2 TSP
250 mg
capsule
250mg capsule 500mg
Erythromycin
250mg
adults: QID 3 days
children: TID for 3
days
½ TSP 1 TSP 1 TSP 1 ½ TSP 250 mg tab 250 mg
55. Zinc supplementation for children
Reduces the frequency
and severity of the
episode as well as the
frequency of subsequent
diarrhea episodes over
the following 2-3 months.
Schedule:-
Children 0-6 months:
10mg (½ tablet) daily for
10 days
Children 6-59
months: 20mg daily for
10 days
56. Do not use the following drugs in
patients with cholera:
Anti-emetics such as chlorpromazine and
prometazine
anti-motility drugs
anti-diarrheal drugs
Nalidixic Acid
Health -AWD/cholera training sesssion for
CTC staffs1.1
57. 5. Identifying and treating complications
1. Hypoglycaemia
2. Acute pulmonary oedema=> over hydration
3. Renal failure (Anuria)=> rare complication -> if
shock is not rapidly corrected
4. Hypokalemia => painful cramps occur -> after the first 24
hours of IV rehydration if patients do not eat or do not drink
ORS (ORS provides enough potassium )
58. Prevention of cholera
o Access and use of safe
drinking water
• Good sanitation
practises
o Good hygiene including
personal and food
hygiene
o Health education
61. Guard spraying feet of person leaving CTCSee
footbath at entrance / exit
Latrine in CTC – with plastic floor so latrine
can be easily cleaned
Guard at exit and by han dwashing
facility
Latrine slab sunken into the ground for ease of
cleaning
Isolation ward with cholera beds, plastic covered
floor for easy cleaning and sunken drain for ease
of cleaning
Shower unit – water drains into
protected hole next to unit through hole
in the floor
Clothes washing area and soakpit filled
with stones
Washing clothes in chlorine solution or
boiling and drying before leaving the
CTC
Cleaning equipment and different
concentrations of chlorine in different
coloured containers
62. Disinfected water for showering in
marked container
Covered waste pits for syringes and other
wastes
Incinerator drum
63. Learning objectives:
By the end of the session the participants will be
able to:
• Describe key characteristics of cholera as a disease
• List the characteristics of cholera causing agent “Vibrio cholerae”
Describe It’s risk factors and mode of transmission
• Mention the case definition for cholera (suspected and confirmed)
• Describe pathogenesis , Incubation period ,clinical presentation of
AWD/cholera
• Clinical management, prevention and control of AWD/cholera
