Cholera

By : Gosaye b

Dec,2024
Epidemiology and surveillance
of Cholera
Cholera Clinical Presentation and Case
Management
 Learning objectives:
At the end of the session able to:
• To assess level of dehydration
• Understand steps for effective management
• Identify and treat complications
• Identify discharge criteria
Clinical Feature of Cholera
 BACKGROUND
Cholera: “Greek word” means the
gutter of a roof.

It is caused by bacteria vibrio

cholerae,

First discovered in 1883 by Robert

Koch during diarrhea outbreak in
Egypt? Florence in Italy? India?.
 Incubation Period and Period of
Infectivity
• It is usually 1 to 3 days but can range from several hours to

5 days.

• Symptoms usually last 2 to 3 days

• Infected persons whether they are symptomatic or not, can

carry and transmit vibrios during 1 to 4 weeks

• A small number of individuals can remain healthy carriers

for several months

7
 Definition
Diarrhea

– Having three or more loose or liquid stools per day, or as having

more stools than is normal for that person(WHO).
Acute diarrhea

– is defined as an abnormally frequent discharge of semisolid or fluid

fecal matter from the bowel, lasting less than 14 days (WHO )

Cholera
– is an acute watery diarrheal disease caused by infection of the
intestine with the gram-negative bacteria Vibrio cholerae, either
type O1 or O139
 Types of Diarrhea
Diarrhea

Acute Watery Persistent

Dysentery
diarrhea diarrhea

Rota virus Shigellosis, Causes are

diarrhea, E. Coli
diarrhea, Amebiasis, mostly
Cholera typhoid unknown
 Common Cause of Diarrhea
Cause of Diarrhea

Bacteria Virus Parasite • Others

Metab
Vibrio
olic
cholerae • E.
disease,
, • Rotavir histolyti • Food
Shigella, us, ca, G.
allergy,
Escheric Adenovi lamblia,
Antibioti
hia coli, ruses, Cryptos
cs,
Salmone Calicivir poridiu
Irritable
lla, uses m,
bowel
Staphylo Isospora
syndro
coccus
me
 Epidemiology of Cholera
Cholera

• Is a diarrheal disease of the acute enteric disease.

• Caused by gram negative bacteria: Vibrio cholerae

• Vibrio cholerae species are divided into 2 sero-

groups.
 Vibrio cholerae sero group O1
 Vibrio cholerae sero-group-O139

• Over 100 vibrio species known but only the V.

cholerae species are responsible for cholera
epidemics.
 Epidemiology of Cholera…
Cholera infected persons

– Over 80% are asymptomatic making diagnosis

difficult
– Around 80-90% = No and Some dehydration
– Around 10-20% of cases progress to severe
dehydration, shock and deaths if not treated
– Case Fatality Rate (CFR) may reach up to 30-50% if
cases are untreated in time
• Can affected both children and adults
 Epidemiology of Cholera…

Infectious dose of Cholera depend on individual

susceptibility
– Acidity

– Immunity due to vaccination or prior

infection
– Breast feeding protects infants and young
children in endemic area
 Reservoirs

Main reservoirs for Vibrio cholerae

– Humans are the main reservoirs

– Other potential reservoirs like water, some molluscs, fish and

aquatic plants.

Vibrios grow easily in saline water and alkaline media and

can be destroyed by:
– Gastric acid in the stomach

– Chlorine disinfectant solutions

– Boiling during at least one minute

 Mode of transmission

• Fecal-oral route
 Entry = oral
 Discharge = fecal
• A dose of one million organisms is usually needed to cause illness
• Transmission is almost exclusively by contaminated water or food
• Corpses of cholera patients are highly infectious especially
physical contact during funerals & food preparation
• Cholera treatment centers can become main sources of
contamination if hygiene and isolation measures are
• Transmission by contact, such as touching patients is rare
• Most epidemics have started from a single source and spread
 Risk factors
Most epidemics have started from a single
source and
spread rapidly.
• Insufficient water supply (quality and quantity)

