Download Diarrhoeal Diseases – Cholera

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Diarrhoeal Diseases
– Cholera
General Objective
To provide participants with basic medical knowledge in Diarrhoeal Diseases (DD) and basic principles for
preparedness and response to cholera and epidemic diarrhoeal diseases.
Specific Objectives
At the end of the session, participants will be familiar with:
➠ Clinical manifestations and diagnosis of DD
➠ Treatment options and prevention of DD
➠ Clinical practice in DD
➠ preparedness and detection of cholera
➠ appropriate response
➠ administration of treatment with the implementation of community
Content
Morbidity and mortality attributable to diarrheal disease in infants and young children can be reduced
by a variety of preventive measures and by improved clinical management of those episodes that occur.
Recent evidence indicates that the incidence of diarrheal disease can be diminished by decreasing
exposure to enteropathogens that frequently are present in foods, and that the severity (purging rate
and duration) and frequency of illness can be diminished by improving the host's nutritional status.
At the same time about 20% of those who are infected of cholera develop acute, watery diarrhoea
(10–20% of these individuals develop severe watery diarrhoea with vomiting). If these patients are
not promptly and adequately treated, the loss of such large amounts of fluid and salts can lead
to severe dehydration and death within hours. The case-fatality rate in untreated cases may reach
30–50%.
Treatment is straightforward (basically rehydration) and, if applied appropriately, should keep casefatality rate below 1%.
➠ Clinical manifestations and Diagnosis of acute diarrhoea
● Clinical evaluation
● Laboratory evaluation
● Prognostic Factors and differential diagnosis
➠ Treatment Options and Prevention
● Rehydration
● Supplemental Zinc Therapy, Multivitamins, and Minerals
● Diet – Non specific antidiarrheal treatment
● Prevention (water, sanitation and hygiene – vaccines)
➠ Clinical Practice in acute diarrhoea (adults, children)
➠ Cholera
● New strategies: oral cholera vaccines
● Case definition - confirmation
● Improved preparedness and treatment (training of health workers, rehydration,
intravenous therapy, antibiotics, health education, vaccination, trade and travel
restrictions, mass chemoprophylaxis)
● Surveillance of patients with severe cholera
Methodology
➠ PPt Presentations
➠ Lecture/discussion format
➠ Case study
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References
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Diarrhoeal Diseases
Clinical Manifestations and Diagnosis
Despite clinical clues, determining the causative agent of diarrhea in an individual patient on the
basis of clinical grounds alone is usually difficult.
Episodes of diarrhea can be classified into three categories:
Acute diarrhea
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Dysentery
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Bloody diarrhea, visible blood and mucus present
Persistent diarrhea
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Episodes of diarrhea lasting more than 14 days
Presence of three or more loose, watery stools
within 24 hours
Table: Linking the Main
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Bloody stools
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Vomiting
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Common and associated with invasive pathogens
Invasive and cytotoxin releasing pathogens
Suspect Enterohemorrhagic Escherichia (E.) coli (EHEC) infection
in the absence of fecal leukocytes
Not with viral agents and enterotoxins releasing bacteria
Frequently in viral diarrhea and illness caused by ingestion
of bacterial toxins (e.g., Staphylococcus aureus).
Symptoms to the Causes of Acute Diarrhea
CLINICAL EVALUATION
The initial clinical evaluation of the patient (see “Table: Levels of Dehydration in Children with
Acute Diarrhea” below) should focus on:
➠ Assessing the severity of the illness and the need for rehydration
➠ Identifying likely causes on the basis of the history and clinical findings
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Fever
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Table: Evaluation of the Acute Diarrhea Patient
History
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Onset frequency, quantity
Chara‘ cter - bile/blood/mucus
Vomiting
Past medical history,
underlying medical conditions
Epidemiological clues
Physical Examination
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Body weight
Temperature
Heart & respiratory rate
Blood pressure
Assess Dehydration
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General appearance, alertness
Pulse and blood pressure
Postural hypotension
Mucous membranes and tears
Sunken eyes, skin turgor
Capillary refill, jugular
venous pressure
Sunken fontanelle
Table: Levels of Dehydration in Children with Acute Diarrhea
No Dehydration
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Alertness normal
No sunken eyes
Normal drinking
Immediate skin pinch
Mild Dehydration
(≥ 2 signs)
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Restless or irritable
Sunken eyes
Drinks eagerly
Slow skin pinch (<2 sec)
Severe Dehydration
(> 2 signs)
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Abnormally sleepy or lethargic
Sunken eyes
Drinking poorly or not at all
Very slow skin pinch (>2 sec)
Cautionary note: Being lethargic and sleepy are not the same. A lethargic child is not simply asleep: the child’s
mental state is dull and the child cannot be fully awakened; the child may appear to be drifting into
unconsciousness. In some infants and children, the eyes normally appear somewhat sunken. It is helpful
to ask the mother if the child’s eyes are normal or more sunken than usual. The skin pinch is less useful
in infants or children with marasmus or kwashiorkor, or obese children. Other signs that may be altered in
children with severe malnutrition are described in section 8.1 of the World Health Organization (WHO)
2005 Guideline.
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Signs of dehydration in adults
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Pulse rate >90
Postural hypotension
Supine hypotension and absence of palpable pulse
Dry tongue
Sunken eyeballs
Skin pinch
Laboratory Evaluation
For acute enteritis and colitis, maintaining adequate intravascular volume and correcting fluid
and electrolyte disturbances take priority over the identification of the causing agent. Stool cultures
are usually unnecessary for immunocompetent patients who present within 24 hours after the onset
of acute, watery diarrhea. Microbiologic investigation is indicated in patients who are dehydrated
or febrile or have blood or pus in their stool.
Epidemiologic clues to infectious diarrhea can be found by evaluating the incubation period,
history of recent travel, unusual food or eating circumstances, professional risks, recent use of
antimicrobials, institutionalization, and human immunodeficiency virus (HIV) infection risks.
Stool analysis and culture costs can be reduced by improving the selection and testing of the
specimens submitted on the basis of interpreting the case information — such as patient history,
clinical aspects, visual stool inspection, and estimated incubation period.
The identification of a pathogenic bacterium, virus, or parasite in a stool specimen from a child
with diarrhea does not indicate in all cases that it is the cause of illness.
