Cholera

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Cholera is an acute gastrointestinal infection caused by Vibrio cholerae. Infection occurs through  ingestion of contaminated water or food by Vibrio cholerae leading to severe diarrhoea and emesis associated with body fluid and electrolyte depletion. 

Note: Rational approaches to case management of cholera with oral and intravenous rehydration therapy  have reduced the case fatality of cholera from more than 50% to much less than 1%. When a case  of  cholera  is  suspected  at  home,  advise  to  rehydrate  the  patient  using  ORS  if  available  while  preparing to take the patient to the nearest health facility or Cholera Treatment Centre.

Clinical Presentation 

A sudden onset of painless watery diarrhoea that may quickly become severe with profuse watery stool, vomiting, severe dehydration and muscular cramps, leading to hypovolemic  shock and death 

Case Definition 

• Suspected cholera case: In areas where a cholera outbreak has not been declared: any patient  aged  two  years  and  older  presenting  with  acute  watery  diarrhoea  and  severe  dehydration or dying from acute watery diarrhoea 
• In areas where a cholera outbreak is declared: any person presenting with or dying from acute watery diarrhoea 
• Confirmed cholera case: A suspected case with Vibrio cholerae O1 or O139 confirmed by culture or PCR (Polymerase Chain Reaction)

Laboratory Investigation 

• Specimen: Liquid stool or rectal swab
• Diagnostic test: Isolate V. cholerae from stool culture and determine O1 serotype using polyvalent  antisera  for  V.  cholerae  O1.  If  desired,  confirm  identification  with  Inaba  and  Ogawa antisera. 
• If specimen is not serotypable, consider, V. cholerae O139
• Antibiotic Susceptibility Testing  before provision of antibiotics; Follow up 48-72 hours after antibiotic initiation 

Note:

• For confirmation at the beginning of an outbreak, rectal swab or stool specimen should be taken from first 5 to 10 suspected cases. 
• If  any  are  positive,  every  tenth  case  will  be  sampled  for  specimen  throughout  the outbreak 
• Manage  a  suspected  cholera  case  in  an  isolation  ward  or  in  an  established  Cholera Treatment Centre 

Prevention 

• Drink treated or boiled water from safe sources (taps, decontaminated deep wells, bottles)
• Boil water or treat to kill bacteria and make it safe for drinking and for other domestic uses
• Wash hands with liquid soap and running water after visiting the toilet, before preparing foods, and before eating 
• DO NOT eat uncooked food from the street and do not eat cooked food that is no longer hot 
• DO NOT eat street prepared fruits. Always eat home prepared fresh fruits

Management 

Pharmacological Treatment 

Cholera requires immediate treatment because the disease can cause death within hours. There are  three elements of treatment: Rehydration, Antibiotic Treatment, Zinc and Folic Acid Supplements. 

i. Rehydration

• Assess  the  patient's  level  of  dehydration  as  per  National  Guidelines  for  Prevention  and Control of Cholera. It is of paramount importance to make correct diagnosis and administer  the right treatment. 
  • plan A: No dehydration
  • plan B: Moderate dehydration and
  • plan C: Severe dehydration

For Severe dehydration: 

• Administer intravenous (IV) fluid immediately to replace fluid deficit; Use Ringer Lactate solution or, if that is not available, 0.9% sodium chloride solution. Give 100 ml/kg IV in 3 hours, 30 ml/kg as rapidly as possible (within 30 min) then 70 ml/kg in the next 2.5 hours.
• After  the  initial  30  ml/kg  has  been  administered,  the  radial  pulse  should  be  strong  and blood pressure should be normal. If the pulse is not yet strong, continue to give IV fluid rapidly. Administer ORS solution (about 5 ml/kg/hour) as soon as the patient can drink, in addition to IV fluid.
• If the patient can drink, begin giving A: oral rehydration salt solution (ORS) by mouth while the drip is being set up; ORS can provide the potassium, bicarbonate, and glucose that saline solution lacks.