• Unsafe excreta disposal

• Inappropriate, poor sanitation and hygiene

practices

• Environmental and seasonal factors ( At the end

of dry season or at the beginning of rainy season)

• Inadequate food and safety

• High population density: camps, IDPs

• Inappropriate funeral services for cholera victims

 Pathogenesis(1)
• To establish disease, V. cholerae must be
survive the passage through the gastric
barrier of the stomach.
• On reaching the lumen of the small
intestine, the bacteria must:
 overcome the clearing mechanism of
the intestine (peristalsis),
 penetrate the mucous layer
 and establish contact with the
epithelial cell layer.
 Pathogenesis(2)
• Colonization of the intestinal microvilli and the subsequent
production and release of cholera toxin, lead to the purging
diarrhea.
• Thus, the net effect of the toxin is to cause cAMP(cyclic Adenosine
monophosphate) to be produced at an abnormally high rate which
stimulates mucosal cells to pump large amounts of Cl- into the
intestinal contents.
 Pathogenesis: Mechanism of Action (3)
• H2O, Na+ and other • Thus, the toxin-damaged cells
electrolytes follow due to become pumps for water and
the osmotic and electrical electrolytes causing the
gradients caused by the loss diarrhea, loss of electrolytes,
of Cl-. and dehydration that are
• The lost H2O and characteristic of cholera.
electrolytes in mucosal cells
are replaced from the blood.
Pathogenesis: Mechanism of Action(4)
 Signs and Symptoms

 Symptoms begin with sudden onset of profuse

painless watery diarrhea, which may be followed by
vomiting and abdominal cramp.
 For severe cases, patients may have cramps in the
stomach, arms, or legs.

 Fever is typically absent.

 The diarrhea has fishy odor in the beginning, but

became less smelly and more watery over time.
 Visible Signs
• Decreased skin pinch
• Sunken eye ball
• Almost no urine production
• Dry mucous membranes
• Reduced BP
• Absent/Weak radial Pulse
 Cholera In Children

• Breast-fed infants are protected.

• Symptoms are severe & fever is frequent.
• Shock, drowsiness & coma are common.
• Hypoglycemia is a recognized complication, which may lead to
convulsions.
• Rotavirus infection may give similar picture & need to be
excluded.
 Diagnosis
• Based on clinical presentation

• Microbiological confirmation of Vibrio cholerae by direct observation can

be obtained immediately, but it usually takes 2 days to get culture results.

• RDT test for surveillance purpose

• This culture is important to gather information on:

 Serogroup of Vibrio (O1 or O139)

 Antimicrobial sensitivity patterns

24
 Stool Sample Transportation

• Cary-Blair Medium-

– After sampling, transport at normal temperature to

the laboratory within 2 days maximum
• In case there is no medium

– screw-cap bottle- with 2hours

 Consequences of Severe
Dehydration
• Intravascular volume depletion
• Severe metabolic acidosis
• Hypokalemia
• Cardiac and renal failure

Mortality Rate
• With prompt rehydration: <1%
• Without treatment: 30%-50%
Cholera Case Management
Effective case management requires systematic
and stepwise approaches.
1. Assessments for the level of dehydration
2. Decide the level of dehydration,
3. Re-hydrating patients accordingly
4. Monitoring the patient condition closely
5. Administration antibiotic only for severely
dehydrated patients
6. Identifying and treating complications
7. Continue feeding the patient
8. Advise the family on follow up and preventive
actions from cholera
9. Instruction to the patients and the families on
discharge
10. Discharging the patient
 STEP 1. Assessment for level of DHN
The severity of dehydration in patient with AWD is
detected by:
I. General condition of the patient
A. Lethargic or unconscious OR
B. Restless and irritable OR
C. Alert/normal
II. Eye condition:
A. Very sunken
B. Sunken
C. Normal
 Assessment…

III Drinking condition:

 Patient should be offered fluid and observed for:
▬ Unable to drink or poorly drinking
▬ Eager to drink/thirsty
▬ Normally drinking

IV. Skin condition: observe for one of the following

sign.
▬ Skin pinch going back very slowly staying more than 2
seconds
▬ Skin pinch going back slowly
▬ Skin pinch going back immediately
32
 Treatment
Rehydration
• The primary goal is:
 To replenish fluid losses.
 Has 2 phases (loading & maintenance).

