Cholera Dr Iftikhar

Understanding Cholera By Dr.Iftikhar.uddin

Introduction 

Cholera is a Greek word, which means the gutter of the roof. It is caused by bacteria Vibrio cholerae, which was discovered by Robert Koch in 1883, in a diarrhoeal outbreak in Egypt.

“Cholera” by Dhiman Barua and William B. Greenough III

ICD 10 Classification A00 Cholera A00.0 Cholera due to Vibrio cholerae 01, biovar cholerae Classical cholera A00.1 Cholera due to Vibrio cholerae 01, biovar eltor Cholera eltor A00.9 Cholera, unspecified. WHO

Incubation period 

Between 1 and 5 days.

Mode of transmission 

Faecal-oral route through  

contaminated water Contaminated food. “DEWS” August 2009 by NIH

History of cholera 

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First pandemic – 1816 – 1826  Started in India – spread to Indonesia, China and Russia.  10 000 British troop died in India  15 million people died world-wide. Second pandemic – 1829 – 1851  Spread to Russia, Hungary, Germany, England, France, USA, Canada, Egypt  Estimated mortality of 500 000

“A History Of Epidemic Cholera” by Thomas Hepburn Buckler

History of cholera (contd.) 

Third pandemic – 1852 – 1860  

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Russia – over 1 million deaths. Chicago – 5.5% of the population died.

Fourth pandemic – 1863 – 1875   

30 000 out of 90 000 pilgrims to Makkah died. Italy – 113 000 dead. Total estimated 340 000.

“A History Of Epidemic Cholera” by Thomas Hepburn Buckler

History of cholera (contd.) 

Fifth pandemic – 1881 - 1896 

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250 000 lives in various European countries, 50 000 in Americas and 270 000 in Russia. 120,000 in Spain; 90 000 in Japan and 60 000 in Persia. In Egypt cholera claimed more that 58 000 lives

Sixth pandemic – 1899 – 1923   

Little effect in Europe because of advances in public health. 500 000 people died in Russia 200 000 lives in The Philippines, 800 000 in India “A History Of Epidemic Cholera” by Thomas Hepburn Buckler

History of cholera (contd.) 

Seventh pandemic – 1961 - 1970 

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Started in Indonesia – spread to India, USSR, North Africa, Italy, Japan and South Pacific.

Eight “pandemic” – 1991 - 1994 

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Ship discharging contaminated ballast water. South America – 1.04 million cases in Peru with 10 000 deaths. Spread to Asia (India) A History Of Epidemic Cholera” by Thomas Hepburn Buckler

Recent outbreaks  

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2007 – Iraq, India, Vietnam, Congo Aug 2008 – April 2009 – Zimbabwe (1810 recorded mortalities with a 4.2% mortality rate. January 2009 – South Africa – 2276 cases with 19 mortalities. 9 June 2009 -- 98 424 suspected cases, including 4 276 deaths (Case Fatality Rate of 4.3%) have been reported in Zimbabwe. WHO

Country policy 

Pakistan is a cholera free country. In collaboration with WHO the following policy has been chalked out by the National Institute of Health and Ministry of Health.

Alert Threshold 

One case of suspected AWD/cholera is an alert must be investigated.

Outbreak threshold 

One confirm case of cholera is an outbreak.

“DEWS” August 2009 by NIH

Case definition Suspected case 



In an area where the disease is not known to be present :severe dehydration or death from acute watery diarrhea in a patient aged 5 years or more. For management of cases of acute watery diarrhea in an area where there is a cholera epidemic, cholera should be suspected in all patients with acute watery diarrhoea. “DEWS” August 2009 by NIH

Confirmed cases 

Any suspected case confirmed by laboratory through isolation of Vibrio cholerae from stool in any patient with diarrhea.

“DEWS” August 2009 by NIH

Mechanisms under Ministry of Health 

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Health Management Information System at the National level. Health Information Resource Centre (NHIRC) Diseases surveillance initiatives at NIH Pakistan Public health testing for Communicable Diseases, Food & Water at NIH MoH-WHO Disease Surveillance and Response System in disaster hit areas.

“National Disease Surveillance Mechanisms” A.Ikram AFIP, M.Safdar NIH

Diseases surveillance  National and Provincial Task Forces initiatives at NIH   

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National Steering Committees (NSC) Field Epidemiology & Laboratory Training Program Early detection, investigation and response to the outbreaks through Epidemic Investigation Cell Disease Early Warning System (DEWS) Seasonal Awareness and Alert Letter (SAAL) upcoming seasons

“National Disease Surveillance Mechanisms” A.Ikram AFIP, M.Safdar NIH

Diseases surveillance initiatives NIH  at Field Epidemiology and Laboratory Training   

Programme (FELTP) Focal Point for IHR 2005 Legal framework for diseases surveillance Capacity building of health professionals through training workshops under WHO-MoH Program on: – Health Laboratory Support and – Disease Early Warning System (DEWS)

“National Disease Surveillance Mechanisms” A.Ikram AFIP, M.Safdar NIH

Epidemic Investigation Cell (EIC) 1. 2.

3.

4. 5.

Nationwide monitoring Technical support - guidelines, SOPs, trainings and DEWS Tools Response when called by respective departments International collaboration Disease Early Warning System > 600 alert/outbreak responded since 1998

“National Disease Surveillance Mechanisms” A.Ikram AFIP, M.Safdar NIH

Disease Early Warning System 

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Operational since 1998 as a joint MOH/ WHO initiative Early detection of outbreak Syndromic Case Definitions, Reporting Forms and watch charts help in disease monitoring Data analysis at facility/local level

“National Disease Surveillance Mechanisms” A.Ikram AFIP, M.Safdar NIH

KPCFP

Keep Pakistan Cholera Free Programme

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Project Director: Donor Agencies:

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Technical Advisors Partners for BCC

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Working partners

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Dr.Iftikhar.uddin World Bank, UNICEF USAID WHO, CDC Atlanta Bloomberg School of Public Health John Hopkins JICA, ICRC

Aim 

To keep Pakistan cholera free country

Objectives 1.

Ensuring of safe drinking water and proper sanitation to all the citizens of Pakistan by 2015.

2.

To ensure 100% detection of an outbreak with in two days, all over Pakistan with in three years.

3.

To ensure prompt actions to control the out break.

Strategies Three pronged strategy 1.

Ensuring safe drinking water and proper sanitation for all the citizens of Pakistan.

2.

Early detection of an outbreak.

3.

Prompt action to control the out break.

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1. Ensuring safe drinking water and proper sanitation alland the citizens of BCC for boiling offor water proper Pakistan. sanitation.  

School sessions Mass media   

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Television Radio Newspaper

Community sessions

Installation of Filtration Plants

2. Early detection of an

outbreak 

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118 districts and approx 10,000 Public sector facilities Appointment of 118 surveillance officer in each district for Surveillance activities for cholera. Capacity building of all the reporting staff. Provisions of computers and internet facilities for timely reporting.

3. Prompt action to control the out break.  

Safe drinking water supplies. Stocks    

ORS IV fluids Antibiotics after culture and sensitivity. Soaps and towels.

Indicators for Evaluation          

# of Water filtration plants installed # Schools sessions conducted # community sessions conducted # of HCPs trained for reporting cholera # of outbreaks occurred # of outbreaks responded within two days of outbreak # of cholera cases reported # of deaths due to cholera # of People of using safe drinking water # of People washing hands before meals

Thank you