CHOLERA

ASHLY PJ
Roll no:20
5 th semester BSc Nursing
Govt. college of nursing Alappuzha
TOPICS

• Epidemiology
• Screening and diagnosing
• Primary management
• Referral and follow up
• Prevention and control
 Definition

“ Cholera is an acute diarrheal disease caused by the

infection of the intestine with bacterium vibrio cholerae
characterized by vomiting and rice watery stools ”

• It spread by the ingestion of the contaminated food or

water
• The severity of the diarrhoea and vomiting Can lead to
rapid dehydration and Electrolyte imbalance
Causes and mode of transmission

• Drinking Contaminated water

• Eating contaminated food
• Eating raw or undercooked shellfish that are
naturally contaminated
• Ingestion of food that are contaminated by
hands of the Patients & flies
• Food and drinks sold by the street vendors
• Poor sanitation
• Crowding
Incidence and prevalence
• Kills ( approx) 95000 people in India Per year
• Over 1 million cases and nearly 10000 fatalities
• Infected people about 2.9 millions per year
• Prevalence rate: less than 5000 cases per year in India

Incubation period – 2 hours

to 5 days
EPIDEMIOLOGICAL DETERMINANTS

• Agent factors
• Carriers
• Host factors
• Environmental factors
Agent factors

• Agent: the organism that cause cholera is labelled as Cholera O1 and

O139.these vibrio’s are also called epidemic strains

• Resistance: v cholera can be killed within 30 minutes by heating at

56°c or within a few seconds by boiling. They remain in ice for for 4-6
weeks or longer and drying and sunshine will kill them in a few hours.
They ate easily destroyed by coal tar disinfectants such as cresol
bleaching powder is another good disinfectant which kills vibrios
instant by 6 mg/ liter
• Toxin production: The vibrio’s Multiply in the lumen
of the small intestine and produce an exotoxin . This
exotoxin causes diarrhoea through its effect on the
acetylate cyclase Amp system of the mucosal cells of the
small intestine .The exotoxin ha no effect on any other
tissue except the intestinal epithelial cells

• Reservoir: Human being is the only known reservoir of

cholera infection
• Infective material : The source of infection are the stools and
vomitus of cases. The watery stools of the cholera patients
carries large number of vibrios

• Infective dose: The infective dose of vibrio cholera is 10 ^3

CFU

• Period of communicability: A case of cholera is infective for

period of 7-10 days convalescent carriers are infectious for 2-
3 weeks. The chronic carrier state may last from a month
upto 1 years or more
Carriers in cholera ( 4 types)

• Preclinical or incubatory: Incubatory period of cholera is short ( 1-5

days ) incubatory carriage is of short duration the incubatory
carriers are the potential patients
• Convalescent carriers: The patient who has recovered from an
attack of cholera may continue to excrete vibrios during his
convalescence has been for 2-3 weeks( due to poor antibiotic
treatment)
• Contact/ healthy carrier : This is the result of subclinical infection
contracted through association with a source of infection The
duration of contact carrier state is usually less than 1 days
• Chronic carrier: A chronic carrier State occurs infrequently .The
longest carrier state was found to be over 10 years
Host factors

• Age and sex: cholera affects all ages . In endemic areas

attack rate is highest in children
• Gastric acidity: The vibrio is destroyed in an acidity of
pH5 or lower conditions
• Population mobility: movement of population results in
increased risk of exposure to infection
• Economic status: The incidence of cholera tends to be the
highest in the lower socio economic groups
• Immunity: An attack of cholera is followed by immunity to
reinfection, but the duration and degree of immunity are not
known
 Environmental factors

• Poor environmental sanitation

• Contaminated water and food
• Human habits that favoring the water and soil pollution
• Low standards of personal hygiene
• Lack of education
• Poor quality of life
• Flies may carry vibrio cholera but not a vector proven
importance
 Screening of cholera
Clinical Screening
1. Diarrhea: Assess onset, duration, and characteristics
2. Vomiting: Evaluate presence and severity
3. Dehydration: Check for signs like excessive thirst, dark urine, and
decreased urine output
4. Fever: Verify presence of fever

Risk Factor Screening

1. Inquire about recent travel to cholera-outbreak areas
2. Ask about consumption of potentially contaminated food or water
3. Investigate contact with individuals diagnosed with cholera
Laboratory Diagnosis of Cholera

Isolation of Vibrio cholerae

1. Stool Culture: Collect stool sample and culture on selective media
such as TCBS (Thiosulfate-Citrate-Bile-Sucrose) agar.
2. Biochemical Tests: Perform biochemical tests such as oxidase,
catalase, and string test to confirm the identity of Vibrio cholerae.

Rapid Diagnostic Tests (RDTs)

1. Dipstick Tests : Use dipstick tests to detect cholera antigens in stool
samples.
2. Immunochromatographic Tests : Use Immunochromatographic
tests to detect cholera antigens in stool samples.
CONTD….

Molecular Diagnostic Techniques

1. PCR : Use PCR to detect the genetic material of Vibrio cholerae.
2. Real-Time PCR: Use real-time PCR to detect and quantify the
genetic material of Vibrio cholerae

Serological Tests
1. ELISA : Use ELISA to detect antibodies against Vibrio cholerae
in serum samples.
2. Microscopic Agglutination Test: Use microscopic agglutination
test to detect antibodies against Vibrio cholerae in serum samples.
Primary management of cholera

Fluid Replacement Therapy

1. Oral Rehydration Solution (ORS): Contains essential electrolytes

and glucose to replace lost fluids
• WHO recommended ors - containing 75 mmol/L sodium ,20 mmol/L
potassium, 10 mmol/L citrate and 13.5 g/ L glucose
2. Intravenous Fluids: Used for patients with severe dehydration or
those who cannot take ORS
• Ringer lactate containing 130 mmol/ L sodium,4 mmol/L pottasium,3
mmol/L calcium and 28 mmol/L lactate
• Normal saline solution contain 154 mmol/L sodium and 154mmol/L
chloride
CONTD….

