General Objective

To provide participants with basic medical knowledge in Diarrhoeal Diseases (DD) and basic principles forpreparedness and response to cholera and epidemic diarrhoeal diseases.

Specific Objectives

At the end of the session, participants will be familiar with:

➠ Clinical manifestations and diagnosis of DD

➠ Treatment options and prevention of DD

➠ Clinical practice in DD

➠ preparedness and detection of cholera

➠ appropriate response

➠ administration of treatment with the implementation of community

Content

Morbidity and mortality attributable to diarrheal disease in infants and young children can be reducedby a variety of preventive measures and by improved clinical management of those episodes that occur.Recent evidence indicates that the incidence of diarrheal disease can be diminished by decreasingexposure to enteropathogens that frequently are present in foods, and that the severity (purging rateand duration) and frequency of illness can be diminished by improving the host's nutritional status.

At the same time about 20% of those who are infected of cholera develop acute, watery diarrhoea

DDiiaarrrrhhooeeaall DDiisseeaasseess–– CChhoolleerraa

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(10–20% of these individuals develop severe watery diarrhoea with vomiting). If these patients arenot promptly and adequately treated, the loss of such large amounts of fluid and salts can leadto severe dehydration and death within hours. The case-fatality rate in untreated cases may reach30–50%.Treatment is straightforward (basically rehydration) and, if applied appropriately, should keep case-fatality rate below 1%.

➠ Clinical manifestations and Diagnosis of acute diarrhoea● Clinical evaluation● Laboratory evaluation● Prognostic Factors and differential diagnosis

➠ Treatment Options and Prevention● Rehydration● Supplemental Zinc Therapy, Multivitamins, and Minerals● Diet – Non specific antidiarrheal treatment● Prevention (water, sanitation and hygiene – vaccines)

➠ Clinical Practice in acute diarrhoea (adults, children)

➠ Cholera● New strategies: oral cholera vaccines● Case definition - confirmation● Improved preparedness and treatment (training of health workers, rehydration,

intravenous therapy, antibiotics, health education, vaccination, trade and travelrestrictions, mass chemoprophylaxis)

● Surveillance of patients with severe cholera

Methodology

➠ PPt Presentations

➠ Lecture/discussion format

➠ Case study

References

Clinical Manifestations and Diagnosis

Despite clinical clues, determining the causative agent of diarrhea in an individual patient on thebasis of clinical grounds alone is usually difficult.

Episodes of diarrhea can be classified into three categories:

Symptoms to the Causes of Acute Diarrhea

CLINICAL EVALUATION The initial clinical evaluation of the patient (see “Table: Levels of Dehydration in Children with

Acute Diarrhea” below) should focus on:

➠ Assessing the severity of the illness and the need for rehydration

➠ Identifying likely causes on the basis of the history and clinical findings

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AAccuuttee ddiiaarrrrhheeaa ● Presence of three or more loose, watery stools within 24 hours

DDyysseenntteerryy ● Bloody diarrhea, visible blood and mucus present

PPeerrssiisstteenntt ddiiaarrrrhheeaa ● Episodes of diarrhea lasting more than 14 days

FFeevveerr ● Common and associated with invasive pathogens

BBllooooddyy ssttoooollss ● Invasive and cytotoxin releasing pathogens● Suspect Enterohemorrhagic Escherichia (E.) coli (EHEC) infection

in the absence of fecal leukocytes● Not with viral agents and enterotoxins releasing bacteria

VVoommiittiinngg ● Frequently in viral diarrhea and illness caused by ingestion of bacterial toxins (e.g., Staphylococcus aureus).

Table: Linking the Main

Diarrhoeal Diseases

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Signs of dehydration in adults

➠ Pulse rate >90

➠ Postural hypotension

➠ Supine hypotension and absence of palpable pulse

➠ Dry tongue

➠ Sunken eyeballs

➠ Skin pinch

Laboratory Evaluation

For acute enteritis and colitis, maintaining adequate intravascular volume and correcting fluidand electrolyte disturbances take priority over the identification of the causing agent. Stool culturesare usually unnecessary for immunocompetent patients who present within 24 hours after the onsetof acute, watery diarrhea. Microbiologic investigation is indicated in patients who are dehydratedor febrile or have blood or pus in their stool.

Epidemiologic clues to infectious diarrhea can be found by evaluating the incubation period,

Table: Evaluation of the Acute Diarrhea Patient

HHiissttoorryy PPhhyyssiiccaall EExxaammiinnaattiioonn AAsssseessss DDeehhyyddrraattiioonn

● Onset frequency, quantity ● Body weight ● General appearance, alertness● Char‘acter - bile/blood/mucus ● Temperature ● Pulse and blood pressure● Vomiting ● Heart & respiratory rate ● Postural hypotension● Past medical history, ● Blood pressure ● Mucous membranes and tears

underlying medical conditions ● Sunken eyes, skin turgor● Epidemiological clues ● Capillary refill, jugular

venous pressure● Sunken fontanelle

Table: Levels of Dehydration in Children with Acute Diarrhea

CCaauuttiioonnaarryy nnoottee: Being lethargic and sleepy are not the same. A lethargic child is not simply asleep: the child’smental state is dull and the child cannot be fully awakened; the child may appear to be drifting intounconsciousness. In some infants and children, the eyes normally appear somewhat sunken. It is helpfulto ask the mother if the child’s eyes are normal or more sunken than usual. The skin pinch is less usefulin infants or children with marasmus or kwashiorkor, or obese children. Other signs that may be altered inchildren with severe malnutrition are described in section 8.1 of the World Health Organization (WHO)2005 Guideline.

NNoo DDeehhyyddrraattiioonn MMiilldd DDeehhyyddrraattiioonn SSeevveerree DDeehhyyddrraattiioonn((≥≥ 22 ssiiggnnss)) ((>> 22 ssiiggnnss))

● Alertness normal ● Restless or irritable ● Abnormally sleepy or lethargic● No sunken eyes ● Sunken eyes ● Sunken eyes● Normal drinking ● Drinks eagerly ● Drinking poorly or not at all● Immediate skin pinch ● Slow skin pinch (<2 sec) ● Very slow skin pinch (>2 sec)

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history of recent travel, unusual food or eating circumstances, professional risks, recent use ofantimicrobials, institutionalization, and human immunodeficiency virus (HIV) infection risks.

Stool analysis and culture costs can be reduced by improving the selection and testing of thespecimens submitted on the basis of interpreting the case information — such as patient history,clinical aspects, visual stool inspection, and estimated incubation period.

The identification of a pathogenic bacterium, virus, or parasite in a stool specimen from a childwith diarrhea does not indicate in all cases that it is the cause of illness.

Certain laboratory studies may be important when the underlying diagnosis is unclear ordiagnoses other than acute gastroenteritis are possible.

