Cholera Prevention and Control                                WHO Iraq Epidemiologist                                     ...
Introduction: Cholera is an acute, secretory diarrhoea caused by infection with Vibrio  choleraeof the O1 or O139 serogro...
Introduction: Management of patients with cholera involves aggressive fl uid replacement;  eff ective therapy can decreas...
History of CholeraCholera Epidemics in England  – 1831-1832: 22 000 deaths  – 1848-1849 : 54 000 deaths  – 1853-1854 : Jo...
EPIDEMIOLOGY Cholera continues to be an important public health problem  among many communities It is one of the oldest ...
Cholera: Causal agent While over 100 vibrio species have been isolated, only  the “cholerae” species are responsible for ...
Cholera : Causal Agent. Both El Tor and Classic biotypes are divided into 3 serotypes:  Ogawa, Inaba and Hikojima The th...
Cholera : Causal Agent Species: Vibrio Cholerae Serogroup: O139 & O1 Biotypes :EL Tor Classic Serotypes Hikojima, Ogaw...
ReservoirHumans are the main reservoir of Vibrio cholerae. Other potential reservoirs are water,Vibrios grow easily in s...
Carriers and transmissionThe reservoir is mainly human, asymptomatic (healthy) carriers and patients carry huge quantitie...
TRANSMISION Cholera is transmitted by the fecal –oral route through contaminated  water & food Person to person infectio...
RISK FACTORS Poor social and economic environment, precarious living conditions  associated with Insufficient water suppl...
Period of communicability Infected persons (symptomatic or not) can carry and  transmit vibrios during 1-4 weeks A small...
PATHOGENESIS V.cholerae cause clinical disease by producing an  enterotoxin that promotes the secretion of fluid and  ele...
15 |   Cholera | 3 October 2012
16 |   Cholera | 3 October 2012
Case Definitions for CholeraSuspected In an area where the disease is not known to be present:  severe dehydration or dea...
Case definition for choleraConfirmed A suspected case that is laboratory-confirmed.( Isolation  of Vibrio cholerae O1 or ...
CLINICAL FEATURE Cholera is an acute enteric disease characterized by the sudden  onset of profuse painless watery diarrh...
Clinical features No fever Dehydration appears within 12 to 24 hours. Asymptomatic and/or minor forms: in more than 80%...
21 |   Cholera | 3 October 2012                                  2
22 |   Cholera | 3 October 2012
23 |   Cholera | 3 October 2012
Role of laboratory test Bacteriological confirmation is compulsory on the first       suspected cases, in order to:      ...
Laboratory Test Confirmation on 10 to 20 stool samples is sufficient. Samples can       be taken using different methods ...
Selection of cases for bacteriologic sampling For confirmation of an outbreak, stool samples should be  collected from up...
Selection of transport media The most reliable, currently available transport medium is  Carry-Blair. The CB transport me...
Collection of specimens Stool should be collected either by: Collecting a swab from a freshly passed stool specimen  (fr...
CASE MANAGEMENT The main stay of case management of correction of  dehydration status29 |   Cholera | 3 October 2012
Clinical Management of Cholera        Aim for case fatality ratio of 1% or less        80-90% of patients can be treated...
31 |   Cholera | 3 October 2012
32 |   Cholera | 3 October 2012
What type of Dehydration is this ?33 |   Cholera | 3 October 2012
34 |   Cholera | 3 October 2012
35 |   Cholera | 3 October 2012
Severe Dehydration Loss of at least 10% of body weight Hypovolemic shock Low blood pressure Rapid, weak, or undetectab...
What type of Dehydration is this ?.37 |   Cholera | 3 October 2012
38 |   Cholera | 3 October 2012
What type of dehydration is this ?39 |   Cholera | 3 October 2012
40 |   Cholera | 3 October 2012
Moderate Dehydration Loss of 5-10% of body weight Normal blood pressure Normal or rapid pulse Increased thirst, drinks...
42 |   Cholera | 3 October 2012
Step-2: Maintenance of hydration and monitoring the                 hydration status  Reassess the patient for signs of d...
Step-3: Giving antibiotics if needed Why give antibiotic in cholera patients ?       – Reduces the volume and duration of...
Which Antibiotics ?45 |   Cholera | 3 October 2012
ANTIBIOTICS        Should be given only in severe cases to reduce the          duration of symptoms and carriage of the p...
Use of Ciprofloxacin : Offers short course          for cholera treatment  Offers short course for cholera treatment     ...