• it use to - replace ongoing losses

- provide daily requirement.

 Treatment …

• Rehydrate when:
 Pt is severely or moderately dehydrated
 Unable to drink due to vomiting

• Ringer lactate solution is preferred over normal saline

because it corrects metabolic acidosis occurred due to

electrolytes imbalance.
Step 3 and 4. Rehydration and Monitoring
the patient’s condition
 Rehydration

▬ to refill fluid losses caused by diarrhea and

vomiting
▬ Oral and IV rehydration

IV Fluid Therapy
• Used when:
▬ Pt is in Severe Dehydration
▬ Unable to drink due to vomiting

• Ringer lactate solution is preferred over normal

saline because it corrects the associated metabolic
acidosis.
 Plan A: Oral rehydration therapy

• For patients with no dehydration

• Patients should receive ORS after each loose stool to maintain
hydration until diarrhea stops
• Because clinical status may deteriorate rapidly, these patients
may initially need to be kept under monitoring (observation)
 Plan A
Age Amount of ORS ORS quantity
after each loose needed
stool
Less than 24 50 to 100 ml Enough for 500
months ml/day

2 to 10 years 100 to 200 ml Enough for 1000

ml/day
(1 sachet)*

Over 10 years as much as Enough for 2000

wanted ml/day
(2 sachets)*
 Plan B: Oral rehydration therapy

• For patients with moderate dehydration

• Patients must be admitted to the treatment center,
• Receive oral rehydration solution
• be monitored until diarrhea/vomiting stops.
 Oral rehydration during the first 4 hours

Age < 4M 4-11M 12- 2-4yrs 5- >14y

23M 14yrs rs
weight <5kg 5-7.9kg 8- 11- 16- >30k
10.9k 15.9 29.9 g
g kg kg
ORS in 200- 400- 600- 800- 1200- 2200-
ML 400m 600ml 800ml 1200ml 2200m 4000
l l ml

ORS in 1- 2-3cup 3- 4-6cup 6- 11-

200ml 2cup 4cup 11cup 20cu
cup p
Monitoring during oral rehydration therapy and re assessment of patient’s condition

1. FL U I D S I N P U T
• Monitor the patient frequently to ensure that ORS solution is
taken satisfactorily.
• Check that the patient always has a cup and the ORS container
within arm’s reach.
• If the patient wants more ORS, give more.
• If the patient vomits, wait 10 minutes and continue slowly.
 ASSE S S M E N T O F T H E H Y D R ATI O N S TATU S

• Check signs of dehydration every hour in the first 2 hours, or more

frequently if the clinical condition requires closer monitoring
• If there are no signs of dehydration after the first 4 hours: follow
Treatment Plan A.
• If there are still signs of moderate dehydration after the first 4
hours: repeat Treatment Plan B for 4 hours and reassess.
• If sever dehydration/shock, shift immediately to Treatment
Plan C
 Plan C: IV rehydration for patients with severe dehydration