Measurement of serum electrolytes is only required in children with severe dehydration or withmoderate dehydration and an atypical clinical history or findings. Hypernatremic dehydrationrequires specific rehydration methods — irritability and a doughy feel to the skin are typicalmanifestations and should be sought specifically.

Prognostic Factors and Differential Diagnosis

Differential diagnosis of acute diarrhea in children

➠ Meningitis

➠ Bacterial sepsis

➠ Pneumonia

➠ Otitis media

➠ Urinary tract infection

Table: Prognostic Factors in Children

MMaallnnuuttrriittiioonn● Approximately 10 percent of children in developing countries are severely underweight.● Macronutrient or micronutrient deficiencies in children are related with more severe and

prolonged diarrhea.● A poor nutritional status causes an elevated risk for diarrheal death.

ZZiinncc DDeeffiicciieennccyy● Suppresses immune system function and is associated with an increased prevalence of persistent

diarrhea

PPeerrssiisstteenntt DDiiaarrrrhheeaa● Often results in malabsorption and significant weight loss, further promoting the cycle

IImmmmuunnoossuupppprreessssiioonn● Secondary to infection with HIV or other chronic conditions may have an increased risk for the

development of clinical illness, prolonged resolution of symptoms, or frequent recurrence ofdiarrheal episodes

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Treatment Options and Prevention

Rehydration

Oral rehydration therapy (ORT) is the administration of fluid by mouth to prevent or correctdehydration that is a consequence of diarrhea. ORT is the standard for efficacious and cost-effectivemanagement of acute gastroenteritis, also in developed countries.

Oral rehydration salt (ORS) solution is the fluid specifically developed for ORT. A more effective,lower-osmolarity ORS (with reduced concentrations of sodium and glucose, associated with lessvomiting, less stool output, and a reduced need for intravenous infusions in comparison withstandard ORS) has been developed for global use (see Table 4 in the original guideline document).The hypotonic WHO-ORS is also recommended for use in treating adults and children with cholera.ORT consists of:

➠ Rehydration – water and electrolytes are administered to replace losses

➠ Maintenance fluid therapy (along with appropriate nutrition)In children who are in hemodynamic shock or with abdominal ileus, ORT may be contraindicated.

For children who are unable to tolerate ORS via the oral route (with persistent vomiting),nasogastric (NG) feeding can be used to administer ORS.

Global ORS coverage rates are still less than 50%, and efforts must be made to improvecoverage.

Rice-based ORS is superior to standard ORS for adults and children with cholera, and can be usedto treat such patients wherever its preparation is convenient. Rice-based ORS is not superior tostandard ORS in the treatment of children with acute noncholera diarrhea, especially when foodis given shortly after rehydration, as is recommended to prevent malnutrition.

Supplemental Zinc Therapy, Multivitamins, and Minerals

For all children with diarrhea: 20 mg zinc for 14 daysZinc deficiency is widespread among children in developing countries. Micronutrient

supplementation — supplementation treatment with zinc (20 mg per day until the diarrhea ceases)reduces the duration and severity of diarrheal episodes in children in developing countries.

Supplementation with zinc sulfate (2 mg per day for 10 to 14 days) reduces the incidence ofdiarrhea for 2 to 3 months. It helps reduce mortality rates among children with persistent diarrhealillness. Administration of zinc sulfate supplements to children suffering from persistent diarrheais recommended by the WHO.

All children with persistent diarrhea should receive supplementary multivitamins and mineralseach day for 2 weeks. Locally available commercial preparations are often suitable; tablets that canbe crushed and given with food are least costly. These should provide as broad a range of vitaminsand minerals as possible, including at least two recommended daily allowances (RDAs) of folate,vitamin A, zinc, magnesium, and copper.

As a guide, one RDA for a child aged 1 year is:

➠ Folate: 50 micrograms

➠ Zinc: 20 micrograms

➠ Vitamin A: 400 micrograms

➠ Copper: 1 mg

➠ Magnesium: 80 mg

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Diet

The practice of withholding food for >4 hours is inappropriate. Food should be started 4 hoursafter starting ORT or intravenous fluid. The notes below apply to adults and children unless ageis specified.

GGiivvee::

➠ An age-appropriate diet — regardless of the fluid used for ORT/maintenance

➠ Infants require more frequent breast feedings or bottle feedings — special formulas ordilutions unnecessary

➠ Older children should be given appropriately more fluids

➠ Frequent, small meals throughout the day (six meals/day)

➠ Energy and micronutrient-rich foods (grains, meats, fruits, and vegetables)

➠ Increasing energy intake as tolerated following the diarrheal episode

AAvvooiidd::

➠ Canned fruit juices – these are hyperosmolar and can aggravate diarrhea.

➠ Probiotics are specific defined live microorganisms, such as Lactobacillus GG (American TypeCulture Collection [ATCC] 53103), which have demonstrated health effects in humans.

Nonspecific Antidiarrheal Treatment

None of these drugs addresses the underlying causes of diarrhea. Antidiarrheals have no practicalbenefits for children with acute/persistent diarrhea. Antiemetics are usually unnecessary in acutediarrhea management.

ANTIMOTILITY: LLooppeerraammiiddee is the agent of choice for adults (4 to 6 mg/day; 2 to 4 mg/dayfor children >8 years).

Should be used mostly for mild to moderate traveler’s diarrhea (without clinical signs ofinvasive diarrhea).Inhibits intestinal peristalsis and has mild antisecretory properties.Should be avoided in bloody or suspected inflammatory diarrhea (febrile patients).Significant abdominal pain also suggests inflammatory diarrhea (this is a contraindication forloperamide use).Loperamide is not recommended for use in children <2 years.

AAnnttiisseeccrreettoorryy aaggeennttss:: Bismuth subsalicylate can alleviate stool output in children or symptoms ofdiarrhea, nausea, and abdominal pain in traveler’s diarrhea.

RRaacceeccaaddoottrriill is an enkephalinase inhibitor (nonopiate) with antisecretory activity, and is nowlicensed in many countries in the world for use in children. It has been found useful in childrenwith diarrhea, but not in adults with cholera.

AAddssoorrbbeennttss:: Kaolin-pectin, activated charcoal, attapulgite. Inadequate proof of efficacy in acuteadult diarrhea

Antimicrobials

Antimicrobial therapy is not usually indicated in children. Antimicrobials are reliably helpful onlyfor children with bloody diarrhea (most likely shigellosis), suspected cholera with severe dehydration,

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and serious nonintestinal infections (e.g., pneumonia). Antiprotozoal drugs can be very effectivefor diarrhea in children, especially for Giardia, Entamoeba histolytica, and now Cryptosporidium,with nitazoxanide.

