CDAlert

Monthly Newsletter of National Institute of Communicable Diseases,

Directorate General of Health Services, Government of India

April-June 2008 Vol.12 : No.2

CHOLERA : A continuing challenge to Public Health
INTRODUCTION cholera and other diarrheal diseases - though
expensive to the exchequer.
Cholera is an acute diarrhoeal disease caused by
Vibrio cholerae 01 or 0139. Though the disease Cholera outbreaks therefore need prompt
primarily affects gastrointestinal tract (acute diagnosis, treatment, public heath intervention and
gastroenteritis), the exotoxin produced by Vibrios notification to the State and WHO. Areas endemic
may lead to excessive (sometimes rapid) fluid and for cholera should have a regular system of
electrolyte loss resulting in dehydration, surveillance to know the disease burden, its
circulatory failure, shock and electrolyte changing epidemiology and early warning signals
imbalance. The chain of events may lead to of any outbreaks.
acidosis, myocarditis, hear t failure, tubular HISTORICAL PERSPECTIVE
necrosis and eventual death unless timely
History of cholera dates back to 18 th Century
intervention is carried out.
when John Snow diagnosed a cholera outbreak
This disease has major historical and public in London city by pure epidemiological
health importance. It may spread like a wild fire observation and analysis. He discovered that a
in a community with overcrowding, poor sanitation handpump was responsible for the cholera
and poor-hygiene. outbreak and controlled the said outbreak by
Sometimes, this commoner disease can require closure of that pump and water supply. This
real public health skills of the Health achievement of John Snow was commendable.
Administrators to control the malady as He succeeded in the desired public health action
epidemiology (associated risk factors) of the said long before the causative agent of cholera was
disease is known to vary according to different discovered.
geographical locations, type and source of water Cholera has been endemic in the Ganges Delta
supply, age group of affected persons and other since time immemorial. There were annual
local conditions and factors. This disease has epidemics in West Bengal and Bangladesh. From
environmental linkages and it is possible that 1817 to 1926, the disease has spread worldwide
global warming is increasing its incidence – a resulting in six pandemics. The seventh pandemic
hypothesis that is thought nowadays. that started in 1961 from Indonesia has spread to
Shortage of potable water plays an important role most of South Asia, Middle East, Africa, Southern
in the disease development. Other contributory Europe and Western Pacific regions.
factors could be: neutral or alkaline pH, increased The number of cholera cases notified to WHO
salinity and faecal contamination of surface water during the year 2006 was 2,36,896 from 52
or drinking water sources. This disease is clearly countries, including 6311 deaths, an overall
waterborne, though food borne transmission, is also increase of 79% compared with 2005. It could
reported. Improvement of water supply and be due to several outbreaks that had occurred
sanitation is the best strategy for the control of in the repor ting countries. According to the
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2005 data from WHO, the Indian subcontinent CASE DEFINITION (AS PER WHO)
repor ted 46% of all cases notified from Asia
with India notifying a total of 3155 cases and Category Case Definition
6 deaths. Information about the occurrence of Suspected · In an area where the disease is
infection with Vibr io cholerae 0139, which not known to be present- severe
emerged in the Bay of Bengal in 1992 is dehydration or death from acute
available from China only. The 0139 serogroup watery diarrhea in a patient aged
has the potential to become the cause of the 5 years or more/ or
· In an area where there is a
next pandemic and WHO encourages countries
cholera epidemic- acute watery
from South East Asia to test Vibrio cholerae
diarrhea with or without vomiting
isolates for both 01 and 0139 serogroups. in a patient aged 5 years or more
According to the data compiled by CBHI, the
Confirmed · A suspected case that is
cholera situation in our country has improved. laboratory confirmed (isolation of
While in 1991 there were 7088 cases (150 Vibrio cholerae O1 or O139 from
deaths) the same declined to 2635 cases (3 stools in any patient with
deaths) in the year 2007. However this may diarrhea is the laboratory criteria
not be actually true as there might be for diagnosis)
underrepor ting (CD Aler t: Jan 2000) due to Case Counted · Only confirmed cases for a
inadequate surveillance or non-availability of single isolated case.
· All cases to be counted having
laboratory facilities.
epidemiological linkage to a
EPIDEMIOLOGY confirmed case during epidemic