• IV treatment must be given quickly, to restore normal hydration

within 3 to 6 hours.
• Hang the infusion bag as high as possible to facilitate rapid flow.
• Ringer Lactate solution is the best option.
• It provides an adequate concentration of sodium, some potassium
and enough lactate, which is metabolized into bicarbonate for the
correction of acidosis.
 Plan C……..
• If the patient can drink without difficulty, give ORS by mouth
while the drip is setup. Start ORS only if the patient is
conscious.
• Oral (or nasogastric) route should not be used in patients
severely hypovolaemic or unconscious.
 For patients age 15 and over
First 15 minutes:
• Administer 1 liter of Ringer Lactate very rapidly, until radial
pulse is restored.
• (management of shock)
• If the pulse remains weak or no detectable: administer another
liter of Ringer Lactate in 15 minutes
• After first 15 minutes:
• If the pulse slows down or becomes stronger, reduce the
amount and administer 1 liter in 45 minutes, followed by
another liter in 2-5 hours.
 Over 15 Years
• On average a severely dehydrated adult patient needs 8-10 liters
Ringer Lactate and 10 liters of ORS for a full course of
treatment.
• Do not spend time calculating the number of drops/minute, but
monitor patient's condition, especially during the first hours.

• Large calibre catheters (16G, 18G) should be

used.
 For under 14 years
Age First give 30 ml/kg in: Then give 70
ml/kg in:

Children less 1 hour (repeat once if 5 hours

than 1 year radial pulse is still
very weak or non
detectable)

Children aged 30 minutes 2 1/2 hours

1 year to 14 (repeat once if radial
years pulse is still very
weak or non
detectable)
 Monitoring during IV rehydration therapy and reassessment of patient’s condition

Assessment of the patient condition

• Pulse: stay next to patient’s bed until a strong radial pulse is
present.
• Check signs of dehydration every 15 minutes in the first hour,
then every 2 hours, or more frequently if the clinical condition
requires closer monitoring.
• Respiratory rate: if the patient breathes with difficulty, look for
acute pulmonary edema due to over hydration
• Except for patients in shock, monitoring blood
pressure is not compulsory, especially when staff is
 Drug Therapy

• to eradicate infection, reduce morbidity and prevent

complications.
• reduces volume of stool and shortens period of hospitalization
• For adults - doxycycline, tetracycline, cotrimoxazole and
ciprofloxacin.
• For children- erythromycin, cotrimoxazole are the drugs of
choice.
 Complications

• If dehydration is not corrected adequately and promptly it

can lead to hypovolemic shock, acute renal failure and
death.
• Electrolyte imbalance is common.
• Hypoglycemia occurs in children.
• Over hydration and side effects of drug therapy
are rare.
Identifying and Treating
Complications
 Hypoglycemia

• After dehydration, hypoglycemia is the most common lethal

complication of cholera in children.
• Early intake of ORS and re-starting of feeding can prevent
hypoglycemia.
• For patients under IV rehydration who can drink without
difficulty, give ORS orally as soon as possible.
• If hypoglycemia is suspected (lethargy, convulsions, eyes rolled-
back, etc.) give 1ml/kg of glucose 50% by slow IV injection.
 Acute Pulmonary Odema

• Acute pulmonary edema is related to over hydration, due to

excessive IV rehydration.
• It is a common risk among elderly, young children and severely
anaemic patients.
• Use of sodium chloride 0.9% instead of Ringer Lactate can
also contribute.
• Oral rehydration does not cause pulmonary edema.
• Signs of IV fluid overload include: dry cough, dyspnea,
crepitations on auscultation.
 Management:

• Put patient in a half-sitting position, legs hanging out of the

bed.
• Slow down infusion rate as much as possible.
• Administer furosemide by slow IV injection:
– Children: 1 mg/kg/injection
– Adults: 40 mg/injection

• If needed, repeat the same dose after 15 minutes, according to

patient’s condition
• (maximum dose in adults: 250 mg).
 Renal failure (Anuria)

• This rare complication occurs when shock is not rapidly

corrected.
• Urine output normally resumes within 6 to 8 hours after starting
rehydration.
• If not, check that patient is correctly rehydrated and try
furosemide 1 mg/kg IV under close medical supervision.
 Hypokalemia

• Hypokalemia should be suspected if repeated episodes of painful cramps

occur.

