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{{Cholera}}
{{Cholera}}
{{CMG}}
{{CMG}}; '''Associate Editors-In-Chief:''' [[Priyamvada Singh|Priyamvada Singh, MBBS]] [mailto:psingh13579@gmail.com]


==Overview==
==Overview==
Choleria is a severe bacterial gastrointestinal, diarrheal disease. In its most severe forms, cholera is one of the most rapidly fatal illnesses known. A healthy person may become [[hypotension|hypotensive]] within an hour of the onset of symptoms and may die within 2-3 hours if no treatment is provided. More commonly, the disease progresses from the first liquid stool to shock in 4-12 hours, with death following in 18 hours to several days without [[rehydration]] treatment.<ref name=McLeod_2000>{{cite journal |author=McLeod K |title=Our sense of Snow: John Snow in medical geography |journal=Soc Sci Med |volume=50 |issue=7-8 |pages=923-35 |year=2000 |pmid = 10714917}}</ref><ref> WHO Cholera [http://www.who.int/topics/cholera/control/en/index.html]</ref>
Primary prevention of cholera can be achieved on an individual level by appropriate personal hygiene, use of sanitary water supply, appropriate preparation of food, as well as prompt identification, isolation, and treatment of cases. Primary preventive methods may also be implemented on a community level through effective water sanitation, appropriate and broad vaccination of the community to develop [[herd immunity]] as well as early detection of an outbreak.<ref name="pmid23301693">{{cite journal| author=Waldman RJ, Mintz ED, Papowitz HE| title=The cure for cholera--improving access to safe water and sanitation. | journal=N Engl J Med | year= 2013 | volume= 368 | issue= 7 | pages= 592-4 | pmid=23301693 | doi=10.1056/NEJMp1214179 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23301693  }} </ref><ref name="pmid16326125">{{cite journal| author=Sepúlveda J, Valdespino JL, García-García L| title=Cholera in Mexico: the paradoxical benefits of the last pandemic. | journal=Int J Infect Dis | year= 2006 | volume= 10 | issue= 1 | pages= 4-13 | pmid=16326125 | doi=10.1016/j.ijid.2005.05.005 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16326125  }} </ref><ref name="pmid17141709">{{cite journal| author=Sepúlveda J, Bustreo F, Tapia R, Rivera J, Lozano R, Oláiz G et al.| title=Improvement of child survival in Mexico: the diagonal approach. | journal=Lancet | year= 2006 | volume= 368 | issue= 9551 | pages= 2017-27 | pmid=17141709 | doi=10.1016/S0140-6736(06)69569-X | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17141709  }} </ref><ref>{{cite journal |author=Graves PM, Deeks JJ, Demicheli V, Jefferson T |title=Vaccines for preventing cholera: killed whole cell or other subunit vaccines (injected) |journal=Cochrane Database Syst Rev |volume= |issue=8 |pages=CD000974 |year=2010 |pmid=20687062 |doi=10.1002/14651858.CD000974.pub2 |url= |editor1-last=Graves |editor1-first=Patricia M}}</ref><ref name="pmid21412922">{{cite journal |author=Sinclair D, Abba K, Zaman K, Qadri F, Graves PM |title=Oral vaccines for preventing cholera |journal=Cochrane Database Syst Rev |issue=3 |pages=CD008603 |year=2011 |doi=10.1002/14651858.CD008603.pub2 |pmid=21412922}}</ref><ref>{{cite web |url=http://www.who.int/topics/cholera/vaccines/en/index.html |title=Cholera vaccines |publisher=WHO |work=Health topics |year=2008 | accessdate=2010-02-01}}</ref>
==Primary prevention==
 
