1. Training on Management of Cholera - Short Course
November, 2010
Departments, Haiti
Good Morning/Afternoon
U.S. Department of Health and Human Services
Centers for Disease Control and Prevention

2. Vibrio cholerae O1
Cholera is an intestinal infection caused by Vibrio cholerae O1 and related strains. This bacterium is a gram-negative, curved rod with a single polar flagellum that makes it highly mobile. This slide shows three Vibrios, stained with a flagellar stain.

3. Cholera – The Epidemic Microorganism
Vibrio cholerae
O1/O139
Epidemic Strains
Toxigenic
There are many different strains within the species Vibrio cholerae, represented on this slide by the large circle. Many of these can cause illness, but only a subset have caused epidemic cholera. Some strains have the O antigen 1, and some strains produce cholera toxin. It is strains that are both O1 and toxigenic that produce epidemic cholera. Recently, a related strain with the O antigen 139 caused epidemics of cholera in Asia.

4. Clinical Presentation
Dehydrating diarrheal illness with loss of fluid and electrolytes
Severe or moderate case
Profuse watery diarrhea
Vomiting
Leg cramps (hypokalemia)
Symptoms range from asymptomatic infection through mild diarrhea, to severe hypovolemic shock
Cholera is a dehydrating diarrheal illness. The symptoms and signs are caused by rapid and profound loss of fluid and electrolytes in watery diarrhea and vomitus. The severe or moderate case presents with profuse watery diarrhea leading to dehydration and electrolyte loss, vomiting because of acidosis, and leg cramps because of hypokalemia. Infection with V. cholerae O1 is associated with a range of clinical symptoms, from asymptomatic infection to mild diarrhea, to severe diarrhea with hypovolemic shock. Severe diarrhea can be nearly continuous and can exceed 1 liter per hour. In severe cases, the diarrhea has the appearance of “rice water stool” as shown in this picture.

5. Electrolyte Composition of Cholera Stools and of Fluids Recommended for Treatment of Cholera, in mmol/L
NA+ K+
Cl -
Base*
Glucose
Cholera stools
135 15
105 45
WHO ORS 90 20 80 10
111
Ringers lactate
130 4
109 28
Normal saline
154
This slide shows the electrolyte composition of cholera stools and treatment solutions. Cholera stools have an electrolyte composition similar to that of hyperkalemic plasma, and they are isotonic with plasma. The optimum replacement solutions provide sodium, potassium, chloride, and base, whether it is WHO oral rehydration salts (ORS) or Ringers lactate. Cholera stools from children may contain more potassium and proportionately less sodium and bicarbonate. This makes ORS therapy, alone or as a supplement to initial intravenous therapy, particularly important for children.

6. Spectrum of Illness in Persons Infected with Vibrio cholerae O1, Biotype El Tor
Infection with toxigenic V. cholerae O1 has a wide clinical spectrum. 75% of persons with infections are asymptomatic, and most of the 25% with symptomatic infections have mild illness. Approximately 2% of those infected will have severe cholera, or "cholera gravis", which is often fatal without treatment, and another 5% will have moderate illness that brings them to medical attention, but does not require hospitalization. Persons most likely to have severe infection are those who ingest a high dose of organisms, those whose gastric acid production has been diminished by gastrectomy or antacid therapy, and those who have blood group O. It is not known why blood group O is a risk factor.

7. Moderate Dehydration Loss of 5-10% of body weight
Normal blood pressure
Normal or rapid pulse
Restless, irritable
Sunken eyes
Dry mouth and tongue
Increased thirst, drinks eagerly
Skin goes back slowly after skin pinch
An infant: decreased tears, depressed fontanel
Patients with moderate dehydration have lost 5-10% of their body weight in diarrhea; that is liters for a 70 kg person, a gallon or more of fluid. The blood pressure is normal, and the pulse is normal or rapid. The patient feels restless and irritable. The patient has sunken eyes, a dry mouth and tongue. The patient is thirsty and will drink fluids eagerly. The skin goes back slowly after a fold is pinched up. An infant will have decreased tears and a depressed fontanel.

