1. CHOLERA
Presented By:
Kamal Bahadur Budha

2. EPIDEMIOLOGY OF CHOLERA
 Introduction
 Magnitude of the Program
 Agent, Host and Environment
 Sign and symptoms
 Complications.
 Prevention and Control Program Status
 National Policy and Strategies
 References
2

3. INTRODUCTION
 Cholera is an infection in the small intestine
caused by the bacterium Vibrio cholerae.
 The word cholera is from Greek: kholera
from kholē "bile".
 The main symptoms are watery diarrhea and
vomiting.
 Transmission occurs primarily by drinking
water or eating food that has been
contaminated by the feces (waste product ).
3

4. Contd. …
 Vibrio cholerae is a Gram-negative bacterium that
produces cholera toxin,
 Vibrio cholerae, which causes cholera, has 139 serotypes,
based on cell antigens.
 Only two of them produce an enterotoxin and are
pathogens: 0:1 and 0:139
 Cholera endemic and epidemic today in developing
countries, some cases also found in developed countries.
 Cholera became one of the most widespread and deadly
4 diseases.

5. EPIDEMIOLOGY OF CHOLERA
 Introduction
 Magnitude of the Program
 Agent, Host and Environment
 Sign and symptoms
 Complications.
 Prevention and Control Program Status
 National Policy and Strategies
 References
5

6. GLOBAL STATUS
6

7. OCCURRENCE:
 Cholera likely has its origins in the Indian
Subcontinent; it has been prevalent in the Ganges
delta since ancient times.
 The disease first spread by trade routes (land and
sea) to Russia in 1817, then to the rest of Europe,
and from Europe to North America.
 Seven cholera pandemics have occurred in the
past 200 years, with the seventh originating in
Indonesia in 1961.
7

8. OCCURRENCE:
 The first cholera pandemic occurred in the Bengal region
of India starting in 1817 through 1824.
 The disease dispersed from India to Southeast Asia,
China, Japan, the Middle East, and southern Russia.
 The second pandemic lasted from 1827 to 1835 and
affected the United States and Europe.
 It killed 150,000 Americans during the second pandemic.
 The third pandemic erupted in 1839, persisted until 1856,
extended to North Africa, and reached South America, for
8 the first time specifically infringing upon Brazil.

9. OCCURRENCE:
 In Russia alone, between 1847 and 1851, more than one
million people perished of the disease.
 Cholera hit the sub-Saharan African region during the
fourth pandemic from 1863 to 1875.
 The fifth pandemic raged from 1881–1896.
 sixth pandemics raged from 1899-1923.
 Between 1900 and 1920, perhaps 8 million people died
of cholera in India.
 These epidemics were less fatal due to a greater
9 understanding of the cholera bacteria.

10. OCCURRENCE:
 Egypt, the Arabian peninsula, Persia, India, and the
Philippines were hit hardest during these epidemics, while
other areas, like Germany in 1892 and Nepalese from
1910–1911, experienced severe outbreaks.
 The final pandemic originated in 1961 in Indonesia and is
marked by the emergence of a new strain, nicknamed El
Tor.
 which still persists today in developing countries.
 cholera became one of the most widespread and deadly
diseases of the 19th century.
10

11. SIZE OF THE PROBLEM GLOBALLY:
 140 000 – 290 000 cases were reported between
1997- 1998.
 In 1999, global incidence was about 254 000 , and
Africa alone accounted for about 81% of the global
total number of cases.
 In 2000, multiple outbreaks were reported in
populations in various islands of Oceania .
11

12.  Cholera affects an estimated 3–5 million people
worldwide, &
 causes 100,000–130,000 deaths a year as of 2010.
 This occurs mainly in the developing world.
 In the early 1980s, death rates are believed to
have been greater than 3 million a year.
 Cholera remains both epidemic and endemic in
many areas of the world.
12

13. 13

14. NATIONAL STATUS
14

15. 15

16. Nepalese origin of cholera
epidemic in Haiti.
 Cholera appeared in Haiti in October 2010 for the
first time in recorded history.
 Vibrio cholerae serogroup O1, serotype Ogawa,
biotype El Tor.
 The isolates were obtained from 30 July to
1 November 2010 from five different districts in
Nepal.
 24 cases of V. cholerae isolates from Nepal
16

17. Doti cholera outbreak under control
 A total of 14 persons had lost their lives due to the
epidemic from June 13 to July 1 in the district.
 District Health Office informed that it has treated
more than 700 cholera patients till now.
 Cholera was found in people from Doti’s Dipayal
Silgadi municipality along with Kalena, Bagalek,
Khatiwada, Gajari, Kadamandau, Sanagaun,
Basudev, Durgamandau, Barwata and Gajunda
17 VDCs.