===Steps to take in case of suspected cholera outbreak===
==Primary Prevention==
* Inform and ask for help (supervisor, other centers)
===Individual Prevention===
* Treat patients promptly specially patients presenting as some or severe cholera symptoms (as they may deteriorate frequently)
Effective methods for individual primary prevention of [[cholera]] include:<ref name="pmid23301693">{{cite journal| author=Waldman RJ, Mintz ED, Papowitz HE| title=The cure for cholera--improving access to safe water and sanitation. | journal=N Engl J Med | year= 2013 | volume= 368 | issue= 7 | pages= 592-4 | pmid=23301693 | doi=10.1056/NEJMp1214179 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23301693  }} </ref><ref name="pmid16326125">{{cite journal| author=Sepúlveda J, Valdespino JL, García-García L| title=Cholera in Mexico: the paradoxical benefits of the last pandemic. | journal=Int J Infect Dis | year= 2006 | volume= 10 | issue= 1 | pages= 4-13 | pmid=16326125 | doi=10.1016/j.ijid.2005.05.005 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16326125  }} </ref><ref name="pmid17141709">{{cite journal| author=Sepúlveda J, Bustreo F, Tapia R, Rivera J, Lozano R, Oláiz G et al.| title=Improvement of child survival in Mexico: the diagonal approach. | journal=Lancet | year= 2006 | volume= 368 | issue= 9551 | pages= 2017-27 | pmid=17141709 | doi=10.1016/S0140-6736(06)69569-X | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17141709  }} </ref>
* Protect the community (prevent spread to others)
*Practice appropriate hand washing and personal hygiene
===Checklist for medical professional in case of suspected outbreak===
*Avoid defecation in bodies of water
In case of suspected cholera in community medical professionals and hospitals should check the supplies to treat the patients.
*Appropriate preparation and cooking of food (e.g., seafood)
* IV fluids (Ringer Lactate is the best, in case of nonavailability of ringer lactate cholera saline or normal saline)
*Peeling of fruits and vegetables
* Oral Rehydration Salt (ORS)
*Use of sanitary water supply
* Antibiotics (doxycycline, erythromycin, tetracycline)
 
* Drips
===Prevention in the Community===
* Nasogastric tubes
Primary prevention of [[cholera]] in the community include:
* Soap
* Broad vaccination of the community for [[herd immunity]]
* Chlorine or bleaching powder
* '''Sickbed:''' Isolate the severe cases. Proper disposal and treatment of the germ-infected fecal waste (and all clothing and bedding that come in contact with it) produced by cholera victims is of primary importance as stool and vomit are highly contagious
* Rectal swabs and transport medium (Cary Blair or TCBS) for stool samples
* '''Sewage:''' Treatment of general sewage before it enters the waterways or underground water supplies prevent possible undetected patients from spreading the disease.
* Safe water is needed to rehydrate patients and to wash clothes and instruments
* '''Education:''' Warnings about cholera contamination posted around contaminated water sources through simple messages with directions on how to decontaminate the water.
===Steps to protect the community===
 
* Disinfect water sources with chlorine
===Prevention in Healthcare settings===
* Promote water disinfection at home using chlorine
Primary Prevention in a health care setting includes appropriate sanitation of potentially infected surfaces and equipment as follows:<ref name="cdc chlorine">Center for Disease Control Infection Control Guideline HCP. http://www.cdc.gov/cholera/infection-control-hcp.html Accessed on October 7th, 2016</ref>
* Stool and vomit are highly contagious
*2% chlorine
* Wash your hands with soap after using toilets and latrines, before preparing food, before eating
**Made by mixing 3 parts water and 2 parts bleach
* Boil or disinfect the water with chlorine solution
**Used for disinfecting vomit, feces, and corpses
* Only eat freshly cooked food
*0.5% chlorine
* Do not defecate near the water sources
**Made by mixing 9 parts water and 1 part bleach
* Use latrines and keep them clean
**Used for foot baths, cleaning floors, bedding, latrines
* Isolate the severe cases
*0.05% chlorine
* Provide information on how to avoid cholera through simple messages on the outbreak
**Made by mixing 9 parts water and 1 part 0.5% chlorine solution
===Precautions for funerals===
**Used for bathing soiled patients, handwashing, rinsing dishes, laundry
* Disinfect corpses with chlorine solution (2%)
===Vaccine===
* Fill mouth and anus with cotton wool soaked with chlorine solution
A number of safe and effective oral [[vaccines]] for cholera are available.<ref name="pmid21412922">{{cite journal |author=Sinclair D, Abba K, Zaman K, Qadri F, Graves PM |title=Oral vaccines for preventing cholera |journal=Cochrane Database Syst Rev |issue=3 |pages=CD008603 |year=2011 |doi=10.1002/14651858.CD008603.pub2 |pmid=21412922}}</ref> Dukoral, an orally administered, inactivated whole cell [[vaccine]], has an overall efficacy of about 52% during the first year after being given and 62% in the second year, with minimal side effects.<ref name="pmid21412922"/> It is available in over 60 countries. However, it is not currently recommended by the [[Centers for Disease Control and Prevention]] (CDC) for most people traveling from the United States to [[endemic]] countries.<ref name="CDC_Vacc">{{cite web| title=Is a vaccine available to prevent cholera? | work=CDC disease info: Cholera| url=http://www.cdc.gov/cholera/general/#vaccine| date=2010-10-22| accessdate=2010-10-24}}</ref> ShanChol is another oral [[vaccination]] which is based on the O1 and O139 serotypes.<ref name="who"> World Health Organization Cholera Epidemiological Report. http://www.who.int/wer/2012/wer8731_32.pdf. Accessed on October 7th, 2016</ref>. An injectable vaccine was found to be effective for two to three years. The protective efficacy was 28% lower in children less than 5 years old.<ref>{{cite journal |author=Graves PM, Deeks JJ, Demicheli V, Jefferson T |title=Vaccines for preventing cholera: killed whole cell or other subunit vaccines (injected) |journal=Cochrane Database Syst Rev |volume= |issue=8 |pages=CD000974 |year=2010 |pmid=20687062 |doi=10.1002/14651858.CD000974.pub2 |url= |editor1-last=Graves |editor1-first=Patricia M}}</ref> However, as of 2010, it has limited availability. Work is underway to investigate the role of mass [[vaccination]].<ref>{{cite web |url=http://www.who.int/topics/cholera/vaccines/en/index.html |title=Cholera vaccines |publisher=WHO |work=Health topics |year=2008 | accessdate=2010-02-01}}</ref> The [[World Health Organization]] (WHO) recommends immunization of high risk groups, such as children and people with [[HIV]], in countries where this disease is [[endemic]]. If people are immunized broadly, [[herd immunity]] results, with a decrease in the amount of contamination in the environment.
* Wash hands with soap after touching the corpse
 