In adults, the clinical benefit should be weighed against the cost, the risk of adverse reactions,harmful eradication of normal intestinal flora, the induction of Shiga toxin production, and theincrease of antimicrobial resistance.

Antimicrobials are to be considered the drugs of choice for empirical treatment of traveler’sdiarrhea and of community-acquired secretory diarrhea when the pathogen is known (see Figure11 in the original guideline document).

Considerations with regard to antimicrobial treatment:

✒ Consider antimicrobial treatment for:● Persistent Shigella, salmonella, campylobacter, or parasitic infections● Infections in the aged, immunocompromised patients, and patients with impaired

resistance, sepsis, or with prostheses● Moderate/severe traveler’s diarrhea or diarrhea with fever and/or with bloody stools –

quinolones (co-trimoxazole second choice)

✒ Nitazoxanide is an antiprotozoal and may be appropriate for Cryptosporidium and otherinfections, including some bacteria.

✒ Rifaximin is a broad-spectrum, non-absorbed antimicrobial agent that may be useful.

Note well (N.B.):

➠ Erythromycin is hardly used for diarrhea today. AAzziitthhrroommyycciinn is widely available and has theconvenience of single dosing. For treating most types of common bacterial infection, therecommended azithromycin dosage is 250 mg or 500 mg once daily for 3 to 5 days. Azithromycindosage for children can range (depending on body weight) from 5 mg to 20 mg per kilogramof body weight per day, once daily for 3 to 5 days.

➠ QQuuiinnoolloonnee--rreessiissttaanntt CCaammppyylloobbaacctteerr is present in several areas of South-East Asia (e.g., inThailand) and azithromycin is then the appropriate treatment.

➠ Treatment for aammooeebbiiaassiiss should, ideally, include diloxanide furoate following the metronidazole,to get rid of the cysts that may remain after the metronidazole treatment.

➠ All doses shown are for oral administration. If drugs are not available in liquid form for use inyoung children, it may be necessary to use tablets and estimate the doses given in this table.

➠ Selection of an antimicrobial should be based on the sensitivity patterns of strains of Vibrio(V.) cholerae O1 or O139, or Shigella recently isolated in the area.

➠ An antimicrobial is recommended for patients older than 2 years with ssuussppeecctteedd cchhoolleerraa aannddsseevveerree ddeehhyyddrraattiioonn.

➠ Alternative antimicrobials for treating cholera in children are ttrriimmeetthhoopprriimm//ssuullffaammeetthhooxxaazzoollee(TMP-SMX) (5 mg/kg TMP + 25 mg/kg SMX, b.i.d. [twice a day] for 3 days), furazolidone (1.25mg/kg, q.i.d. [four times a day ] for 3 days), and norfloxacin. The actual selection of anantimicrobial will depend on the known resistance/sensitivity pattern of V. cholerae in theregion, which requires the availability of a well-established and consistent surveillance system.

➠ For adults with acute diarrhea, there is good evidence that an uullttrraasshhoorrtt ccoouurrssee ((oonnee oorr ttwwooddoosseess)) ooff cciipprrooffllooxxaacciinn or another fluoroquinolone reduces the severity and shortens theduration of aaccuuttee ttrraavveelleerr’’ss ddiiaarrrrhheeaa. This area is still controversial; use should be limited to high-risk individuals or those needing to remain well for short visits to a high-risk area.

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Prevention

WWaatteerr,, ssaanniittaattiioonn,, aanndd hhyyggiieennee::● Safe water● Sanitation: houseflies can transfer bacterial pathogens● Hygiene: hand washing

SSaaffee ffoooodd::● Cooking eliminates most pathogens from foods● Exclusive breastfeeding for infants● Weaning foods are vehicles of enteric infection

Micronutrient supplementation: the effectiveness of this depends on the child’s overallimmunologic and nutritional state; further research is needed.

VVaacccciinneess::

➠ Salmonella typhi: Two typhoid vaccines currently are approved for clinical use. No availablevaccine is currently suitable for distribution to children in developing countries.

➠ Shigella organisms: Three vaccines have been shown to be immunogenic and protective in fieldtrials. Parenteral vaccines may be useful for travelers and the military, but are impractical for usein developing countries. More promising is a single-dose live-attenuated vaccine currently underdevelopment in several laboratories.

➠ V. cholerae: Oral cholera vaccines are still being investigated, and their use is recommended onlyin complex emergencies such as epidemics. Their use in endemic areas remains controversial.In traveler’s diarrhea, oral cholera vaccine is only recommended for those working in refugeeor relief camps, since the risk of cholera for the usual traveler is very low.

➠ Enterotoxigenic E. coli (ETEC) vaccines: The most advanced ETEC vaccine candidate consists ofa killed whole cell formulation plus recombinant cholera toxin B subunit. No vaccines arecurrently available for protection against Shiga toxin-producing E. coli infection.

➠ Rotavirus: In 1998, a rotavirus vaccine was licensed in the USA for routine immunization ofinfants. In 1999, production was stopped after the vaccine was causally linked to intussusceptionin infants. Other rotavirus vaccines are being developed, and preliminary trials are promising.Currently, two vaccines have been approved: a live oral vaccine (RotaTeqì) made by Merckfor use in children, and GlaxoSmithKline’s Rotarixì.

➠ Measles immunization can substantially reduce the incidence and severity of diarrheal diseases.Every infant should be immunized against measles at the recommended age.

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Clinical Practice

Adults

Children

In 2004, WHO and UNICEF revised their recommendations for the management of diarrhea,including zinc supplementation as an adjunct therapy to oral rehydration. Since then, therecommendations have been adopted by more than 40 countries throughout the world. In countrieswhere both the new ORS and zinc have been introduced, the rate of ORS usage has dramaticallyincreased.

Table: The Approach in Adults with Acute Diarrhea

PPeerrffoorrmm iinniittiiaall aasssseessssmmeenntt PPrroovviiddee ssyymmppttoommaattiicc ttrreeaattmmeenntt ● Dehydration ● Rehydration● Duration (>1 day) ● Treatment of symptoms (if necessary consider ● Inflammation (indicated by fever, bloody stool, bismuth subsalicylate or loperamide if

tenesmus) diarrhea is not inflammatory or bloody)

SSttrraattiiffyy ssuubbsseeqquueenntt mmaannaaggeemmeenntt OObbttaaiinn ffeeccaall ssppeecciimmeenn ffoorr aannaallyyssiiss● Epidemiological clues: food, antibiotics, sexual ● If severe, bloody, inflammatory, or persistent

activity, travel, day-care attendance, diarrhea or if outbreak is suspectedother illness, outbreaks, season

● Clinical clues: diarrhea, abdominal pain, dysentery, wasting, fecal inflammation