48 |   Cholera | 3 October 2012
Zinc Supplementation in Cholera : What is the                evidence ?  Supplementation of zinc to the children with cho...
WHO and UNICEF’s Recommendation for       Zinc Supplementation          Age group                   Dose              Dura...
51 |   Cholera | 3 October 2012
Cholera Prevention Measures                 Other Than Rehydration        Antibiotics are not necessary for patient recov...
53 |   Cholera | 3 October 2012
Cholera Cot54 |   Cholera | 3 October 2012
Complications Pulmonary edema if excessive IV fluid has been given Renal failure if too little IV fluid is given; Hypog...
IV Fluid Therapy Ringer’s lactate is the preferred IV fluid Normal 9% saline or half –normal saline with 5% glucose  can...
57 |   Cholera | 3 October 2012
Composition of Standard and                      Reduced Osmolarity ORS                                   Standard ORS    ...
Proper preparation of ORS59 |   Cholera | 3 October 2012
Home based ORS.60 |   Cholera | 3 October 2012
.61 |   Cholera | 3 October 2012
CHOLERA TREATMENT CENTRE (CTC) The organization of the CTC is meant to offer the best  care to patients but also to prote...
Cholera Treatment Centre63 |   Cholera | 3 October 2012
Infection control.64 |   Cholera | 3 October 2012
 Assume infectious agent could be present in the                         patient’s                          – Blood      ...
Personal Protective Equipment (PPE) When used properly can  protect you from exposure to  infectious agents Know what ty...
Key Infection Control Points      Minimize exposures        – Plan before entering room        –   Minimize number of vis...
DISINFECTION OF PATIENT’S BEDDING AND                     CLOTHINGPatient’s bedding and clothing can be disinfected by st...
Can we all now manage a cholera            patient ?               Yes?             Yes!
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Cholera: WHO & Lancet statements.

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  • World Health Organization अक्तॊबर 3, 2012 It is useful to explain how cholera causes disease. Vibrio pass through the intestinal tract and produce a toxin that paralyzes the normal pumping mechanism of the epithelial cells. This ‘locks’ the cellular pump in the ‘on’ position and results in a major loss of water and electrolytes with little reabsorption. Dehydration ensues. But there is rapid turnover of the superficial epithelium of the intestine and both vibrio and dead, poisoned cells occurs. Regeneration of health epithelium stops the disease. Cholera is self-limiting. All that is required is rehydration. There is no invasion of the intestinal wall by the organism, and antibiotics are not required .
  • World Health Organization अक्तॊबर 3, 2012 Do not disrespect the importance of intravenous therapy -- however, treatment with anything other than Ringer’s Lactate is a waste of time. Also, careful monitoring is important -- some articles suggest that up to 25% of mortality in a cholera outbreak can be due to congestive heart failure secondary to over-hydration .
  • World Health Organization अक्तॊबर 3, 2012
  • World Health Organization अक्तॊबर 3, 2012 This slide should usually be accompanied by the film on clinical dehydration from WHO .
  • World Health Organization अक्तॊबर 3, 2012
  • World Health Organization अक्तॊबर 3, 2012 These are examples of ORS packets that have been used in emergencies or for epidemic control. Do all UNICEF health offices know how to order ?
  • World Health Organization अक्तॊबर 3, 2012 The most significant change is the reduction in sodium concentration from 90milliequivalents per liter to 75 and the resulting reduction in osmolarity from 311milliosmoles per liter to 245. The net result of these changes will be fewer complications in non-cholera diarrhea patients. But the overall effectiveness of this newer formulation for cholera may be lessened .
  • World Health Organization अक्तॊबर 3, 2012 Use of Barriers-PPE's Session # 7
  • World Health Organization अक्तॊबर 3, 2012 Use of Barriers-PPE's Session # 7
  • World Health Organization अक्तॊबर 3, 2012 Use of Barriers-PPE's Session # 7
  • World Health Organization अक्तॊबर 3, 2012 DAVID
  • Cholera: WHO & Lancet statements.

