Epidemiology and Control of

Cholera

Cholera is an acute bacterial enteric disease

with sudden onset, profuse painless watery stool,
occasional vomiting, rapid dehydration, acidosis
and circulatory collapse.

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Importance:
• The number of cholera patients worldwide is
uncertain because many cases are unreported,

• The number of cases is increased during

epidemics & is affected by environmental factors,

• Case-fatality rates are usually around 5% but

have reached 40% in large outbreaks in refugee
camps (e.g. Goma, Democratic Republic of
Congo in 1994),
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 Importance – cont.

• Improved modes of treatment in well-organized

health facility can reduce case fatality rates for
cholera to as little as 1%,

• Mass vaccination and mass chemoprophylaxis

are ineffective in preventing or controlling out
breaks.

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Global cholera situation
 In 2018, 18 countries reported a total of 132 121
confirmed cholera cases.
 Haiti, Congo, Yemen , Somalia, and Tanzania
accounted for 80% of all cases.

 Estimated burden of 1.4 – 4 million cases, and

21 000 – 143 000 deaths per year worldwide.
 Many countries report as cholera many cases of
acute watery diarrhea.

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 Importance – cont.

• Where cholera is present but not epidemic, it

causes fewer than 5% of all acute diarrhea,

• More than 90% of cholera cases are mild, and

may be difficult to distinguish from other types of
acute diarrheal diseases.

• Individuals living in places with inadequate

water treatment, poor sanitation, and inadequate
hygiene are at a greater risk for cholera.

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Cholera situation in Yemen
 2 waves: wave 1 (25 839 cases), wave 2 (1 055 504
cases).
 Deaths 2255.
 Case fatality rate 0.21%.
 Governorates affected 96%.
 Western part of Yemen was more affected.
 Vibrio cholera 01 serotype Ogawa was confirmed
(same strain during two waves).

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 Epidemiology
I. Since 1817, there have been 7 cholera
pandemics.

The first 6 occurred from 1817-1923 and were

caused by V. cholerae, the classical biotype. The
pandemics originated in Asia with subsequent
spread to other continents.

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 EPIDEMIOLOGY – cont.

II. The seventh pandemic began in Indonesia in

1961 and affected more countries and
continents than the previous 6 pandemics. It
was caused by V. cholerae, the El Tor biotype.

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 EPIDEMIOLOGY – cont.

III.In October 1992, an epidemic of cholera

emerged from Madras, India as a result of a new
serogroup - Bengal strain (o139). Some experts
regard this as an eighth pandemic.

IV.This Bengal strain has now spread throughout

Bangladesh, India, and neighboring countries in
Asia.

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 Epidemiology - cont.
V. Crowding & gathering of people during
religious rituals (e.g. Muslims pilgrimage to
Mecca or Hindu swimming festivals in holy
rivers) enhance the spread of infection.

VI.Index cases when travelled back to their homes

may pass the organism to at risk individuals
leading to secondary epidemic or small scale
infection.

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Reservoir :
Cholera has 2 main reservoirs:
1)Man:
Cases
Carriers.

2)Environmental reservoir.

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Agent :
Gram-negative bacillus Vibrio cholerae O1 and
Vibrio cholerae O139 .
Vibrio cholerae produces a powerful enterotoxin.
V. cholerae has 2 major biotypes: classical and El
Tor.

Serogroup O1 includes serotypes Ogawa, Inaba

and Hikojima
 Currently, El Tor is the predominant cholera
pathogen worldwide.
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Mode of Transmission :
• Fecal-oral route through contaminated water &
food by:

 ingestion of organisms in food and water,

 directly from person to person.

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Susceptibility :
Patients with chronic gastritis secondary to
Helicobacter pylori infection or those who have
had a gastrectomy.

The use of antacids, histamine-receptor blockers,

and proton-pump inhibitors increases the risk of
cholera infection and predisposes patients to
more severe disease as a result of reduced gastric
acidity.

Breast-fed infants are protected.

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Incubation period :
24-48 hours.

Period of communicability:
Presumably for the duration of the stool-positive
stage, usually only a few days after recovery.
Occasionally the carrier state may persist for
several months. Effective antibiotics, e.g.
tetracycline, shorten the period of
communicability.

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 Prevention and control
Being Prepared: Long –Term Activities
Training in clinical management of acute
diarrhea,
Health education;
Environmental sanitation;
 Disposing human waste,
 Assuring a safe water supply,
 Food safety.
Detecting a cholera out breaks: Surveillance and
case reporting;
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 Prevention and control - cont
Early Responses to the threat of an outbreaks
1) National coordinating committee;
 Regional and international collaboration,
 Collecting and reporting of information,
 Organization of any necessary training,
 Procurement, storage, and distribution of required
supplies,
 Implementation, monitoring, and evaluation of control
activities.
2)Establishing mobile control teams;
3)Supplies and equipment.
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TREATMENT
The primary goal of therapy is to replenish fluid
losses caused by diarrhea & vomiting.

Fluid therapy is accomplished in 2 phases:

 rehydration,
 and maintenance.
Rehydration should be completed in 4 hours &
maintenance fluids should replace ongoing losses
& provide daily requirement.

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Fluid Therapy :
Ringer lactate solution is preferred over normal
saline because it corrects the associated metabolic
acidosis.

The oral route is preferred for maintenance &

the use of ORS at a rate of 500-1000 ml/h is
recommended.

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Drug therapy :
o The goals of drug therapy are to eradicate
infection, reduce morbidity and prevent
complications.

o The drugs used for adults include tetracycline,

doxycycline, cotrimoxazole & ciprofloxacin.

o For children erythromycin, cotrimoxazole and

furazolidone are the drugs of choice.

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 Drug therapy – cont.
o Drug therapy reduces volume of stool & shortens
period of hospitalization. It is only needed for few
days (3-5 days).

o Drug resistance has been described in some areas

& the choice of antibiotic should be guided by the
local resistance patterns .

o Antibiotic should be started when cholera is

suspected without waiting for lab confirmation.

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Preventing the spread of the outbreaks:
Health education,

Disposal of dead, and disinfection,

Chemoprophylaxis: has never succeed in limiting

the spread of cholera.

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 Preventing the spread of the outbreaks – cont.

Vaccination: The vaccines currently approved by

WHO only Oral Cholera Vaccines (OCVs).
 Killed whole cell monovalent (O1) vaccines with a
recombinant B subunit of cholera toxin: DukoralR.

 Killed modified whole cell bivalent (O1 and O139)

vaccines without the B subunit: ShancholTM.

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 Vaccination – cont.
Doses:
 ShancholTM at least 2 doses – 2-4 weeks apart.
 DukoralR at least 2 doses – 2-4 weeks apart.
Conferred protection:
 Up to 85% for first 6 months.
 50-62% in the first year.
 ˂50% after 2 years.
 ˂40% for 6 months if used as single dose.
 Revaccination is recommended in endemic areas.
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 Vaccination – cont.
Regarding to WHO Position august 2017:
 Vaccines should be used in areas with endemic
cholera, humanitarian crises with high risk of
cholera, and during cholera outbreaks.
 The vaccines should always be used in conjunction
with other cholera prevention and control strategies.
 Vaccination should not disrupt the provision of other
high priority health interventions to prevent and
control cholera outbreaks.

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