Epidemics of cholera are characteristically abrupt

children below 2 yrs of age, is not entirely true
and often create an acute public health problem.
as there are now, a number of studies available,
Cholera is a waterborne disease and epidemics
which show that cholera is common not only in
are known to occur following floods or during
under 5 age group but also in infants.
pilgrimage where large number of people may
assemble during festival seasons like Kumbh EPIDEMIIOLOCICAL CHARACTERISITICS
festival of UP. Typical cases are characterized by a) Infective material: Stools or vomitus from cases
the sudden onset of profuse, effortless, watery or carriers.
diarrhea followed by vomiting, increased thirst,
b) Mode of transmission: Through faecally
rapid dehydration, muscular cramps and
contaminated water, food or drinks. Direct person-
suppression of urine. Unless there is rapid
to-person contact, especially in overcrowded, low
replacement of fluid and electrolytes, the case
sanitation settings, also plays an important role.
fatality is likely to be high.
c) Incubation period: From few hours to 5 days;
In non-outbreak situations, cholera may present
commonly 1-2 days.
as simple gastroenteritis or as watery diarrhea.
In an endemic situation, there could be many mild d) Infective dose: 106 or more organisms. If the
or asymptomatic cases or carriers. Unless stool gastric acidity is neutralized then 103 organisms
samples are tested in a public health laboratory, are sufficient.
most of cholera cases remain undiagnosed and e) Period of communicability: Case : 7 to 10 days;
pass off as simple diarrhea cases. Convalescent carriers: 2 to 3 weeks.
The disease is known to affect all age groups f) Attack rate: Variable; depends upon endemicity,
and both sexes. In endemic areas, cholera is infective dose, age of the affected population, and
predominantly a disease of children. A common outbreak soluation. In endemic regions, attack rate
notion that cholera does not usually infect is usually below 1%. However, during outbreaks

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 in endemic areas, it is usually in the range of 2-5 Venkatraman and Ramakrishnan (VR fluid) fluid at
%. During outbreaks in a non-endemic area with room temperature unless viral infection or dysentery/
susceptible population, the attack rate may be diarrhea due to non-cholera organisms is suspected.
as high as 30 %. The calculation of attack rate is Stool samples should preferably be collected in
important for the Public Health Administrator as duplicate. In field situations, if transport medium is
it tells about the magnitude of the problem. Based not available, the rectal swab can be placed in a
on this data control measures logistics can be sterile bijou bottle, sealed with leucoplast and sent
finalised. to the testing laboratories.

g) Source of infection: The main source of infection Direct microscopic examination of stool specimen,
is human being who is case or carrier. if shows darting motility, cholera can be suspected.
Motility ceases on mixing with polyvalent anti cholera
h) Reservoir: Aquatic sources such as brackish
diagnostic serum. This presumptive test can be used
water and estuaries often associated with algal
in field situations. During outbreaks, this test can
blooms (planktons). Recent hypothesis states
become useful adjunct to diagnosis along with
that global warming might increase the growth
epidemiological information.
of zooplankton in aquatic environments due to
rise in water temperature and thus may lead to Culture methods:
an increased incidence of cholera in vulnerable (a) Bile salt agar medium (BSA) (pH 8.6) is used
areas. routinely for culturing the stool sample after
i) Population mobility: Movement of population enrichment in APW for 4-6 hrs. The translucent,
(pilgrimages, marriages, fairs and festivals) that oil drop like colonies on BSA that stain as gram
leads to temporary overcrowding with ad-hoc negative coccobacilli, are oxidase, lysine and
arrangements enhances the risk of acquisition ornithine positive suggest isolation of Vibrio
of infection. Slums and refugee camps are at cholerae. Unless antisera is available locally such
risk. presumptive strains could be stocked in 1%
nutrient agar slants and sent to regional or national
j) Lower socio-economic status: Increased
reference laboratories for serotype and biotype
incidence of disease is attributable to poor
confirmation.
hygiene, especially in rural areas where open-air
defaecation is still prevalent. (b) TCBS (Thiosulphate Citrate Bile Salt Sucrose
agar) is a good selective medium that is used
k) Immunity: Natural infection confers immunity that
extensively for the isolation of vibrios. This medium
may last for several years but re-infection is depicts yellow colonies and can be used in field
possible with new serogroup or increased infective situations. The medium identify cases even in the
dose. presence of lesser number of cholera bacilli for eg.
LABORATORY DIAGNOSIS in antibiotic treated cases, carriers etc.