8. Severe Dehydration Loss of >10% of body weight Hypovolemic shock
Low blood pressure
Rapid, weak or undetectable peripheral pulse
Minimal or no urine
Skin has lost normal turgor (“tenting”)
Mouth and tongue are very dry
Sunken eyes
Mental status is dulled
Cholera patients with severe dehydration have typically lost 10% or more of their body weight in diarrhea and vomitus. They are in hypovolemic shock, with low blood pressure, and rapid, weak or undetectable peripheral pulses. Their skin has lost its turgor, and flattens very slowly after a fold of loose skin is pinched up; this is called "tenting" of the skin. Their mouth and tongue are dry, unless they have just vomited, their eyes are sunken, and their thinking may be dulled. This is a medical emergency.

9. This child has severe dehydration as shown by the sunken eyes, scaphoid abdomen and poor skin turgor, and tenting.

10. Treatment According to Dehydration Status
Maintain hydration
Oral rehydration
IV and oral rehydration
ASSESS
No dehydration
Moderate dehydration
Severe dehydration
EXAMINE
Well, alert
Sunken eyes: No
Drinks normally
Skin pinch goes back quickly
Restless, irritable
Sunken eyes: Yes
Thirsty, drinks eagerly
Skin pinch goes back slowly
Lethargic or unconscious
Not able to drink
Skin pinch goes back very slowly
Dehydration status determines treatment
Examine the patient: mental status, do they have sunken eyes, can they drink, and test skin turgor with a pinch, to assess quickly what
their dehydration status is.
Assess the patient: are they not dehydrated, moderately dehydrated, or severely dehydrated?
Treat the patient accordingly, which we will now go over in detail

11. Rehydration Therapy Can reduce mortality to less than 1% Oral therapy:
Oral rehydration salts (ORS) are recommended
80-90% of patients can be treated with ORS
Patients requiring IV can soon switch to ORS
Intravenous therapy:
Ringers lactate is the recommended IV fluid
Normal or ½ normal saline are less effective, but can be used
D5W is ineffective, and should not be used
Successful treatment of cholera depends on rapid replacement of fluid and electrolyte losses. Before discovery of rehydration therapy, 30-50% of patients with typical severe cholera died; now, with proper treatment, mortality is 1% or less. Fluids and electrolytes can be replaced rapidly through either oral or intravenous routes. The oral route is possible because bowel epithelial cells will absorb fluid and electrolytes when presented with sugar or other carbohydrates, even in the face of active secretion. The optimum mix of electrolytes and sugar for oral treatment of cholera and other secretory diarrheas is called oral rehydration solution (ORS). Most cholera patients can be treated with ORS alone, and even those who require intravenous therapy initially can soon be switched to ORS. Administration of ORS via nasogastric tube can correct even profound volume depletion successfully.
Rapid intravenous therapy is required for patients who are in profound shock or cannot drink. The recommended solution is Ringers lactate, which contains both potassium and base. If no Ringers is available, acute volume replacement with normal or half normal saline may be attempted, but such therapy does not correct acidosis or hypokalemia, and may even worsen the electrolyte imbalance unless it is supplemented with sufficient bicarbonate and potassium. 5% dextrose is ineffective and should not be used.

12. ORS is provided in inexpensive foil packets that are stable for many months at room temperature. Each packet is mixed in a liter of clean water, and given to the patient to drink.

13. The cholera patient should be encouraged to drink ORS
The cholera patient should be encouraged to drink ORS. Even patients who are vomiting can often be treated orally if they take small frequent sips. The vomiting will subside when the acidosis is corrected.