Certain laboratory studies may be important when the underlying diagnosis is unclear or
diagnoses other than acute gastroenteritis are possible.
Measurement of serum electrolytes is only required in children with severe dehydration or with
moderate dehydration and an atypical clinical history or findings. Hypernatremic dehydration
requires specific rehydration methods — irritability and a doughy feel to the skin are typical
manifestations and should be sought specifically.
Prognostic Factors and Differential Diagnosis
Table: Prognostic Factors in Children
Malnutrition
Approximately 10 percent of children in developing countries are severely underweight.
● Macronutrient or micronutrient deficiencies in children are related with more severe and
prolonged diarrhea.
● A poor nutritional status causes an elevated risk for diarrheal death.
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Zinc Deficiency
● Suppresses immune system function and is associated with an increased prevalence of persistent
diarrhea
Persistent Diarrhea
Often results in malabsorption and significant weight loss, further promoting the cycle
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Immunosuppression
● Secondary to infection with HIV or other chronic conditions may have an increased risk for the
development of clinical illness, prolonged resolution of symptoms, or frequent recurrence of
diarrheal episodes
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Meningitis
Bacterial sepsis
Pneumonia
Otitis media
Urinary tract infection
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Differential diagnosis of acute diarrhea in children
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Treatment Options and Prevention
Rehydration
Oral rehydration therapy (ORT) is the administration of fluid by mouth to prevent or correct
dehydration that is a consequence of diarrhea. ORT is the standard for efficacious and cost-effective
management of acute gastroenteritis, also in developed countries.
Oral rehydration salt (ORS) solution is the fluid specifically developed for ORT. A more effective,
lower-osmolarity ORS (with reduced concentrations of sodium and glucose, associated with less
vomiting, less stool output, and a reduced need for intravenous infusions in comparison with
standard ORS) has been developed for global use (see Table 4 in the original guideline document).
The hypotonic WHO-ORS is also recommended for use in treating adults and children with cholera.
ORT consists of:
➠ Rehydration – water and electrolytes are administered to replace losses
➠ Maintenance fluid therapy (along with appropriate nutrition)
In children who are in hemodynamic shock or with abdominal ileus, ORT may be contraindicated.
For children who are unable to tolerate ORS via the oral route (with persistent vomiting),
nasogastric (NG) feeding can be used to administer ORS.
Global ORS coverage rates are still less than 50%, and efforts must be made to improve
coverage.
Rice-based ORS is superior to standard ORS for adults and children with cholera, and can be used
to treat such patients wherever its preparation is convenient. Rice-based ORS is not superior to
standard ORS in the treatment of children with acute noncholera diarrhea, especially when food
is given shortly after rehydration, as is recommended to prevent malnutrition.
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Supplemental Zinc Therapy, Multivitamins, and Minerals
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For all children with diarrhea: 20 mg zinc for 14 days
Zinc deficiency is widespread among children in developing countries. Micronutrient
supplementation — supplementation treatment with zinc (20 mg per day until the diarrhea ceases)
reduces the duration and severity of diarrheal episodes in children in developing countries.
Supplementation with zinc sulfate (2 mg per day for 10 to 14 days) reduces the incidence of
diarrhea for 2 to 3 months. It helps reduce mortality rates among children with persistent diarrheal
illness. Administration of zinc sulfate supplements to children suffering from persistent diarrhea
is recommended by the WHO.
All children with persistent diarrhea should receive supplementary multivitamins and minerals
each day for 2 weeks. Locally available commercial preparations are often suitable; tablets that can
be crushed and given with food are least costly. These should provide as broad a range of vitamins
and minerals as possible, including at least two recommended daily allowances (RDAs) of folate,
vitamin A, zinc, magnesium, and copper.
As a guide, one RDA for a child aged 1 year is:
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Folate: 50 micrograms
Zinc: 20 micrograms
Vitamin A: 400 micrograms
Copper: 1 mg
Magnesium: 80 mg
Diet
The practice of withholding food for >4 hours is inappropriate. Food should be started 4 hours
after starting ORT or intravenous fluid. The notes below apply to adults and children unless age
is specified.
Give:
➠ An age-appropriate diet — regardless of the fluid used for ORT/maintenance
➠ Infants require more frequent breast feedings or bottle feedings — special formulas or
dilutions unnecessary
➠ Older children should be given appropriately more fluids
➠ Frequent, small meals throughout the day (six meals/day)
➠ Energy and micronutrient-rich foods (grains, meats, fruits, and vegetables)
➠ Increasing energy intake as tolerated following the diarrheal episode
Avoid:
➠ Canned fruit juices – these are hyperosmolar and can aggravate diarrhea.
➠ Probiotics are specific defined live microorganisms, such as Lactobacillus GG (American Type
Culture Collection [ATCC] 53103), which have demonstrated health effects in humans.
Nonspecific Antidiarrheal Treatment
ANTIMOTILITY: L o p e r a m i d e is the agent of choice for adults (4 to 6 mg/day; 2 to 4 mg/day
for children >8 years).
Should be used mostly for mild to moderate traveler’s diarrhea (without clinical signs of
invasive diarrhea).
Inhibits intestinal peristalsis and has mild antisecretory properties.
Should be avoided in bloody or suspected inflammatory diarrhea (febrile patients).
Significant abdominal pain also suggests inflammatory diarrhea (this is a contraindication for
loperamide use).
Loperamide is not recommended for use in children <2 years.
A n t i s e c r e t o r y a g e n t s : Bismuth subsalicylate can alleviate stool output in children or symptoms of
diarrhea, nausea, and abdominal pain in traveler’s diarrhea.
R a c e c a d o t r i l is an enkephalinase inhibitor (nonopiate) with antisecretory activity, and is now
licensed in many countries in the world for use in children. It has been found useful in children
with diarrhea, but not in adults with cholera.
A d s o r b e n t s : Kaolin-pectin, activated charcoal, attapulgite. Inadequate proof of efficacy in acute
adult diarrhea
Antimicrobials
Antimicrobial therapy is not usually indicated in children. Antimicrobials are reliably helpful only
for children with bloody diarrhea (most likely shigellosis), suspected cholera with severe dehydration,
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None of these drugs addresses the underlying causes of diarrhea. Antidiarrheals have no practical
benefits for children with acute/persistent diarrhea. Antiemetics are usually unnecessary in acute
diarrhea management.
