02/05/1443

Epidemiology & control of

cholera

Cholera is an acute, diarrheal illness caused

by infection of the intestine with Vibrio
cholerae.

Infectious Agent: Vibrio.Cholerae

Comma shaped , Gram negative , aerobic
bacilli (may be straight after lab culture),
Polar Flagellum

1
02/05/1443

Vibrio cholerae

Classification of v.cholerae
Vibrio .cholerae species can be
classified according to:
A. Biotypes: V. Cholerae has 2 major
biotypes: classical and El Tor. Currently,
El Tor is the predominant cholera pathogen
worldwide.

2
02/05/1443

B. Serotypes: V. Cholerae strains share H

antigens; have different 0 antigens. The
differentiation of the 0 antigen that allows
for separation into pathogenic and
nonpathogenic strains.
1. V.Cholerae 01: This type is
pathogenic and toxigenic
Three types:
Ogawa (A,B)
Inaba (A,B)
Hikojima (A,B,C)
5

2. V. Cholerae 0139 Bengal ( appeared

first in India in 1992):

 V.cholerae 0139 differs from 01 strains

in lipopolysacharide structure (LPS) and
in producing capsular antigen.

 Toxigenic ( produces the same cholera

toxin as V.cholerae 01).

3
02/05/1443

3. Atypical V.cholerae 01: non pathogenic

and non toxigenic.

4. V. Cholerae non 01:

 Vibrios that are biochemically
indistinguishable from V.cholerae 01 but
do not agglutinate in its antiserum. They
are also known as Non-Agglutinable
Vibrios (NAGs) or as Non-Cholera
Vibrios (NCVs).
 Some are toxigenic

Determinants of survival of Vibrios

• Survive in water for 4-7 days
• Does not tolerate drying & acidic
conditions
• Survives better in brackish water than in
fresh water
Reservoir of infection
 Man is the main reservoir of infection
 Aquatic reservoir: e.g seafood, plankton
or water plants may exist
Source of infection
During the cholera season
-Clinical cases , asymptomatic infection &
carriers
8

4
02/05/1443

EPIDEMIOLOGY
•Since 1817, there have been 7 cholera pandemics.
•The first pandemic broke out in 1817.
•The last pandemic (the 7th ) broke out in 1961.
•The first 6 pandemics occurred from 1817-1923 and
were caused by V. cholerae, the classical biotype. The
pandemics originated in Asia with subsequent spread to
other continents.
• The seventh pandemic broke out in 1961 . It began in
Indonesia and affected more countries and continents
than the previous 6 pandemics. It differed from previous
pandemics by :
a. It was caused by V. cholerae El Tor.
b. Modern therapy markedly reduced case fatality rate.
9

• In October 1992, an epidemic of cholera

emerged from Madras, India as a result of
a new serogroup (0139). Some experts
regard this as an eighth pandemic.
Currently:
• Cholera is endemic in areas of poor
sanitation like India and Bangladesh
• Common in India, Sub-Saharan Africa,
Southern Asia
• Very rare in industrialized countries

10

5
02/05/1443

Epidemiological types of Cholera

• Epidemic type:
1. Occurs in previously uninfected areas
with sero-negative population
2. Affects all age groups equally
3. Associates with single mode of spread
4. Associates with low rate of
asymptomatic infection
5. There is no environmental reservoir of
infection

11

• Endemic type:
1. Incidence is highest among 2-15 years
of age.
2. yearly seasonal outbreaks are
prominent.
3. Transmission is associated with
environmental aquatic reservoir
4. Multiple modes of spread
5. Frequent asymptomatic infections
leading to high antibody titer by 20
years of age

12

6
02/05/1443

Mode of TRANSMISSION

Cholera is transmitted primarily through ingestion of

contaminated water or food.
Transmission of cholera is characterized by the following
:
1. High infective dose (108-1010 organisms)
2. Person to person spread by direct contact is unlikely
mode of transmission (since it is impossible to ingest
such high inoculums by this mode)

13

3. For the same reason fomites and flies are

not important modes of transmission.
4. Contamination of water or food provides
the opportunity for multiplication and
intake of the inoculums.
5. In USA most sporadic cases of infection
follow the ingestion of raw or under
cooked sea food from polluted
water(eating raw or undercooked
shellfish) .

14

7
02/05/1443

PATHOGENESIS

• V.Cholerae remains in lumen of small

intestine (does not invade the intestinal
wall).
• V. cholerae causes clinical disease by
producing an enterotoxin Which acts
locally & promotes the secretion of fluid
and electrolytes into the lumen of the gut.
• Fluid loss originates in the duodenum and
upper jejunum; the ileum is less affected.

15

Incubation period
Few hours- 5 days ( usually 2-3 days)

Clinical features
 The disease is characterized by a sudden
onset of profuse painless watery diarrhea
(rice water stool), occasional vomiting.
Followed by rapid dehydration , acidosis
and circulatory collapse.
 Fever is typically absent

16

8
02/05/1443

 It can be rapidly fatal (death may occur

within few hours ). In untreated severe
cases the case fatality rate may reach 30-
50%, but with proper treatment the death
rate is below 1%.
 Generally asymptomatic infection is
much more than clinical illness ,
especially with organisms of the Eltor
biotype.
 Ratio of infected cases: clinical cases
For El Tor 36:1 Classical 4:1

17

 Severity of the disease is also determined

by Biotype of V.cholerae.
% of severe cases (requiring
hospitalization):
-El Tor 2%,
-Classical 11%