Sample collection: Collect fresh stool specimen SEROTYPING OF VIBRIOS

before the administration of antibiotics to the The organism that causes cholera can be
patients. Using a rubber catheter one can easily
serotyped using polyvalent cholera O1 antiserum
collect the liquid stool sample. One should use
and labelled as Vibrio cholerae serogroup O1. If
gloves while collecting/ handling samples. Rectal
agglutination with anticholera O1 antiserum is
swabs should be of collected in field situations,
negative, then an attempt should be made with
specially during outbreaks. Apart from stool,
Vibrio cholerae O 139 antiserum. If agglutination
attempt should be made to collect water or food
does not occur with both VC O1 or O 139 then the
samples (if any).
isolate is labelled as Non agglutinable (NAG)
Transportation: Stool or rectal swab samples should vibrios or Non cholera vibrios (NCV) or Non O1
be transported in alkaline peptone water (APW) or Vibrios. This is a misnomer as the isolate can still
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be typed with some antiserum provided antisera Table-1
for all cholera serogroups are made available. Both Dehydration Signs Treatment
VC O1 and O139 serogroups can be further divided Stage
into 3 serological sub- types namely Inaba, Ogawa Severe Lethargic, IV therapy+
and Hikojima. unconscious, floppy antibiotics+
Sunken eyes ORS
During 1992, VC O139 Bengal was first discovered Drinks poorly/ unable
from Bangladesh. Due to non-availability of specific to drink,
O139 antiserum, initial O139 serotypes were Mouth very dry
Skin pinch goes back
diagnosed as NAG. Later specific O139 cholera
very slowly
antiserum became available. This can now be used No tears (only for
routinely. Therefore, isolation of NAG strains in large children)
numbers should arouse suspicion for a new emerging Mild Restless and irritable ORS + very
serogroup. Sunken eyes close
Dry mouth monitoring
Biotyping: There are two biotypes: classical and El
Thirsty, drinks eagerly
-tor. The classical biotype that used to cause severe Skin pinch goes
cholera outbreaks in the past has been replaced back slowly
these days by El –Tor biotypes (Characterized by No tears (only for
resistance to Mukherjee cholera phage V, hemolysis children)
on blood agar plates and chicken cell agglutination) No None of the above ORS at
dehydration signs home
that are less severe but leads to more extensive
morbidity. Source: Cholera Outbreak: Assessing the outbreak
response and improving preparedness. WHO 2004.
TREATMENT Global Task Force on Cholera Control.

Cholera can be effectively treated provided early

intervention with Oral Rehydration Solution (ORS) recommended by WHO for intravenous rehydration
or IV fluids is undertaken. Mortality rates can be are:
brought down to less than 1% by early and effective a) Ringer’s Lactate Solution
rehydration therapy. As per the details given in
b) Diarrhoea Treatment Solution
table1, the patient should receive rehydration
therapy. c) Normal Saline (if nothing else is available)

Packets of WHO-ORS are generally available at These should be given under supervision of medical
all PHCs, Sub-centres and hospitals. The ORS doctor in the hospital.
solution should be made fresh daily with boiled Antibiotic Therapy: Antibiotic should be used with
drinking water after it has been cooled to room reservation depending upon requirements of the
temperature. This reconstituted ORS solution case, its severity, age of the patients and local
should be used within 24 hrs. After reconstitution susceptibility pattern of Vibrios. It diminishes the
of ORS solution, it should not be boiled again for
duration of diarrhoea, reduces the volume of
sterilization purposes.
rehydration fluids and shortens the duration of vibrio
Intravenous Rehydration: It is required for the rapid excretion. The antibiotic can be started by the
correction of fluid and electrolyte imbalance in treating clinician keeping in mind the age, drug, and
severely dehydrated patients who are in shock or route of administration. Resume feeding with a
are unable to retain fluid due to excessive vomiting. normal diet when vomiting is under control. Breast
Such patients require immediate attention and transfer feeding of infants and young children should be
to a nearby hospital or treatment centre. The solutions continued.
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Mass chemoprophylaxis is neither effective non Cholera vaccination is not mandatory for international
recommended for control of cholera outbreak. travel.

