1. General Cholera Case Management

2. Case management of cholera cases in health care settings Case Definition Acute watery diarrhea 3x per day ( often like rice water) with or without vomiting with or without severe dehydration Any patient with acute watery diarrhea must go to the nearest health facility as soon as possible

3. Cholera. Early rehydration treatment could save more than 95 % of patients if it is implemented very quickly and follows recommended protocols Contamination of health care workers is rare if they follow the recommended hygiene and disinfection measures.

4. TOILETS / LATRINE Hospitalisation IV ORS Observation Triage Entrance Patients + relatives Mortuary Exit Corpses Exit Set up of a cholera treatment centre Patient flow ORS Convalescence stock / clean zone Patient flow Exit Fence

5. TOILETS / LATRINE Hospitalisation IV ORS Observation D Triage H Entrance Patients + relatives Morgue Exit G Corpses H D Exit D G H Washing hand point Foot Désinfection Garbage Set up of a cholera treatment centre ORS Convalescence D D O ORS O O O Stock / clean area H O H Patient flow Exit Fence D H S S S Sprayer

6. To give the right rehydration Protocol A, B, or C receive assess orient TRIAGE 1. Objectives The patient Check in =

7. LOOK AT: 1.CONDITION 2.EYES 3.MOUTH & TONGUE 4.THIRST FEEL: 1. SKIN PITCH Plan A No dehydration  Well, Normal  Normal  Moist tongue  Drinks normally, not thirsty  Skin pinch goes back quickly Plan B Some dehydration  Restless, irritable  Sunken eyes  Dry tongue  Thirsty, drinks eagerly  Skin pinch goes back slowly Plan C Severe dehydration Lethargic or unconscious  Very sunken and dry  Very dry  Drinks poorly or is not able to drink  Skin pinch goes back very slowly 2. Assess the dehydration level Triage

8. Quickly send the patient to the right area Triage 3. Protocol ORS- Observation OR IV - Hospitalisation E Plan A or BPlan C

9. Triage 4. Fill the register

10. PLAN A No dehydration

11. TOILETS / LATRINE Hospitalisation IV ORS Observation Triage Entrance Patients + relatives Mortuary Exit Corpses Exit Plan A : ORS Convalescence stock / clean zone Patient flow Exit 1.Place the patient in Observation Room H O D D D D S S O ORS H Washing hand point D Foot Désinfection H O H

12. Plan A :  Ask the relative to give to the patient : 2.Rehydrate with Oral Rehydration Solution (ORS) © Ralph Penel  As many glasses as he can drink,  plus one glass after each stool

13. Plan A 3. Check on regular basis all the following signs Observations for Plan A Start time : Frequency Observation at admission 30 min1h2h3h Pulse G (good) W (weak) A (Absent0 General condition W (well) L (lethargic) or U (unconscious) Skin pitch N (normal) S (slow) VS( very slow) Diarrhea (Number of stools or volume in liters) Vomiting (Number of episodes or volume in liters) ORS Number of glasses taken New signs

14. Plan A : → How to prepare ORS at home → Quantities of ORS he must drink during the two following days.  For a child <2 years: 500 ml/ day =1/2 sachet / d (total of 2 sachets for 2-day period)  For a child 2 to 10 years old:1 liter / day ( 2 sachets)  For an adult: 2 liters / day, (4 sachets) 4. If the patient feels better after 1 or 2 hours and does not vomit he can be discharged with the following advice 5.If the patient status is worsening ( vomiting or first dehydration symptoms)  Keep him in observation room  Start Plan B

15. PLAN B Some dehydration

16. TOILETS / LATRINE Hospitalisation IV ORS Observation Triage Entrance Patients + relatives Mortuary Exit Corpses Exit Plan B : ORS Convalescence stock / clean zone Patient flow Exit 1.Place the patient in Observation Room H O D D D D S S O ORS H Washing hand point D Foot Désinfection H O H

17. Plan B :  Help the patient to drink ORS  If the patient vomits: give ORS in small quantities but very often (wait 10 min after each vomit and give ORS again) © Ralph Penel 2.Rehydrate with Oral Rehydration Solution (ORS)

18. Plan B 3.Check on regular basis all the following signs during six hours Observations for Plan B Start time : Frequency Observation at admission 30 min1h2h3h4h5h6h Pulse G (good) W (weak) A (Absent0 General condition W (well) L (lethargic) or U (unconscious) Skin pitch N (normal) S (slow) VS (very slow) Diarrhoea (Number of stools or volume in liters) Vomiting (Number of episodes or volume in liters) ORS number of glasses taken New signs

19. Plan B : 4. If the patient feels better after 5 or 6 hours and does not vomit he can be discharged with the following advices 5.If the patient status is worsening (vomiting and first dehydration symptoms) → Send him quickly in hospitalization room → Start Plan C → How to prepare ORS at home → Quantities of ORS he must drink during the two following days.  For a child <2 years: 500 ml/ day =1/2 sachet / d (total of 2 sachets for 2-day period)  For a child 2 to 10 years old:1 liter / day ( 2 sachets)  For an adult: 2 liters / day, (4 sachets)

20. PLAN C Severe Dehydration

21. TOILETS / LATRINE ORS Observation Triage Entrance Exit Morgue Exit Plan C stock E 1.Place the patient in hospitalization room ORS Convalescence Hospitalisation IV O ORS H Washing hand point D Foot Désinfection D D D D s Sprayer s s H H H H O O