* Disinfect the clothing and bedding of the deceased by stirring them in boiling water or by drying them thoroughly in the sun
===Signals of an Outbreak===
Increase number of acute diarrhea cases and patients having common symptoms:
* Watery [[diarrhea]], [[dehydration]] and [[vomiting]]
* Cases from same area or location
* Eaten the same food (e.g., at a burial ceremony)
* Sharing the same water source
* Outbreak in the neighboring community
 
==Risk for travellers==
Risk for travellers is low even in epidemic regions. However, humanitarian relief workers in disaster areas and refugee camps may be at risk.
==General precautions==
*Cholera vaccination is not required as a condition of entry to any country.
*Avoid drinking or eating unsafe water or foods.
==Vaccine==
*Oral vaccine consisting of killed whole-cell V. cholerae O1 in combination with a recombinant B-subunit of cholera toxin (WC/rBS).
*Primary immunization consists of two oral doses  ≥7 days (but <6 weeks) apart for adults and children aged 6 years and over.
*For children aged 2–5 years, three doses are recommended.
*Following primary immunization, protection against cholera may be expected after about 1 week.
*The vaccine is not licensed for children under 2 years of age.
 
== Summary of vaccine data ==
{| class="wikitable"
!
!Considerations
|-
| rowspan="2" |Type of vaccine
|Killed oral O1 whole-cell with Bsubunit.
|-
|Killed oral O1 and O139.
|-
| rowspan="2" |Number of doses
|
* Two doses (minimum 1 week and maximum 6 weeks apart).
 
* Three doses for children aged 2–5 years (minimum 1 week and maximum 6 weeks apart)
|-
|
* Two doses 14 days apart for individuals aged ≥2 years. One booster dose is recommended after 2 years.
|-
|Contraindications
|Hypersensitivity to previous dose.
|-
|Adverse reactions
|Mild gastrointestinal disturbances.
|-
|Before departure
|2 weeks.
|-
|Indication
|Travellers at high risk (e.g. emergency/relief workers).
|}