    1. 1. Cholera Prevention and Control WHO Iraq Epidemiologist + Lancet 20121| Cholera | 3 October 2012
    2. 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. 2| Cholera | 3 October 2012
    3. 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. 3| Cholera | 3 October 2012
    4. 4. History of CholeraCholera Epidemics in England – 1831-1832: 22 000 deaths – 1848-1849 : 54 000 deaths – 1853-1854 : John Snow’s work4| Cholera | 3 October 2012
    5. 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 .5| Cholera | 3 October 2012
    6. 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 India6| Cholera | 3 October 2012
    7. 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 7| Cholera | 3 October 2012
    8. 8. Cholera : Causal Agent Species: Vibrio Cholerae Serogroup: O139 & O1 Biotypes :EL Tor Classic Serotypes Hikojima, Ogawa& Inaba8| Cholera | 3 October 2012
    9. 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;9| Cholera | 3 October 2012
    10. 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 route10 | Cholera | 3 October 2012
    11. 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 disease11 | Cholera | 3 October 2012
    12. 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 factors12 | Cholera | 3 October 2012
    13. 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.13 | Cholera | 3 October 2012
    14. 14. PATHOGENESIS V.cholerae cause clinical disease by producing an enterotoxin that promotes the secretion of fluid and electrolytes into the lumen of the gut14 | Cholera | 3 October 2012
    15. 15. 15 | Cholera | 3 October 2012
    16. 16. 16 | Cholera | 3 October 2012
    17. 17. Case Definitions for CholeraSuspected 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 vomitting17 | Cholera | 3 October 2012
    18. 18. Case definition for choleraConfirmed 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)18 | Cholera | 3 October 2012
    19. 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 same19 | Cholera | 3 October 2012
    20. 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 loss20 | Cholera | 3 October 2012
    21. 21. 21 | Cholera | 3 October 2012 2
    22. 22. 22 | Cholera | 3 October 2012
    23. 23. 23 | Cholera | 3 October 2012
    24. 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 sensitivity24 | Cholera | 3 October 2012
    25. 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.25 | Cholera | 3 October 2012
    26. 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;26 | Cholera | 3 October 2012
    27. 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)27 | Cholera | 3 October 2012
    28. 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)28 | Cholera | 3 October 2012
    29. 29. CASE MANAGEMENT The main stay of case management of correction of dehydration status29 | Cholera | 3 October 2012
    30. 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/Hartmanns) only for severely dehydrated30 | Cholera | 3 October 2012
    31. 31. 31 | Cholera | 3 October 2012
    32. 32. 32 | Cholera | 3 October 2012
    33. 33. What type of Dehydration is this ?33 | Cholera | 3 October 2012
    34. 34. 34 | Cholera | 3 October 2012
    35. 35. 35 | Cholera | 3 October 2012
    36. 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 dulled36 | Cholera | 3 October 2012
    37. 37. What type of Dehydration is this ?.37 | Cholera | 3 October 2012
    38. 38. 38 | Cholera | 3 October 2012
    39. 39. What type of dehydration is this ?39 | Cholera | 3 October 2012
    40. 40. 40 | Cholera | 3 October 2012
    41. 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 pinch41 | Cholera | 3 October 2012
    42. 42. 42 | Cholera | 3 October 2012
    43. 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. 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 cost44 | Cholera | 3 October 2012
    45. 45. Which Antibiotics ?45 | Cholera | 3 October 2012
    46. 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 patient46 | Cholera | 3 October 2012
    47. 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) 47 | Cholera | 3 October 2012
    48. 48. 48 | Cholera | 3 October 2012
    49. 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)49 | Cholera | 3 October 2012
    50. 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 200450 | Cholera | 3 October 2012
    51. 51. 51 | Cholera | 3 October 2012
    52. 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.52 | Cholera | 3 October 2012
    53. 53. 53 | Cholera | 3 October 2012
    54. 54. Cholera Cot54 | Cholera | 3 October 2012
    55. 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 only55 | Cholera | 3 October 2012
    56. 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 electrolytes56 | Cholera | 3 October 2012
    57. 57. 57 | Cholera | 3 October 2012
    58. 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 24558 | Cholera | 3 October 2012
    59. 59. Proper preparation of ORS59 | Cholera | 3 October 2012
    60. 60. Home based ORS.60 | Cholera | 3 October 2012
    61. 61. .61 | Cholera | 3 October 2012
    62. 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 visitors62 | Cholera | 3 October 2012
    63. 63. Cholera Treatment Centre63 | Cholera | 3 October 2012
    64. 64. Infection control.64 | Cholera | 3 October 2012
    65. 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 criticalInfection Prevention 2012 65 | Cholera | 3 October
    66. 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 correctly66 | Cholera | 3 October 2012
    67. 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 gloves67 | Cholera | 3 October 2012
    68. 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 sun68 | Cholera | 3 October 2012
    69. 69. Can we all now manage a cholera patient ? Yes? Yes!

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