What are the potential causes? October 24 2010 Doctor reports 4 cases of acute watery diarrhoea with severe dehydration in last 24 hours Gradual increase in admissions with watery diarrhoea in last 5 days Abrupt onset profuse watery diarrhoea with vomiting and fever Is this an outbreak? What are the potential causes?

October 25 Health cluster meeting: 2 other districts report 40 deaths form diarrhoea since 20 October Case definition? How will you confirm cause of the outbreak? What outbreak control measures are needed?

What outbreak control measures are needed? Case management Logistics Infection Prevention and Control Health education

Case management

Case management Cholera treatment centre Cholera cots – plastic sheeting – buckets Fluids Treatment: Oral IV Antibiotics Train health workers

Logistics Supplies IV fluids Giving sets Specimen containers

Infection Prevention and Control Soap and water Handwashing stations Chlorination of piped and tankered water Latrines

Health education Handwashing Safe food Safe water Funerals

a high case fatality rate? 8 November 9971 cases reported 643 deaths Actual number of cases could be much higher Why is there such a high case fatality rate?

High Case Fatality Rate Lack of knowledge: public, healthcare staff Delays in accessing health care Large numbers of cases High infective dose with rapid onset Poorly trained staff Inappropriate treatment Poor triage mechanisms Lack of supplies

What are the potential sources? Importation from cholera endemic area International staff Imported food: ?seafood

UN military base Battalion of Nepalese soldiers arrived early October Raw sewage discharged to river Water used downstream for cooking, drinking, bathing 90% of cases in first 5 days along bank of river No reported cases among UN military

Kathmandu 23 September 2010: Cholera outbreak reported DNA fingerprinting and genotyping

Spread to Dominican Republic, USA, Mexico, Venezuela, Cuba