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Management of Cholera in Kenya


Date Posted: 6/21/2013 7:45:21 AM

Posted By: jvk  Membership Level: Silver  Total Points: 330


Cholera is an intestinal disease which is characterized by sudden onset of profuse watery stools and vomiting, leading to severe dehydration, acidosis and circulatory collapse.

Epidemiology of Cholera
It is caused by a small comma-shaped motile organism called vibrio cholerae. There are about four sub-strains of the cholera vibrio, namely,
El Tor, Ogawa, Luaba and Hikojima. The El Tor sub-strain causes cholera epidemics in
East Africa.
Cholera is transmitted through the fecal-oral route, mostly by water which has been contaminated with fecal matter. The vibrios are very sensitive to the hydrochloric acid found in the human stomach, and so a large number of organisms must be ingested for infection to occur.
Cholera occurs in all parts of the world where the living conditions are unsanitary.
The human being is the reservoir and host. Vibrios prefer brackish (salty) water. In seawater, the organisms can live even longer multiplying in crabs and shrimps. Vibrios also multiply in certain foods such as milk and boiled rice.

What is the role and importance of carriers?
The reservoir of infection in cholera is formed mainly by the carriers. For every clinical case of cholera there may be 50 - 100 asymptomatic carriers. Although the carriers excrete a smaller number of vibrios than the patients, they form the greatest danger to the community because of their sheer number and freedom of movement.

Clinical Features
Cholera has a short incubation period of two to three days. The vibrios remain in the digestive tract from where they cause water loss and electrolyte imbalance.

What signs and symptoms would lead you to suspect cholera?
Unlike typhoid, cholera is not a systemic infection and therefore fever is generally low or absent. Cholera progresses through the following three stages.

First Stage
This stage lasts for 3 - 12 hours. During this stage profuse watery stool is passed by the patient until

fecal matter disappears. The stool becomes almost clear fluid with flakes of mucus, giving it the classical rice-water stool appearance. Vomiting follows diarrhea. Initially the patient vomits food but soon after only clear fluid or rice-water is vomited. The patient develops severe cramps in the abdomen and limbs due to electrolyte loss.

Second Stage
The patient becomes severely dehydrated, the skin is cold, dry and inelastic. Blood pressure drops severely, and it may not be recordable. The pulse becomes weak and rapid, urine production ceases, patient collapses and may go into irreversible shock.

Third Stage
This is the stage of recovery. Some patients recover spontaneously or with treatment. The general condition rapidly improves, diarrhea becomes less profuse and the patient is able to take oral fluids.

Cholera should be suspected in any outbreak of diarrhea diseases. The diagnosis is made on clinical grounds and also through laboratory isolation of vibrio cholerae from a rectal swab, stool or vomitus specimen.

The management of cholera is easily done at health centre level and so there is no need to refer patients to hospital. This is because the main cause of death in cholera patients is dehydration. This can occur very quickly and early in an outbreak before the urgency of treatment is recognized. Therefore early re-hydration is the most important part of management.
Other measures taken in the management of cholera include the following:
• The immediate notification of district medical officer. Cholera is an internationally notifiable disease.
• Admission of patients in temporary treatment centres, such as school or church and the treatment of patients on "cholera beds", that is beds with a central hole through which the stools can pass into a bucket and measured.
• Barrier nursing and patient isolation should be practiced to prevent spread of
the disease.
• Disinfection of hospital equipment and proper disposal of stool and vomitus into a pit latrine or septic tanks.
Now move on to see more measures that are taken in the management of cholera.

Measures taken in the management of cholera also include the following:
• Immediate introduction of intravenous fluids to correct the severe fluid and electrolyte loss. If this is started in time it can save many cholera cases. As soon as a patient is able to drink, Oral Re-hydration Solution (ORS) should be given in water at a rate of 200 - 300ml per hour.
• Intravenous fluids for patients who are in shock or too weak to drink.
• Oral tetracycline, 500mg six hourly for five days. This speeds up recovery and prevents convalescent carrier state.
• Oral cotrimoxazole, two tablets 12 hourly for three days can also be
used effectively.

Prevention and Control
The following measures are useful in the prevention and control of cholera.
• Surveillance: early detection is central to the success of cholera control because it enables immediate action to be taken as soon as there is an outbreak of the disease. Surveillance leads to immediate notification of
an outbreak.
• Provision of clean safe water to the community can easily control cholera because it is mainly a water borne disease.
• Teaching and demonstrating to members of the community cheap and effective methods of purifying water at their home.
• Foods which can transmit cholera such as milk, should be pasteurized or boiled; raw or uncooked food should be avoided or washed in safe water, foods should be protected from flies and markets inspected.
Now move on to see more measures that are useful in the prevention and control of cholera.
Measures that are useful in the prevention and control of cholera also include.
• Encouraging the digging and use of pit latrines.
• Provision of chemoprophylaxis to all contacts of the patients including family, friends and visitors using oral tetracycline.
• Administering cholera vaccine to health care workers in contact with the patients during the epidemics.
• Enrolling the assistance of formal and informal community leaders to address negative cultures and customs that contribute to the spread of cholera. Such communities should be targeted with information, education and communication messages.

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