14. Oral Rehydration Therapy
Replace estimated losses at 100cc/5 min
Replace ongoing losses plus 1 liter water daily
Reassess every 1-2 hours
May need > 5 liters: Give it!
Oral rehydration therapy must be vigorous. It is helpful to weigh the patient to estimate fluid needs. The lost volume may be 5 to 10 liters in a patient with severe cholera. These losses should be replaced at the rate of 100 cc per 5 minutes. In addition, ongoing losses should be measured and replaced with equal volumes of ORS, and the patient should be given additional water to drink. The patient's volume status should be reassessed every 1-2 hours. Be ready to give 5 liters or more acutely.

15. Treatment When There is No Dehydration
Age
< 24 months
2 to 9 years
≥ 10 years
Amount of ORS after each loose stool
100 ml
200 ml
As much as wanted
ORS quantity needed
~ 500 ml/day
(1 sachet)*
~ 1000 ml/day
~ 2000 ml/day
(2 sachets)*
Patients who have no dehydration should receive ORS after each loose stool to maintain hydration until diarrhea ceases.

16. Treatment of Moderate Dehydration
Provide ORS immediately, according to weight and age (see handout)
Monitor every hour for first 2 hours
Fluid input:
Ensure adequate intake of ORS
Count number of cups drunk
Re-administer 10 minutes after patient vomits
Fluid output:
Number and nature of stools
Vomitus
Reassess hydration status after 4 hours and treat accordingly (no, moderate, severe)
Can administer ORS by nasogastric tube
For a patient with moderate dehydration, start giving ORS immediately, according to weight and age. Monitor them every hour for two hours and encourage adequate intake of ORS. Record how much they drink, and give them additional ORS if they vomit. Also record the number and nature of stools and vomitus. Reassess hydration status after 4 hours and treat accordingly as to whether they have no moderate, or severe dehydration.
The ORS can be administered via a carefully placed nasogastric tube.

17. Treatment of Severe Dehydration
Give intravenous (IV) fluid rapidly until blood pressure normal (3-6 hours)
Hang infusion bag high
Use 2 intravenous lines if necessary
For adults, give a liter in the first 15 minutes
Remember, Ringers lactate solution is the best option
Use a new IV set for every patient
Give ORS if patient can drink
Only if conscious
Do not use oral or nasogastric route if severely hypovolemic or unconscious
IV treatment must be given quickly to restore normal blood pressure within 3 to 6 hours. Hang the infusion bag as high as possible to facilitate rapid flow. Use 2 intravenous lines if necessary. For adults, give a liter in the first 15 minutes. Ringers lactate solution is the best option. Use a new IV set for every patient.
If the patient can drink, give ORS by mouth while the drip is set up. Start ORS only if patient is conscious. Oral or nasogastric route should not be used in patients severely hypovolemic or unconscious.

18. Intravenous (IV) Rehydration Therapy of Severe Dehydration
Give IV fluid rapidly until blood pressure normal
First 30 mins:
30 ml/kg
Next 2.5 hours:
70 ml/kg
> 1 year old
First 60 mins:
Next 5 hours:
≤ 1 year old
Intravenous treatment should be given rapidly through large bore catheters. Initial replacement should be given swiftly until blood pressure is normal; several liters may be required acutely.
For persons more than 1 year old: 30 milliliters per kilogram in first 30 min., then 70 milliliters per kilogram in 2.5 hours.
For persons less than 1 year old: 30 milliliters per kilogram in first hour, then 70 milliliters per kilogram in the next 5 hours. 200 milliliters per kilogram or more may be needed in the first 24 hours.
200 ml/kg or more may be needed in first 24 hours

19. Intravenous Rehydration Therapy
Monitor pulse and stay with patient until strong radial pulse
Reassess hydration status at 30 minutes, then every 1-2 hours until rehydration is complete
Check for rapid respiratory rate, a sign of possible overhydration
Add oral solution as soon as possible
Discontinue and remove IV when patient is stable and drinking ORS
Monitor pulse and stay with patient until you feel a strong radial pulse. Reassess rehydration status at 30 minutes, and then every 1-2 hours until volume replacement is complete. Check for rapid respiratory rate, which is a sign of possible overhydration. As soon as the patient can drink, he or she should be encouraged to take ORS. When oral intake matches ongoing losses, and the patient's hemodynamics are stable, the intravenous line can be discontinued and removed.