Antibiotic Therapy

1. Doxycycline: Single dose – 7 mg/ kg not exceed 300 mg

: Multiple dose – 2 mg/ kg BD on day 1 then 2 mg/ kg OD on day
2&3

2.Tetracycline : single dose 25 mg/ kg not to exceed 1g

: Multiple dose: 40 mg/ kg/ day given for 3 days

3. Ciprofloxacin: Alternative antibiotic especially for patients allergic to

doxycycline

4. Azithromycin: Effective antibiotic especially for children and pregnant women

CONTD ….

Other Medications

1. Zinc supplements
2. Probiotics

Supportive care

1. Monitoring
2. Rest
3. Nutritional support
 Prevention & control of cholera
1. Verificationation of the diagnosis : It is important to have
confirmation of the outbreak as quickly as possible. All cases of
diarrhoea should be investigated even on the slightest suspection
2. Notification : health workers at all levels should be trained to
identify and notify cases immediately . Under the international
health regulation cholera is notifiable to the WHO within 24
hours of its occurrence
3. Early case finding : early detection of cases also permits the
detection of infected house hold contacts and helps the
epidemiologist in investigating the means of spread for deciding
on specific intervention
 CONTD….

4. Establishment of treatment centers : The mildly dehydrated patients

should be treated at home with oral rehydration fluids. Severely
dehydrated patients requiring IV fluids should be transferred to the
nearest treatment center . If there is no hospital or treatment center
within a convenient distance, a local school or public buildings should be
taken over and converted into a temporary treatment center

5. Rehydration therapy: Cholera mortality rate have been brought down

to less than 1 percentage by effective rehydration therapy

6. Adjuncts to therapy : Antibiotics should be given as soon as the

vomiting ha stopped usually after 3-4 hours of oral rehydration
7. Sanitation measures

• Water control – provision for permanent piped water supply on a

permanent basis and elimination of unsafe water sources

• Excreta disposal – provision for simple , cheap and effective excreta

disposal system is a basic need of all human settlements

• Food sanitation – health education must stress the importance of

eating cooked hot food and of proper individual food handling
technique cooking utensils should be cleaned and dried after use

• Disinfection – The most effective disinfectant for general use is a

coal tar disinfectant with a rideal – Walker coefficient of less than 5
8.Chemoprophylaxis

Chemoprophylaxis is advised only for household contacts or of a closed

community in which cholera has occurred . Tetracycline Is the drug of
choice for chemoprophylaxis

• It is given over a 3 day period in a twice daily dose of 500 mg for

adults,125 mg for children aged 4-13 years and 50 mg for children aged
0-3 years
• If the prevailing strains are not resistant a single oral dose of doxycycline
300 mg for adults and 6 mg/ kg for children under 15 years has proved
to be effective
9.vaccination

Cholera vaccines are available in 3 forms oral , injectable and live

attenuated

1. Oral cholera vaccines – Dukoral , Shanchol , Euvichol

2. Injectable – They are widely used before 1980 but the WHO no
longer recommends them due to their limited effectiveness and
short duration of protection
3. Live attenuated Single - dose oral vaccines : These vaccines are
available for people traveling to areas With cholera but are not
approved by the WHO for public health use
CONTD….

DUKORAL

• Monovalent
• Provided in 3 ml single dose vials together with
the bicarbonate buffer
• Primary immunization consist of 2 oral dose
given >7 days apart for adults and children
aged above 6 years
• Children aged 2-5 years should receive 3
doses>7 days apart
• Intake of food should be avoided for 1 hour
before and after vaccination
SANCHOL

• They are closely related oral cholera vaccine

that are based on serogroups O1 and O139
• Unlike DUKORAL these vaccines doesn’t
contain the bacterial toxin B subunit
therefore it does not require buffer
• Vaccine should be administered orally in
2 liquid doses 14 days apart for individuals
aged more than 1 years
• A booster dose is recommended after 2
years
EUVICHOL

It was pre-qualified In December 2015

And has the same characteristics as
SANCHOL
Referral and follow up
Referral Criteria

1. Severe Dehydration : Patients with severe dehydration, shock, or

life-threatening complications should be referred to a higher-level
healthcare facility.
2.Complicated Cholera: Patients with complicated cholera, such as
those with underlying medical conditions, pregnant women, or
children under 5 years, should be referred to a higher-level healthcare
facility.
3. Treatment Failure :Patients who do not respond to treatment or
experience treatment failure should be referred to a higher-level
healthcare facility.
Follow-up Care

Monitoring : Monitor patients for signs of dehydration,

electrolyte imbalance, and other complications. Fluid
Replacement: Continue fluid replacement therapy as needed
to maintain hydration and electrolyte balance.
• Antibiotics : Administer antibiotics as prescribed to treat
cholera
• Nutritional Support: Provide nutritional support to
help patients recover from malnutrition and dehydration.
 Role of nurse
1. Asses the patient condition
2. Triage patients
3. Administer oral rehydration solution
4. Administer intravenous fluids
5. Monitor vital signs
6. Monitor fluid status
7. Provide supportive care
8. Educate patients and families
9. Promote health and hygiene practices
10. Implement infection control measures
 Conclusion

Cholera is a highly infectious and potentially life-

threatening disease that requires prompt and effective
treatment. It is clear that a comprehensive approach,
including proper hydration, antibiotics, and nutritional
support, is essential for managing cholera cases.
Additionally, prevention measures such as improved
sanitation, hygiene, and vaccination play a critical role in
controlling outbreaks.