1. Cholera: Gaps and Opportunities for Public Health Systems in Developing Countries Gabriele Rossi, MPH student Walden University PH 6165-1 Instructor: Dr. Shana Morrell Summer Quarter, 2009

2. Cholera: a Gap Indicator for Public Health Systems During the 2008 cholera epidemic in Zimbabwe the Ministry of Health admitted the powerlessness of the national health system by stating “our central hospitals are literally not functioning” (BBC, 2008). BBC. (2008). Zimbabwe cholera “an emergency”. Retrieved from: http://news.bbc.co.uk/2/hi/africa/7764200.stm http://news.bbc.co.uk/2/hi/africa/7764200.stm

3. What is Cholera? Cholera (caused by Vibrio cholera) affects public health resources around the globe. Associated with watery stools, vomiting, and dehydration Spread by contaminated drinking water or food and poor sanitation Heymann, D.L. (2008). Control of communicable diseases manual. 19th edition. Washington, DC: American Public Health Association. Snow, J. On the mode of communication of cholera. 2 nd ed. London, England: Churchill, 1855. Reprinted as Snow J. Snow on cholera. New York, NY: Hafner Publishing Co; 1965.

4. History of Cholera Six pandemics occurred between 1817 and 1923, the first of which started from the Gange delta and were caused by Vibrio cholerae O1, classic biotype The ongoing 7th pandemic is caused by Vibrio cholerae O1, El Tor biotype, which started in Indonesia in 1961, gaining ground in Africa in 1970. Twenty years later it reached the Americas (Heymann, 2008) Cholera has become endemic in many parts of the world Heymann, D.L. (2008). Control of Communicable diseases manual. 19th edition. Washington, DC: American Public Health Association.

5. Species Vibrio Cholerae Serogroup O139 (Bengal) in 1992 Serogroup O1 Biotypes El Tor (1961) Serotype Ogawa Serotype Inaba Serotype Hikojima Biotype Classic Serotypes WHO. (2009). Cholera: prevention and control. Retrieved from: http://www.who.int/topics/cholera/control/en/index.html

6. Features Clinical manifestation: watery stool and vomiting Reservoir: mainly human beings Environmental and seasonal factors: onset at the end of the dry season/beginning of the rainy season Heymann, D.L. (2008). Control of Communicable diseases manual. 19th edition. Washington, DC: American Public Health Association.

7. Risk Factors and Transmission Poor social and economic environment, with precarious living conditions and high population density (Brown et al, 2002) Person to person transmission Contaminated food and water Brown, V., Jacquier, G., Bachy, C., Bitar, D., & Legros, D. (2002). Management of cholera epidemics in a refugee camp. Bulletin de la Société de pathologie exotique, 95, 351-354. Heymann, D.L. (2008). Control of Communicable diseases manual. 19th edition. Washington, DC: American Public Health Association.

8. Insufficient Response in Many Under- developed Countries (Naidoo & Patric, 2002) Lack of knowledge and capability to adequately respond to an emergency situation Lack of education and resilience by the population Lack of coordination of the relief efforts Lack of sustainability of these efforts, over time Naidoo, A., & Patric, K. (2002). Cholera: a continuous epidemic in Africa. The Journal of the Royal Society for the Promotion of Health, 122, 89-94.

9. Cholera Preparedness The country’s government and its Ministry of Health represent the key subjects to be empowered, in order to bring solutions to the cholera’s continuous epidemics outraging Africa and other very poor countries all over the world

10. Solutions: Knowledge and Prompt Medical Response During an Outbreak. Confirming the diagnosis by laboratory test (WHO, 2009) by –Confirming cholera by using 5 to 10 stool or vomit samples –Identify the strain –Assess antibiotic sensitivity WHO. (2009). Cholera: prevention and control. Retrieved from: http://www.who.int/topics/cholera/control/en/index.html http://www.who.int/topics/cholera/control/en/index.html

11. Outbreak Investigation Establishing and disseminating a case definition depends on the context… Unknown in the area: severe dehydration or death from acute watery diarrhea in a patient aged 5 or more Epidemic for cholera: acute watery diarrhea with or without vomiting in any patient Endemic for cholera: acute watery diarrhea with or without vomiting in a patient aged 5 or more WHO. (2009). Cholera: prevention and control. Retrieved from: http://www.who.int/topics/cholera/control/en/index.htmlhttp://www.who.int/topics/cholera/control/en/index.html

12. Data Collection Describe the situation, by collecting data by person, time, and place –Calculation of incidence rate –Calculation of attack rate –Calculation of case fatality rate Analyzing and interpret the data, for a meaningful action (WHO, 2009): distinguish between close (slum in the town) and open (rural area) settings where epidemics can take place WHO. (2009). Cholera: prevention and control. Retrieved from: http://www.who.int/topics/cholera/control/en/index.htmlhttp://www.who.int/topics/cholera/control/en/index.html

13. Solutions: Meaningful Actions and Intervention Strategy (WHO, 2009) Reducing mortality Ensuring effective sanitation Reducing the epidemic spread WHO. (2009). Cholera: prevention and control. Retrieved from: http://www.who.int/topics/cholera/control/en/index.htmlhttp://www.who.int/topics/cholera/control/en/index.html

14. Reducing Mortality Cholera is an emergency and is highly contagious It is important to set up treatment centers, for the most severe cases to be isolated and treated (MSF, 2004) Approach may be different, depending on the setting (urban vs rural) (Brown et al, 2002) Brown, V., Jacquier, G., Bachy, C., Bitar, D., & Legros, D. (2002). Management of cholera epidemics in a refugee camp. Bulletin de la Société de pathologie exotique, 95, 351-354. Medecins Sans Frontieres. (2004). Cholera Guidelines.

