1Dr. Malik Muhammad Abdul Razzaq. Assistant Professor Department of Community Medicine Sheikh Zayed Medical College Rahim Yar Khan 2Dr. Malik Muhammad

1Dr. Malik Muhammad Abdul Razzaq

Dr. Malik Muhammad Abdul RazzaqAssistant Professor

Department of Community Medicine Sheikh Zayed Medical College Rahim Yar Khan



Cholera is an acute diarrhoeal disease caused by V. Cholerae 01 (classical or El Tor). It is now commonly due to the El Tor biotype. Cases range from symptom-less to severe infections. The majority of infections are mild or asymptomatic. Typical cases are characterized by the sudden onset of profuse, effortless, watery diarrhea followed by vomiting, rapid dehydration


Cholera occurs at intervals even in endemic areas.

Three explanations are offered (a) the existence of long-term carriers (b) the existence of diminished but

continuous transmission involving asymptomatic cases

(c) the persistence of the organism in a free-living, perhaps altered form in the environment.


Epidemics of cholera are frequent, striking adults as well as children.

Epidemiological studies have shown that cholera is responsible for about 5-10 per cent of all acute diarrhea cases in non epidemic situation.

It creates problem only in areas where other acute enteric infections are endemic, i.e. where sanitation is defective


Cholera is both an epidemic and endemic disease. Epidemics of cholera are characteristically abrupt and often create an acute public health problem.

They have a high potential to spread fast and cause deaths. The epidemic reaches a peak and subsides gradually as the "force of infection" declines.

The "force of infection" is composed of 2 components namely the force of infection through water and the force of infection through contacts


(a) AGENT : The organism that causes cholera is labelled as V. cholerae O Group 1 or Vibrio cholerae 01

The El Tor biotype of V. Cholerae 01 has rapidly replaced the classical biotype in all parts of the country. Most of the El Tor biotype isolated today belong to the serotype Ogawa

Incubation period From a few hours up to 5 days, but commonly 1 -

2 days


Contaminated Water&Food: It can be a source of infection. After preparation, cooked food may be

contaminated through contaminated hands and flies.

Person to person transmission: It happens through contaminated fingers

while carelessly handling excreta and vomit of patients and contaminated linen and fomites


The vibrio becomes adherent to the mucosa, it produces enterotoxin which consists of 2 parts - the light or L toxin and the heavy or H toxin. The L toxin combines with substances in the epithelial cell membrane called gangliosides and this binds the vibrio to the cell wall.

There is no evidence that V. cholerae invades any tissue, nor the enterotoxin to have any direct effect on any organ other than the small intestine


A typical case of cholera shows 3 stages : (a) STAGE OF EVACUATION (b) STAGE OF COLLAPSE (c) STAGE OF RECOVERY

STAGE OF EVACUATION: The onset is abrupt with profuse, painless,

watery diarrhea followed by vomiting. The patient may pass as many as 40 stools in a day. The stools may have a "rice water" appearance. Patient soon passes into stage of sever dehydration


The classical signs are : sunken eyes, hollow cheeks, scaphoid

abdomen, sub-normal temperature, washer man's hands and feet, absent pulse, un-recordable blood pressure, loss of skin elasticity, shallow and quick respirations. The output of urine decreases and may ultimately cease.


The patient becomes restless, and complains of intense thirst and cramps in legs and abdomen. Death may occur at this stage, due to dehydration and acidosis resulting from diarrhoea.

STAGE OF RECOVERY : With prompt diagnosis and management ,

the patient begins to show signs of clinical improvement


Stool Specimen Collection: A fresh specimen of stool should be collected for laboratory examination.

WATER : Samples containing 1-3 liters of

suspected water should be collected in sterile bottles or 9 volumes of the sample water added to 1 volume of 10 per cent peptone water, and dispatched to the laboratory by the quickest method of transport.


Samples of food suspected to be contaminated with V. choler (or other enteric bacteria) amounting to 1 to 3 g are collected in transport media and sent to the laboratory.

TRANSPORTATION The stools should be transported in sterilized

McCartney bottles, 30 ml capacity containing alkaline peptone water or VR medium.

Gram stain and motility : Gram negative and curved rods with characteristic scintillating type of movement in hanging drop preparations are very characteristic of V. cholerae

(ii) Serological test: Slide agglutination test is done by picking up suspected colonies


1. Verification of the diagnosis 2. Notification 3. Early case finding 4. Establishment of Treatment Centers 5. Re-hydration therapy


Oral fluid therapy is based on the observation that glucose given orally enhances the intestinal absorption of salt and water, and is capable of correcting the electrolyte and water deficit. The composition of oral re-hydration fluids is recommended by WHO


Ingredient Quantity

Sodium chloride 3.5g

Sodium bicarbonate 2.5 g

Potassium chloride 1.5g

Glucose (dextrose) 20.0 g

Potable water 1 liter


(1) Patient's appearance

(2) Radial pulse

(3) Blood pressure

(4) Skin elasticity

(5) Tongue

(6) Ant. Fontanelle

(7) Urine Flow

(8) % body weight loss Estimated fluid deficit

Mild Dehydration

Thirsty; alert, restless

Normal rate and volume

Normal

Pinch retracts immediately

Moist

Normal

Normal

4-5% 40-50 ml/kg

Sever Dehydration

Drowsy; limp, cold, sweaty; may be comatose

Rapid, feeble,sometimes

Impalpable

Less than 80mmHg

Pinch retracts very slowly (more than 2 seconds)

Very dry

Very sunken

Little or none

10% or more

100-110 ml/kg


The solutions recommended by WHO for intravenous infusion are:

(a) Ringer's lactate solution (also called Hartmann's solution for injection) : It supplies adequate concentrations of sodium , potassium and the lactate yields bicarbonate for correction of the acidosis.

