CHOLERA

Dr. Priyanka Sachdeva

 CONTENTS
 Introduction
 History
 Magnitude of the Program
 Agent, Host and Environment
 Sign and symptoms
 Complications
 Prevention and Control Program Status
 National Policy and Strategies

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 INTRODUCTION
 Cholera is an acute diarrheal illness caused by infection
of the intestine with the bacteria Vibrio cholerae.
 The word cholera is derived from Greek word : kholera
which means kholē "bile".
 The main symptoms are watery diarrhea and vomiting.
 Transmission occurs primarily by drinking water or
eating food that has been contaminated by the feces
(waste product ).

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 HISTORY
Origins in India, cases reported as early as 1563
About 8 pandemics to date
1817-`23: First Pandemic
1829-`50: Second Pandemic
1852-`60: Third Pandemic* Pacini
1863-`79: Fourth Pandemic
1881-`96: Fifth Pandemic * Koch
1899-`1923: Sixth Pandemic
1961-?: Seventh Pandemic
1992-?: Eighth Pandemic
 DISCOVERY
 Filippo Pacini (1812-1883)
1854: Cholera reaches
Florence, Italy. Pacini
discovers causative agent
Publishes “Microscopical
Observations and
Pathological Deductions on
Cholera”
1965: Bacterium named
Vibrio cholerae Pacini
1854
CAUSATIVE AGENT DISCOVERY
John Snow (1813-
1858)

Water borne
transmission of
Cholera (1855)
 DISCOVERY
Robert Koch (1843-
1910)

1884: Rediscovers
Vibrio cholerae
 Vibrio cholerae is a Gram-negative bacterium
that produces cholera toxin,
 Vibrio cholerae, which causes cholera, has 139
serotypes, based on cell antigens.
 Only two of them produce an enterotoxin and
are pathogens: 0:1 and 0:139
 Cholera causes endemic and epidemic in developing
countries & some cases also found in developed
countries.
 Cholera became one of the most widespread and
deadly diseases.
 GLOBAL STATUS

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 OCCURRENCE
 Cholera likely has its origins in the Indian
Subcontinent; it has been prevalent in the
Ganges delta since ancient times.
 The disease first spread by trade routes (land
and sea) to Russia in 1817, then to the rest of
Europe, and from Europe to North America.
 Seven cholera pandemics have occurred in
the past 200 years, with the seventh
originating in Indonesia in 1961.
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 OCCURRENCE
 The first cholera pandemic occurred in the Bengal region
of India starting in 1817 through 1824.
 The disease dispersed from India to Southeast Asia,
China, Japan, the Middle East, and southern Russia.
 The second pandemic lasted from 1827 to 1835 and
affected the United States and Europe.
 It killed 150,000 Americans during the second
pandemic.
 The third pandemic
extended to North erupted in 1839,
Africa, and persisted
reached Southuntil
1856
America,
, for the first time specifically infringing
upon Brazil.

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 OCCURRENCE
 In Russia alone, between 1847 and 1851, more than one
million people perished of the disease.
 Cholera hit the sub-Saharan African region during the
fourth pandemic from 1863 to 1875.
 The fifth pandemic ranged from 1881–1896.
 sixth pandemics ranged from 1899-1923.
 Between 1900 and 1920, perhaps 8 million people died
of cholera in India.
 These epidemics were less fatal due to a greater
understanding of the cholera bacteria.

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 OCCURRENCE
 Egypt, the Arabian peninsula, Persia, India, and the
Philippines were hit hardest during these epidemics,
while other areas, like Germany in 1892 and Npalese
from 1910–1911, experienced severe outbreaks.
 The final pandemic originated in 1961 in Indonesia
and is marked by the emergence of a new strain,
nicknamed El Tor which still persists today in
developing countries.
 cholera became one of the most widespread and
deadly diseases of the 19th century.

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 EPIDEMIOLOGICAL FEATURES
• Cholera is both an epidemic and endemic disease

• The epidemicity and endemicity of the disease

depends on characteristics of the agent and the
prevailing environment.

• The characteristics of the agent influencing its

distribution include its ability to survive, its virulence,
average number of organism required to cause
infection
• Epidemics of cholera are characteristically abrupt
and can cause an acute public health problem.

