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Facilitator : Facilitator : Dr.NAVEEN Professor & HEAD, Department of Community Medicine Professor & HEAD, Department of Community Medicine Govt.MedicalCollegeHospital,Chandigarh. Introduction seriousacutediarrhoealbycholeraeTor)O139. I i h i d b dd f ff l l I t i sc h aracter i ze d by su dd pro f use, e ff ort l ess w ater y stoo l s, vomiting,rapiddehydration,cramps,acidosisandcirculatory collapse collapse

. Fatalityratesinuntreatedmayexceedcent. Inapparent Inapparent and wholly wholly asymptomatic omatic infections are are many y times times more and asympt infections man more frequentclinicallyrecognizedcases. History History Century, J Snowdia g g choleraoutbreakinLondoncit y y bypureobservationandanalysis. Hediscoveredhandpumpwasresponsibleforcholeraoutbreakcontrolledtheoutbreakbyclosure f andwatersupply. Hesucceede

ddesired before the causati e agent of cholera as discoered before the causati v e agent of cholera w as disco v ered . Ch l h b d i i h G Dl i i Ch o l era h as b en d em i c i nt h e G anges D e l ta s i nce i me immemorial. Th Th ere were l annua l id i ep id em i cs i i n W W est B l B enga l d an d Bangladesh. F F rom 8 6 h 1 8 192 6 ,t h e di di sease h h as d sprea d ld id wor ld w id e

resultinginsixpandemics. Si b Si xsu b sequent p d an d em i cs i kill kill e d d illi m illi ons f o f p l eop l e acrosscontinents. Th th d i ttd i Sth Ai i 6 d Th eseven th pan d em i cs t ar t e d i n S ou th A s i a i n19 6 1, an d reachedAfricain1971and1991.    cholerastrains TwoserogroupsofcholeraeO1andO139causeoutbreaks. V cholerae O O 1 1 causes causes the the majority majority of of outbreaks ou

tbreaks , while O 139 – first identified in V . cholerae while O 139 first identified in Bangladeshin1992confinedto Noncholeraecausediarrhoeabutgenerateepidemics. Newvariantstrains ( ( Tor ) ) havedetectedseveralparts Observations suggest that these strains cause more severe cholera with higher Observations suggest that these strains cause more severe cholera with higher rates. Carefulmonitoringcirculatingstr

ainsrecommended.    Problem Magnitude of Problem Estimated:to4.3caseseveryyear,to deaths per year worldwide due to cholera deaths per year worldwide due to cholera . Reported(toWHO):129064werenotifiedfrom47countries, including 2102 2 deaths deaths during 2013 . including 210 during 2013 . discrepancybetweenfiguresisduetofactthatmanycasesarerecordedforto:surveillancesystems fea r o f tradeandtravelsanctions

. INDI A : Since1964,followingintroductionofCholeraTor:“Home” Cholerai.e. W lostitsreputation Nonareasbecomefoci severe w highmortalit y becomeuncommon. Explosiveoutbreaksfollowingandfestivalsarenowrare. Idi I n di a: a bt b ou t 1,127cases (G u j j ra t , Mh M a h aras ht ht ra, K K arna t t a k k a, TN & & WB) (G t TN WB) reported2013. EpidemiologicalFeatures Eid d i d d i di E p id em i c, en d em i can

d pan d em i c di upon: ti f t d c h arac t er i s ti cs o f agen t an d characteristicsofthesystem(environment). cholera: Abrupt onset spread fast peak subsides gradually Abrupt onset , spread fast , peak , subsides gradually limiting:Acquisitiontemporaryimmunityoccurrenceofclinicalcases. Forceofinfection:throughwaterthroughcontacts. Epidemiologically, cholera due to El Tor biotype differs from classical Ep

idemiologically, cholera due to El Tor biotype differs from classical cholera.Tor Thereishigherincidenceofandasymptomaticinfection.thatthecharacteristicpicturericewaterstoolsandothersignscholeramaynotoften.TherearefewersecondaryinaffectedOccurrenceofchronicarecommon Torvibriossurvivelongerinextraintestinalenvironmentandhence epidemics continue longer epidemics continue longer aremoreresistantcholeravibrios. determinants E

pidemiological determinants Agent cholerae w firstisolatedin1883 y Kochfromstoolspatientscholera. a G G ram ti ti ve,aero bi bi comma h h ape d d ro d d . antigenicclassificationdependsspecificsomatic antigens antigens . flagellarantigenisnonspecificcommontoall.Ogawa,andHikojima: Both classical V .choleraebiot yp eElto r havedividedinto 3 serot yp es. yp yp ontheantigeniccomponents. Ri R es i stance choleraeby: Heatin

gat56°Cwit h h in 30 mins CoaldisinfectantsCresol,andpowder. Drying and sunshine for a few hours Drying and sunshine for a few hours . Commerciallypreparedacidic(pHorless)foodsarerisk. Gamma irradiation irr and and temperatures temper above abov 70 degrees degrees Celsius Celsius . . Gamma adiation atures e 70 �y cansurviveon v ariet y o f foodstuffs r u p fiveda y satambienttem p eratureand y p y p to

daysdegreesCelsius.organismcansurvivefreezing. L L ow h li i lif temperatures, h owever, li m i tpro lif erat i on f o f h i t h eorgan i sm d an d h t h us ma y preventlevelofcontaminationfromreachinganinfective Toxinproduction V ibrios multi p l y lumen f intestine py Produceenterotoxinswhichactadenylcyclasecyclicsystemofmucosalcellsproducediarrhoea.ReservoirinfectionHumanonly,caseorcarrier. areandasymptomatic The

The ratio ratio of of severe severe cases to to mild mild or or inapparent infections has been shown to to be be cases inapparent infections has been shown aboutforclassicalcholeraand1:25to:100forElTorcholera. Chronicarerare.Types:incubatorycarriers,convalescentcarriers,healthycarriersandcontactcarriers. Duration of carrier period is short about 4 or 5 days Duration of carrier period is short , about 4

or 5 days . Infective material : Infective material : Stoolsandvomitofcasescarriers. Carriers excrete fewer vibrios as compared to cases Carriers excrete fewer vibrios as compared to cases . Incubation period : Incubation period : todays,commonly2days.Periodcommunicability A choleraisinfectiousforperiodoftodays. Convalescentareinfectiousforweeks. Chroniccarrierstatema y fromtoyearsormore.            