Note: When using 0.9% sodium chloride solution there is a possibility of hyper-metabolic acidosis causing kidney injury 

ii. Antibiotic treatment

Antibiotic treatment to patients with severe dehydration is as follows: 

Adults (Not for pregnant women) 

A: doxycycline (PO) 300 mg or 5mg/kg stat then 200mg (PO) 12 hourly for 7 days 

OR 

A: ciprofloxacin (PO) 1g stat then 15mg/kg 12 hourly for 7 days  or 500mg (PO) 12 hourly for 7 days  

OR 

A: azithromycin (PO) 500mg once a day for 7 days 

Expectant mothers: 

A: erythromycin (PO) 500mg 8 hourly for 7 days 

Children: 

A: erythromycin syrup (PO) 12.5mg/kg 6 hourly for 5 days 

OR 

A: Azithromycin 250mg (PO) once a day for 7 days 

For adolescents: 

A: ciprofloxacin (PO) 12mg/kg 2 times for 5 days 

OR 

A: doxycycline (PO) 300mg as stat or 5mg/kg (PO) stat 

OR 

A: azithromycin (PO) 500mg once a day for 7 days 

Note:  

• Ciprofloxacin was previously contraindicated to children under 12 years. Recent studies have shown it to be safe for use in children
• Start feeding 3-4 hours after oral rehydration begins. Preferably, give antibiotics with food to minimize vomiting

For moderate Dehydration 

• Give oral rehydration, approximately 75-100ml/kg in the first four hours
• Reassess  after  four  hours;  if  improved,  continue  giving  WHO  based  ORS,  in  quantity corresponding to losses (e.g. after each stool) or 10 to 20ml/kg. If not improved, treat as severe dehydration

If no signs of dehydration 

• Patients who have no signs of dehydration when first observed can be treated at home
• Give these patients ORS packets to take home, enough for 2 days
• Demonstrate how to prepare and give the solution
• Instruct  the  patient  or  the  caretaker  to  return  if  any  of  the  following  signs  develop; increased  number  of  watery  stools  repeated  vomiting  or  any  signs  indicating  other problems (e.g. fever, blood in stool)

For each loose stool or vomiting give; 

• 50-100 ml (¼ - ½ cup) of ORS solution for a child less than 2 years old
• 100-200 ml for older children. Adults can take as much as they want

Note: Prophylactic treatment of cholera contacts with antibiotics is not recommended. Routine treatment of  a community with antibiotics, or mass chemoprophylaxis, has no effect on the spread of cholera, can  have adverse effects by increasing antimicrobial resistance and provides a false sense of security. 

iii. Zinc and Folic Acid Supplements

• Zinc  (PO)  20mg  once  daily  decreases  diarrhea  and  shortens  the  duration  of  illness  in children with cholera.
• Provide zinc supplementation, at a dosage of 20 milligrams per day for children older than six months or 10 mg per day for those younger than six months, for 10–14 days. 
• Folic acid (PO) 2.5mg once daily for children < 6 months, or 5mg once daily for children >6 months for the duration of the treatment. For Pregnant women use folic acid (PO) 5mg once daily for the duration of the treatment.

Public Health Control Measures

• Establish treatment centre in locality where cases occur. Treat cases onsite rather than referring them to treatment centers elsewhere.
• Initiate a line listing of suspected and confirmed cases and ensure laboratory results are linked with cases.
• Strengthen case management.
• Mobilize community early to enable rapid case detection and treatment.
• Work with community leaders to limit the number of large gatherings, if seen as mandatory, establish by-laws
• Ensure availability and continuous access to clean and safe water.
• Promote safe preparation of food, including fruits, and vegetables.
• Promote safe disposal of human waste.
• Ensure  adequate  collaboration  with  various  sectors  including  water  and  sanitation  to ensure appropriate interventions are addressed.

Note: Cholera  vaccine  is  available  however  its  utilization  must  be  accompanied  with  strategies  to  improve water and sanitation.