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and serious nonintestinal infections (e.g., pneumonia). Antiprotozoal drugs can be very effective
for diarrhea in children, especially for Giardia, Entamoeba histolytica, and now Cryptosporidium,
with nitazoxanide.
In adults, the clinical benefit should be weighed against the cost, the risk of adverse reactions,
harmful eradication of normal intestinal flora, the induction of Shiga toxin production, and the
increase of antimicrobial resistance.
Antimicrobials are to be considered the drugs of choice for empirical treatment of traveler’s
diarrhea and of community-acquired secretory diarrhea when the pathogen is known (see Figure
11 in the original guideline document).
Considerations with regard to antimicrobial treatment:
✒ Consider antimicrobial treatment for:
● Persistent Shigella, salmonella, campylobacter, or parasitic infections
● Infections in the aged, immunocompromised patients, and patients with impaired
resistance, sepsis, or with prostheses
● Moderate/severe traveler’s diarrhea or diarrhea with fever and/or with bloody stools –
quinolones (co-trimoxazole second choice)
✒ Nitazoxanide is an antiprotozoal and may be appropriate for Cryptosporidium and other
infections, including some bacteria.
✒ Rifaximin is a broad-spectrum, non-absorbed antimicrobial agent that may be useful.
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Note well (N.B.):
Erythromycin is hardly used for diarrhea today. Azithromycin is widely available and has the
convenience of single dosing. For treating most types of common bacterial infection, the
recommended azithromycin dosage is 250 mg or 500 mg once daily for 3 to 5 days. Azithromycin
dosage for children can range (depending on body weight) from 5 mg to 20 mg per kilogram
of body weight per day, once daily for 3 to 5 days.
Quinolone-resistant Campylobacter is present in several areas of South-East Asia (e.g., in
Thailand) and azithromycin is then the appropriate treatment.
Treatment for amoebiasis should, ideally, include diloxanide furoate following the metronidazole,
to get rid of the cysts that may remain after the metronidazole treatment.
All doses shown are for oral administration. If drugs are not available in liquid form for use in
young children, it may be necessary to use tablets and estimate the doses given in this table.
Selection of an antimicrobial should be based on the sensitivity patterns of strains of Vibrio
(V.) cholerae O1 or O139, or Shigella recently isolated in the area.
An antimicrobial is recommended for patients older than 2 years with suspected cholera and
severe dehydration.
Alternative antimicrobials for treating cholera in children are trimethoprim/sulf amethoxazole
(TMP-SMX) (5 mg/kg TMP + 25 mg/kg SMX, b.i.d. [twice a day] for 3 days), furazolidone (1.25
mg/kg, q.i.d. [four times a day ] for 3 days), and norfloxacin. The actual selection of an
antimicrobial will depend on the known resistance/sensitivity pattern of V. cholerae in the
region, which requires the availability of a well-established and consistent surveillance system.
For adults with acute diarrhea, there is good evidence that an ultrashort course (one or two
doses) of ciprofloxacin or another fluoroquinolone reduces the severity and shortens the
duration of acute traveler’s diarrhea. This area is still controversial; use should be limited to highrisk individuals or those needing to remain well for short visits to a high-risk area.
Prevention
Water, sanitation, and hygiene:
● Safe water
● Sanitation: houseflies can transfer bacterial pathogens
● Hygiene: hand washing
Safe food:
● Cooking eliminates most pathogens from foods
● Exclusive breastfeeding for infants
● Weaning foods are vehicles of enteric infection
Micronutrient supplementation: the effectiveness of this depends on the child’s overall
immunologic and nutritional state; further research is needed.
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Vaccines:
Salmonella typhi: Two typhoid vaccines currently are approved for clinical use. No available
vaccine is currently suitable for distribution to children in developing countries.
Shigella organisms: Three vaccines have been shown to be immunogenic and protective in field
trials. Parenteral vaccines may be useful for travelers and the military, but are impractical for use
in developing countries. More promising is a single-dose live-attenuated vaccine currently under
development in several laboratories.
V. cholerae: Oral cholera vaccines are still being investigated, and their use is recommended only
in complex emergencies such as epidemics. Their use in endemic areas remains controversial.
In traveler’s diarrhea, oral cholera vaccine is only recommended for those working in refugee
or relief camps, since the risk of cholera for the usual traveler is very low.
Enterotoxigenic E. coli (ETEC) vaccines: The most advanced ETEC vaccine candidate consists of
a killed whole cell formulation plus recombinant cholera toxin B subunit. No vaccines are
currently available for protection against Shiga toxin-producing E. coli infection.
Rotavirus: In 1998, a rotavirus vaccine was licensed in the USA for routine immunization of
infants. In 1999, production was stopped after the vaccine was causally linked to intussusception
in infants. Other rotavirus vaccines are being developed, and preliminary trials are promising.
Currently, two vaccines have been approved: a live oral vaccine (RotaTeqì) made by Merck
for use in children, and GlaxoSmithKline’s Rotarixì.
Measles immunization can substantially reduce the incidence and severity of diarrheal diseases.
Every infant should be immunized against measles at the recommended age.
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Clinical Practice
Adults
Table: The Approach in Adults with Acute Diarrhea
Perform initial assessment
Dehydration
● Duration (>1 day)
● Inflammation (indicated by fever, bloody stool,
tenesmus)
Provide symptomatic treatment
Rehydration
● Treatment of symptoms (if necessary consider
bismuth subsalicylate or loperamide if
diarrhea is not inflammatory or bloody)
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Stratify subsequent management
● Epidemiological clues: food, antibiotics, sexual
activity, travel, day-care attendance,
other illness, outbreaks, season
● Clinical clues: diarrhea, abdominal pain,
dysentery, wasting, fecal inflammation
Obtain fecal specimen for analysis
● If severe, bloody, inflammatory, or persistent
diarrhea or if outbreak is suspected
Consider antimicrobial therapy for specific
pathogens
Report to public health authorities
In outbreaks save culture plates and isolates;
freeze fecal and food or water specimens at -70ÆC
● Notifiable in the USA: cholera, cryptosporidiosis,
giardiasis, salmonellosis, shigellosis, and
infection with shiga toxin producing E. coli
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Children
In 2004, WHO and UNICEF revised their recommendations for the management of diarrhea,
including zinc supplementation as an adjunct therapy to oral rehydration. Since then, the
recommendations have been adopted by more than 40 countries throughout the world. In countries
where both the new ORS and zinc have been introduced, the rate of ORS usage has dramatically
increased.