20. IV Rehydration: Fluid Management
Input
Record liters of IV fluids and cups of ORS administered
Mark quantity per hour on each bag
Ensure cup and ORS are within reach
ORS consumption is easier sitting up, if able
Output
Record volume and nature of stool
Record presence of urine
Input
Record liters of IV fluids and cups of ORS administered. Mark quantity per hour on each bag. Ensure cup and ORS are within reach. ORS consumption is easier sitting up, if able
Output
Record volume and nature of stool. Record presence of urine.

21. Signs of Adequate Rehydration
Skin goes back normally when pinched
Thirst has subsided
Urine has been passed
Pulse is strong
The patient is adequately rehydrated, when the skin goes back normally when pinched, thirst has subsided, urine has been passed, and the pulse is strong.

22. Antimicrobial Therapy
Antimicrobial therapy reduces
Fluid losses
Duration of illness
Duration of carriage
Recommended for severe cases
Resistance pattern can change over time
Not recommended for prophylaxis
Antimicrobial therapy is helpful, though not required, in the treatment of cholera. Antimicrobials reduce the total volume of fluid lost, and shorten the duration of illness and the duration of carriage of Vibrio cholerae bacteria in the feces.
It is recommended for treatment of severe diarrheal cases to reduce duration and severity. The resistance pattern can change over time. Antimicrobial therapy is not generally recommended for prophylaxis because of the risk of developing antimicrobial resistance.

23. Zinc Supplementation in Children
Reduces the severity and duration of most childhood diarrhea caused by infection
Reduces severity and duration of cholera in children by ~10%
Zinc supplementation (10-20 mg zinc by mouth per day) should be started immediately, if available
Zinc supplementation is recommended for children as zinc reduces the severity and duration of most childhood diarrhea caused by infection. It has also been shown to reduce the duration and severity of cholera by about 10%. The recommended dose is mg of zinc by mouth per day, and this should be started immediately for all children, if available, and continued until diarrhea ceases.

24. Summary of Treatment No dehydration Moderate dehydration
ORS to maintain hydration
Moderate dehydration
ORS to replace losses
Severe dehydration
IV Fluids (Ringers lactate)
Switch to ORS when tolerated
Antibiotics
Monitor for treatment complications
Zinc supplementation
All children with diarrhea
So to summarize, cases with no dehydration need ORS to maintain their adequate hydration status. Cases with moderate hydration need ORS to replace fluid losses. Severe dehydration cases need immediate IV Ringers lactate which should be switched to ORS when tolerated. They may also receive antibiotics. During treatment, cases should be monitored for complications. Zinc supplementation should be provided to all children with diarrhea when available.

25. Transmission By water or food contaminated with V. cholerae O1 from:
Human feces
Environmental reservoir (estuarine environment)
NOT by person-to-person contact
The organism that causes cholera is transmitted through contaminated water and food. The source of contamination in epidemics is usually the feces of a cholera patient. Because V. cholerae O1 has an environmental reservoir, particularly in warm coastal brackish waters, water or food from those reservoirs may also be contaminated. Person-to-person spread through direct contact, as by shaking hands, or by touching or taking care of a patient, has not been shown to occur.