PREVENTION AND CONTROL (c) Action on occurrence of the disease

(a) Control of cholera (i) Isolation: The patient must be isolated in a

special fly proofed ward. Adequate
The following strategies are useful for the control of
arrangements for hospitalization of all
cholera in an outbreak situation.
critically ill and dehydrated patients must be
Ø Epidemiological investigations made.
Ø Establishment of cholera treatment centers (ii) Disinfection: Disinfect soiled beddings,
Ø Improve sanitation clothing, floors of wards with cresol (5%). The
stool and vomit should be poured into a
Ø Provision of safe drinking water and food supply
receptacle containing 5% cresol solution and
Ø Proper disposal of night soil/sewage left for 4 hrs before disposal.
Ø Health education (Table-2) (iii) Notification: Since 15 June 2005, the official
notification of cholera is no longer mandatory
Table-2 : Key points for public education
but countries are required to inform WHO of
about cholera
public health events of international concern
To prevent cholera
(iv) Attendants: Should be isolated from the
l Drink water only from a safe source or water that
nursing staff of main hospital. They should
has been disinfected (boiled or chlorinated)
disinfect their hands after contact with
l Cook food or reheat it thoroughly and eat it while
patients, their beddings etc. They should be
it is still hot. Boil milk before drinking. Avoid ice
creams from unreliable sources inoculated against cholera before hand.
l Avoid uncooked food unless it can be peeled or (v) Contacts: They need not be isolated. They
shelled should be kept under surveillance for 5 days.
l Wash your hands after any contact with excreta
(vi) Food and drinks: Control for the safety of food
and before preparing or eating food
and drinks is most important as detailed in
l Dispose off human excreta promptly and safely
Table-2.
l Avoid ice from unreliable sources
Remember (vii) Mild cases: A search for mild cases should be
l With proper treatment cholera is not fatal carried out by examination of the stools of all
l Take patients with suspected cholera immediately those who are suffering from diarrhea.
to a health worker for treatment STEPS OF OUTBREAK INVESTIGATIONS
l Give increased quantities of fluids as soon as
diarrhoea starts. A team comprising of clinician, epidemiologist and
microbiologist should be rushed to the affected site.

(b) Immunization For a suspected cholera outbreak affecting about 200

persons with about 20 severe cases, following
The efficiency of the cholera vaccine is limited and
materials are suggested for an immediate supply to
duration of protection is short, hence it is essential tackle the outbreak for initial two days:
that vaccine is used with discrimination. Cholera
vaccines can be used as an adjunct to other (A) For treatment
preventive measures such as drug prophylaxis, Establishment of Cholera Treatment Units (CTU)
proper sanitation and health education. Immunization (preferably with isolation facility) at Local Level with
against cholera is not regarded as an effective means dedicated staff conversant with drip treatment
of preventing the spread of cholera internationally. should be attempted on priority basis for any

5
suspected cholera outbreak. If facilities for IV date of onset of illness; date of sample
treatment cannot be arranged at Local level then collection; type of sample collected (stool in
transportation should be made available for early plain bottle/ rectal swab in Cary Blair/ rectal
shifting of cases to nearby CHC or PHC under ORS swab in APW / Stool in Cary Blair); whether
or IV drip cover. the patient took any antibiotics prior to sample
i. ORS Packets: collection. It should be signed by the Medical
Officer in charge with address, fax/ email/
a. WHO formula: 400 packets
contact no.
b. Isotonic formula: 200 packets
(C) For epidemiological investigations
ii. Ringer lactate solution: 200 bottles
1. A simple Performa needs to be developed to
iii. Normal saline: 200 bottles. investigate any gastroenteritis outbreak and a
iv. IV drip sets: 30 possible suggestion is as under:

v. Disposable needles: size: 18 /20/21: 50 each. Name; age; sex; no. of members in the household;
date of onset of diarrhea; no. of members suffering
vi. Micro drip set: 10
from diarrhea; any history of antibiotic taken prior
vii. Pediatric cannula size 24: 50 nos to this. The Performa can be further modified if
needed. The important information is number of
(B) For microbiological sample collection
cases and deaths by area, by time period and by
i. Cary Blair Medium: 20 population subgroups. Calculation of attack and
ii. Rectal swab: 30 case fatality rates allows comparison of different
areas and periods. The distribution of cases
iii. Alkaline Peptone water: 20
according to sex, age, social class etc. should be
iv. Plain Universal Container or MacCartney’s calculated.
Bottle: 20
2. For environmental sanitation, water quality
v. Polypropylene autoclavable screw capped bottle checking and treatment of these items may
500 ml capacity: 10 be carried. Chlorine tablets: 5000 tablets
vi. Leucoplast or Sticker type of Label: 2 sheets/ along with black polythene for distribution in
rolls. the community; bleaching powder (25 kg in
HDPE bag with min 33% available chlorine);
vii. Discarding Bag (5 litres)-50
Orthotoluidine Kit for checking chlorine in
viii. Zipper Bags: 50 pcs water, IEC material (Posters), WHO ORS
ix. Marker Pen:2; Ball Pen: 2 packets – 1000. 4-5 samples from the area
can be collected and sent to the public health
x. Scissors: one pair
laboratory for bacteriological and chemical
xi. Binocular microscope for Hanging Drop analyses.
preparation
3. A working case definition should be formed
xii. Vaccine Carrier with ice: For transportation of based on the examination of initial 10-15 cases.
water samples or in case viral diarrhea is This case definition should be local situation
suspected. specific and may vary as per the situation or
need of the case.
xiii. Samples should be sent with following
information preferably in a tabulated form: 4. What is the possible mode of transmission of
Name; age; sex; father’s name; complete the outbreak? Is it water borne/ food borne/food
residential address (town/ locality/ taluka); poisoning type.
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5. An attempt should always be made to identify hand washing ritual; use of night soil for growing
the risk factors that may have contributed or vegetables.
precipitated the cholera outbreak. Common
FUTURE DIRECTIONS
known risk factors that are known to cause
diarrhoea outbreaks are: faecal contamination Since all diarrhoeal diseases are mainly waterborne,
of drinking water sources; floods leading to there is a need to develop a comprehensive national
overflowing of rainwater into wells; shallow hand programme for the control of diarrhoeal diseases
pumps and wells getting sewage or fecal (including cholera) supported by an improved
contamination due to adjoining leaking septic sanitary, economic and educational campaign. Such
tank , leaking drinking water pipes drawing fecal a programme with an integrated approach should
contamination from adjacent pipes; lack of aim at carrying out continuous surveillance for
health care facility or health care facility at a cholera and other waterborne diarrhoeal diseases
distant place; lack of availability of potable for the generation of useful data and early warning
water; overcrowding; open air defaecation; no signals.