CCoonnssiiddeerr aannttiimmiiccrroobbiiaall tthheerraappyy ffoorr ssppeecciiffiicc RReeppoorrtt ttoo ppuubblliicc hheeaalltthh aauutthhoorriittiieessppaatthhooggeennss ● In outbreaks save culture plates and isolates;

freeze fecal and food or water specimens at -70ÆC

● Notifiable in the USA: cholera, cryptosporidiosis,giardiasis, salmonellosis, shigellosis, andinfection with shiga toxin producing E. coli

Table: Principles of Appropriate Treatment for Children with Diarrhea and Dehydration

UUssee OORRSS ffoorr rreehhyyddrraattiioonn WWhheenn rreehhyyddrraattiioonn iiss ccoorrrreecctteedd -- rraappiidd rreeaalliimmeennttaattiioonn

Perform ORT rapidly – within 3 to 4 hours ● Age-appropriate unrestricted diet● Continue breastfeeding● Regular formula feeding

AAddmmiinniisstteerr aaddddiittiioonnaall OORRSS ffoorr oonnggooiinngg lloosssseess NNoo uunnnneecceessssaarryy llaabboorraattoorryy tteessttss oorr mmeeddiiccaattiioonnsstthhrroouugghh ddiiaarrrrhheeaa

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Treatment for Children Based on the Degree of Dehydration

The Therapeutic Approach to Acute Bloody Diarrhea (Dysentery) in Children

The main principles are: treatment of dehydration; stool cultures and microscopy to guidetherapy; and frequent smaller meals with higher protein intakes. (See Figure 15 in the originalguideline document for an algorithm for the therapeutic approach to acute bloody diarrhea[dysentery] in children.)

∏ome Management of Acute Diarrhea

With ORS, uncomplicated cases of diarrhea in children can be treated at home, regardless of theetiologic agent. Caregivers need proper instructions regarding signs of dehydration, when children

Table: Minimal or No Dehydration

NNoottee: If vomiting is persistent, the patient (child or adult) will not take ORS and is likely to need intravenousfluids.

RReehhyyddrraattiioonn tthheerraappyy RReeppllaacceemmeenntt ooff lloosssseess NNuuttrriittiioonn

None <10 kg body weight: 60 to 120 mL Continue breastfeeding or age-ORS for each diarrheal stool or appropriate normal dietvomiting episode

Table: Mild to Moderate

RReehhyyddrraattiioonn tthheerraappyy RReeppllaacceemmeenntt ooff lloosssseess NNuuttrriittiioonn

ORS 50 to 100 mL/kg body <10 kg body weight: 60 to 120 mL Continue breastfeeding, or ORS for each diarrheal stool or resume normal diet after vomiting episode initial rehydration

Table: Severe Dehydration

CCaauuttiioonnaarryy NNoottee: Treating a patient with severe dehydration due to infectious diarrhea with 5% dextrose with1/4 normal saline is unsafe. Severe dehydration occurs, usually as a result of bacterial infection (cholera,ETEC), which usually leads to more sodium loss in feces (60 to 110 mmol/L). A 1/4 normal saline solutioncontains sodium (Na) 38.5 mmol/L, and this does not balance the sodium losses. Intravenous infusion with5% dextrose with 1/4 normal saline will thus lead to severe hyponatremia, convulsion, and loss ofconsciousness. Five percent dextrose with 1/2 standard normal saline can only be used when Ringer’slactate is not available.

RReehhyyddrraattiioonn tthheerraappyy RReeppllaacceemmeenntt ooff lloosssseess NNuuttrriittiioonn

Rehydrate with Ringer’s lactate(100 mL/kg) intravenously within4 to 6 hours, then administer ORS

to maintain hydration untilpatient recovers

<10 kg body weight: 60 to 120 mL ORS for eachdiarrheal stool or vomitingepisode

Continue breastfeeding, orresume age-appropriate normaldiet after initial hydration

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appear markedly ill, or do not respond to treatment. Early intervention and administration of ORSreduces dehydration, malnutrition, and other complications and leads to fewer clinic visits andpotentially fewer hospitalizations and deaths.

SSeellff--mmeeddiiccaattiioonn in otherwise healthyadults is safe. It relieves discomfort and socialdysfunction. There is no evidence that itprolongs the illness.

IInn aadduullttss wwhhoo ccaann mmaaiinnttaaiinn tthheeiirr fflluuiidd iinnttaakkee,,OORRSS ddooeess nnoott pprroovviiddee aannyy bbeenneeffiittss.. IItt ddooeess nnoottrreedduuccee tthhee dduurraattiioonn ooff ddiiaarrrrhheeaa oorr tthhee nnuummbbeerrooff ssttoooollss. In developed countries, adults withacute watery diarrhea should be encouraged todrink fluids and take in salt in soups and saltedcrackers. Nutritional support with continuedfeeding improves outcomes in children.

Among hundreds of over-the-counterproducts promoted as antidiarrheal agents,only loperamide and bismuth subsalicylatehave sufficient evidence of efficacy and safety.

Principles of self-medication:

➠ Maintain adequate fluid intake.

➠ Consumption of solid food should beguided by appetite in adults — small lightmeals.

➠ Antidiarrheal medication with loperamide(flexible dose according to loose bowelmovements) may diminish diarrhea andshorten the duration.

➠ Antimicrobial treatment is reserved forprescription only in residents’ diarrhea orfor inclusion in travel kits (add loperamide).Family knowledge about diarrhea must be

reinforced in areas such as prevention,nutrition, ORT/ORS use, zinc supplementation,and when and where to seek care (see“Indications for In-Patient Care” above). Wherefeasible, families should be encouraged tohave ORS ready-to-mix packages and zinc(syrup or tablet) readily available for use, asneeded.

Cascades

A cascade is a hierarchical set of diagnosticor therapeutic techniques for the samedisease, ranked by the resources available.

Indications for Patient Care

● Caregiver’s report of signs consistent withdehydration

● Changing mental status● Young age (<6 months old or <8 kg body

weight)● History of premature birth, chronic medical

conditions, or concurrent illness● Fever >38ÆC for infants <3 months old or

>39oC for children 3 to 36 months old● Visible blood in stool● High-output diarrhea including frequent and

substantial volumes● Persistent vomiting, severe dehydration,

persistent fever● Suboptimal response to ORT or inability of

caregiver to administer ORT● No improvement in 48 hours - symptoms

exacerbate; overall condition gets worse

Table: Cascade for Acute Watery Diarrhea – Cholera-like, with Severe Dehydration

LLeevveell 11Intravenous fluids + antibiotics + diagnostic tests● Tests: tetracycline, fluoroquinolone or other +

stool microscopy/culture

LLeevveell 22Intravenous fluids + antibiotics● Empirical: tetracycline, fluoroquinolone or other

LLeevveell 33Intravenous fluids + ORS

LLeevveell 44Nasogastric tube ORS (if persistent) (vomiting)

LLeevveell 55Oral ORS

LLeevveell 66Oral ‘home made’ ORS● Salt, glucose, orange juice dissolved in water

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Cautions:

➠ If facilities for referral are available, patients with severe dehydration (at risk of acute renal failureor death) should be referred to the nearest facility with intravenous fluids (levels 5 and 6 cannotreplace the need for referral in case of severe dehydration).