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Table: Principles of Appropriate Treatment for Children with Diarrhea and Dehydration
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Use ORS for rehydration
Perform ORT rapidly – within 3 to 4 hours
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Administer additional ORS for ongoing losses
through diarrhea
When rehydration is corrected - rapid
realimentation
Age-appropriate unrestricted diet
Continue breastfeeding
Regular formula feeding
No unnecessary laboratory tests or medications
Treatment for Children Based on the Degree of Dehydration
Table: Minimal or No Dehydration
Rehydration therapy
None
Replacement of losses
Nutrition
<10 kg body weight: 60 to 120 mL
Continue breastfeeding or ageappropriate normal diet
ORS for each diarrheal stool or
vomiting episode
Note: If vomiting is persistent, the patient (child or adult) will not take ORS and is likely to need intravenous
fluids.
Table: Mild to Moderate
Rehydration therapy
ORS 50 to 100 mL/kg body
Replacement of losses
Nutrition
<10 kg body weight: 60 to 120 mL
ORS for each diarrheal stool or
vomiting episode
Continue breastfeeding, or
resume normal diet after
initial rehydration
Table: Severe Dehydration
Rehydration therapy
Replacement of losses
Nutrition
Rehydrate with Ringer’s lactate
(100 mL/kg) intravenously within
4 to 6 hours, then administer ORS
to maintain hydration until
patient recovers
<10 kg body weight: 60
to 120 mL ORS for each
diarrheal stool or vomiting
episode
Continue breastfeeding, or
resume age-appropriate normal
diet after initial hydration
Cautionary Note: Treating a patient with severe dehydration due to infectious diarrhea with 5% dextrose with
1/4 normal saline is unsafe. Severe dehydration occurs, usually as a result of bacterial infection (cholera,
ETEC), which usually leads to more sodium loss in feces (60 to 110 mmol/L). A 1/4 normal saline solution
contains sodium (Na) 38.5 mmol/L, and this does not balance the sodium losses. Intravenous infusion with
5% dextrose with 1/4 normal saline will thus lead to severe hyponatremia, convulsion, and loss of
consciousness. Five percent dextrose with 1/2 standard normal saline can only be used when Ringer’s
lactate is not available.
The main principles are: treatment of dehydration; stool cultures and microscopy to guide
therapy; and frequent smaller meals with higher protein intakes. (See Figure 15 in the original
guideline document for an algorithm for the therapeutic approach to acute bloody diarrhea
[dysentery] in children.)
∏ome Management of Acute Diarrhea
With ORS, uncomplicated cases of diarrhea in children can be treated at home, regardless of the
etiologic agent. Caregivers need proper instructions regarding signs of dehydration, when children
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The Therapeutic Approach to Acute Bloody Diarrhea (Dysentery) in Children
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appear markedly ill, or do not respond to treatment. Early intervention and administration of ORS
reduces dehydration, malnutrition, and other complications and leads to fewer clinic visits and
potentially fewer hospitalizations and deaths.
Self-medication in otherwise healthy
Indications for Patient Care
adults is safe. It relieves discomfort and social
● Caregiver’s report of signs consistent with
dysfunction. There is no evidence that it
dehydration
prolongs the illness.
● Changing mental status
In adults who can maintain their fluid intake,
● Young age (<6 months old or <8 kg body
ORS does not provide any benefits. It does not
weight)
reduce the duration of diarrhea or the number
● History of premature birth, chronic medical
of stools. In developed countries, adults with
conditions, or concurrent illness
acute watery diarrhea should be encouraged to
● Fever >38ÆC for infants <3 months old or
drink fluids and take in salt in soups and salted
>39oC for children 3 to 36 months old
crackers. Nutritional support with continued
● Visible blood in stool
feeding improves outcomes in children.
● High-output diarrhea including frequent and
Among hundreds of over-the-counter
substantial volumes
products promoted as antidiarrheal agents,
● Persistent vomiting, severe dehydration,
only loperamide and bismuth subsalicylate
persistent fever
have sufficient evidence of efficacy and safety.
● Suboptimal response to ORT or inability of
Principles of self-medication:
caregiver to administer ORT
➠ Maintain adequate fluid intake.
● No improvement in 48 hours - symptoms
➠ Consumption of solid food should be
exacerbate; overall condition gets worse
guided by appetite in adults — small light
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meals.
➠ Antidiarrheal medication with loperamide
(flexible dose according to loose bowel
movements) may diminish diarrhea and
shorten the duration.
➠ Antimicrobial treatment is reserved for
prescription only in residents’ diarrhea or
for inclusion in travel kits (add loperamide).
Family knowledge about diarrhea must be
reinforced in areas such as prevention,
nutrition, ORT/ORS use, zinc supplementation,
and when and where to seek care (see
“Indications for In-Patient Care” above). Where
feasible, families should be encouraged to
have ORS ready-to-mix packages and zinc
(syrup or tablet) readily available for use, as
needed.
Cascades
A cascade is a hierarchical set of diagnostic
or therapeutic techniques for the same
disease, ranked by the resources available.
Table: Cascade for Acute Watery Diarrhea –
Cholera-like, with Severe Dehydration
Level 1
Intravenous fluids + antibiotics + diagnostic tests
● Tests: tetracycline, fluoroquinolone or other +
stool microscopy/culture
Level 2
Intravenous fluids + antibiotics
● Empirical: tetracycline, fluoroquinolone or other
Level 3
Intravenous fluids + ORS
Level 4
Nasogastric tube ORS (if persistent) (vomiting)
Level 5
Oral ORS
Level 6
Oral ‘home made’ ORS
● Salt, glucose, orange juice dissolved in water
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Notes:
Tetracycline is not recommended in children.
Nasogastric (NG) feeding is not very feasible for healthy and active older children, but it is
suitable for malnourished, lethargic children.
NG feeding requires skilled staff.
Often, intravenous fluid treatment is more easily available than NG tube feeding.