(b) Diarrhoea Treatment Solution (DTS): It contains in one liter, sodium chloride 4 g, sodium acetate 6.5 g, potassium chloride 1 g, and glucose 10 g


Amount of diarrhoea

Mild diarrhoea

(not more than one stool every 2 hours or longer or less than 5 ml stool per kg

Severe diarrhoea (more than one stool every 2 hours, or more than 5 ml of stool per kg per hour)

Amount of oralfluid

100 ml/kg body weight per day until diarrhoea stops

Replace stool losses volume for volume .If not measurable give 10-15 ml/kg body weight per hour 21Dr. Malik Muhammad Abdul Razzaq

Antibiotics

Doxycycline once

Tetracycline

4 times a day for 3 days

Trimethroprim(TMP Sulfamethoxazole (SMX) twice a day for 3 days

Furazolidone

4 times a day for 3 days

Children

----

12.5mg/kg

TMP 5 mg/kg and SMX 25 mg/kg

1.25 mg/kg

Adults

300 "mg“

500 mg

TMP 160 mg SMX 800 mg

100 mg22Dr. Malik Muhammad Abdul Razzaq

CONTROL of WATER Contamination EXCRETA DISPOSAL FOOD SANITATION DISINFECTION


Tetracycline is the drug of choice for chemoprophylaxis. It has to be given over a 3-day period in a twice-daily dose of 500 mg for adults, 125 mg for children aged 4-13 years, and 50 mg for children aged 0-3 years.

Alternatively, the long-acting tetracycline (doxycycline) may be used for chemoprophylaxis


Parenteral vaccine Primary immunization consists of 2 equal doses,

injected subcutaneously, at an interval of 4 to 6 weeks.

The dosage is as follows : 1st Dose 2nd

Dose Adults and children 0.5 ml 0.5 ml over 10 years Children aged 2-10 years 0.3ml 0.3ml

Children aged 1 -2 years 0.2 ml 0.2 ml


The protective value of currently available vaccines is estimated to be about 50 per cent for a period of 3-6 months.

Increasing the antigenic content did not improve the effectiveness of the vaccine.

Oral vaccine Two types of oral cholera vaccines are

available, killed whole cell V.cholerae and live attenuated CVD103


The most effective prophylactic measure is perhaps health education. It should be directed mainly to

(a) the effectiveness and simplicity of oral re-hydration therapy

(b) the benefits of early reporting for prompt treatment.

(c) food hygiene practices (d) hand washing after defecation and

before eating, (e) the benefit of cooked, hot foods and

safe water.


Diarrhoeal Diseases


Diarrhoea : It is defined as the passage of loose, liquid or watery stools. These liquid stools are usually passed more than three times a day

Acute Diarrhoea: WHO/UNICEF define "" as an attack of sudden onset, which usually lasts 3 to 7 days, but may last up to 10-14 days . The term "gastroenteritis" is most frequently used to describe acute diarrhoea.

Chronic Diarrhoea :Diarrheas lasting 3 weeks or more may be called chronic .


Diarrhoea is a major public health problem in developing countries. An estimated 1.8 billion episodes of diarrhoea occur each year and 3 million children under the age of 5 years die of diarrhea

When the WHO initiated the Diarrhoeal Diseases Control Programme in 1980, approximately 4.6 million children were dying each year of the dehydration caused by diarrhea


Infections causing diarrhoea 1. Viruses : 2. Bacteria : Campylobacter jejuni Escherichia coli Shigella Salmonella Vibrio cholerae Vibrio parahaemolyticus Bacillus cereus 3. Others E. histolytica Giardia intestinalis Trichuriasis

Cryptosporidium SPP intestinal worms


A great many diarrhoeal diseases are caused by viruses

Rotaviruses Astroviruses Adenoviruses Calciviruses Coronaviruses Norwalk group viruses Enteroviruses


Amoebiasis, giardiasis and other intestinal parasitic infections are associated with diarrhea. Besides the above causes, malnutrition may lead to certain nutritional diseases such as kwashiorkor, sprue, coeliac disease and pellagra which are all associated with diarrhoea


For some enteric pathogens, man is the principal reservoir and thus most transmission originates from human factors.

Diarrhoea is most common in children especially those between 6 months and 2 years. Incidence is highest in the age group 6-11 months, when weaning occurs


Distinct seasonal patterns of diarrhoea occur in many geographical areas. Bacterial diarrhoea occur more frequently during the warm season, whereas viral diarrhoea, particularly diarrhoea caused by rotavirus peak during the winter


Faecal-oral transmission: It may be water-borne; food-borne, or direct

transmission which implies an array of other faecal-oral routes such as via fingers, or fomites, or dirt which may be ingested by young children


Components of a Diarrhoeal Diseases Control Programme :

The intervention measures recommended by WHO may be classified as below :

1. Short term : a. Appropriate clinical management 2. Long-term : b. Better MCH care practices c. Preventive strategies d. Preventing diarrhoeal epidemics


SANITATION (ii) HEALTH EDUCATION IMMUNIZATION : Immunization against

measles is potential intervention for diarrhoea control.

FLY CONTROL : Flies breeding in association wit human or animal faeces should be controlled.

Hand washing-program-decreases-incidence-of-diarrhea



Documents

1Dr. Malik Muhammad Abdul Razzaq. Assistant Professor Department of Community Medicine Sheikh Zayed Medical College Rahim Yar Khan 2Dr. Malik Muhammad