CHOLERA. Kirsten Schmidt-Hellerau

Transcription

1 CHOLERA Kirsten Schmidt-Hellerau

2 Reported Cases (WHO) : : cases - estimated 1.4 to 4 million cases including deaths/year 37% 41%

3 Cholera guidelines MSF Cholera guideline 2004

4 Vibrio Cholerae Vibrio Cholerae Species: Vibrio cholerae Serogroup: O139 and O1 Biotypes of O1: El Tor and Classic Serotypes of O1: Hikojima, Ogawa, Inaba Humans (asymptomatic/ symptomatic) are the main reservoir Transmissison person to person, Contaminated food/water Corpses Treatment centers protecting factors Risk factors

5 Clinical features Sudden onset of profuse painless watery stools, sometimes rice-water like, often accompanied by vomiting. No fever. Dehydration within hours or less, loss of up to 20 litres /day Incubation: few hours to 5 days Communicability: 1-4 weeks (- several months) Mortality: 20-50%, with adequate treatment under 2% More than 80% of cases are asymptomatic or present as simple diarrhea

6 Defining an outbreak Confirming the diagnosis : laboratory confirmation of index cases Case definiton for a suspected case: In an area where the disease is not known to be present, WHO Standard Case Definition In an area where there is a cholera epidemic, In an area where there is a cholera MSF definition epidemic, A patient aged 5 years or more develops severe dehydration or dies from acute watery diarrhoea. A patient aged 5 years or more develops acute watery diarrhoea, with or without vomiting Any patient presenting 3 or more liquid stools and/or vomiting for the last 24 hours

7 Cholera outbreak management What do we want? Reduce mortality Reduce the spread of the epidemic What to do? Outbreak investigation Estimating the need Assessing the capacity of local health system Intervention strategies Coordination meetings, crisis commitee/task force

8 Intervention strategies Reducing mortality Adequate case management (training, protocols), Regular supplies No delay in reaching a treatment center Early case finding by community workers Distribution of treatment centers Reducing the epidemic spread Water access and safety Promote and enable hygienic conditions and practices Ensure effective sanitation Organise public information (chemoprophylaxis, vaccination)

9 Interventions to reduce mortality: Treatment Centers Type of center? CTC: at central level, hospital strucure CTU: smaller, decentralized, inpatient structure ORP: simple, decentralized, wide spread, ORS

10 Cholera Treatment Center

11 Case management Table 7. Classification table for dehydration (adapted from the WHO) Hydration status? Treatment Plan? present rapid, weak (thready) none CHECK PULSE EXAMINE Condition Well, alert Restless, irritable L e t h a rgic or unconscious Eyes (sunken) No Yes Yes Thirst Drinks normally Thirsty, drinks eagerly Not able to drink Skin pinch Goes back quickly Goes back slowly Goes back very slowly (> 2 seconds) CONCLUDE No dehydration Moderate dehydration Severe dehydration TREAT Maintain hydration Oral rehydration IV + oral rehydration Use Treatment Use Treatment Use Treatment Plan A Plan B Plan C

12 Rehydration therapy and monitoring PLAN A (no dehydration) Treatment at home ORS after each loose stool, quantity according to age (adults at least 2 liters/day) Give sachets for 2 days advice PLAN B (moderate dehydration) Admission to treatment center ORS over 4 hours, quantity according to age (adults ml) After 4 hours: switch to Plan A or repeat Plan B Switch to Plan C any time when severe dehydration occurs

13 Rehydration therapy and monitoring: PLAN C principles About 20% of symptomatic patients Ringers lactate is the recommended iv fluid When the patient is conscious he additionally drinks ORS On average 8-10 litres iv and 10 litres po are needed Antibiotic treatment (after iv rehydration): e.g. Doxycycline Pulse, (BP, T) monitoring Fluid input and output Signs of dehydration/overhydration Identifying and treating complications: Hypoglycemia Hypothermia Acute pulmonaty edema Hypokalemia Renal failure Reassessment after 3 hours

14 Plan C: Recovery area/ Discharge Observation at recovery area for 6 hours (drinking ORS) Discharge criteria: No vomiting Less than 3 liquid stools in 6 hours No more dehydration Donal Gorman/MSF

15 Chemoprophylaxis Mass Chemo Prophylaxis No proven effect on the spread of cholera Creating antibiotic resistance False sense of security Oral vaccination Global shortage of supply Two dose regime New: trials testing one dose regime Consider only in specific situations: Feeding Center, Prison

16 Maps/Global_Cholera_2010_2015.png cholera/cases/en/ resources/ humanitarian_bulletin_29_august_2016.pdf MSF Cholera guidelines 2004