NG feeding (ORS and diet) is especially helpful in long-term severely malnourished children
(anorexia).
Table: Cascade for Acute Watery Diarrhea,
with Mild/Moderate Dehydration
Level 1
Intravenous fluids (consider) + ORS
Level 2
Nasogastric tube ORS (if persistent vomiting)
Table: Acute Bloody Diarrhea,
with Mild/Moderate Dehydration
Level 3
Oral ORS
Level 1
Oral ORS + antibiotics consider for:
● S. dysenteriae
● E. histolitica
● Severe bacterial colitis + diagnostic tests
● Stool microscopy, culture
Level 4
Oral “home made” ORS
● Salt, glucose, orange juice dissolved in water
Level 2
Oral ORS + antibiotics consider for:
● Empirical antibiotics for moderate/severe illness
Level 3
Oral ORS
Level 4
Oral “home made” ORS
● Salt, glucose, orange juice dissolved in water
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Cautions:
If facilities for referral are available, patients with severe dehydration (at risk of acute renal failure
or death) should be referred to the nearest facility with intravenous fluids (levels 5 and 6 cannot
replace the need for referral in case of severe dehydration).
Levels 5 and 6 must be seen as interim measures and are better than no treatment if no
intravenous facilities are available.
When intravenous facilities are used, it must be ensured that needles are sterile and that needles
and drip sets are never reused, to avoid the risk of hepatitis B and C.
Do not diagnose moderate dehydration as severe dehydration and thus initiate referral for
intravenous feeding because oral rehydration is more time-consuming. It is in the mother’s
interest to avoid the unnecessary complications that may be associated with using intravenous
therapy.
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Benefits/Harms
of implementing the guidelines recommendatios
Potential Benefits
➠ Appropriate diagnosis, treatment, and management of acute diarrhea in children and adults
➠ Reduced morbidity and mortality from acute diarrhea
Potential Harms
➠ Antimicrobials: In adults, the clinical benefit of antimicrobials should be weighed against the
cost, the risk of adverse reactions, harmful eradication of normal intestinal flora, the induction
of Shiga toxin production, and the increase of antimicrobial resistance.
➠ Tetracycline is not recommended in children.
➠ Loperamide should be avoided in bloody or suspected inflammatory diarrhea (febrile patients).
➠ Use of ciprofloxacin or another fluoroquinolone is still controversial; use should be limited to
high-risk individuals or those needing to remain well for short visits to a high-risk area.
➠ Diarrhea vaccine use remains controversial.
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Cholera
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Cholera is a diarrhoeal disease caused by infection of the intestine with the bacterium Vibrio
cholerae, either type 01 or 0139. Both children and adults can be infected.
About 20% of those who are infected develop acute, watery diarrhoea – 10–20% of these
individuals develop severe watery diarrhoea with vomiting. If these patients are not promptly and
adequately treated, the loss of such large amounts of fluid and salts can lead to severe dehydration
and death within hours.
The case-fatality rate in untreated cases may reach 30–50%.
Treatment is straightforward (basically rehydration) and, if applied appropriately, should keep
case-fatality rate below 1%.
Cholera is usually transmitted through faecally contaminated water or food and remains an everpresent risk in many countries.
New outbreaks can occur sporadically in any part of the world where water supply, sanitation,
food safety, and hygiene are inadequate. The greatest risk occurs in over-populated communities
and refugee settings characterized by poor sanitation, unsafe drinking-water, and increased personto-person transmission. Because the incubation period is very short (2 hours to 5 days), the number
of cases can rise extremely quickly.
It is impossible to prevent cholera from being introduced into an area – but spread of the disease
within an area can be prevented through early detection and confirmation of cases, followed by
appropriate response. Because cholera can be an acute public health problem – with the potential
to cause many deaths, to spread quickly and eventually internationally, and to seriously affect travel
and trade – a well coordinated, timely, and effective response to outbreaks is paramount. Response
activities should always be followed by the planning and implementation of preparedness activities
that will allow future cholera outbreaks to be dealt with more effectively.
A strong cholera preparedness plan and programme is the best preparation for outbreaks in
countries at risk of cholera, whether or not they have yet been affected, or countries in which
seasonal recurrence of the disease may be expected.
New Strategies: Oral Cholera Vaccines
In the long term, improvements in water supply, sanitation, food safety and community awareness
of preventive measures are the best means of preventing cholera, as well as other diarrhoeal
diseases. However, WHO is currently evaluating the use of newer tools to complement these
traditional measures. Oral cholera vaccines of demonstrated safety and effectiveness have recently
become available for use by individuals. Some countries have already used oral vaccine to immunize
populations considered to be at high risk for cholera outbreaks. Use of these vaccines in both
endemic and epidemic situations requires further assessment.
Work is under way to investigate the role of mass vaccination as a public health strategy for
protecting at-risk populations against cholera. Issues being addressed include logistics, cost, timing,
vaccine production capacity, and criteria for the use of mass vaccination to contain and prevent
outbreaks.
Case Definition
Laboratory Confirmation
The treatment of dehydrated patients should not be delayed until laboratory testing of samples has
been completed. Microbiological confirmation of Vibrio cholerae by direct observation can be
obtained immediately, but it usually takes 2 days to get culture results. It is important to gather
information on:
serogroup of Vibrio (O1 or O139);
antimicrobial sensitivity patterns.
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It is most important to ascertain that all patients considered to be cholera cases in fact have the
same disease. According to the WHO case definition, a case of cholera should be suspected when:
in an area where the disease is not known to be present, 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.
A case of cholera is confirmed when Vibrio cholerae O1 or O139 is isolated from any patient with
diarrhoea.
In children under 5 years of age, a number of pathogens can produce symptoms similar to those
of cholera, such as rice-water diarrhoea. To maintain specificity, therefore, children under 5 are
not included in the case definition of cholera.
15
Improved Preparedness and Treatment
Training of health workers is an essential element for preparedness, especially in high-risk areas.
Emergency supply needs should be evaluated in the light of the particular situation:
likely attack rate in refugee camps, with high-risk populations (because of malnutrition), is
5-8%;
in open settings, an attack rate of 0.2% might be used;
in rural communities of 5000 people or less, the attack rate might reach 2%.
Emergency stocks of basic supplies should be prepared so that they can be mobilized quickly.
