Cholera is an acute diarrheal illness caused by the bacteria Vibrio cholerae. It causes severe watery diarrhea that can lead to dehydration and death if untreated. It kills an estimated 95,000 people each year and infects 2.9 million more. The infection is often mild or without symptoms but sometimes can be severe and life threatening. Treatment involves oral and intravenous rehydration. Antibiotics are also given to help reduce duration of diarrhea. Prevention focuses on drinking safe water, hand washing, and vaccination.

2. INTRODUCTION
 Cholera is an acute diarrheal illness caused
by infection of the intestine with the bacteria
Vibrio cholerae.
 Cholera is an infectious disease that causes
severe watery diarrhea, which can lead to
dehydration and even death if untreated.

3. INCIDENCE
 Cholera has become an increasing public
health concern around the world.
 It kills an estimated 95,000 people each year
and infects 2.9 million more

4. DEFINITION
 Cholera is an acute, diarrheal illness caused
by infection of the intestine with the
bacterium Vibrio cholerae.
 It is spread by ingestion of contaminated food
or water.
 The infection is often mild or without
symptoms, but sometimes it can be severe
and life threatening.

5. INCIDENCE

6. AGENT
• V cholerae is
– comma-shaped,
– gram-negative aerobic or facultative anaerobic
bacillus
– bacillus that varies in size from 1-3 µm in length
by 0.5-
0.8 µm in diameter

9. • Its antigenic structure consists of
–flagellar H antigen
–somatic O antigen
 Bacteria are easily destroyed by coal
tar disinfectants such as cresol and
bleaching powder.

10.  The vibrios multiply in the lumen of the small
intestine and produce an exotoxin
(enterotoxin).


11. HOST FACTORS
1. Age: Children: 10x more susceptible than
adults, And Elderly also higher susceptible.
2. Sex:Equal in both male and female.
3. Immunity: Less immune higher risk.
4. People with low gastric acid levels
5. Blood types
 O>> B > A >AB.

12.  Highest in the lower socioeconomic
groups.
 Movement of population(pilgrimages,
marriages, fairs and festivals) results in
increased risk of exposure to infection.

13. ENVIRONMENTAL FACTORS
 Contaminated water and food.
 Certain human habit favoring water
and soil pollution.
 Low standard of personal hygiene.
 Lack of education and poor quality of
life.

14. INFCTIVE MATERIAL
 The immediate source of
infection are the stools and vomit
of cases & carriers.

15. INCUBATION PERIOD
 From a few hours up to 5 days, but commonly
1-2 days.

16. MODE OF TRANSMISSION
 Feacally contaminated water.
 Contaminated food and drinks
 Direct contact.

17. • Rare in developed countries
• Common in Asia, Africa, & Latin America
Poor sanitary
conditions
• Contaminated seafood, even in developed
countries.
• Especially shellfish.
• People with low levels of stomachacid
• Such as children, older adults, and some
medications.
• Reasons aren't entirely clear
• Twice more likely
Raw or undercooked
food
Hypochlorhydria
Type O blood
RISK FACTORS

18. VIRULENCE &PATHOGENICITY
Ingestion of V.cholerae
Resistant to gastric acid
Colonize small intestine
Virulence of Non-toxigenic V.cholera O1 strain not well understood

19. Enterotoxin binds to intestinal cells
Chloride channels activated
Release Large quantities of electrolytes & bicarbonates
Fluid hypersecretion
Diarrhea
Dehydration
Secrete enterotoxin

22. CLINICAL MENIFESTATIONS
 Cholera is an extremely virulent disease
that can cause severe acute watery
diarrhea.
 It takes between 12 hours and 5 days for
a person to show symptoms after
ingesting contaminated food or water .
 90 % of ER tor Cholera cases are mild.

23. • Usually mild, or no symptoms at all
• 75% asymptomatic
• 20% mild disease
• 2-5% severe
• Vomiting
• Cramps
– profuse, painless diarrhea and vomiting of clear fluid. "rice
water" (1L/hour) >20 mL/kg during a 4-hour observationperiod
• Without treatment, death in 18 hours-several days

24. TYPICAL RICE WATER DIARRHOEA

26. CHOLERA SICCA
• Cholera sicca is an old term describing a rare, severe form of
cholera that occurs in epidemic cholera.
• This form of cholera manifests as ileus and
abdominal distention from massive outpouring
of fluid and electrolytes into dilated intestinal
loops.

27. • Mortality is high, with death resulting from toxemia before
the onset of diarrhea and vomiting.
• The mortality in this condition is high: Because of the unusual
presentation, failure to recognize the condition as a form of
cholera is common

28. 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.