• This may happen after the first 24 hours of IV rehydration if patients do not eat
or do not drink ORS (ORS provides enough potassium).

• If cramps occur, try to correct with ORS. In patients with cramps who cannot
drink ORS, add 1 or 2 grams of KCl in one liter of Ringer lactate if clearly
needed, closely monitor the rate of infusion and reassess.

• Do not administer KCl by IM injection (risk of necrosis) or by rapid IV

injection (risk of cardiac arrest).

• Do not administer KCl on the first day (the infusion rate is too high and
hypokalemia is unlikely).
 Cholera and Severe Malnutrition

• Many classical signs of dehydration are unreliable.

• Malnutrition seriously disturbs the fluid and electrolyte balance.

• Excessive and indiscriminate use of rehydration fluid may

rapidly result in over hydration and fatal heart failure.

 Oral rehydration therapy

• If no shock, rehydrated orally using ORS.

• Use standard WHO-ORS instead of ReSoMal (ReSoMal does
not contain enough sodium)
• The rate of rehydration should be slower
• 5 ml/kg every 30 minutes for the 1st 2 hours,
• followed by 5ml/kg/hour for up 10 hours (up to 10 ml/kg/hour
if needed, until dehydration is corrected).
 Oral rehydration therapy …..
• Use nasogastric tube only if the patient is conscious but too
weak to drink.
• The patient’s condition must be assessed every 30 minutes
during the first 2 hours, then every hour for the next 6-12 hours.
• Monitoring is based on pulse and respiratory rates; and the
frequency of urine, stool, and vomiting.
• Regular urinary output (every 3-4 hours) is a good sign that
enough fluid is given.
 Oral rehydration therapy….
• Increasing edema is evidence of over hydration.
• Continued fast breathing and a rapid pulse rate during
rehydration may be early signs of heart failure.
• ORS should be immediately stopped if a patient exhibits any of
these signs.
• Reassess after one hour.
• Note: therapeutic milk and breast-feeding must not be
interrupted during oral rehydration.
 Intravenous Rehydration

 IV fluid should be restricted to patients with signs of shock.

 Use Ringer Lactate: 15 ml/kg/hour over 2 hours, then stop the
infusion, and change to oral treatment with ORS: 10 ml/kg/hour
until dehydration is corrected (for up to 10 hours if needed).
 At the same time that ORS treatment begins, re-start feeding.
 Patients should always be placed under close medical supervision.
 Intravenous rehydration…..

• Monitor the vital signs every 15 minutes:

 reduced respiratory rate, reduced pulse rate, stronger radial
pulse and increased blood pressure indicate that there is an
improvement
 increased respiratory rate (by 5 breaths/min), increased pulse
rate (by 25 beats/min), puffy eyelids are early signs of over
hydration.
Prevention and Control

of CHOLERA
Water, Sanitation and Hygiene(WASH)
 Introd…
 Cholera usually affects areas that are lacking access to a
safe source of drinking water, poor sanitation, and
hygiene.
 it is critical to communicate to the affected community that
making water safer and proper sanitation and hygiene
practices at
 Household,
 Community, and
 Institutions level is critical.
 Water Supply

 Households need to take several actions in

making water safer from the time of fetching
water from the source till consumption i.e.
collect, transport, store, and use.
 Safer water begins from the container used to
collect, transport, and store and consume.
 Water for household, community and institution
Hand pump water
 Water Sup…