26. Documented Vehicles of Cholera Transmission
Water:
Seafood:
Others:
Municipal
Raw mussels
Millet gruel
Shallow wells
Raw oysters
Leftover rice, corn porridge, peas
River water
Raw “concha”
Rice with peanut sauce
Bottled water
Raw clams
Airline hors d’oeuvres
Ice
Raw fish
Frozen coconut milk
Partly dried fish
Raw vegetables
Undercooked crab
Street-vended squid
Since 1961, when the 7th pandemic began, many water and food vehicles have been shown to transmit V. cholerae O1. Contaminated water has included municipal water supplies, water drawn from shallow wells, rivers, or streams, and, in one instance, commercially bottled spring water. Ice made from contaminated water has been implicated.
Seafoods have been a recurrent source of cholera. A particularly important vehicle has been shellfish harvested from sewage-contaminated beds or from environments where V. cholerae O1 occurs naturally, and then eaten raw or undercooked. Partially dried raw fish and undercooked crab have also been implicated.
A variety of other foods have also transmitted V. cholerae. Several are moist grains, such as millet, or rice or corn or peas, held out for many hours after cooking. In one investigation in Africa, rice served with peanut sauce transmitted cholera. The same rice served with tomato sauce was protective; tomatoes made that sauce acid, which inhibited the growth of vibrios. An outbreak on an Australian jumbo jet was caused by hors d'oeuvres prepared in a Middle Eastern city that was experiencing a cholera epidemic. An outbreak in Maryland was traced to frozen coconut milk imported from Southeast Asia. Raw vegetables were the source of cases in Africa.

27. Drinking contaminated surface water is also an important source of epidemic cholera. Rivers, streams, and ponds may be contaminated by human waste. These people in Kenya and Bolivia are collecting their drinking water in buckets to take home.

28. This slide from 1991 shows a Peruvian street vendor selling a corn-based drink he made at home. He has a single glass that he fills with a dipper, and which he rinses in a second bucket. Street vendors of beverages and foods play an important role in transmission of cholera in some parts of the world. They live in poor parts of the city, often with poor sanitation and unsafe water supplies. They prepare beverages or food in their homes, where initial contamination is likely, and then take them to a street corner or market where they sell them over many hours, allowing time for incubation and growth of the organisms.

29. Prevention in the Patient’s Household
Education
Drink and use safe water
Wash hands with soap and safe water
Use latrines or bury your feces; do not defecate in any body of water
Cook food thoroughly
Clean up safely in kitchen and bathing areas
If diarrhea develops, drink ORS and go to clinic quickly
Chemoprophylaxis
Not recommended
When a case of cholera occurs, the family members must be aware of specific preventive measures to avoid getting ill. The patient and his or her family need to be instructed on how to make their drinking water safe,
to wash their hands with soap after defecation and before eating or preparing food. The family should not eat food prepared by the patient. If one of them develops diarrheal illness, they should go quickly to the clinic to be assessed and treated.
Public health assessment should include investigation of the patient's home, to ensure proper disposal of the patient's feces through adequate sewerage or septic tank, and to investigate possible sources of the infection. Prophylactic antibiotics are not recommended for family members.

30. Advice for Travelers to Areas Affected by Epidemic Cholera
Do not drink unboiled or untreated water
Carbonated drinks without ice are safe
Avoid food and beverages from street vendors
Avoid raw and undercooked seafood
Eat foods that are cooked and hot, and fruits you peel yourself
-- Boil it, cook it, peel it, or forget it. --
Travelers should be advised of simple precautions that will prevent cholera. Do not drink unboiled and untreated water for drinking and don’t use it for toothbrushing. Carbonated drinks without ice are safe. Avoid food and beverages sold by street vendors. Particularly avoid raw and undercooked seafoods, including shellfish and crayfish. Eat foods that are cooked and hot, and fruits that you peel yourself. Do not bring back perishable seafoods as souvenirs.
A simple rule of thumb is "boil it, peel it, cook it, or forget it".