Rehydration
Rehydration with replacement of electrolytes lost is the mainstay of cholera treatment.
According to the dehydration stage (A, B, C), the patient should receive different rehydration
therapy (oral or intravenous fluids). Oral rehydration solution (ORS) should be used during and after
IV therapy. Surveillance of the patient is crucial during the early stage of treatment.
Dehydration stage
Severe
Mild
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No dyhydration
16
Signs
Treatment
Lethargic, unconscious, floppy
Very sunken eyes
Drinks poorly, unable to drink
Mouth very dry
Skin pinch goes back very
slowly
No tears (only for children)
IV therapy +
antibiotics +
Restless and irritable
Sunken eyes
Dry mouth
Thristy, drinks eagerly
Skin pinch goes back slowly
No tears (only for children)
ORS +
None of the above signs
ORS at home
ORS +
very close
surveillance
Intravenous Therapy for Severe Cases
Ringer’s lactate is the preferred IV fluid. Normal (9%) saline or halfnormal saline with 5% glucose
can also be used, but ORS solution must be given at the same time to replace the missing
electrolytes. Plain glucose solution is not effective in rehydrating cholera patients.
When IV rehydration is not possible and the patient cannot drink, ORS solution can be given
by nasogastric tube. However, nasogastric tubes should not be used for patients who are
unconscious.
Antibiotics
They should be given only in severe cases, to reduce the duration of symptoms and carriage of
the pathogen.
Antimicrobial resistance is increasing. In most countries Vibrio cholera is resistant to cotrimoxazole; in some settings it has also developed resistance to tetracycline. The laboratory should
be asked about patterns of resistance of the strain at the beginning of and during the outbreak:
antibiotic sensitivity to antibiotics may return after a certain period.
Mass chemoprophylaxis is not effective in controlling a cholera outbreak.
Selective chemoprophylaxis (one dose of doxycycline) may be useful for members of a household
who share food and shelter with a cholera patient. However, in societies where intimate social
mixing and the exchange of food between households are common, it is difficult to identify close
contacts. Nevertheless, chemoprophylaxis may be useful when a cholera outbreak occurs in a closed
population, such as a prison.
Health Education
The most important messages to prevent the family from being contaminated are:
FOOD SAFETY
Cholera and dysentery can be transmitted through contaminated food. Food may be
contaminated before, during or after preparation. Raw or undercooked seafood, and foods cooked
and then kept at room temperature for several hours are especially dangerous. Fruits and vegetables
may be contaminated if they were fertilized with human waste (nightsoil), irrigated with
contaminated water or “freshened” with contaminated water.
HAND WASHING
People can prevent the transmission of cholera and dysentery by washing their hands. Careful
and frequent hand-washing is especially important to stop the transmission of dysentery. If soap
is expensive, or not available, ashes or mud can be used instead. Children, as well as adults, should
wash their hands.
Hand Washing is highly recommended:
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ENSURE A SAFE SUPPLY OF WATER
Access to safe water is a basic requirement for health, and it is more critical when there is an
outbreak of diarrhoeal disease. Since contaminated water can be the source of cholera and epidemic
dysentery, every effort must be made to provide safe drinking- water, and safe water for food
preparation and for personal hygiene.
Each person should have at least 20 litres of water a day for drinking, cooking and washing.
Health facilities need 40-60 litres per patient a day to maintain adequate levels of hygiene. Every
family should know how to treat water so that it will be safe for drinking.
Piped water, or water that is delivered in trucks or drums, must be adequately chlorinated.
Environmental sanitation workers can test water to be sure that the amount of chlorine is adequate.
Other sources of water are usually contaminated (e.g. rivers, shallow wells), so you must take
measures to reduce the risk of people becoming ill. You may have to close the water source or
provide another source of safe water. If that is not possible, be sure that people using the water
know how to make it safe.
17
➠
➠
➠
➠
➠
after defecation
after any contact with stools (cleaning up after children or patients)
before preparing food
before eating food
before feeding children.
ENVIRONMENTAL SANITATION
In the long term, cholera and dysentery will become rare as environmental hygiene and water
supplies improve. However, in areas where sanitation is poor, you must use temporary measures to
guarantee that stools are disposed of safely when there is an outbreak of diarrhoeal disease.
The methods to apply are:
➠ not to defecate on the ground or near a water supply
➠ to wash hands with soap or ash after any contact with stools
➠ to dispose of children’s stools in toilets, in latrines, or to bury the stools
➠ to build and use latrines
➠ if there is no latrine, to bury the stools away from water sources, as a temporary measure.
➠ safe practices at funerals (discourage ritual washing of the dead, hold the funeral soon after
death ensure that people who clean up and prepare the body in the hospital do not prepare
food or serve food etc)
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INEFFECTIVE CONTROL MEASURES
The measures described in this section do not stop the spread of epidemics. However, pressure
to use them may come from a frightened public or from uninformed officials. When ineffective
measures are carried out, it gives a false sense of security, and wastes time and resources that could
be used on efforts that are truly effective.
18
Vaccination: No vaccine currently exists for Shigella dysenteriae type 1. The old parenteral cholera
vaccine is not recommended. Two new oral cholera vaccines offer high-level short-term
protection; they are available for use in travellers in a few countries, but are not yet
recommended for large scale public health use.
Trade and travel restrictions (cordon sanitaire): It is not possible to detect and isolate all infected
travellers, most of whom have no signs of illness. A cordon sanitaire requires setting up checkposts and restricting movement. This diverts substantial resources from more effective control
measures. Trade and travel restrictions disrupt the economy of an area, which may encourage
suppressing information about outbreaks.
Mass chemoprophylaxis for cholera: Mass chemoprophylaxis – treating an entire community with
antibiotics – does not limit the spread of cholera. In some places, it contributed to making the
vibrio resistant to antibiotics, which deprives severely ill patients of a valuable treatment.
Selective chemoprophylaxis is usually not recommended. It is justified only if surveillance shows
that the secondary attack rate in the community is high (an average of at least one household
member in five becoming ill after the first case occurs in the household). If selective
chemoprophylaxis is used, it should be given to all close contacts as soon as possible after the
initial case is recognized. The prophylactic dose of antibiotics is the same as the therapeutic dose.
Doxycycline is preferred because only a single dose is needed.