29. CONSEQUENCES OF SEVERE DEHYDRATION
1. Intravascular volume depletion
2. Severe metabolic acidosis
3. Hypokalemia →cardiac arrest
4. low blood sugar (hypoglycemia)
1. Seizures
2. coma, especially in the
young
5. Cardiac and renal failure
6. Sunken eyes, decreased skin
turgor
7. Almost no urine production

31. DIAGNOSIS EVALUATION
• Stool specimen.
• Confirm presence of cholera toxin by
culture
• Cholera Rapid Test Dipsticks.
• Additional tests

32. STOOL SPECIMEN
Rectal swab method
Cather method
Blotting Paper method

35. OTHER LAB FINDINGS
 Dehydration leads to high blood urea & serum
creatinine.
 Hematocrit & WBC will also be high due to
hemoconcentration.
 Dehydration & bicarbonate loss in stool leads to
metabolic acidosis with wide-anion gap.
 Total body potassium is depleted, but serum
level may be
 normal due to effect of acidosis.

36. CHOLERA RAPID TEST
 In areas with limited or no laboratory testing,
the Crystal® VC dipstick rapid test can provide an early
warning to public health officials that an outbreak of
cholera is occurring.
 However, the sensitivity and specificity of this test is
not optimal.
 Therefore, it is recommended that fecal specimens
that test positive for V. cholerae O1 and/or O139 by
the Crystal® VC dipstick always be confirmed using
traditional culture-based methods suitable for the
isolation and identification of V. cholerae.

37. SE ROLOGICAL TESTS
 Slide agglutination test : Picking
up suspected colonies and make
suspension in 0.85 % sterile saline .
 Add one drop of polyvalent anti-
cholera diagnostic serum.
 If agglutinin is positive , the test is
repeated with Inaba and Ogawa
antisera.

39. NOTIFICATION
 Cholera is a notifiable disease locally and
nationally.
 Since 2005 cholera notification is no longer
mandatory internationally.
 Cholera is notifiable to the WHO within 24
hours of its occurrence by the national
government .
 The number of cases and deaths are also to
be reported daily and weekly till the area is
declared free of cholera.

40. TREATMENT
REHYDRATION:
Oral &
Intravenous
Antimicrobial
therapy

44. REHYDRATION
Rehydration phase
Maintenance phase

45. REHYDRATION PHASE
• The goal of the rehydration phase is to restore normal
hydration status, which should take no more than 4
hours.
• Set the rate of intravenous infusion in severely
dehydrated patients at 50-100 mL/kg/hr.
• Lactated Ringer solution is preferred over isotonic
sodium chloride solution because saline does not correct
metabolic acidosis

46. MAINTAINENCE PHASE
 The goal of maintenance phase is
maintain normal hydration status by
replacing ongoing losses.
 The oral route is preferred , the use
of ORS at a rate of 500-1000 ml/hr.
 Fluids should never be restricted.

47. SIGN OFDEHYDRATION
No dehydration
(<5 percent)
Some dehydration
(5-10 percent)
2 or more of the followingsigns?
1. sunken eyes
2. absence of tears
3. dry mouth and tongue
4. thirsty and drinks eagerly
5. Goes back slowly(< 2 sec)
Oral Rehydration
If NO IfYES
2 or more of the followingsigns?
1. lethargic, unconscious orfloppy
2. unable to drink
3. radial pulse is weak
4. Goes back very slowly(>2 sec)
If YES
Severe
dehydration
(>10 percent)
If NO
Age Amount After Loose
Stool
< 24 mo 50-100 mL
2-9 y 100-200 mL
>10 y As much as is wanted
Age < 4 mo 4-11 mo 12-23 mo 2-4 y 5-14 y >15 y
Weight < 5 kg 5-7.9 kg 8-10.9 kg 11-15.9
kg
16-29.9
kg
>30 kg
ORS
solution in
200-
400
400-600 600-800 800-1200 1200-
2200
2200-
4000
ORS solution to give in the first 4 hours
If improve

48. Treat Severe dehydration in cholera
younger than 1 year
100 mL/kg IV in 6 hours
older than 1 year + adult
30 mL/kg in the first hour then 70
mL/kg in the next 5 hours.
30 mL/kg as rapidly as possible (within30
min) then 70 mL/kg in the next 2 hours.
Fluids should never
be restricted.
maintained intravenously with RL
Total amount per day RL+ORS = 200 ml/kg during the first 24 hours + Administer ORS solution (about 5
mL/kg/h) as soon as the patient can drink, in addition to IV fluid.
Continue to reassess at least every 4 hours; radial pulse should be strong and Bld pressur shouldbe
normal.
goal of the rehydration phase is to restore normal hydration status, must be less than 4 hours
The goal of maintenance phase is to maintain normal hydration by replacing ongoing losses.
100 mL/kg IV in 6 hours
Continue
monitor

49. CRITERIA FOR HOSPITAL
DISCHARGE
• After receiving therapy of adequate hydration,
patients that fulfill
 these three criteria can be discharged of the
hospital:
1. Adequate oral intake
2. Normal urinary flow (40-50 cc by hour)
3. Maximum diarrhea flow of 400 cc per hour

50. ANTIBIOTIC TREATMENT
• Antimicrobial therapy is useful for
1. prompt eradication of the Vibrio
2. diminish the duration of diarrhea
3. decrease the fluid loss.
• Antibiotics should be administered to moderate or severe
cases

53. ZINK THERAPY

54. ISOLATION
 Case should be quickly removed from
homely environment .
 Local schools, community buildings,
mobile hospital under tents are the places
to be converted into temporary treatment
centers.
 Isolation is necessary till the patient is no
longer infectious.