• The epidemics have potentials to reach a peak and

subside gradually as the force of infection declines.

• Often times by the time control measures are

instituted the epidemic has already reached its peak
and is waning.

• Thus a cholera epidemic in a community is

self limiting.
• This is attributed to the acquisition of temporary
immunity as well as due to occurrence of a large
number of clinical cases.
• The force of infection is composed of force of
infection through water and force of infection
through living contacts
• Therefore the elimination of contaminated water
does not immediately bring an outbreak to an end as
the tail of epidemic is produced due to continuation
of transmission through contacts.
• In areas where cholera is endemic it does
not show a stable endemicity.

• It undergoes seasonal
fluctuations as well as epidemic
outbreaks.
 EPIDEMIOLOGICAL
DETERMINANTS

• AGENT FACTORS
• HOST FACTORS
• ENVIRONMENT FACTORS.
 AGENT FACTORS
 Agent: Vibrio cholerae

Has over 150 identified serotypes based on O-antigen

Only O1 and O139 are toxigenic and cause Cholera

disease (Water-borne illness)

 Source of infection: case of Cholera by Fecal-oral

transmission

 Infective materials: secretion of the Intestine cases.

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VIBRIO cholerae
 Resistance:
V Cholerae are killed within 30 minutes by heating at 56deg.C.
or within a few seconds by boiling.
They remain in ice for 4-6 weeks or longer.
Drying & sunshine will kill them in few hours
Bleaching powder kills vibrios instantly at 6mg/liter.

Toxin Production:
Vibrios multiply in the lumen of intestine & produce an
exotoxins(enterotoxin). This toxin produce diarrhea through its
effect on the adenlate-cyclase-cyclicAMP system of mucosal
cells of the small intestine.
Reservoir of infection:
Human being is the only known reservoir of infection. He
may be a case or carrier.

Case -Range from Inapparent case to severe ones.

75% of people infected with v cholerae do not develop any
symptoms, although bacteria are present in their feces for
7-14 days after infection.
Carriers- Usually temporary, rarely chronic
 Infective material: Immediate source of infection are the stools
and vomit of cases & carriers.

 Infective dose: Cholera is dose related. Infection occurs when

the number of vibrios ingested exceed the dose that is infective
for the individual. In normal persons a very high dose-something
like 10 11 organisms-is required to produce a clinical disease.

 Period of Communicability:
A case of Cholera is infectious for a period of 7-10 days.
Convalescent carriers are infectious for 2-3 weeks.
Chronic carrier state may last from a month up to 10 years or
more. By end of week, 70% of patients become non-infectious
& By end of third week, 98% become non-infectious
 Carriers in cholera
A cholera carrier can be defined as an apparently healthy person who is
excreting V. cholerae O1(classical or El Tor) in stools.
4 types of cholera carriers have been described:
 Pre-clinical or Incubatory Carriers: Incubatory period of cholera is short(1-
5) days, it is of short duration. These are potential patients.

 Convalescent Carriers: Patient has recovered from an attack of cholera may

continue to excrete vibrios for 2-3 weeks. This is found in those patients who
did not receive effective antibiotics treatment & often become chronic or long-
term carriers.

 Contact or Healthy Carriers: Result of sub-clinical infection contracted

through a source of infection, be it a case or infected environment. Duration is
usually less than 10 days & gall bladder is not infected.

 Chronic Carriers: Occurs infrequently, duration was found to be over 10

years Gall bladder is infected.
 HOST FACTORS
1. Age: Children: 10x more susceptible than adults,
And Elderly also higher susceptible.
2. Sex: Equal in both male and female.
3. Immunity: Less immune higher risk.
4. People with low gastric acid levels
5. Blood types
O>> B > A > AB
6. Population Mobility: Movement of population
(pilgrimage, marriages, fairs & festivals) results in increased
risk of exposure to infection.
7. Economic Status: Incidence of cholera tends to be
highest in the lower socio economic groups which could be
attributed to poor hygiene
 ENVIRONMENTAL FACTORS
 at risk areas include peri urban slums, refugee camps
where clean water and sanitation are not met
 Consequences of a disaster
 Lack of education, poor quality of life.
 Poor sanitation
 Contaminated water, food,
 Flies
 Fomites