➠ Levels 5 and 6 must be seen as interim measures and are better than no treatment if nointravenous facilities are available.

➠ When intravenous facilities are used, it must be ensured that needles are sterile and that needlesand drip sets are never reused, to avoid the risk of hepatitis B and C.

➠ Do not diagnose moderate dehydration as severe dehydration and thus initiate referral forintravenous feeding because oral rehydration is more time-consuming. It is in the mother’sinterest to avoid the unnecessary complications that may be associated with using intravenoustherapy.

Notes:

❶ Tetracycline is not recommended in children.

➋ Nasogastric (NG) feeding is not very feasible for healthy and active older children, but it issuitable for malnourished, lethargic children.

➌ NG feeding requires skilled staff.

➍ Often, intravenous fluid treatment is more easily available than NG tube feeding.

➎ NG feeding (ORS and diet) is especially helpful in long-term severely malnourished children(anorexia).

Table: Cascade for Acute Watery Diarrhea, with Mild/Moderate Dehydration

LLeevveell 11Intravenous fluids (consider) + ORS

LLeevveell 22Nasogastric tube ORS (if persistent vomiting)

LLeevveell 33Oral ORS

LLeevveell 44Oral “home made” ORS● Salt, glucose, orange juice dissolved in water

Table: Acute Bloody Diarrhea, with Mild/Moderate Dehydration

LLeevveell 11Oral ORS + antibiotics consider for:● S. dysenteriae● E. histolitica● Severe bacterial colitis + diagnostic tests● Stool microscopy, culture

LLeevveell 22Oral ORS + antibiotics consider for:● Empirical antibiotics for moderate/severe illness

LLeevveell 33Oral ORS

LLeevveell 44Oral “home made” ORS● Salt, glucose, orange juice dissolved in water

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Benefits/Harms of implementing the guidelines recommendatios

Potential Benefits

➠ Appropriate diagnosis, treatment, and management of acute diarrhea in children and adults

➠ Reduced morbidity and mortality from acute diarrhea

Potential Harms

➠ Antimicrobials: In adults, the clinical benefit of antimicrobials should be weighed against thecost, the risk of adverse reactions, harmful eradication of normal intestinal flora, the inductionof Shiga toxin production, and the increase of antimicrobial resistance.

➠ Tetracycline is not recommended in children.

➠ Loperamide should be avoided in bloody or suspected inflammatory diarrhea (febrile patients).

➠ Use of ciprofloxacin or another fluoroquinolone is still controversial; use should be limited tohigh-risk individuals or those needing to remain well for short visits to a high-risk area.

➠ Diarrhea vaccine use remains controversial.

Cholera is a diarrhoeal disease caused by infection of the intestine with the bacterium Vibriocholerae, either type 01 or 0139. Both children and adults can be infected.

About 20% of those who are infected develop acute, watery diarrhoea – 10–20% of theseindividuals develop severe watery diarrhoea with vomiting. If these patients are not promptly andadequately treated, the loss of such large amounts of fluid and salts can lead to severe dehydrationand death within hours.

The case-fatality rate in untreated cases may reach 30–50%.Treatment is straightforward (basically rehydration) and, if applied appropriately, should keep

case-fatality rate below 1%.Cholera is usually transmitted through faecally contaminated water or food and remains an ever-

present risk in many countries.New outbreaks can occur sporadically in any part of the world where water supply, sanitation,

food safety, and hygiene are inadequate. The greatest risk occurs in over-populated communitiesand refugee settings characterized by poor sanitation, unsafe drinking-water, and increased person-to-person transmission. Because the incubation period is very short (2 hours to 5 days), the numberof cases can rise extremely quickly.

It is impossible to prevent cholera from being introduced into an area – but spread of the diseasewithin an area can be prevented through early detection and confirmation of cases, followed byappropriate response. Because cholera can be an acute public health problem – with the potentialto cause many deaths, to spread quickly and eventually internationally, and to seriously affect travel

Cholera

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and trade – a well coordinated, timely, and effective response to outbreaks is paramount. Responseactivities should always be followed by the planning and implementation of preparedness activitiesthat will allow future cholera outbreaks to be dealt with more effectively.

A strong cholera preparedness plan and programme is the best preparation for outbreaks incountries at risk of cholera, whether or not they have yet been affected, or countries in whichseasonal recurrence of the disease may be expected.

New Strategies: Oral Cholera Vaccines

In the long term, improvements in water supply, sanitation, food safety and community awarenessof preventive measures are the best means of preventing cholera, as well as other diarrhoealdiseases. However, WHO is currently evaluating the use of newer tools to complement thesetraditional measures. Oral cholera vaccines of demonstrated safety and effectiveness have recentlybecome available for use by individuals. Some countries have already used oral vaccine to immunizepopulations considered to be at high risk for cholera outbreaks. Use of these vaccines in bothendemic and epidemic situations requires further assessment.

Work is under way to investigate the role of mass vaccination as a public health strategy forprotecting at-risk populations against cholera. Issues being addressed include logistics, cost, timing,vaccine production capacity, and criteria for the use of mass vaccination to contain and preventoutbreaks.

Case Definition

It is most important to ascertain that all patients considered to be cholera cases in fact have thesame disease. According to the WHO case definition, a case of cholera should be suspected when:

� in an area where the disease is not known to be present, a patient aged 5 years or moredevelops severe dehydration or dies from acute watery diarrhoea;

� in an area where there is a cholera epidemic, a patient aged 5 years or more develops acutewatery diarrhoea, with or without vomiting.

A case of cholera is confirmed when Vibrio cholerae O1 or O139 is isolated from any patient withdiarrhoea.

In children under 5 years of age, a number of pathogens can produce symptoms similar to thoseof cholera, such as rice-water diarrhoea. To maintain specificity, therefore, children under 5 arenot included in the case definition of cholera.

Laboratory Confirmation

The treatment of dehydrated patients should not be delayed until laboratory testing of samples hasbeen completed. Microbiological confirmation of Vibrio cholerae by direct observation can beobtained immediately, but it usually takes 2 days to get culture results. It is important to gatherinformation on:

� serogroup of Vibrio (O1 or O139);

� antimicrobial sensitivity patterns.