                           Hostfactors Age: agesareaffected. di I n en d em i areas, hild renaremore ff ecte d . Sex: sexesareaffected sexesareaffected . Populationpilgrimages,fairs,festivalsEconomiclowerhygiene I I mmun i i ty: reinfection,durationdegreeknowneffectivebarrier. Environmentalfactors Contaminatedwaterandfoodareenvironmentalfactorsinofcholera. Fli V hl b f i Fli es ma y carr y V .c

h o l erae b arevectors f proven i mportance. factorsresponsiblefor li poor li teracy, hygiene, lii tdd d poor li v i ng s t an d ar d san d unhealthyinrelationtowaterfood.    Transmission M i d f ii i h h ll i d M ost i mportant mo d eo f transm i ss i on i st h roug h f aeca ll contam i nate d water Disease may spread through food contaminated by food handlers and flies Disease may spread through food c

ontaminated by food handlers and flies . Fruitsvegetableswashedcontaminatedwatermaytransmit the infection . the infection . Persontocontactparticularlyovercrowdeddwellingswithoutsanitaryveryduetocarelessexcretaunderconditions. Clinicalfeatures severityofcholeraonrapiditydurationoffluid loss loss cholerashowsstages Stageofevacuation 2 Stage of collapse 2 . Stage of collapse Stageofrecovery Stage of Evacuation : Stag

profuse,painless,watery(ricewater)diarrhoeafollowedbyvomiting.StageofCollapsepatientcollapsebecausedehydration.classicalsignsare:sunkeneyes,hollowcheeks, temperature,pulse,unrecordablepressure,loss skin elasticit shallo and quick respiration skin elasticit y, shallo w and quick respiration . urinarydecreasesandmayultimatelycease. Restless cramps in legs and abdomen and complains of intense thirst Restless , cra

mps in legs and abdomen and complains of intense thirst . Death mayoccurstage,todehydrationacidosisresulting from diarrhoea . from diarrhoea . StageofRecoverydoesoccur,beginstoshowsigns i i mprovement.bloodpressuretotemperaturereturnsto and urine output is re established and urine output is re established . If persists,mayrenalfailure. The The classical form form of of severe cholera occurs in only 5 10

percent of classical severe cholera occurs in only 5 10 percent of cases. In rest , , tendstobecharacterised y y diarrhoeavomitingormarkeddehydration. rule,recover3days. Lab diagnosis Stools V Water Food Lab methods : Lab methods : Directexaminationundermicroscopedarkfieldillumination Clt C u lt ureme th th o d d s Gramand Serological test e g Slide agglutination test Serological test e . g . Slide agglutination

test . Recentlydevelopeddipsticks(sensitivityspecificityabove92and 91 % , respectively) for for the rapid rapid detection of of Vibrio Vibrio cholerae serotypes serotypes 91 % , respectively) the detection cholerae O139fromrectalswabsbeensuccessfullytocholera. Management Management Q Q uic k restorationofbod y y fluidselectrol y y tes w ith a pp pp ro p p riateandadequatefluids. volumeofreplacementondegreedehydrationand

ratefluidloss. Antibiotics,oftenrequiredinmanagementseverecases,have h h own t t ore d d uce th th evo l l ume an d d d d ura ti ti on o f f di di arr h h oea. Doxycycline,singleof300orallyforthreedays Tetracycline 500 mg orally QID for three days Tetracycline , 500 mg orally QID for three days Forchildrenpregnantwomen,ErythromycinorAzithromycin.    PreventionControl I f i l i i I mprovement f env i ronmenta l s

an i tat i Adequatelychlorinatedandprotectedwatersupply, P di l f ih il/ d P roper di sposa l o f n i g h tso il/ sewage d Safefoodsupply. Hlth ti i i t t f i t f l hi H ea lth e d uca ti on i s i mpor t an t f or i mprovemen t o f persona l h yg i ene. Immunization: Whole cell killed vaccine Whole cell killed vaccine wholecellvaccine CVD 103 HgR live vaccine CVD 103 HgR live vaccine       Â

 Â Â Â Â Â Â Â Â Â  occurrence V erification NotificationEarlyfindingtreatmentcentres Rehydrationtherap y Adjunctstherapy Ep id id em i i o l l og i i ca l i l i nvest i i gat i i ons measures hi Ch emoprop h y l l ax i s Vaccination Hlth H ea lth e d d uca ti ti on        Keypointsforeducationcholera Key points for public education about cholera Topreventcholera: wateronlyfromsafesourceorwaterbeendisinfected(boiled

hl hl or i i nate d) d) Cookfoodreheatthoroughlywhileitis Boil milk before drinking Boil milk before drinking . AvoidicecreamsfromunreliablesourcesAvoiduncookedfoodbepeeled W you r afte r an y contactwithexcretabeforepreparing r food offexcretapromptlysafely Remember : Remember : propertreatmentcholerafatal Take p p with p p ectedcholeraimmediatel y y healthworke r fo r treatment Giveincreasedoffluidsasdiarrhoeasta