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 Unsanitary environment:

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CASE DEFINITION FOR CHOLERA

Suspected
 In an area where the disease is not known to be
present: severe dehydration or death from acute
watery diarrhoea in a patient aged 5 years or more;
 In an area where there is cholera endemic: acute
watery diarrhoea, with or without vomiting in a
patient aged 5 years or more
 Epidemic ongoing: acute watery diarrhoea with or
without vomitting
CASE DEFINITION FOR CHOLERA

Confirmed
•A suspected case that is laboratory-confirmed.
(Isolation of Vibrio cholerae O1 or O139 from stools
in any patient with diarrhoea is the laboratory criteria
for diagnosis)
 VIRULENCE
&PATHOGENICITY
Ingestion of V.
cholerae

Resistant to
gastric acid

Colonize small
intestine

Virulence of Non-toxigenic V. cholera O1 strain not

well understood
 Secrete
enterotoxin

Enterotoxin binds to intestinal cells

Chloride channels activated

Release Large quantities of electrolytes &

bicarbonates
Fluid hypersecretion

Diarrhea

Dehydration
 MODE OF TRANSMISSION
Primary ingestion of water (contaminated with faeces)
OR
Ingestion of food contaminated by dirty water, faeces,
soiled hands or flies.
Improperly cooked shellfish
OR
The disease transmitted from one person to another person in
over crowded and unhygienic conditions.
 INCUBATION PERIOD

Ranges from a few hours to 5 days.

Universal I/P is 5 days.
Shorter incubation period:
High gastric pH (from use of antacids)
Consumption of high dosage of cholera
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 INFECTIOUS DOSE
• water, the infectious dose is 103-106 organisms.

• ingested with food, fewer organisms (102 -104)

 CLINICAL FEATURES
Severity of cholera depend upon the rapidity and duration of
fluid loss. Epidemiological studies have shown that more
than 90% of El Tor cases are mild & clinically
indistinguishable from other acute diarrheas.
However a typical case of cholera shows 3 stages:
Stage of Evacuation:
Onset is abrupt with profuse, painless, watery diarrhea
followed by vomiting.
Patient may pass 40 stools in day.
Stools may have rice watery appearance.

.
 CLINICAL FEATURES

Stage of Collapse:
Patient soon pass in to the stage of collapse due to
dehydration.
Classical signs are sunken eyes, hallow cheeks, scaphoid
abdomen, sub-normal temperature, absent pulse,
unrecordable blood pressure, loss of skin elasticity,
shallow & quick respiration. Patient become restless &
complain of intense thirst with cramps in legs.
 Death may occur at this stage due to dehydration &
acidosis resulting from diarrhea.
 CLINICAL FEATURES
Stage of Recovery:
 If death does not occur patient shows signs of recovery, blood
pressure begins to rise, urine secretion is established.
 If anuria persists, patient may die of renal failure.
 Classical form of severe diarrhea occurs only in 5-10% cases.
 Epidemiologically, cholera due to El Tor biotype differs from
classical cholera in following respects:
 A higher incidence of mild & asymptomatic cases.
 Fewer secondary cases in the affected families.
 Occurrence of chronic carriers
 SIGNS AND SYMPTOMS
 The primary symptoms of cholera are profuse,
painless diarrhea and vomiting of clear fluid.
 The diarrhea is frequently described as "rice water" in
nature and may have a fishy odor.
 An untreated person with cholera may produce 10 to 20
litres of diarrhea a day with fatal results.
 Patient's skin turning a bluish-gray hue from extreme loss
of fluids.

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Typical "rice water" diarrhea
 • If the severe diarrhea is not treated with
intravenous rehydration, it can result in life-
threatening dehydration and electrolyte
imbalances.

• The typical symptoms of dehydration include

low blood pressure, poor skin turgor (wrinkled
hands), sunken eyes and a rapid pulse.