18. EPIDEMIOLOGY OF CHOLERA
 Introduction
 Magnitude of the Program
 Agent, Host and Environment
 Sign and symptoms
 Complications.
 Prevention and Control Program Status
 National Policy and Strategies
 References
18

19. AGENT FACTORS
 Agent: Vibrio cholerae
Has over 150 identified serotypes based on O-antigen
Only O1 and O139 are toxigenic and cause Cholera disease (Water-borne
illness)
 Source of infection: case of Cholera by Fecal-oral transmission
 Infective materials: secretion of the Intestine cases.
19 .

20. Period of Communicability
During acute stage
A few days after recovery
By end of week, 70% of patients non-infectious
By end of third week, 98% non-infectious
20

21. HOST FACTORS
1. Age: Children: 10x more susceptible than adults,
And Elderly also higher susceptible.
2. Sex: Equal in both male and female.
3. Immunity: Less immune higher risk.
4. People with low gastric acid levels
5. Blood types
O>> B > A > AB
21

22. ENVIRONMENTAL FACTORS
 at risk areas include peri urban slums,
refugee camps where clean water and
sanitation are not met
 Consequences of a disaster
 Lack of education, poor quality of life
22

23. Unsanitary environment:
23

24. EPIDEMIOLOGY OF CHOLERA
 Introduction
 Magnitude of the Program
 Agent, Host and Environment
 Sign and symptoms
 Complications.
 Prevention and Control Program Status
 National Policy and Strategies
 References
24

25. SIGNS AND SYMPTOMs
 The primary symptoms of cholera are profuse,
painless diarrhea and vomiting of clear fluid.
 The diarrhea is frequently described as "rice water"
in nature and may have a fishy odor.
 An untreated person with cholera may produce 10 to
20 litres of diarrhea a day with fatal results.
 patient's skin turning a bluish-gray hue from extreme
loss of fluids.
25

26.  Typical "rice water" diarrhea

27.  If the severe diarrhea is not treated with
intravenous rehydration, it can result in life-
threatening dehydration and electrolyte
imbalances.
 The typical symptoms of dehydration include
low blood pressure, poor skin turgor
(wrinkled hands), sunken eyes, and a rapid
pulse.
27

28.  A person with severe dehydration due to cholera -
note the sunken eyes and decreased skin turgor
28 which produces wrinkled hands and skin

29. MODE OF TRANSMISSION
A. Primary ingestion of water (contaminated
with faeces)
OR
B. Ingestion of food contaminated by dirty
water, faeces, soiled hands or flies.
OR
C. The disease transmitted from one person to
another person in over crowded and
unhygienic conditions.
29

30. INCUBATION PERIOD
Ranges from a few hours to 5 days.
Universal I/P is 5 days.
Shorter incubation period:
High gastric pH (from use of antacids)
Consumption of high dosage of cholera
30

31. EPIDEMIOLOGY OF CHOLERA
 Introduction
 Magnitude of the Program
 Agent, Host and Environment
 Sign and symptoms
 Complications
 Prevention and Control Program Status
 National Policy and Strategies
 References
31

32. COMPLICATIONS
 The degree and duration of fluid and electrolyte
loss determines the medical consequences of
cholera.
 For example, renal failure may stem from the
reduced fluid flow through the kidneys; low blood
sugar (hypoglycemia)
 may result in seizures or coma, especially in the
young; or
 lowered potassium levels may trigger serious
cardiac complications
32

33. EPIDEMIOLOGY OF CHOLERA
 Introduction
 Magnitude of the Program
 Agent, Host and Environment
 Sign and symptoms
 Complications
 Prevention and Control Program Status
 National Policy and Strategies
 References
33

34. Control and prevention
 Sterilization: Proper disposal and treatment of
infected fecal waste water produced by cholera
victims and all contaminated materials (e.g.
clothing, bedding, etc.) are essential.
 Sewage: antibacterial treatment of general
sewage by chlorine, ozone, ultraviolet light or
other.
 Source: to decontaminate the water (boiling,
chlorination etc.) for possible use.
34