 Household water treatment is one of the cholera

outbreak response activities that are effective,
simple, and inexpensive.
 Treating water at all levels should continue on
sustainable manner even after the outbreak is
contained.
Water Treatment Mechanisms
Household, community, and
institutions have many choices for
treating water. This includes
 boiling,
 filtration,
 chlorination (chemical treatment),
 solar,
 ultra-violet lamp disinfection, and
 flocculation.
• Sedimentation removes larger particles and often >
50% of pathogens
• Filtration removes smaller particles and often >
90% of pathogens
• Disinfection removes, deactivates or kills any
remaining pathogens
 Sedimentation
• Sedimentation is a physical treatment process
used to reduce the turbidity of the water.
• This could be as simple as letting the particles in
the water settle for some time in a small container
such as a bucket or pail.
• It can be quickened by adding special chemicals or
native plants, also known as coagulants, to the
water.
• Coagulants help the sand, silt and clay join
together and form larger clumps, making it
easier for them to settle to the bottom of the
container.
 Sediment…
• The common chemical coagulants used are
– aluminium sulphate (alum),
– polyaluminium chloride (also known as PAC or
liquid alum),
– alum potash and iron salts (ferric sulphate or
ferric chloride).

• Native plants are also traditionally used in some

countries, depending on the local availability, to help
with sedimentation.
– For example, moringa seeds have been used to help
sediment water.
 Filtration
• Filtration is a physical process which
involves passing water through
filter media.
• Filtration is commonly used after
sedimentation to further reduce
turbidity and remove pathogens.
• There are various types of filters that
are used by households around the
world including:
Straining through a cloth
Ceramic pot filter
Ceramic candle filter
Membrane filters
 Disinfection
• The last step in household water
treatment is to remove or kill any
remaining pathogens through
disinfection.
• The most common methods used by
households around the world to disinfect
their drinking water are
– Chlorine disinfection
– Solar disinfection (SODIS)
– Ultraviolet (UV) disinfection
– Boiling
 Boiling
 Destroy pathogens within suspended particulate matter in the water.

 It is an effective, traditional, physical method and more reliable than

chemical disinfection or complete sterilization.

 Applied for small quantities of water.

Procedures
 Boiling must continue for 5-10 minutes after reaching the boiling
point.
 Immediately cool and safely store boiled water for consumption
since it may be re-contaminated through poor handling and storage.
 Chlorination
 The aim of chlorination is to destroy the
pathogens that cause diseases through chemical
means.
 To achieve this, a chlorine dose must be
sufficient
 One of the pre-condition for effective
chlorination is that the turbidity of the water
must be low.
 In an emergency water supply the aim is to
have a turbidity of less than 5Nephelometric
Turbidity Unit (NTU).
 Procedures for the use of water
purification chemicals:
Woha Agar (Water Guard)
 Pour 20 liters of water into a jerry can.
 Use the cap of the bottle and pour 1 cap(3ml) of water
Guard and add it to the 20 liters of water.
 Close the jerry can and shake to mix the contents.
 Wait for 30 minutes until the germs die.
 The water is ready to be used after 30 minutes.
 If necessary pour the treated water into another container.
 To avoid contamination close the water container.
 Use separate jug to fetch water from the container
Aqua tab
 Prepare 20 liters of water to be treated, if the water

is not turbid, treat by adding one tablet. But if the

water is turbid, filter through a cloth and then add 2
tablets
 After adding the tablets, mix the tablets with the

water thoroughly
 Wait at least for 30 minutes and then use the water

for intended purposes

PUR (Purifier of Water)
 Prepare 10 liters of water to be treated
 Open the sachet and add the contents to an
open bucket containing 10 liters of water
 Stir for 5 minutes, let the solids settle to the
bottom of the bucket
 Strain or filter the water through a cotton cloth
into a second container and wait 20 minutes
for the hypochlorite to inactivate the
microorganisms.
 Use the water intended purposes.
 Bishangari
 Prepare 20 liters of water to be treated
 Open the sachet and add the contents to an open
bucket containing 20 liters of water
 Stir for 5 minutes, let the solids settle to the
bottom of the bucket
 Strain or filter the water through a cotton cloth
into a second container, and wait 20 minutes for
the hypochlorite to inactivate the microorganisms.
 Use the water intended purposes.
 Hygiene
Food hygiene
 Wash hands with clean water and soap/ash/sand before

preparing, eating, serving food to other family members,

feeding a child.
 Avoid eating raw food items during cholera outbreak, such as

vegetables and wash fruits thoroughly before eating.