Antibiotic chemoprophylaxis for dysentery: Giving people antibiotics for dysentery before they
become ill does not prevent dysentery and worsens the problem of antibiotic resistance. It
should never be done.
Surveillance of Patients with Severe Cholera
Surveillance and regular reassessment of patients for the following are crucial:
➠ pulse;
➠ dehydration signs;
➠ number and appearance of stools;
➠ respiratory rhythm;
➠ temperature (cholera usually provokes hypothermia – if the temperature is high there may
be associated pathology, e.g. malaria);
➠ urine (present or not);
➠ state of consciousness.
Complications
➠ pulmonary oedema if excessive IV fluid has been given;
➠ renal failure if too little IV fluid is given;
➠ hypoglycaemia and hypokalaemia in children with malnutrition rehydrated with Ringer
lactate only.
References
ñ
Centers for Disease Control and Prevention. Managing acute gastroenteritis among children: oral
rehydration, maintenance, and nutritional therapy. Atlanta, GA: Centers for Disease Control and Prevention
– Federal Government Agency [U.S.]. 2003 Nov 21.
ñ
UNICEF/WHO. Clinical management of acute diarrhea: UNICEF/WHO Joint Statement, May 2004
http://www.who.int/child-adolescent-health/New_Publications/CHILD_HEALTH/ISBN_92_4_159421_7.pdf
ñ
World Health Organization. Production of zinc tablets and zinc oral solutions: guidelines for programme
managers and pharmaceutical manufacturers. Geneva: World Health Organization http://www.who.int/
child-adolescent-health/publications/CHILD_HEALTH/ISBN_92_4_159494_2.htm
ñ
World Health Organization. The treatment of diarrhea: a manual for physicians and other senior health
workers, 4th rev. ed. Geneva: World Health Organization, 2005 http://www.who.int/child-adolescenthealth/New_ Publications/CHILD_HEALTH/ISBN_92_4_159318_0.pdf
ñ
The treatment of diarrhoea – a manual for physicians and other senior health workers. Geneva, World
ñ
WHO recommended strategies for prevention and control of communicable diseases. Geneva, World
Health Organization, 2001 (WHO/CDS/CPE/SMT/2001.13).
ñ
Hanquet G. Refugee health – an approach to emergency situations. London, Médecins Sans
Frontières/Macmillan, 1997.
ñ
Guidelines for cholera control. Geneva, World Health Organization, 1993.
ñ
Guidelines for the collection of clinical specimens during field investigation of outbreaks. Geneva, World
Health Organization, 2000 (WHO/CDS/CSR/EDC/2000.4).
ñ
Handbook for emergency field operations. Geneva, World Health Organization, 1999 (EHA/FIELD/99.1).
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Health Organization, 1995 (WHO/CDR/95.3).
19
Case Study Rivas Distict outbreak
Read the descriptions and then write brief answers to the questions (write key words instead of
complete sentences). You may look in your modules, if you need help in answering the questions.
Notify the facilitator if you cannot understand a question, and when you have finished. There will
be a discussion afterwards.
Background
Rivas District has a population of 100 000. About half the people live in Rivas Town, and the
others live in scattered villages. The town, which has piped water and sewerage, includes a very
crowded neighbourhood, Bayside, where sanitation is poor and there is no trained health worker.
Village A is a prosperous farming village, with a well-functioning health centre. Most families have
latrines and get water from a borehole. Some people in Village A use shallow wells during the rainy
season (October to March) because the wells are closer than the borehole. Village B (about 5000
people) is further from the town, on poor roads, and has a health post staffed by a nurse who
has not been trained in case management of diarrhoea in years. The nurse is unhappy at being
posted to a rural clinic, and often escapes to town. Water is from shallow wells and the river, and
very few families have latrines.
The district shares a border with the neighbouring country, and there is much traffic across the
border, especially during the yearly festival in Rivas Town. There was an outbreak of cholera in 1991,
but none has been reported since then. The District Medical Officer wants to be sure the district
is ready if another outbreak occurs.
Q 1:
What are the main things that should be done to prepare for an outbreak?
Q 2:
If cholera or epidemic dysentery should appear in the district, are there groups or individuals
at high risk of getting ill? Are there any at high risk of dying, once they are ill? Name them
and explain why you think they are at risk.
High risk of getting ill:
High risk of dying once ill:
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Week of 9-15 January
20
The District Medical Officer has made an Epidemic Preparedness Plan. On Monday, the District
Medical Officer gets a phone call from the nurse in village A. The nurse is concerned because a 4year-old boy from the village presented to the clinic with severe dehydration caused by acute watery
diarrhoea, and died while being treated.
Q 3:
Should the District Medical Officer start the Epidemic Preparedness Plan?
Explain why or why not.
The nurse from village A calls again on Tuesday. She has treated the sister, the mother and
the father of the boy who died, all for acute watery diarrhoea. She has also treated 6 other people
from village A for acute watery diarrhoea. The District Medical Officer asked the nurse to tell
him the age of each patient, their degree of dehydration and the outcome of their treatment.
These were the cases:
Patient
Degree of dehydration
Outcome
14-year-old sister
severe
mild
moderate
severe
moderate
severe
severe
severe
mild
recovered
recovered
recovered
recovered
recovered
recovered
recovered
died
recovered
50-year-old father
45-year-old mother
20-year-old woman
28-year-old man
5-year-old boy
10-month-old girl
65-year-old man
3-year-old boy
Q 4: On the list above, put a check next to each patient who meets the casedefinition for
reporting a case of cholera.
Q 5: Should the District Medical Officer start the Epidemic Preparedness Plan?
Explain why or why not.
The District Medical Officer decided to call a meeting of the Epidemic Control Committee.
Q 6: What four things do you think the Epidemic Control Committee should do first?
Q 7: What are the duties of the Epidemic Control Committee?
Week of 16-22 January
There have been more cases of cholera in village A. The nurse and the District
Medical Officer investigated the cases in village A. They found that, about a week before the
four-year-old became ill, he and his family had attended the funeral in village B of a man who
died of diarrhoea. The District Medical Officer checked the records, and found that the nurse posted
to village B had not sent in any reports for two months.
Q 8: What should the District Medical Officer do?
Week of 23-29 January
The District Medical Officer receives a laboratory report that confirms cholera.