15. Location Refugee camp or Slum District town+rural villages Population 30,000120,000= 30,000 intown+90,000 scattered Estimated (attack rate) AR 5%1% Peak reached at week Week number 3 to 4, after beginning outbreak Week 6 to 10 Nb cases during the peak 30%10-30% Average length of stay 2 days3 days Proportion of severe cases 75% Epidemiological Calculation of Expected Number of Patients, Based on Different Settings (MSF, 2004) Medecins Sans Frontieres. (2004). Cholera guidelines.

16. Ensuring Effective Sanitation (WHO, 2009) Excreta disposal Waste Water Vector control WHO. (2009). Cholera: prevention and control. Retrieved from: http://www.who.int/topics/cholera/control/en/index.html http://www.who.int/topics/cholera/control/en/index.html

17. Reducing the Epidemic Spread Ensuring access to water: quantity and quality Enabling hygienic conditions Promoting hygienic practices WHO. (2006). Guidelines for drinking-water quality, third edition, incorporating first and second addenda. Retrieved from: http://www.who.int/water_sanitation_health/dwq/gdwq3rev/en/index.htmlhttp://www.who.int/water_sanitation_health/dwq/gdwq3rev/en/index.html

18. Promoting Hygienic Practices (picture used with the permission from Oxfam. Retrieved from:http://www.un.org.np/ocha-situation-updates/2008/Oxfam%20Sitrep%20Saptari%2013Sept08.pdf) Promoting hygienic practices

19. Promoting Hygienic Practices

20. Public Information is Integral!

21. Multisectoral Approach WHO (2009) called for a national, coordinated, multisectoral approach to efficiently control cholera outbreak, and to more effectively rationalize the international aids WHO. (2009). Cholera: prevention and control. Retrieved from: http://www.who.int/topics/cholera/control/en/index.html http://www.who.int/topics/cholera/control/en/index.html

22. Inter-regional Committees Are Needed To ensure a rapid and coordinated response to the regional cholera situation To improve the procurement and distribution of cholera supplies at a regional level To agree to standardized effective prevention and treatment policies Naidoo, A., & Patric, K. (2002). Cholera: a continuous epidemic in Africa. The Journal of the Royal Society for the Promotion of Health, 122, 89-94.

23. 1.Form coordination committee at interregional level 2.Prioritize areas of high risk 3. Mobilize resources 4. Treat people 5. Improve water quality 6. Conduct awareness Programs (1 m) Within 2 months from the outbreak: 7. Establish program to improve water quality and waste disposal systems in high-risk areas 8. Conduct a health and hygiene education campaign 9. Iniziate a transmission control program 10. establish a monitoring system Inter-regional Coordination (Naidoo & Patric, 2002)

24. Cholera: An Opportunity, According to the Ecological Model ( Naidoo & Patric, 2002) Improve regional dialogue Improve education Improve water system and sanitation Naidoo, A., & Patric, K. (2002). Cholera: a continuous epidemic in Africa. The Journal of the Royal Society for the Promotion of Health, 122, 89-94.

25. For Further Reading BCC History – John Snow. Retrieved from: www.bbc.co.uk/history/historic...snow_john.shtml Cholera: traking the first truly global disease. Retrieved from: news.nationalgeographic.com/.../0614_040614_tvcholera.html. Chambers, K. (2009). Zimbabwe’s battle against cholera. Lancet, 373, 993-994. Mathematical model predicts cholera outbreaks. Retrieved from: www.sciencedaily.com/.../02/070218135349.htm. Prevention and control of cholera outbreaks: WHO policy. Retrieved from: www.emro.who.int/CSR/Media/PDF/cholera_whopolicy.pdf. Roberts, L., & Toole, M.J. (1995): Cholera deaths in Goma: Lancet, 346, 1431. (Book) “Love in the Time of Cholera”, by Gabriel Garcia Marquez.

26. References BBC. (2008). Zimbabwe cholera “an emergency”. Retrieved from: http://news.bbc.co.uk/2/hi/africa/7764200.stmhttp://news.bbc.co.uk/2/hi/africa/7764200.stm Brown, V., Jacquier, G., Bachy, C., Bitar, D., & Legros, D. (2002). Management of cholera epidemics in a refugee camp. Bulletin de la Société de pathologie exotique, 95, 351-354. Heymann, D.L. (2008). Control of Communicable diseases manual. 19th edition. Washington, DC: American Public Health Association. Hunt, M.D., Woodward, W.E., Kewsick, B.H., & Dupont, H.L.(1988). Seroepidemiology of cholera in Gulf coastal Texas. Applied and Environmental Microbiology, 54, 1673-1677. Medecins Sans Frontieres. (2004). Cholera Guidelines. Moeller, D. W. (2005). Environmental health (3rd ed.). Boston: Harvard University. Naidoo, A., & Patric, K. (2002). Cholera: a continuous epidemic in Africa. The Journal of the Royal Society for the Promotion of Health, 122, 89-94. WHO. (2006). Guidelines for drinking-water quality, third edition, incorporating first and second addenda. Retrieved from: http://www.who.int/water_sanitation_health/dwq/gdwq3rev/en/index.htmlhttp://www.who.int/water_sanitation_health/dwq/gdwq3rev/en/index.html WHO. (2009). Cholera: prevention and control. Retrieved from: http://www.who.int/topics/cholera/control/en/index.htmlhttp://www.who.int/topics/cholera/control/en/index.html

27. The End Thanks! Gabri