35. CONT. ..
 Water purification: All water used for drinking,
washing, or cooking should be sterilized by
either boiling, chlorination, ozone water
treatment, ultraviolet light sterilization.
 Surveillance and prompt reporting allow for
containing cholera epidemics rapidly.
 practice of folding a sari (a long fabric
garment) multiple times to create a simple
filter for drinking water.
35

36. HWTS options (and ORS/medicines)
distributed

37. VACCINE
 A number of safe and effective oral vaccine for cholera are
available.
 Dukoral, inactivated whole cell vaccine, has an overall
efficacy of about 52% during the first year after being given
and 62% in the second year, with minimal side effects.
 It is available in over 60 countries.
 One injectable vaccine was found to be effective for two to
three years.
 Work is under way to investigate the role of mass vaccination.
 WHO recommends immunization of high risk groups, such as
37 children and people with HIV, in countries.

38. Treatment
 Continued eating speeds the recovery of normal
intestinal function.
 The World Health Organization recommends this
generally for cases of diarrhea no matter what the
underlying cause.
 A CDC training manual specifically for cholera
states: “Continue to breastfeed your baby if the
baby has watery diarrhea, even when traveling to
get treatment. Adults and older children should
38 continue to eat frequently.”

39.  Fluids: In most cases, cholera can be successfully
treated with oral rehydration therapy (ORT),
which is highly effective, safe, and simple to
administer.
 Electrolytes: As there frequently is initially
acidosis, the potassium level may be normal, even
though large losses have occurred.
39

40.  Cholera
40 patient being treated by medical staff in 1992

41.  Antibiotic treatments for one to three days shorten
the course of the disease and reduce the severity of
the symptoms. Doxycycline is typically used first
line,
 Other antibiotics proven to be effective include
cotrimoxazole, erythromycin, tetracycline,
chloramphenicol, and furazolidone.
41

42. EPIDEMIOLOGY OF CHOLERA
 Introduction
 Magnitude of the Program
 Agent, Host and Environment
 Sign and symptoms
 Complications
 Prevention and Control Program Status
 National Policy and Strategies
 References
42

43. DIARRHOEA CONTROL PROGRAM IN
NATIONAL CONTEXT
CONTROL OF DIARRHOEAL DISEASE (CDD)
 the CB-IMCI programme was expanded up to
community level.
 Although the incidence of diarrhoea has increased
significantly in this fiscal year but the proportion of
severe dehydration cases was decreased at the last year.
 Almost half of the diarrhoeal cases (50%) were treated
by the Female Community Health Volunteers (FCHVs).
43

44. STRATEGY FOR DIARRHOEA CONTROL
 Training to all health workers on CB‐IMCI including zinc
treatment for diarrhoea;
 Nutritional supplementation, enrichment, nutrition
education and Rehabilitation
 Environmental sanitation
 School Health Program
 Raise public awareness; and promote specific prevention
measure through communication.
 increase access to the Zinc tablets through CHW
44 (FCHVs, VHWs & MCHWs).

45. Community Based Integrated Management
of Childhood Illness (CB-IMCI) Program
 CB-IMCI programme intensely focuses on
management of Diarrhoeal diseases among
the under five year’s children.
 Standard case management of diarrhoea
with Oral Rehydration therapy and Zinc tablet
has been provided in the community level.
 All health facilities and community health
volunteers at community level will serve as
the primary health care providers in the
45 treatment of Diarrhoea

46. Prevention and control of cholera outbreaks:
WHO policy and recommendations
 The main tools for cholera control are:
 proper and timely case management in cholera treatment
centres;
 specific training for proper case management, including
avoidance of nosocomial infections;
 sufficient pre-positioned medical supplies for case
management (e.g. diarrhoeal disease kits);
 improved access to water, effective sanitation, proper waste
management and vector control;
 enhanced hygiene and food safety practices;
46 improved communication and public information.

47. EPIDEMIOLOGY OF CHOLERA
 Introduction
 Magnitude of the Program
 Agent, Host and Environment
 Sign and symptoms
 Complications.
 Prevention and Control Program Status
 National Policy and Strategies
 References
47

48. REFERENCES
 www.wikipedia.org
 http://www.who.int/mediacentre/factsheets/fs286/en/
 Applied epidemiology in Nepalese context.
 Annual report of DoHS.
 www.mohp.gov.np
 www.health24.com/Medical/Cholera/About-cholera
 http://bodyandhealth.canada.com/channel_condition_info_d
etails.asp?disease_id=31&channel_id=1020&relation_id=7
0907
48
 http://www.health24.com/Medical/Cholera

49. wGo
afb