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 Integrated Disease Surveillance Project (IDSP)

l Integrated Disease Surveillance Project (IDSP) was launched by Hon’ble sUnion Minister of Health & Family Welfare in
November 2004. It is a decentralized, state based surveillance program in the country. It is intended to detect early warning
signals of impending outbreaks and help initiate an effective response in a timely manner.

l The project was implemented in Mizoram in 2004-05, in Manipur, Tripura, Nagaland and Meghalaya in 2005-06, and in
Arunachal Pradesh, Sikkim and Assam in 2006-07.

l All the states are reporting weekly outbreak alerts to the Central Surveillance Unit. Six states are sending weekly epidemiological data
also in IDSP reporting format. The list shows outbreaks detected and responded to by the IDSP in the NE States in the past 6 months.

Outbreaks detected through IDSP in last 6 months in the North Eastern States

State (District) Disease/Illness Date of reporting No. of No. of Comments

of outbreak cases deaths
Arunachal Measles December 2007 29 5 District RRT investigated and
Pradesh confirmed outbreak of
(Papum Pare) measles in unimmunized
children.
Manipur Deaths in February 2008 — 28 Rapid Response Team (RRT)
(Churachandpur) children from district visited the
affected area. The team
confirmed that there was no
outbreak and some children
died due to Acute respiratory
tract infection, Pneumonia, &
non-availability of health care.
Assam Acute Diarrhoeal March 2008 34 13 The cases were reported
(Jorhat & Disease (ADD) from the tea estates in the
Golaghat) affected districts. ADD
outbreak was confirmed as
cholera.
Meghalaya Meningitis March 2008 389 44 Following an alert from a
(All districts Private hospital and state
except South IDSP preliminary report, a
Garo Hills) central RRT team assisted
the state authorities in the
investigation of outbreak.
Tripura Measles March 2008 20 1 Measles cases in one locality,
(West Tripura) investigated by District RRT
and confirmed as measles.
Sikkim Dysentery March 2008 40 1 Investigated by District RRT.
(West District)
Mizoram Acute Diarrhoeal April 2008 80 0 District RRT investigated the
(Lunglei) Disease (ADD) outbreak.

...about CDAlert
CDAlert is a monthly newsletter of the National Institute of Communicable Diseases (NICD) , Directorate General of Health
Services, to disseminate information on various aspects of communicable diseases to medical fraternity and health administrators.
The newsletter may be reproduced, in part or whole, for educational purposes.
Chief Editor: Dr. R. K. Srivastava
Editorial Board: Dr. Shiv Lal, Dr. R. L. Ichhpujani, Dr. Shashi Khare, Dr. A. K. Harit
Guest Editor: Dr. Uma Chawla, Dr. A.C. Dhariwal, Dr. Somenath Karmakar, Dr. Monica Chaudhary, Dr. Arti Bahl
Publisher: Director, National Institute of Communicable Diseases, 22 Shamnath Marg, Delhi 110 054
Tel: 011-23971272, 23971060 Fax : 011-23922677
E-mail: dirnicd@bol.net.in and dirnicd@gmail.com Website: www.nicd.nic.in

Acknowledgement: Financial assistance by WHO/USAID is duly acknowledged.

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