18

9
02/05/1443

Risk Factors for Severe cholera

1) Close contact with a cholera patient
2) Low gastric acidity (natural or acquired
whether surgically induced or due to the
use of antacids)
3) Old Age ( because gastric acidity
declines in old age)
4) Absence or low titre of vibriocidal
antibodies
5) Those who are malnourished
19

5) Blood type : A person's susceptibility to cholera (and

other diarrheas) is affected by their blood type. Those
with type O blood are the most susceptible. Those with
type AB are the most resistant. Between these two
extremes are the A and B blood types, with type A being
more resistant than type B.
6) Absence of breast feeding

20

10
02/05/1443

Diagnosis
1. Cholera should be suspected when patients present
with watery diarrhea,& severe dehydration.
2. Stool culture: diagnosis is confirmed by isolating
V.cholerae of the serogroups 01 or 0139 from
stool or rectal swabs of patients.
3. For clinical purposes , a quick diagnosis can be
made by dark field microscopic visualization of
the characteristic vibrio motility , (moving like
shooting stars), which is inhibited by specific
antiserum. 21

C. Serological by demonstrating a significant rise in

titre of antitoxic and vibriocidal antibodies.

22

11
02/05/1443

Period of Communicability
 Presumably for the duration of the stool positive stage,
Usually for only few days after recovery.
-By end of first week, 70% of patients non-infectious
-By end of third week, 98% non-infectious
 Occasionally the carrier state may persist for several
months.
 Very rarely chronic biliary infection lasting for years ,
has been observed in adults with intermittent shedding
of vibrios in the stool. The carrier state in cholera El
Tor may last for more than 12 years

23

• Antibiotics shorten the period of

communicability.
 The El Tor biotype produces a higher carrier
state than the classical biotype
Control of cholera
 Although cholera can be life-threatening, it is
easily prevented and treated.
 In countries with advanced water and sanitation
systems, cholera is not a major threat; however,
even in such areas ,everyone especially
travelers, should be aware of how the disease is
transmitted and what can be done to prevent it.

24

12
02/05/1443

I. General preventive measures

1. Provision of safe water supply: Protection,

purification, chlorination of public water supply.

2. Provision of effective sewage disposal

3. Protection of food from contamination and
control of flies.
4. Health education & personal hygiene

25

Health education & personal hygiene

Health Education and public awareness
regarding spread of disease, availability of
treatment and precautions at domestic level are
important to control and Prevent Cholera like:
• Use of boiled water if required.
• Avoid uncooked food unless it is peeled or washed
and disinfected.
• Wash hands before preparing or eating food.
• Wash hands after using toilet or any contact with
excreta.
• Dispose off human excreta promptly and safely.

26

13
02/05/1443

II. Specific preventive measures

 Control of patient, contacts & the
environment.
 Measures for the Patients
1) Notification is very important

2) Isolation: hospitalization is desirable for acutely

ill patient but strict isolation is not necessary.

3) Concurrent disinfection of feces & vomitus & of

articles used by the patient.

27

4) Treatment of patients
- Fluid therapy to correct the
dehydration
- Antibiotics: Antibiotics should be
started when cholera is suspected
without waiting for lab confirmation.
- this includes the following
choices
 Tetracycline , 500mgs 4 times daily for 3
days( for children 12.5mg /kg)
 Doxycycline ,200mg orally as a single
dose for 3 days .

28

14
02/05/1443

 Other antibiotics that have been used include

ciprofloxacin and azithromycin.
 Before hospital discharge, two negative stool
cultures are required
Antibiotics:
1) eradicate infection (suppresses vibrio growth in the
gut)
2) reduce morbidity ( reduces volume of stool &
shortens period of hospitalization).
3) shorten the period of vibrio excretion (shorten
period of communicability)
4) prevent complications.

29

Measures for the Contacts

 Surveillance of contacts for 5 days from

last exposure. Investigation of contacts by
stool culture for detection of unreported
cases
 For household contacts, chemoprophylaxis
with tetracycline, or doxycycline, for
three days is recommended.

30

15
02/05/1443

 Measures for the Environment

 Investigation of environmental source of
infection

investigation of possibilities of infection

from polluted drinking water or from
contaminated food.

31

 Vaccination
 Though vaccines are available they are
not used for routine immunization and
not used for prevention and control of
epidemics.
 Vaccination against cholera is indicated
for travelers from non-endemic countries
to endemic countries .

32

16
02/05/1443

Three cholera vaccines are available

1) Parental Killed whole cell vaccine
- 2 doses, injected subcutaneously at an interval of 4
to 6 weeks
-partial protection (50%) for 3 – 6 months
- Not recommended.

- 33

2) Oral killed whole cell / B subunit (Wc /

Bs vaccine)
• Vaccine consisting of Formalin or heat
killed V. cholerae 01 in combination with
a recombinant B sub unit of
cholera toxin.
• It is given orally in two-dose
schedule, 10-14 days apart
• The vaccine confers 50-60%
protection for at least 3 years.

34

17
02/05/1443

3) Oral Live attenuated vibrio cholera

01 vaccine

- Single dose

35

Choose the wrong statement:

• 1.Osmotic diarrhea: a occurs when ingested solute, which
is not fully, absorbed draws fluid into the small intestine as
seen in lactose intolerance.
• 2.Secretory diarrhea: occurs when the intestine secrete
rather than absorb electrolytes and water as that seen with
bacterial toxins as in staphylococcus food poisoning.
• 3.Exudative diarrhea: observed in inflammatory diseases
when mucosal inflammation and ulceration cause
outpouring of plasma, mucus and blood into the stool as in
toxigenic E. coli infection.
• 4.Motility disorder: Motility disorder caused by conditions
such as diabetic neuropathy
36

18
02/05/1443

Thank you

19