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Improved Preparedness and Treatment

TTrraaiinniinngg ooff hheeaalltthh wwoorrkkeerrss is an essential element for preparedness, especially in high-risk areas.Emergency supply needs should be evaluated in the light of the particular situation:

� likely attack rate in refugee camps, with high-risk populations (because of malnutrition), is5-8%;

� in open settings, an attack rate of 0.2% might be used;

� in rural communities of 5000 people or less, the attack rate might reach 2%.Emergency stocks of basic supplies should be prepared so that they can be mobilized quickly.

Rehydration

Rehydration with replacement of electrolytes lost is the mainstay of cholera treatment.According to the dehydration stage (A, B, C), the patient should receive different rehydrationtherapy (oral or intravenous fluids). Oral rehydration solution (ORS) should be used during and afterIV therapy. Surveillance of the patient is crucial during the early stage of treatment.

Intravenous Therapy for Severe Cases

Ringer’s lactate is the preferred IV fluid. Normal (9%) saline or halfnormal saline with 5% glucosecan also be used, but ORS solution must be given at the same time to replace the missingelectrolytes. Plain glucose solution is not effective in rehydrating cholera patients.

When IV rehydration is not possible and the patient cannot drink, ORS solution can be givenby nasogastric tube. However, nasogastric tubes should not be used for patients who areunconscious.

DDeehhyyddrraattiioonn ssttaaggee SSiiggnnss TTrreeaattmmeenntt

Severe

Mild

No dyhydration

Lethargic, unconscious, floppyVery sunken eyesDrinks poorly, unable to drinkMouth very dry Skin pinch goes back veryslowly No tears (only for children)

Restless and irritable Sunken eyes Dry mouth Thristy, drinks eagerly Skin pinch goes back slowly No tears (only for children)

None of the above signs

IV therapy +antibiotics +ORS +

ORS +

very close

surveillance

ORS at home

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Antibiotics

They should be given only in severe cases, to reduce the duration of symptoms and carriage ofthe pathogen.

Antimicrobial resistance is increasing. In most countries Vibrio cholera is resistant to co-trimoxazole; in some settings it has also developed resistance to tetracycline. The laboratory shouldbe asked about patterns of resistance of the strain at the beginning of and during the outbreak:antibiotic sensitivity to antibiotics may return after a certain period.

Mass chemoprophylaxis is not effective in controlling a cholera outbreak.Selective chemoprophylaxis (one dose of doxycycline) may be useful for members of a household

who share food and shelter with a cholera patient. However, in societies where intimate socialmixing and the exchange of food between households are common, it is difficult to identify closecontacts. Nevertheless, chemoprophylaxis may be useful when a cholera outbreak occurs in a closedpopulation, such as a prison.

Health Education

The most important messages to prevent the family from being contaminated are:

ENSURE A SAFE SUPPLY OF WATERAccess to safe water is a basic requirement for health, and it is more critical when there is an

outbreak of diarrhoeal disease. Since contaminated water can be the source of cholera and epidemicdysentery, every effort must be made to provide safe drinking- water, and safe water for foodpreparation and for personal hygiene.

Each person should have at least 20 litres of water a day for drinking, cooking and washing.Health facilities need 40-60 litres per patient a day to maintain adequate levels of hygiene. Everyfamily should know how to treat water so that it will be safe for drinking.

Piped water, or water that is delivered in trucks or drums, must be adequately chlorinated.Environmental sanitation workers can test water to be sure that the amount of chlorine is adequate.

Other sources of water are usually contaminated (e.g. rivers, shallow wells), so you must takemeasures to reduce the risk of people becoming ill. You may have to close the water source orprovide another source of safe water. If that is not possible, be sure that people using the waterknow how to make it safe.

FOOD SAFETYCholera and dysentery can be transmitted through contaminated food. Food may be

contaminated before, during or after preparation. Raw or undercooked seafood, and foods cookedand then kept at room temperature for several hours are especially dangerous. Fruits and vegetablesmay be contaminated if they were fertilized with human waste (nightsoil), irrigated withcontaminated water or “freshened” with contaminated water.

HAND WASHINGPeople can prevent the transmission of cholera and dysentery by washing their hands. Careful

and frequent hand-washing is especially important to stop the transmission of dysentery. If soapis expensive, or not available, ashes or mud can be used instead. Children, as well as adults, shouldwash their hands.

Hand Washing is highly recommended:

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➠ after defecation

➠ after any contact with stools (cleaning up after children or patients)

➠ before preparing food

➠ before eating food

➠ before feeding children.

ENVIRONMENTAL SANITATIONIn the long term, cholera and dysentery will become rare as environmental hygiene and water

supplies improve. However, in areas where sanitation is poor, you must use temporary measures toguarantee that stools are disposed of safely when there is an outbreak of diarrhoeal disease.

The methods to apply are:

➠ not to defecate on the ground or near a water supply

➠ to wash hands with soap or ash after any contact with stools

➠ to dispose of children’s stools in toilets, in latrines, or to bury the stools

➠ to build and use latrines

➠ if there is no latrine, to bury the stools away from water sources, as a temporary measure.

➠ safe practices at funerals (discourage ritual washing of the dead, hold the funeral soon afterdeath ensure that people who clean up and prepare the body in the hospital do not preparefood or serve food etc)

INEFFECTIVE CONTROL MEASURES The measures described in this section do not stop the spread of epidemics. However, pressure

to use them may come from a frightened public or from uninformed officials. When ineffectivemeasures are carried out, it gives a false sense of security, and wastes time and resources that couldbe used on efforts that are truly effective.

VVaacccciinnaattiioonn:: No vaccine currently exists for Shigella dysenteriae type 1. The old parenteral choleravaccine is not recommended. Two new oral cholera vaccines offer high-level short-termprotection; they are available for use in travellers in a few countries, but are not yetrecommended for large scale public health use.

TTrraaddee aanndd ttrraavveell rreessttrriiccttiioonnss ((ccoorrddoonn ssaanniittaaiirree)):: It is not possible to detect and isolate all infectedtravellers, most of whom have no signs of illness. A cordon sanitaire requires setting up check-posts and restricting movement. This diverts substantial resources from more effective controlmeasures. Trade and travel restrictions disrupt the economy of an area, which may encouragesuppressing information about outbreaks.

MMaassss cchheemmoopprroopphhyyllaaxxiiss ffoorr cchhoolleerraa:: Mass chemoprophylaxis – treating an entire community withantibiotics – does not limit the spread of cholera. In some places, it contributed to making thevibrio resistant to antibiotics, which deprives severely ill patients of a valuable treatment.Selective chemoprophylaxis is usually not recommended. It is justified only if surveillance showsthat the secondary attack rate in the community is high (an average of at least one householdmember in five becoming ill after the first case occurs in the household). If selectivechemoprophylaxis is used, it should be given to all close contacts as soon as possible after theinitial case is recognized. The prophylactic dose of antibiotics is the same as the therapeutic dose.Doxycycline is preferred because only a single dose is needed.