Although cholera can be life-threatening, it is nearly always easily prevented, in principle, if proper sanitation practices are followed. In the United States and Western Europe, because of advanced [[water treatment]] and sanitation systems, cholera is no longer a major threat. The last major outbreak of cholera in the United States was in 1911. However, everyone, especially travelers, should be aware of how the disease is transmitted and what can be done to prevent it. Good sanitation practices, if instituted in time, are usually sufficient to stop an epidemic. There are several points along the transmission path at which the spread may be halted:
[[Image:Cholera_hospital_in_Dhaka.jpg|left|thumb|Cholera hospital in Dhaka.]]
* Sickbed: Proper disposal and treatment of the germ infected fecal waste (and all clothing and bedding that come in contact with it) produced by cholera victims is of primary importance.
* Sewage: Treatment of general sewage before it enters the waterways or underground water supplies prevent possible undetected patients from spreading the disease.
* Sources: Warnings about cholera contamination posted around contaminated water sources with directions on how to decontaminate the water.
* [[Sterilization]]: Boiling, filtering, and chlorination of water kill the bacteria produced by cholera patients and prevent infections, when they do occur, from spreading. All materials (clothing, bedding, etc.) that come in contact with cholera patients should be sterilized in hot water using (if possible) chlorine bleach. Hands, etc. that touch cholera patients or their clothing etc. should be thoroughly cleaned and sterilized. All water used for drinking, washing or cooking should be sterilized by boiling or chlorination in any area where cholera may be present. Water filtration, chlorination and boiling are by far the most effective means of halting transmission. Cloth filters, though very basic, have greatly reduced the occurrence of cholera when used in poor villages in Bangladesh that rely on untreated surface water. In general, public health education and good sanitation practices are the limiting factors in preventing transmission.


== References ==
== References ==
{{Reflist|2}}
{{Reflist|2}}


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Latest revision as of 20:55, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Priyamvada Singh, MBBS [2]

Overview

Primary prevention of cholera can be achieved on an individual level by appropriate personal hygiene, use of sanitary water supply, appropriate preparation of food, as well as prompt identification, isolation, and treatment of cases. Primary preventive methods may also be implemented on a community level through effective water sanitation, appropriate and broad vaccination of the community to develop herd immunity as well as early detection of an outbreak.[1][2][3][4][5][6]

Primary Prevention

Individual Prevention

Effective methods for individual primary prevention of cholera include:[1][2][3]

  • Practice appropriate hand washing and personal hygiene
  • Avoid defecation in bodies of water
  • Appropriate preparation and cooking of food (e.g., seafood)
  • Peeling of fruits and vegetables
  • Use of sanitary water supply

Prevention in the Community

Primary prevention of cholera in the community include:

  • Broad vaccination of the community for herd immunity
  • Sickbed: Isolate the severe cases. Proper disposal and treatment of the germ-infected fecal waste (and all clothing and bedding that come in contact with it) produced by cholera victims is of primary importance as stool and vomit are highly contagious
  • Sewage: Treatment of general sewage before it enters the waterways or underground water supplies prevent possible undetected patients from spreading the disease.
  • Education: Warnings about cholera contamination posted around contaminated water sources through simple messages with directions on how to decontaminate the water.

Prevention in Healthcare settings

Primary Prevention in a health care setting includes appropriate sanitation of potentially infected surfaces and equipment as follows:[7]

  • 2% chlorine
    • Made by mixing 3 parts water and 2 parts bleach
    • Used for disinfecting vomit, feces, and corpses
  • 0.5% chlorine
    • Made by mixing 9 parts water and 1 part bleach
    • Used for foot baths, cleaning floors, bedding, latrines
  • 0.05% chlorine
    • Made by mixing 9 parts water and 1 part 0.5% chlorine solution
    • Used for bathing soiled patients, handwashing, rinsing dishes, laundry

Vaccine

A number of safe and effective oral vaccines for cholera are available.[5] Dukoral, an orally administered, inactivated whole cell vaccine, has an overall efficacy of about 52% during the first year after being given and 62% in the second year, with minimal side effects.[5] It is available in over 60 countries. However, it is not currently recommended by the Centers for Disease Control and Prevention (CDC) for most people traveling from the United States to endemic countries.[8] ShanChol is another oral vaccination which is based on the O1 and O139 serotypes.[9]. An injectable vaccine was found to be effective for two to three years. The protective efficacy was 28% lower in children less than 5 years old.[10] However, as of 2010, it has limited availability. Work is underway to investigate the role of mass vaccination.[11] The World Health Organization (WHO) recommends immunization of high risk groups, such as children and people with HIV, in countries where this disease is endemic. If people are immunized broadly, herd immunity results, with a decrease in the amount of contamination in the environment.