 If possible, always eat fresh foods; reheat cooked thoroughly

before eating or serving to other people.

 Always feed fresh food to children.
 Food hygie…

 Wash utensils used for preparation of food,

eating of food and drinking of water (knives,
pots, dishes, forks, spoons, etc.) thoroughly with
detergents.
 Cover food items tightly to avoid contact of
flies; put cooked foods in places where animals
such as cat, dog, and rat cannot reach.
 Food and drinking…….
 Food handlers
 Hygiene precautions during
preparation, transportation and
storage of food
 Latrine service in food and drink
establishments
 Hand-washing practices
When one should wash his/her hands?
 Before you eat or prepare food
 Before feeding your children
 After using the latrine or toilet
 After cleaning your child’s bottom
 After taking care of someone ill with
diarrhea
 Cholera surveillance
Cholera surveillance
• is the ongoing systematic identification, collection, collation, analysis and
interpretation of cholera disease occurrence for the purposes of taking
timely and robust action
key factors for effective Cholera surveillance
– Existence of a standard case definition
– Simple data collection tools, clear reporting procedures, analysis plans
– Rapid diagnosis of suspected cases and laboratory confirmation
– Routine feedback of surveillance data, and
– Appropriate coordination at all levels of the public health sector
 Purpose of effective Cholera surveillance
 Detect outbreaks of cholera early
 Identify hotspot areas (areas where outbreaks regularly occur)
 Enhance cross boarder cholera surveillance
 Assess the size and extent of the outbreak
 Determine if an outbreak is spreading, and where
 Plan the allocation of resources (e.g. personnel and supplies)
 Decide whether control measures are working
 Plan additional epidemiologic investigations
 Cholera Case Definition

Community suspect case definition

• Any person 2 years of age or more with profuse acute watery
diarrhea and vomiting.
Standard case definition
Suspected case
A In areas where a cholera outbreak has not yet been
declared
Any person aged 2 years or older presenting with acute
watery diarrhea and severe dehydration or dying from acute
watery diarrhea.
B. In areas where a cholera outbreak has been declared
 Cholera case detection and notification
•All suspected cases of cholera must be reported
immediately to the appropriate authority
• Cholera alert (suspected cholera outbreak) is
detection of at least one of the following:
– Two or more people aged ≥2 years with Cholera and
severe dehydration, or dying from Cholera from the
same area within 1 week of one another;
– One case of Cholera testing positive for cholera by
 Cholera case detection ( Diagnoses)
Culture or PCR Rapid diagnostic
test
• Collection of stool • At the bed side in the field
sample • Result within 10 minutes
• Transportation in culture • no specific preparation of
media to lab sample
• low cost
• Isolation and
• Improves the reliability of
identification (min 24-48
hr) Cholera alerts
•For confirmation &
declaration of outbreak
 Outbreak Investigation
• Activate RRT & investigate with in 3
hours
• Rapid need ass’t is necessary before
Prepare for field work
field work
• Secure relevant supplies,
communication & data analysis tools
• Establish and verify the existence of
the suspected Cholera outbreak
Field ass’t • Review trend of cases & death , collect
5-10 rectal samples
• Report to decision makers

• Verify the existence of Vibrio Cholerae

Verify the diagnosis
O1 or O139
 Main activities in cholera surveillance

• Active case search

• Contact listing

• Contact tracing

• House spray

• Potential source and risk identification

• Risk communication
 Surveillance indicators
1. Completeness and timelines of reported

2. Incidence rate (IR)

3. Case fatality ratio:

3. Attack rate:

4. Others:
– Laboratory indicators

– Water and Sanitation and Hygiene indicators

– Access and quality of health care services

– Local context information