AAnnttiibbiioottiicc cchheemmoopprroopphhyyllaaxxiiss ffoorr ddyysseenntteerryy:: Giving people antibiotics for dysentery before theybecome ill does not prevent dysentery and worsens the problem of antibiotic resistance. Itshould never be done.

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Surveillance of Patients with Severe Cholera

Surveillance and regular reassessment of patients for the following are crucial:

➠ pulse;

➠ dehydration signs;

➠ number and appearance of stools;

➠ respiratory rhythm;

➠ temperature (cholera usually provokes hypothermia – if the temperature is high there maybe associated pathology, e.g. malaria);

➠ urine (present or not);

➠ state of consciousness.

Complications

➠ ppuullmmoonnaarryy ooeeddeemmaa if excessive IV fluid has been given;

➠ rreennaall ffaaiilluurree if too little IV fluid is given;

➠ hhyyppooggllyyccaaeemmiiaa and hhyyppookkaallaaeemmiiaa in children with malnutrition rehydrated with Ringerlactate only.

ñ Centers for Disease Control and Prevention. Managing acute gastroenteritis among children: oral

rehydration, maintenance, and nutritional therapy. Atlanta, GA: Centers for Disease Control and Prevention

– Federal Government Agency [U.S.]. 2003 Nov 21.

ñ UNICEF/WHO. Clinical management of acute diarrhea: UNICEF/WHO Joint Statement, May 2004

http://www.who.int/child-adolescent-health/New_Publications/CHILD_HEALTH/ISBN_92_4_159421_7.pdf

ñ World Health Organization. Production of zinc tablets and zinc oral solutions: guidelines for programme

managers and pharmaceutical manufacturers. Geneva: World Health Organization http://www.who.int/

child-adolescent-health/publications/CHILD_HEALTH/ISBN_92_4_159494_2.htm

ñ World Health Organization. The treatment of diarrhea: a manual for physicians and other senior health

workers, 4th rev. ed. Geneva: World Health Organization, 2005 http://www.who.int/child-adolescent-

health/New_ Publications/CHILD_HEALTH/ISBN_92_4_159318_0.pdf

ñ The treatment of diarrhoea – a manual for physicians and other senior health workers. Geneva, World

Health Organization, 1995 (WHO/CDR/95.3).

ñ WHO recommended strategies for prevention and control of communicable diseases. Geneva, World

Health Organization, 2001 (WHO/CDS/CPE/SMT/2001.13).

ñ Hanquet G. Refugee health – an approach to emergency situations. London, Médecins Sans

Frontières/Macmillan, 1997.

ñ Guidelines for cholera control. Geneva, World Health Organization, 1993.

ñ Guidelines for the collection of clinical specimens during field investigation of outbreaks. Geneva, World

Health Organization, 2000 (WHO/CDS/CSR/EDC/2000.4).

ñ Handbook for emergency field operations. Geneva, World Health Organization, 1999 (EHA/FIELD/99.1).

References

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Read the descriptions and then write brief answers to the questions (write key words instead ofcomplete sentences). You may look in your modules, if you need help in answering the questions.Notify the facilitator if you cannot understand a question, and when you have finished. There willbe a discussion afterwards.

Background

Rivas District has a population of 100 000. About half the people live in Rivas Town, and theothers live in scattered villages. The town, which has piped water and sewerage, includes a verycrowded neighbourhood, Bayside, where sanitation is poor and there is no trained health worker.Village A is a prosperous farming village, with a well-functioning health centre. Most families havelatrines and get water from a borehole. Some people in Village A use shallow wells during the rainyseason (October to March) because the wells are closer than the borehole. Village B (about 5000people) is further from the town, on poor roads, and has a health post staffed by a nurse whohas not been trained in case management of diarrhoea in years. The nurse is unhappy at beingposted to a rural clinic, and often escapes to town. Water is from shallow wells and the river, andvery few families have latrines.

The district shares a border with the neighbouring country, and there is much traffic across theborder, especially during the yearly festival in Rivas Town. There was an outbreak of cholera in 1991,but none has been reported since then. The District Medical Officer wants to be sure the districtis ready if another outbreak occurs.

Q 1: What are the main things that should be done to prepare for an outbreak?

Q 2: If cholera or epidemic dysentery should appear in the district, are there groups or individualsat high risk of getting ill? Are there any at high risk of dying, once they are ill? Name themand explain why you think they are at risk.High risk of getting ill: High risk of dying once ill:

Week of 9-15 January

The District Medical Officer has made an Epidemic Preparedness Plan. On Monday, the DistrictMedical Officer gets a phone call from the nurse in village A. The nurse is concerned because a 4-year-old boy from the village presented to the clinic with severe dehydration caused by acute waterydiarrhoea, and died while being treated.

Q 3: Should the District Medical Officer start the Epidemic Preparedness Plan?Explain why or why not.

The nurse from village A calls again on Tuesday. She has treated the sister, the mother andthe father of the boy who died, all for acute watery diarrhoea. She has also treated 6 other peoplefrom village A for acute watery diarrhoea. The District Medical Officer asked the nurse to tellhim the age of each patient, their degree of dehydration and the outcome of their treatment.These were the cases:

Case Study Rivas Distict outbreak

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Q 4: On the list above, put a check next to each patient who meets the casedefinition forreporting a case of cholera.

Q 5: Should the District Medical Officer start the Epidemic Preparedness Plan?Explain why or why not.

The District Medical Officer decided to call a meeting of the Epidemic Control Committee.

Q 6: What four things do you think the Epidemic Control Committee should do first?

Q 7: What are the duties of the Epidemic Control Committee?

Week of 16-22 January

There have been more cases of cholera in village A. The nurse and the DistrictMedical Officer investigated the cases in village A. They found that, about a week before the

four-year-old became ill, he and his family had attended the funeral in village B of a man whodied of diarrhoea. The District Medical Officer checked the records, and found that the nurse postedto village B had not sent in any reports for two months.

Q 8: What should the District Medical Officer do?

Q 9: What control measures should NOT be carried out?

Week of 23-29 January

The District Medical Officer receives a laboratory report that confirms cholera.The Rivas Epidemic Control Committee decides to send a Mobile Control Team to village B to

open a Temporary Treatment Centre.

Q 10: What should the team look for when choosing a site for the Temporary Treatment Centre?