The Rivas Epidemic Control Committee decides to send a Mobile Control Team to village B to
open a Temporary Treatment Centre.
Q 10: What should the team look for when choosing a site for the Temporary Treatment Centre?
When they arrived in village B, the Mobile Control Team found that cases that met the cholera
case-definition had been occurring there since before the first cases in village A. The first cases in
village A happened in the week of 9-15 January. The team made this table:
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Q 9: What control measures should NOT be carried out?
21
Village B
Cases
Deaths
2-8 Jan
9-15 Jan
16-22 Jan
23-29 Jan
15
3
50
5
65
3
51
0
Q 11: In what week was there the highest number of deaths?
In what week did patients with suspected cholera have the greatest risk of dying?
Q 12: How could the deaths have been prevented?
Cholera has arrived in Rivas Town and is spreading in the crowded Bayside
neighbourhood. The town officials urge the District Medical Officer not to say there is an
outbreak, because the town’s yearly festival is only two weeks away, and they fear that people will
not come when there is news of an outbreak.
Q 13: What should the District Medical Officer do?
The epidemic has declined in villages A and B, but continues in the town. Water testing has
shown that the town’s piped water is not sufficiently chlorinated. An environmental health
technician also discovered that people in bayside area had dug holes down to the water mains and
pierced the mains. This created little wells” from which they got water. It also allowed
contamination into the water mains.
Q 14: What should be done?
Teams were sent to Bayside to look for patients and to educate the community there on
prevention measures. These are the problems that the team found:
a. the residents could not afford soap
b. the residents could not afford the fuel needed to boil their water
c. men who worked far from home usually carried a home-cooked lunch with them to work, and
ate the lunch 6-8 hours after it had been cooked.
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Q 15: What advice should the team give to solve each problem?
a. (soap)
b. (fuel needed to boil the water)
c. (home-cooked lunch eaten 6-8 hours after it had been cooked).
22
Week of 6-12 January
The District Medical Officer did send notification of the urban outbreak of cholera, and began
an intensive health education campaign. Many people came to the festival, although fewer than in
the past. Many visitors arrived from the neighbouring country.
Q 16: What precautions should be observed to safeguard the health of the people who attend the
festival?
Health officials in the neighbouring country got news of the cholera outbreak the day before
the festival ended. They read about it in the newspaper and immediately ordered border guards
to screen all returning travellers for signs of diarrhoea, and to isolate those who were ill.
Q 17: Will this keep the outbreak from spreading? Explain your answer.
Week of 13-19 January
The outbreak ended.
Q 18: What should the District Medical Officer and the communities involved do now?
FIELD EXERCISE
Cholera Treatment Center – Setting up a CTC
General Objective
To provide participants with basic principles of setting up a Cholera Treatment Center (CTC).
Specific objectives
Content
Case scenario:
A Cholera outbrake occur in a big slum close to your mission area.
Your team has set up a Cholera Treatment Center behind the local hospital.
You are about to screen and treat a few thousands the next weeks. A few of them should be
admitted for parenteral support.
Design an overall map of the CTC and try to find practical ways to make better use of the space.
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At the end of the exercise, participants will be familiar with:
➠ Screening, admission and observation
➠ Hospitalisation of severely dehydrated patients
➠ Recovery
➠ Neutral area
➠ Mortuary
➠ Water, Hygiene and Sanitation
23
Design and architecture of a CTC: the principles
Organisation and design of a CTC are based on simple principles and rules. Patients are first
screened and diagnosed, then sent to specific areas for treatment according to their status. The CTC
is organised in separate areas, following two key principles:
➠ Isolation of the entire facility from other public structures (dispensary, school, market)
➠ Separation of patients (contaminated area) from the “neutral area” (not contaminated)
Suspect patient = screening + ORS
medical examination
No dehydration
No diarrhea
No vomiting
No dehydration or
mild dehydration
Mild / moderate diarrhea
and / or vomiting
Severe dehydration
or
uncontrollable vomiting
No
Simple cholera
Severe cholera
Send to normal
dispensarey
Oral rehydration
Immediate IV
rehydration
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Screening, admission and observation
24
Patients are examined by a medical person for screening. If cholera, admit; otherwise send to
normal dispensary.
Patients are admitted with 1 attendant (caregiver).
Patients who are admitted are registered (cholera register).
Moderate or mild cases receive oral rehydration therapy in observation where they stay under
medical observation for 6 hours . Patients stay under tents or shelters, on mats or benches and
will be discharged directly from there.
Severely dehydrated persons or those with uncontrollable vomiting should be hospitalized
directly: see hospitalization
Hospitalisation of severely dehydrated patients
Patients with severe dehydration and/or uncontrollable vomiting must be hospitalized for
immediate rehydration.
Each patient lies on a pierced bed with 1 bucket for stool collection underneath + 1 bucket for
vomit besides the bed.
Patients needing specific management (children, elderly, pregnant women) should be regrouped
in specific wards.
Do not exceed 20 patients per ward.
Recovery
For oral rehydration after hospitalisation when less surveillance is required. Patients stay on mats
or benches, as in the observation area.
Neutral area
Includes office space, rest area, changing room for staff, pharmacy and logistic stores, water
storage, preparation of chlorine solutions, kitchen.
Logistic store and pharmacy must be organized to ensure at least 7 days autonomy.
In case of reduced access/security constraints, stocks should be increased to avoid any shortage.
Mortuary
Must be isolated from other areas.
Water, Hygiene and Sanitation
➠ 60 litres of safe (chlorinated) water are needed per 1 CTC patient per day (this includes needs
for drinking water, food, hygiene of the patient and the caregiver).
➠ S u fficient storage capacity for 3 days must be ensured in order to avoid any shortage.
➠ Label and clearly differentiate each container (drinking water, ORS, chlorine solutions).
➠ 0.05% chlorine for hand washing, dish rinsing and bathing of soiled patients, 0.2% chlorine
for disinfecting floors, beds, clothes and footbaths, and 2% for disinfecting of vomit, faeces
and corpses.
Hospitalisation wards
20 patients per ward
Neutral area
Store, Office, Kitchen,
Observation area = ORS
Recovery
Morgue
Entry
Waste
area
Screening
Admission
Exit
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Staff Entry
25