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 A person with severe dehydration due to cholera - note the sunken
eyes and decreased skin turgor which produces wrinkled hands and
skin
 CHOLERA GRAVIS
• More severe symptoms
• Rapid loss of body fluids
• produce 10 to 20 litres
• 107 vibrios/mL
• Rapidly lose more than 10% of body weight
• Dehydration and shock
• patient's skin turning a bluish-gray hue from extreme
loss of fluids.
• Death within 12 hours or less
• Death can occur within 2-3 hours
 CHOLERA SICCA
• Cholera sicca is an old term describing a rare, severe form
of cholera that occurs in epidemic cholera.
• This form of cholera manifests as ileus and abdominal
distention from massive outpouring of fluid and
electrolytes into dilated intestinal loops.
• Mortality is high, with death resulting from toxemia before
the onset of diarrhea and vomiting.
• The mortality in this condition is high.
– Because of the unusual presentation, failure to
recognize the condition as a form of cholera is common.
 WHO IS MOST AT RISK?
Those living near lagoons / low lying areas with fresh/ brackish
water/ fishing populations
With unsafe water sources
With poor faecal disposal practices
With poor personal hygiene
With poor food hygiene (esp. moist food of neutral acidity)
Close to cholera patients in early stages (hyper-infectivity) and
dealing with bodies
 WHEN DOES CHOLERA BECOME
EPIDEMIC?
After heavy period of rainfall
When water temperatures rise
When normal diarrhoeal incidence increases
Endemic cholera with good sanitation needs permanent
source reduction of vibrio, but with poor sanitation there
are higher chances secondary transmission.
 CHOLERA IN CHILDREN

Breast-fed infants are protected.

Symptoms are severe & fever is frequent.

Shock, drowsiness & coma are common.

Hypoglycemia is a recognized complication, which

may lead to convulsions.

Rotavirus infection may give similar picture & need

to be excluded.
 LAB DIAGNOSIS
Organism can be seen in stool by direct microscopy
after gram stain and hanging drop is used to demonstrates
motility.

Cholera can be cultured on special alkaline media

like triple sugar agar.

Serologic tests are available to define strains, but this

is needed only during epidemics to trace the source of
infection.
 OTHER LAB FINDINGS
Dehydration leads to high blood urea & serum
creatinine. Hematocrit & WBC will also be high due to
hemoconcentration.

Dehydration & bicarbonate loss in stool leads to

metabolic acidosis with wide-anion gap.

Total body potassium is depleted, but serum level

may be normal due to effect of acidosis.
 TREATMENT
The primary goal of therapy is to replenish fluid
losses caused by diarrhea & vomiting.

Fluid therapy is accomplished in 2 phases:

rehydration and maintenance.

Rehydration should be completed in 4 hours &

maintenance fluids should replace ongoing losses &
provide daily requirement.
 FLUID THERAPY
Ringer lactate solution is preferred over normal saline
because it corrects the associated metabolic acidosis.

IV fluids should be restricted to patients who purge

>10 ml/kg/h.

The oral route is preferred for maintenance & the use

of ORS at a rate of 500-1000 ml/h is recommended.
 DRUG THERAPY

The goal of drug therapy is to eradicate infection,

reduce morbidity and prevent complications.

The drugs used for adults include tetracycline,

doxycycline, cotrimoxazole & ciprofloxacin.

For children- erythromycin, cotrimoxazole and

furazolidone are the drugs of choice.
 DRUG THERAPY
Drug therapy reduces volume of stool & shortens
period of hospitalization. It is only needed for few days
(3-5 days).

Drug resistance has been described in some areas &

the choice of antibiotic should be guided by the local
resistance patterns .

Antibiotic should be started when cholera is suspected

without waiting for lab confirmation.
 CONTROL AND PREVENTION
 Sterilization: Proper disposal and treatment of infected
fecal waste water produced by cholera victims and all
contaminated materials (e.g. clothing, bedding, etc.) are
essential.

 Sewage: antibacterial treatment of general sewage by

chlorine, ozone, ultraviolet light or other.

 Source: to decontaminate the water (boiling,

chlorination etc.) for possible use.

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 CONT. ..
 Water purification: All water used for drinking, washing,
or cooking should be sterilized by either boiling,
chlorination, ozone water treatment, ultraviolet light
sterilization.

