This document discusses guidelines for the control and management of a cholera outbreak at a primary health center in India. It provides: 1) A diagnosis of cholera based on two reported cases of abrupt onset, profuse, painless, watery diarrhea followed by vomiting. 2) Recommended control measures including developing a national diarrhea control program, notifying authorities, active case finding, establishing treatment centers, and providing rehydration therapy. 3) Guidelines from the WHO for verifying diagnosis, notification, case finding, treatment centers, rehydration therapy, epidemiological investigations, sanitation, chemoprophylaxis, vaccination, and health education to control the outbreak.

1. SPM SEMINAR
AS A MO H OW W ILL YOU MAN AGE TH E H EALTH
PR OBLEM
• A B H I J I T H J P U T TA N A N I C K A
• A B I S H E K R
• A B H I S H E K S . S

2. CLINICO - SOCIAL CASE
• 2 cases of diarrhoea reported to your PHC. On examination diarrhoea
was of abrupt onset, profuse, painless and watery followed by
vomiting.
a) What is your diagnosis ?
b) What control measures will you adopt to control the epidemic ?
c) Lab diagnosis of the disease diagnosed.

3. DIAGNOSIS
•Cholera

4. CONTROL MEASURES
• Best way to control cholera is to develop and implement a national
programme for the control of ALL diarrhoeal diseases because of
similarities in the epidemiology, pathophysiology , treatment and
control of cholera and other acute diarrhoeal diseases.
• Cholera is a notifiable disease locally and nationally. Since 2005
cholera notification is no longer mandatory internationally

5. GUIDELINES FOR CHOLERA CONTROL
PROPOSED BY THE WHO
1. Verification of the diagnosis
• All cases of diarrhoea should be investigated even on the slightest suspicion
• For the specific diagnosis of cholera, it is important to identify V. cholera in the
stools of the patient
2. Notification
• Health workers at all levels (community health workers and the multi-purpose
workers) should be trained to identify and notify cases immediately to the local
health authority
• Under the International Health Regulations, cholera is notifiable to the WHO
within 24 hours of its occurrence by the National Government, the number of
cases and deaths are also to be reported daily and weekly till the area is
declared free of cholera.

6. CTS…
3. Early case-finding
• An aggressive search for cases (mild, moderate, severe) should be
made in the community
4. Establishment of treatment centres
• It is necessary to establish easily accessible treatment facilities in the
community.
• Mildly dehydrated patients - be treated at home with oral rehydration fluid
• Severely dehydrated patients, requiring intravenous fluids - should be
transferred to the nearest treatment centre or hospital

7. 5. Rehydration therapy
• Oral rehydration therapy (ORS)
CTS…

8. • Only for the initial rehydration of severely dehydrated patients who are
in shock or unable to drink.
• The solutions recommended by WHO for intravenous infusion are:
• {a) Ringer's lactate solution (also called Hartmann's solution for
injection) : It supplies adequate concentrations of sodium and
potassium and the lactate yields bicarbonate for correction of the
acidosis. It can be used to correct dehydration due to acute diarrhoeas
of all causes.
INTRAVENOUS REHYDRATION

9. {b) Diarrhoea Treatment Solution (DTS):It contains in one litre,
sodium chloride 4 g sodium acetate 6.5 g potassium chloride 1 g and
glucose 10 g
• If nothing else is available, normal saline can be given because it
is often readily available.
• Normal saline is the poorest fluid because it will not correct the
acidosis and will not replace potassium losses.
• Plain glucose and dextrose solutions should not be used as they
provide only water and glucose.

10. • Antibiotics should be given as soon as vomiting has stopped,
(3-4hrs after ORH)
• Injectable antibiotics . have no special advantages.
• The commonly used antibiotics for the treatment of cholera are
fluoroquinolones, tetracycline, Azithromycin, ampicillin and
Trimethoprim TMP Sulfamethoxazole (SMX).
• If diarrhoea persists after 48 hours of treatment, resistance to
antibiotic should be suspected.
6) ADJUNCTS TO THERAPY

11. 7. EPIDEMIOLOGICAL INVESTIGATIONS
• Epidemiological studies must be undertaken to define the
extent of the outbreak and identify the modes of
transmission
• There are certain institutions which are able to assist in
investigating outbreaks.
• The National Institute of Communicable Diseases,
Delhi
• All India Institute of Hygiene and Public Health,