31. Cholera Vaccine Not recommended for epidemic control
Delay in achieving immunity
Immunity begins 1 week after second dose
14-21 days after first dose
Major logistical challenges, as it requires
Dosing the same people twice
Cold chain
Clean water
Personnel and support
Does not prevent carriage
Not recommended for travelers or health care workers
The vaccine is not recommended for epidemic control because it does not produce immunity until a week after the second dose is given, so 2-3 weeks after the first dose. Giving the vaccine poses major logistical challenges, as it requires dosing the same people twice, cold chain capacity, clean water, and personnel and support that are scarce. Vaccination does not prevent carriage of the organism. It does not prevent asymptomatic carriage. It is not recommended for travelers, nor for health care workers. Several experimental vaccines are under development. If a new vaccine can ultimately be shown to rapidly protect against asymptomatic infection and to induce durable immunity, it may have important public health use.

32. This map shows the areas that reported having cholera in 2009 to the WHO. As we can see, the areas most affected are in Sub-saharan Africa. Very few countries in Latin America reported cholera, and cases in the US and Canada were imported.

33. Cholera in the Americas, 1973-1995
This slide shows a map of the appearance of cholera in the Western Hemisphere. A small endemic focus of cholera was identified on the U.S. Gulf Coast in Between 1973 and 1991, there were 65 cases related to this focus. Zero to 5 cases are still reported there each year. The cholera epidemic in Latin America began in coastal Peru in January, 1991, and rapidly spread to neighboring countries. It also leaped 1000 miles south to appear in Santiago, Chile, and 1500 miles north to appear in southern Mexico, before spreading into Central America. That epidemic never affected the Caribbean countries.

34. In Peru, the epidemic affected men, women, and children equally
In Peru, the epidemic affected men, women, and children equally. This slide shows a hospital waiting room converted to an emergency cholera ward. In some of the most heavily affected towns, 2% of the population was treated for cholera in a matter of months. Fortunately, a major campaign to promote the use of oral rehydration solution (ORS) had just begun, so ORS was widely distributed. The cause of the epidemic was rapidly identified by a field epidemiology team from the Ministry of Health that investigated the first outbreak and brought specimens back to the National Laboratory. With early warning and advance preparation for treatment, the cholera epidemic in urban Peru has had the lowest mortality of any cholera epidemic.

35. Cholera in Latin America: Risk Factors for Transmission
Drinking unboiled water
Large municipal water systems
Deficient peripheral distribution
Home water storage
Water contamination in the home
Ice made from untreated water
Eating raw and undercooked shellfish
Shrimp, concha, oysters, crabs
Eating foods and drinking beverages from street vendors
Eating rice left out for > 3 hours
Extensive investigations in the Latin American epidemic by CDC teams in collaboration with Ministries of Health have documented a variety of means of transmission in Latin American epidemic. Waterborne transmission is occurring for several reasons. Large defective municipal systems distribute untreated water in many cities that is not filtered or chlorinated. The water piping is often defective, permitting further contamination during distribution. Storage of water in the home in a variety of open containers permits further contamination. Ice made from the municipal water can be unsafe. Eating raw shellfish, including shrimp, concha and crab, has been a documented source of infection. Eating foods and drinking beverages prepared and sold by street vendors has been an important source of infection. In several investigations, the habit of eating rice that had been left at ambient temperatures for more than 3 hours was associated with infection.

36. Cholera in the Americas: Control Measures
Short term: Emergency Interventions
Improve diagnosis, treatment, and surveillance
Chlorinate water supplies
Educate public
Boil water, avoid raw shellfish
Identify other control measures by epidemiologic investigations
Mid term: Sustainable, cheap control measures
Home water storage vessels
Home chlorination of water
Long term: “Sanitary Reform”
Maintain and upgrade water systems
Build sewage treatment systems
Implement shellfish sanitation
Epidemic cholera in Latin America was controlled in several stages. Short term, emergency control measures include: 1) improving the capacity to diagnose, treat and track epidemic cholera; 2) chlorinating all municipal water supplies; 3) educating the public in simple emergency prevention measures, such as boiling their drinking water and avoiding raw fish and shellfish; and 4) conducting epidemiologic investigations to identify additional specific control measures. Mid term control measures implemented over several years include sustainable and cheap control measures such as distribution of safe home water storage vessels, and methods for chlorinating water in the home. However, the risk of epidemic cholera ultimately is being limited in many parts of Latin America by long term "sanitary reform". This means maintaining and upgrading water systems so that heated water is universally available, building sewage treatment systems, and keeping sewage out of shellfish beds.