 Surveillance and prompt reporting allow for

containing cholera epidemics rapidly.

 practice of folding a sari (a long fabric garment)

multiple times to create a simple filter for drinking
water.
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 VACCIN
E
A number of safe and effective oral vaccine for cholera are
available.
 Dukoral, inactivated whole cell vaccine, has an overall
efficacy of about 52% during the first year after being
given and 62% in the second year, with minimal side
effects.
 It is available in over 60 countries.
 One injectable vaccine was found to be effective for
two to three years.
 Work is under way to investigate the role of mass
vaccination.
 WHO recommends immunization of high risk groups, such as

37 children and people with HIV, in countries.

 HEALTH EDUCATION

It should be directed mainly to:

Effectiveness and simplicity of rehydration therapy.
Benefits of early reporting for prompt treatment.
Food hygiene practices.
Hand washing after defecation and before eating.
Benefits of cooked hot foods and safe water.
Since cholera is mainly the disease of the poor & ignorant,
these groups should be tackled first.
 DIARRHOEA CONTROL PROGRAM IN
NATIONAL CONTEXT
CONTROL OF DIARRHOEAL DISEASE (CDD)
 the IMNCI programme was expanded up to
community level.
 Although the incidence of diarrhoea has increased
significantly in this fiscal year but the proportion of
severe dehydration cases was decreased at the last year.
 Almost half of the diarrhoeal cases (50%) were treated
by the Female Community Health Volunteers (FCHVs).

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 STRATEGY FOR DIARRHOEA
CONTROL
 Training to all health workers on CB‐IMNCI including
zinc treatment for diarrhoea;
 Nutritional supplementation, enrichment,
nutrition education and Rehabilitation
 Environmental sanitation
 School Health Program
Raise public awareness; and promote specific
prevention measures through communication.
 Increase access to the Zinc tablets through CHW
(FCHVs, VHWs & MCHWs).
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COMMUNITY BASED INTEGRATED MANAGEMENT
OF CHILDHOOD ILLNESS (CB-IMCI) PROGRAM
CB-IMCI programme intensely focuses on
management of Diarrhoeal diseases among the under five
year’s children.

Standard case management of diarrhoea with Oral Rehydration

therapy and Zinc tablet has been provided in the community
level.

All health facilities and community health volunteers at

community level will serve as the primary health care providers
in the treatment of Diarrhoea.

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 PREVENTION AND CONTROL OF
CHOLERA OUTBREAKS: WHO POLICY
AND RECOMMENDATIONS
main tools for cholera control are:
 proper and timely case management in cholera treatment
centres;
 specific training for proper case management, including
avoidance of nosocomial infections;
 sufficient pre-positioned medical supplies for case
management (e.g. diarrhoeal disease kits);
 improved access to water, effective sanitation, proper waste
management and vector control;
 enhanced hygiene and food safety practices;
 improved communication and public information.
RISKY CULTURAL PRACTICES/ BELIEFS
The following beliefs about causes of cholera may reduce
effectiveness of key messages:
 Witchcraft, evils eye, wind, climatic change cause the sickness
 Children’s stools are not dangerous
 Soap is believed to wash away luck

The following practices increase risks

 Anal washing is often not followed by hand-washing
 Handshaking transfers bacteria directly from one person to the
next
 Burial ceremonies may spread disease
 KEY MESSAGE
•Cholera is an acute diarrhoeal disease that can kill
within hours if left untreated
•There are 100 000–120 000 deaths due to cholera every
year of which only a small proportion are reported to WHO
•Up to 80% of cases can be successfully treated with
oral rehydration salts (ORS)
•About 75% of people infected with Vibrio cholerae O1
or O139 do not develop any symptoms
•Typical at-risk areas of cholera include peri-urban slums
with limited access to safe drinking water and lack of
proper sanitation
 KEY MESSAGE

•Surveillance is paramount to identify vulnerable

populations living in hotspots
•Cholera is a preventable disease provided that safe water
and proper sanitation are made available
•Safe and effective oral cholera vaccines are now part of
the cholera control package
•Today, no country requires proof of cholera vaccination
as a condition for entry