12. 8. SANITATION MEASURES
A. WATER CONTROL : All steps must be taken to provide properly
treated or otherwise safe water to the community for all purposes
(drinking, washing and cooking).
B.EXCRETA DISPOSAL : Provision of simple, cheap and effective
excreta disposal system (sanitary latrines} is a basic need of all
human settlements.
C.FOOD SANITATION
D.DISINFECTION :The most effective disinfectant for general use is a
coal tar disinfectant with a Rideal-Walker (RW) coefficient of 10 or
more such as cresol

13. 9. CHEMOPROPHYLAXIS
• Tetracycline is the drug of choice for chemoprophylaxis.
• It has to be given over a 3-day period in a twice-daily dose of 500
mg for adults,
• 125 mg for children aged 4-13 years,
• 50 mg for children aged 0-3 years.
• A single oral dose of doxycycline (300 mg for adults and 6 mg/kg
for children under 15 years) has proved to be effective.

14. 10. VACCINATION
• ORAL VACCINE
Two types of oral cholera vaccines are available :
• Dukoral (WC-rBS) -Dukoral is a monovalent vaccine based on
formalin and heat-killed whole cells (WC) of V. cholerae 01
{classical and El Tor, Inaba and Ogawa) plus recombinant cholera
toxin B subunit

15. • (b) Sanchol and mORCVAX The closely related
bivalent oral cholera vaccines are based on
serogroups 01 and 0139.
• Unlike Dukoral, these vaccines do not contain the
bacterial toxin B subunit therefore it does not
require buffer.

16. 11. HEALTH EDUCATION
It should be directed mainly to
(a)the effectiveness and simplicity of oral rehydration therapy
(b)the benefits of early reporting for prompt treatment
(c)Food hygiene practices
(d)Hand washing after defecation and before eating,
(e)The benefit of cooked, hot foods and safe water.

17. LAB DIAGNOSIS
1. COLLECTION OF SAMPLES
A. Fresh specimen of stool ,Sample should be collected before
the person is treated with antibiotics
• Methods of Collection
• Rubber catheter – Best method , The specimen collected
directly into a transport (holding} media, e.g.,
• Venkatraman-Ramakrishnan (VR} medium, alkaline
peptone water.

18. • If no transport medium is available, a cotton-tipped rectal swab should
be soaked in the liquid stool, placed in a sterile plastic bag, tightly
sealed and sent to the testing laboratory
B. VOMITUS : This is practically never used
C. WATER: Samples containing 1-3 litres of suspect water should be
collected in sterile bottles and transported to laboratory
D. SUSPECTED FOOD SAMPLES: 1-3 g sent to laboratory in transport
medium

19. 2. TRANSPORTATION
• The stools should be transported in sterilized McCartney bottles,
30 ml capacity containing alkaline peptone water or VR medium.
• VR medium –Large stool specimen
• Alkaline peptone water or Cary Blair medium - Rectal swab
• If suitable plating media are available (e.g., bile salt agar} at the
bed-side, the stools should be streaked on to the media and
forwarded to the laboratory with the transport media.

20. 3) DIRECT EXAMINATION
• DARK FIELD ILLUMINATION MICROSCOPY
• The vibrios evoke the image of many
“shooting stars in a dark sky”

21. 4) CULTURE METHODS
• Specimen in holding fluid is well shaken, about 0.5 to 1.0 ml of
material is inoculated into peptone water tellurite medium for
enrichment.
After 4 to 6 hrs incubation at 37 deg. C,
• A loopful of the culture from the surface is subcultured on bile
salt agar medium . after overnight incubation, the plates are
screened
under oblique light illumination for vibrio colonies.

22. 4) CHARACTERIZATION
• V. Cholerae usually appears on bile salt agar (bsa) as translucent,
moist, raised, smooth and easily emulsifiable colonies about 1 mm
in diameter
• Typical colonies are picked up and tested as follows
• (i)Gram's stain and motility
Gram negative, curved rods. With characteristic scintillating
type of movement in hanging drop preparations
• (ii)Serological test: Slide agglutination test is done by picking up
suspected colonies

23. (III) BIOCHEMICAL TESTS
Serologically positive colonies should be subcultured in one
tube each of the sugar broths (mannose, sucrose, arabinose)
and a tube of peptone water ph. 7.2 for the cholera red
reaction. Production of acid in sucrose and mannose, but not
arabinose

24. (IV) FURTHER CHARACTERIZATION
• Biotypes of V. Cholerae organisms are identified by slide
agglutination tests
• Using anti - 01 or group
139 antisera and by biochemical reaction patterns.
• Suspicious colonies that do not agglutinate with
anticholera sera are tested further by the oxidase and
string

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