Signals of an Outbreak

Increase number of acute diarrhea cases and patients having common symptoms:

  • Watery diarrhea, dehydration and vomiting
  • Cases from same area or location
  • Eaten the same food (e.g., at a burial ceremony)
  • Sharing the same water source
  • Outbreak in the neighboring community

Risk for travellers

Risk for travellers is low even in epidemic regions. However, humanitarian relief workers in disaster areas and refugee camps may be at risk.

General precautions

  • Cholera vaccination is not required as a condition of entry to any country.
  • Avoid drinking or eating unsafe water or foods.

Vaccine

  • Oral vaccine consisting of killed whole-cell V. cholerae O1 in combination with a recombinant B-subunit of cholera toxin (WC/rBS).
  • Primary immunization consists of two oral doses ≥7 days (but <6 weeks) apart for adults and children aged 6 years and over.
  • For children aged 2–5 years, three doses are recommended.
  • Following primary immunization, protection against cholera may be expected after about 1 week.
  • The vaccine is not licensed for children under 2 years of age.

Summary of vaccine data

Considerations
Type of vaccine Killed oral O1 whole-cell with Bsubunit.
Killed oral O1 and O139.
Number of doses
  • Two doses (minimum 1 week and maximum 6 weeks apart).
  • Three doses for children aged 2–5 years (minimum 1 week and maximum 6 weeks apart)
  • Two doses 14 days apart for individuals aged ≥2 years. One booster dose is recommended after 2 years.
Contraindications Hypersensitivity to previous dose.
Adverse reactions Mild gastrointestinal disturbances.
Before departure 2 weeks.
Indication Travellers at high risk (e.g. emergency/relief workers).


References

  1. ↑ 1.0 1.1 Waldman RJ, Mintz ED, Papowitz HE (2013). "The cure for cholera--improving access to safe water and sanitation". N Engl J Med. 368 (7): 592–4. doi:10.1056/NEJMp1214179. PMID 23301693.
  2. ↑ 2.0 2.1 Sepúlveda J, Valdespino JL, García-García L (2006). "Cholera in Mexico: the paradoxical benefits of the last pandemic". Int J Infect Dis. 10 (1): 4–13. doi:10.1016/j.ijid.2005.05.005. PMID 16326125.
  3. ↑ 3.0 3.1 Sepúlveda J, Bustreo F, Tapia R, Rivera J, Lozano R, Oláiz G; et al. (2006). "Improvement of child survival in Mexico: the diagonal approach". Lancet. 368 (9551): 2017–27. doi:10.1016/S0140-6736(06)69569-X. PMID 17141709.
  4. ↑ Graves PM, Deeks JJ, Demicheli V, Jefferson T (2010). Graves, Patricia M, ed. "Vaccines for preventing cholera: killed whole cell or other subunit vaccines (injected)". Cochrane Database Syst Rev (8): CD000974. doi:10.1002/14651858.CD000974.pub2. PMID 20687062.
  5. ↑ 5.0 5.1 5.2 Sinclair D, Abba K, Zaman K, Qadri F, Graves PM (2011). "Oral vaccines for preventing cholera". Cochrane Database Syst Rev (3): CD008603. doi:10.1002/14651858.CD008603.pub2. PMID 21412922.
  6. ↑ "Cholera vaccines". Health topics. WHO. 2008. Retrieved 2010-02-01.
  7. ↑ Center for Disease Control Infection Control Guideline HCP. http://www.cdc.gov/cholera/infection-control-hcp.html Accessed on October 7th, 2016
  8. ↑ "Is a vaccine available to prevent cholera?". CDC disease info: Cholera. 2010-10-22. Retrieved 2010-10-24.
  9. ↑ World Health Organization Cholera Epidemiological Report. http://www.who.int/wer/2012/wer8731_32.pdf. Accessed on October 7th, 2016
  10. ↑ Graves PM, Deeks JJ, Demicheli V, Jefferson T (2010). Graves, Patricia M, ed. "Vaccines for preventing cholera: killed whole cell or other subunit vaccines (injected)". Cochrane Database Syst Rev (8): CD000974. doi:10.1002/14651858.CD000974.pub2. PMID 20687062.
  11. ↑ "Cholera vaccines". Health topics. WHO. 2008. Retrieved 2010-02-01.


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