22. Plan C: 2.Fill the patient form « observation at admission »and then every 15 minutes  But start immediately the IV rehydration It is extremely important to keep a written record of fluid loss and intake in order to adjust the administration of fluids to patients Observations for Plan C Start time : Frequency Observatio n at admission 15 min 30 min 45 min 60 min 75 min90 min 105 min Pulse G (good) W (weak) A (Absent0 General condition W (well) L (lethargic) or U (unconscious) Skin pitch N (normal) S (slow) VS (very slow) Diarrhoea (Number of stools or volume in liters) Vomiting (Number of episodes or volume in liters) ORS (number of glasses taken) IV infusion (number of liters)

23.  using lactated Ringer’s solution  Following the above rules :  Phase 1 : maximum flow. If needed, use two IV lines Plan C : 3. Rehydrate RAPIDLY with IV fluids during the first hour: Plan C :1) Ringer Lactate Age and WeigthPhase 1EvaluatePhase 2total liters in 12 hours Less than 1 year 30ml / kg in One hourIs Pulse palpable?70ml / kg in 3 hours 500ml to 1L according to the weight 1 - 10 years 30 ml / kg in 30 min YES: Go to phase 2 70 ml / kg in 2hours 30 min 1 to 5 liters according to the weight less than 50 kg1 liter in 15 min 1 liter in 45 min then 2 litres in 2 or 3 hours6 to 8 liters More than 50 kg1 liter in 15 min NO return to phase 1 1 liter in 45 min then 3 liters in 2 or 3 hours8 to 10 liters ( Never use glucose solution )

24.  If the pulse is better go to phase 2.  If no improvement restart phase 1 Plan C : 4. Evaluate the vital signs at the end of the phase 1 Plan C :1) Ringer Lactate Age and WeigthPhase 1EvaluatePhase 2total liters in 12 hours Less than 1 year30ml / kg in One hour Is the Pulse palpable?70ml / kg in 3 hours 500ml to 1L according to the weight 1 - 10 years30 ml / kg in 30 min YES : Go to phase 2 70 ml / kg in 2hours 30 min 1 to 5 liters according to the weight less than 50 kg1 liter in 15 min 1 liter in 45 min then 2 liters in 2 or 3 hours6 to 8 liters More than 50 kg1 liter in 15 min NO return to phase 1 1 liter in 45 min then 3 liters in 2 or 3 hours8 to 10 liters

25. Plan C : 5. If the patient is better, start phase 2:  Reduce the flow of the IV fluids  First for the next 45 minutes  Then for the 2 or 3 following hours Plan C :1) Ringer Lactate Age and WeigthPhase 1EvaluatePhase 2total liters in 12 hours Less than 1 year30ml / kg in One hour Is the Pulse better?70ml / kg in 3 hours 500ml to 1L according to the weight 1 - 10 years30 ml / kg in 30 min YES : Go to phase 2 70 ml / kg in 2hours 30 min 1 to 5 liters according to the weight less than 50 kg1 liter in 15 min 1 liter in 45 min then 2 liters in 2 or 3 hours6 to 8 liters More than 50 kg1 liter in 15 min NO return to phase 1 1 liter in 45 min then 3 liters in 2 or 3 hours8 to 10 liters

26. Plan C :  Continue until the patient urinates normally : approximate total amount of Ringer :  For children; from 500 ml to 4.5 liters depending on age  For adults : a mean of 6 to 10 liters.  Add oral rehydration by ORS  As soon as the patient can drink,  Give at will  After a few hours in observation, the infusion could be stopped 6. Continue the rehydration by Ringer’s Lactate:

27. Plan C :  Give Antibiotics when they can drink following this protocol 7. For the severe cases NB : These recommendations are subject to review as the sensitivity of the pathogen changes

28. Plan C : 8. Transfer the patient to the ORS convalescence area  Continue with oral rehydration  Giving a mean of  6 to 10 additional liters for adults and  3 liters for children,  In a period of 2 days

29. Plan C : 9. Discharge the patient with the following advice → How to prepare ORS at home → Quantities of ORS he must drink during the two following days.  For a child <2 years: 500 ml/ day =1/2 sachet / d (total of 2 sachets for 2-day period)  For a child 2 to 10 years old:1 liter / day ( 2 sachets)  For an adult: 2 liters / day, (4 sachets)

30. 1. Severely Malnourished children:  They must be rehydrated but more slowly than other children (half the quantity per hour)  Give preference to oral rehydration if they can drink  Use IV only if they cannot drink: divide by half the amount of Ringer’s solution  Phase 1: 15 ml / kg in 1st hour  Phase 2: 30 ml / kg in next three hours Particular Cases 2. Children under 5 years: WHO recommends giving zinc sulfate for 10 days if the tablets are available 10 mg zinc / day for children < 5 months old 20 mg zinc / day for children 6 - 59 months old

31. 3. Complications :  rare, < 1%  But must be detected and quickly treated  Hypoglycemia  First, give ORS, then if necessary 1ml / kg glucose 50% in slow IV  Acute pulmonary edema  (cough, dyspnea, spluttering)  Seat the patient, slow down the IV and give Furosemide IV ( Adult 40mg, Child 1mg /kg)  Anuria > 6 - 7 hours after starting the rehydration renal failure could occur  Hypokaliemia (painful cramps after 24h of rehydration) First : give ORS, If it persists, give 1g of potassium (KCl) Particular cases

32. PROTECTION OF STAFF IN CTUs  Personal Protective Equipment is required : Non-sterile gown to cover clothes Non-sterile gloves If possible a plastic apron in hospitalization IV room to protect staff from vomiting and diarrhea  For the staff in charge of disinfection during the preparation of chlorine solutions : Masksbootsplastic apron latex glovesprotective glasses

33.  CHOLERA DEHYDRATES VERY QUICKLY Do not worry about giving too much or too quickly during the first hours  CHOLERA TREATMENT UNIT MUST BE A CLOSED PLACE No one and nothing should go in or out without chlorine spraying

34. Thank you