37. Uses of Laboratory Diagnosis of Cholera
To confirm individual cases in a previously unaffected area
To monitor antimicrobial resistance patterns
To define the end of an outbreak
To support epidemiologic investigations
Cholera can be successfully treated without laboratory diagnosis. Laboratory diagnosis is important to confirm individual cases in a previously unaffected area, to monitor antimicrobial resistance patterns, to define the end of an outbreak, and to support epidemiologic investigations.

38. Testing Recommendations for Haiti: Non-affected Areas
Test patients with acute watery diarrhea
Inform MSPP/DELR and collect stool specimens from up to 10 patients for Rapid Diagnostic Testing (RDT) who meet these criteria
Send samples with positive results to the national laboratory immediately for culture confirmation
If one or more specimens from a previously non-affected location are culture-confirmed for cholera, this area will be considered a “cholera confirmed area”

39. Testing Recommendations for Haiti: Cholera Confirmed Area
Once an outbreak is confirmed, the clinical case definition of acute watery diarrhea is sufficient to diagnose
Only periodic laboratory testing of samples will be needed for antimicrobial sensitivity testing and to confirm when the outbreak has ended
The decision will be made by MSPP as to which departments are affected areas

40. Microbiological Diagnosis
Culture of rectal swab or stool specimen
Transport medium: Cary Blair
Selective agar: TCBS
Thiosulfate
Citrate
Bile salts
Sucrose
Takes 2-3 days
Definitive diagnosis of cholera depends on isolating the organism in the microbiology laboratory. A rectal swab or stool specimen should be cultured. A rectal swab should be collected and placed in Cary Blair transport medium for transport to the laboratory. Laboratorians need to be aware that cholera is suspected, so that they will use an appropriate selective agar, such as TCBS, which greatly improves the chance of recovering the organism. TCBS stands for Thiosulfate, Citrate, Bile salts, and Sucrose.

41. Rapid Diagnostic Test (Crystal VC Dipstick)
Rapid Diagnostic Test (RDT) for screening
Test fresh stools in the field can be read within minutes
Early presumptive diagnosis
Not definitive
The Crystal VC Dipstick has been used in Haiti as a rapid diagnostic test for screening. It can be used to test fresh “rice-water” stool specimens in the field. It can be read within minutes. It provides early presumptive diagnosis, but it is not definitive. False positive results are not rare.

42. Cholera - Haiti
October 21, 2010 – toxigenic Vibrio cholerae O1, serotype Ogawa, biotype El Tor identified by national lab and confirmed by CDC
Immunologically naïve and highly vulnerable population
As of October 27, ,722 confirmed cases and 303 deaths
Mainly reported from Artibonite Department, but spread to 5 departments including Port-au-Prince
Preventive measures and appropriate case management is critical to prevent spread and reduce mortality
On October 21, 2010, toxigenic Vibrio cholerae O1, serotype Ogawa, biotype El Tor was identified by the National Laboratory of Public Health of the Ministry of Public Health and Population in Haiti. Identification of the isolate was confirmed by CDC.
As of October 27, a total of 4,722 cholera cases with onset during October and 303 deaths had been reported in Haiti. Most cases have been reported from Artibonite Department, a rural but densely settled area with several small urban centers. In addition, probable cases have been identified elsewhere in Haiti, including Ouest Department, where the capital city of Port-au-Prince is located.

43. Case Identification in Haiti
A case of cholera should be suspected when:
A patient aged 5 years or more develops acute watery diarrhea, with or without vomiting.
A case of cholera is confirmed when:
Vibrio cholerae O1 is isolated from any patient with diarrhea.