When they arrived in village B, the Mobile Control Team found that cases that met the choleracase-definition had been occurring there since before the first cases in village A. The first cases invillage A happened in the week of 9-15 January. The team made this table:

PPaattiieenntt DDeeggrreeee ooff ddeehhyyddrraattiioonn OOuuttccoommee

14-year-old sister severe recovered50-year-old father mild recovered

45-year-old mother moderate recovered20-year-old woman severe recovered

28-year-old man moderate recovered5-year-old boy severe recovered

10-month-old girl severe recovered65-year-old man severe died3-year-old boy mild recovered

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Q 11: In what week was there the highest number of deaths? In what week did patients with suspected cholera have the greatest risk of dying?

Q 12: How could the deaths have been prevented?

Cholera has arrived in Rivas Town and is spreading in the crowded Baysideneighbourhood. The town officials urge the District Medical Officer not to say there is an

outbreak, because the town’s yearly festival is only two weeks away, and they fear that people willnot come when there is news of an outbreak.

Q 13: What should the District Medical Officer do?

The epidemic has declined in villages A and B, but continues in the town. Water testing hasshown that the town’s piped water is not sufficiently chlorinated. An environmental healthtechnician also discovered that people in bayside area had dug holes down to the water mains andpierced the mains. This created little wells” from which they got water. It also allowedcontamination into the water mains.

Q 14: What should be done?

Teams were sent to Bayside to look for patients and to educate the community there onprevention measures. These are the problems that the team found:a. the residents could not afford soapb. the residents could not afford the fuel needed to boil their waterc. men who worked far from home usually carried a home-cooked lunch with them to work, and

ate the lunch 6-8 hours after it had been cooked.

Q 15: What advice should the team give to solve each problem?a. (soap)b. (fuel needed to boil the water)c. (home-cooked lunch eaten 6-8 hours after it had been cooked).

Week of 6-12 January

The District Medical Officer did send notification of the urban outbreak of cholera, and beganan intensive health education campaign. Many people came to the festival, although fewer than inthe past. Many visitors arrived from the neighbouring country.

Q 16: What precautions should be observed to safeguard the health of the people who attend thefestival?

VViillllaaggee BB 22--88 JJaann 99--1155 JJaann 1166--2222 JJaann 2233--2299 JJaann

Cases 15 50 65 51Deaths 3 5 3 0

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Health officials in the neighbouring country got news of the cholera outbreak the day beforethe festival ended. They read about it in the newspaper and immediately ordered border guardsto screen all returning travellers for signs of diarrhoea, and to isolate those who were ill.

Q 17: Will this keep the outbreak from spreading? Explain your answer.

Week of 13-19 January

The outbreak ended.

Q 18: What should the District Medical Officer and the communities involved do now?

General Objective

To provide participants with basic principles of setting up a Cholera Treatment Center (CTC).

Specific objectives

At the end of the exercise, participants will be familiar with:

➠ Screening, admission and observation

➠ Hospitalisation of severely dehydrated patients

➠ Recovery

➠ Neutral area

➠ Mortuary

➠ Water, Hygiene and Sanitation

Content

Case scenario:A Cholera outbrake occur in a big slum close to your mission area.Your team has set up a Cholera Treatment Center behind the local hospital.You are about to screen and treat a few thousands the next weeks. A few of them should be

admitted for parenteral support. Design an overall map of the CTC and try to find practical ways to make better use of the space.

FIELD EXERCISE Cholera Treatment Center – Setting up a CTC

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Design and architecture of a CTC: the principles

Organisation and design of a CTC are based on simple principles and rules. Patients are firstscreened and diagnosed, then sent to specific areas for treatment according to their status. The CTCis organised in separate areas, following two key principles:

➠ IIssoollaattiioonn ooff tthhee eennttiirree ffaacciilliittyy from other public structures (dispensary, school, market)

➠ SSeeppaarraattiioonn ooff ppaattiieennttss (contaminated area) ffrroomm tthhee ““nneeuuttrraall aarreeaa”” (not contaminated)

Screening, admission and observation

Patients are examined by a medical person for screening. If cholera, admit; otherwise send tonormal dispensary.

Patients are admitted with 11 aatttteennddaanntt (caregiver).Patients who are admitted are registered (cholera register).Moderate or mild cases receive oral rehydration therapy in observation where they stay under

medical observation for 66 hhoouurrss. Patients stay under tents or shelters, on mats or benches andwill be discharged directly from there.

Severely dehydrated persons or those with uncontrollable vomiting should be hospitalizeddirectly: see hospitalization

Hospitalisation of severely dehydrated patients

Patients with severe dehydration and/or uncontrollable vomiting must be hospitalized forimmediate rehydration.

Each patient lies on a ppiieerrcceedd bbeedd with 1 bucket for stool collection underneath + 1 bucket forvomit besides the bed.

PPaattiieennttss nneeeeddiinngg ssppeecciiffiicc mmaannaaggeemmeenntt ((cchhiillddrreenn,, eellddeerrllyy,, pprreeggnnaanntt wwoommeenn)) sshhoouulldd bbee rreeggrroouuppeeddiinn ssppeecciiffiicc wwaarrddss..

Do not exceed 20 patients per ward.

SSuussppeecctt ppaattiieenntt == ssccrreeeenniinngg ++ OORRSS

mmeeddiiccaall eexxaammiinnaattiioonn

No dehydrationNo diarrhea No vomiting

No

Send to normaldispensarey

Simple cholera

Oral rehydration

Severe cholera

Immediate IV rehydration

No dehydration or mild dehydration

Mild / moderate diarrhea and / or vomiting

Severe dehydration or

uncontrollable vomiting

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Recovery

For oral rehydration after hospitalisation when less surveillance is required. Patients stay on matsor benches, as in the observation area.

Neutral area

Includes office space, rest area, changing room for staff, pharmacy and logistic stores, waterstorage, preparation of chlorine solutions, kitchen.

Logistic store and pharmacy must be organized ttoo eennssuurree aatt lleeaasstt 77 ddaayyss aauuttoonnoommyy.In case of reduced access/security constraints, stocks should be increased to aavvooiidd aannyy sshhoorrttaaggee.

Mortuary

Must be isolated from other areas.

Water, Hygiene and Sanitation

➠ 60 litres of safe (chlorinated) water are needed per 1 CTC patient per day (this includes needsfor drinking water, food, hygiene of the patient and the caregiver).

➠ S u fficient storage capacity for 3 days must be ensured in order to avoid any shortage.

➠ Label and clearly differentiate each container (drinking water, ORS, chlorine solutions).

➠ 0.05% chlorine for hand washing, dish rinsing and bathing of soiled patients, 0.2% chlorinefor disinfecting floors, beds, clothes and footbaths, and 2% for disinfecting of vomit, faecesand corpses.

Hospitalisation wards

20 patients per ward

Morgue Recovery

Waste area

Neutral areaStore, Office, Kitchen,

Staff Entry

ScreeningAdmission

EEnnttrryy

Observation area = ORS

EExxiitt