55. PREVENTION & CONTROL
 Ending Cholera: The Global Roadmap to 2030
 Five Basic Cholera Prevention Steps
 How Family Members Can Prevent Infection
 Infection Control for Cholera in Health Care
Settings
 Chemoprophylaxis.
 Vaccines

56. ENDING CHOLERA: THE GLOBAL ROADMAP TO 2030
 Ending Cholera—A Global Roadmap to
2030 operationalises the new global strategy for cholera
control at the country level and provides a concrete path
toward a world in which cholera is no longer a threat to
public health.
 By implementing the strategy between now and 2030,
the Global Task Force on Cholera Control (GTFCC)
partners will support countries to reduce cholera deaths
by 90 percent. With the commitment of cholera-affected
countries, technical partners, and donors, as many as
20 countries could eliminate disease transmission by
2030.

57. FIVE BASIC CHOLERA PREVENTION STEPS
1. Drink and use safe water.
2. Wash hands often with soap and safe water.
3. Use latrines or bury feces (poop); do not
defecate in any body of water.
4. Cook food well (especially seafood), keep it
covered, eat it hot, and peel fruits and
vegetables.
5. . Clean up safely—in the kitchen and in
places where the family bathes and washes
clothes

58. HOW FAMILY MEMBERS CAN PREVENT INFECTION
 Drink and use safe water
 Cook food thoroughly
 Wash hands with soap and safe water after caring for the
patients, and especially after handling fecal matter
 Remove and wash any bedding or clothing that may have had
contact with diarrheal stool, preferably in a washing machine,
in warm or hot water. Usual machine detergents are
sufficient; bleach is not necessary.
 Use a flush toilet or approved septic system; double bag
soiled materials when discarding in trash.
 bathroom, bedpan, as soon as possible after being soiled.

59.  When possible, use rubber gloves when cleaning any room
or surface that may have had contact with the patient’s fecal
matter.
 Patients with cholera should not swim while ill with diarrhea
or for 2 weeks after resolution of symptoms.
 If a household member develops acute, watery diarrhea,
administer oral rehydration solution (ORS) and seek
healthcare immediately

60.  Use any household disinfectant or a 1:10 dilution of bleach
solution (1 part bleach to 9 parts water) to clean any area
that may have contact with fecal matter, including the
patient’s.
 While caring for persons who are ill with cholera, do not
serve food or drink to persons who are not household
members
 Visitors can be allowed if the ill person wants company;
visitors should also observe hand hygiene recommendations

61. INFECTION CONTROL FOR CHOLERA IN
HEALTH CARE SETTINGS
 Healthcare providers should take precautions to
prevent the spread of cholera in clinical setting.
 Hand washing with soap and clean water.
 If no water and soap are available, use an alcohol-
based hand cleaner.
 Several chlorine solutions can be used for
disinfection such as 2% chlorine, 0.2% chlorine,
0.05% chlorine.

64. VACCINATION(ORAL VACCINE)
Dukoral.
Sanchol
Vaxchora

65. DUKORAL
 cholera and travellers' diarrhea vaccine (oral,
inactivated). 3 ml single dose vials.
 works by introducing very small amounts of
dead cholera bacteria and nontoxic
components of cholera toxin into the body.
 This allows the body to make antibodies
against the bacteria.
 Not licensed for Childeren aged < 2 years.

67. SANCHOL
 It is bivalent cholera vaccine.
 Vaccine should be administered
orally in 2 liquid doses 14 days for
individuals aged >1 year.
 Booster dose is recommended after
2 years.

69. VAXCHORA
 VAXCHORA is a vaccine indicated for active
immunization against disease caused by Vibrio
cholerae serogroup O1.
 VAXCHORA is approved for use in adults 18
through 64 years of age traveling to cholera-
affected areas.
 The safety and effectiveness of VAXCHORA
have not been established in
immunocompromised persons.

71. CHOMEOPROPHYLAXIS
 It is advised only for household contacts or of
a closed community in which cholera has
occurred.
 Tetracycline is the drug of choice .
 3 day period in BD of 500 mg for adults, 125
mg for children aged 4-13 years, 50 mg for
age0-3 years.