44. Surveillance Case Definitions: Haiti, 2010
Suspect case: acute watery diarrhea in a non-affected Department
Case: acute watery diarrhea in an affected Department
Affected Department: a Department where one or more cholera cases have been confirmed by laboratory testing (isolation of V. cholerae O1) that have no history of travel to affected departments in the 5 days before onset.
Designation of affected and non-affected Departments is ultimately determined by MSPP.

45. Data Collection and Reporting
For ALL health facilities:
Maintain records daily on new number of cases and deaths at health facility
It is strongly recommended that each health facility record daily the new number of suspect cholera cases and deaths.
Please use the institution report form issued by MSPP

46. Flow of Information
Health facilities should report surveillance data from the institution report form on acute, watery diarrhea patients to your Unite Communale de Sante or the departmental epidemiologist.
The Unite Communale de Sante or the departmental epidemiologist will compile the daily number of suspect cases and deaths you have recorded at your CTC and report cumulative numbers of cases and deaths to MSPP.

47. When to Suspect a Cholera Outbreak
Symptoms of moderate or severe cholera:
Profuse, watery diarrhea
Vomiting
Leg cramps
Symptoms of dehydration
If there is a local increase in the number of cases with these symptoms, please alert your Unite Communale de Sante or the Departmental epidemiologist immediately.

48. This is a photo of a cholera treatment center which can be used in an emergency, for clinical management of large numbers of patients.

49. CTC Organization Hospitalization Area Morgue Waste Area Screening
Patients with severe dehydration and vomiting
Treatment: IV and ORS
Observation Area
Patients with moderate dehydration
Treatment: ORS
Recovery Area
Patients with no remaining signs of dehydration
Continue ORS
Morgue
Waste Area
Neutral Area
Staff only
Stocks, supplies, staff kitchen, staff showers and latrines
Screening
Exit
Admission
CTC should be isolated from other functioning public structures (schools, dispensaries, markets). CTC structure should be able to isolate patient areas (contaminated) from “neutral areas” (not contaminated).
Note each of the different areas. Entry to screening (triage) and admission. Mild and moderate cases go to the observation area. Severely ill patients go to the hospitalization ward. Once severely ill patients are rehydrated and able to drink, they are moved to the recovery area.
Alternative scales for CTC structures may support larger wards (see penultimate slide #45)
The design may be adapted to the situation, but four areas have to be well delimited in order to limit spread of infection

50. Triage at Treatment Center
No dehydration: refer to normal dispensary
Some dehydration = “Moderate Case”: admit to Observation Area for oral rehydration treatment
Severe dehydration and/or uncontrollable vomiting = “Severe Case”: admit to Hospitalization Area for immediate IV and oral rehydration.
Patients are admitted with no more than 1 attendant (caregiver)
Patients who are admitted are registered (cholera register).
Upon Admission: record patient demographics, presenting signs and symptoms, assessment of dehydration severity, and triage status
Upon Exit: record outcome (discharged, died)

51. One Cholera Kit Provides Treatment for:
100 severe cases of cholera: IV fluids, ORS, and antibiotics at the beginning of the treatment and ORS during the recovery phase
AND
400 mild or moderate cases of cholera in a CTC or ORP
Each Kit consists of 4 modules: Basic, ORS, Infusion, and Support

52. Minimum staff requirements to treat 100 patients/day in a 20-bed CTC:
Medical Officer: 3
Nursing staff: 2
Cleaner: 2
Health educator: 2
Cook: 1
Logistics Officer/Storekeeper: 1
Sprayer/Watchman: 1
Total minimum staff requirement: 12 persons

53. CTC Summary
Cholera patients can easily contaminate the environment: isolation and hygiene are priority rules.
The design of CTC should follow standard rules in order to control contamination between steps of patient management: screening, admission, observation, hospitalization, and recovery.
Human resources organization, training and management are key activities, especially in CTCs .
CTCs must be well-staffed and supplies must be organized in order to avoid any shortage.
This slide adapted from the MSF Cholera manual