1 Cholera Guidelines 2004 – Second edition
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1st edition, 1995 – French
© Médecins Sans Frontières – September 2004 All rights reserved for all countries. No reproduction, translation and adaptation
may be done without the prior permission of the copyright owner
Cholera Guidelines
2004
Authors Second Edition Ariane Bauernfeind, Alice Cro i s i e r, Jean-Francois Fesselet, Michel van Herp, Elisabeth Le Saoût, Jean Mc Cluskey, Welmoet Tuynman.
Contributors Dounia Bitar, Gerry Boots, Guy Jacquier.
Editorial committee Lucie Blok, Myriam Henkens, Eric Thomas.
Foreword Poor hygiene and economic environment and precarious living conditions are trigge- ring cholera outbreaks all over the world. Therefore, this guideline will give guidance towards strategies on reduction of mor- tality as well as of reduction of transmission. As one cannot exclude the other in order to be sufficient to tackle this disease. Nevertheless, if resources are limited, first priority will be given to case management and proper isolation of those ones. The implementation of the strategies will differ as well when be addressed to rural, urban or closed (camp settings) situations. This guideline is closing with cholera preparedness, which can be applied as well as first step before an outbreak occurs. Various practical tools are presented in the annexes. Those annexes and in addition training, health education material and data collection tools are available in the atta- ched CD-rom. The authors would welcome any remarks or critical comments from those using this guide, so as to allow revision in keeping with the realities of working in the field.
Comments should be addressed to: Medecins Sans Frontieres – Medical Department 8 rue St-Sabin – 75544 Paris Cedex 11 - FRANCE
Tel. : +33.(0)1.40.21.29.29 Fax : +33.(0)1.48.06.68.68
FO R E W O R D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
TA B L E O F C O N T E N T S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
CH A P T E R 1. FE AT U R E S O F C H O L E R A O U T B R E A K S . . . . . . . . . . . . . . . . . . . . . . . 1 2 1. Epidemiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 2. Transmission and immunity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 3. Clinical features of cholera infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Key points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
CH A P T E R 2. OU T B R E A K I N V E S T I G AT I O N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 9 1. Triggering the alert . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 2. Confirming the diagnosis by laboratory tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 3. Establishing and disseminating a case definition. . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 4. Describing the situation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 5. Assessing response capacity of the health system . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 6. Identifying priority areas for intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 7. Reporting and formulating recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Key points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
CH A P T E R 3. IN T E RV E N T I O N S T R AT E G I E S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2 1. Reducing mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 2. Reducing the epidemic spread . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 3. Coordination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
CH A P T E R 4. IN T E RV E N T I O N S TO R E D U C E M O RTA L I T Y . . . . . . . . . . . . . . . . . . . . . 3 6 1. Setting up treatment centres, multiplying their numbers and decentralising . . . . 37 2. Organization of cholera treatment facilities: example of a CTC. . . . . . . . . . . . . . . . 40 3. Human resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 4. Supplies in a cholera treatment facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Key points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
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Cholera guidelines
CH A P T E R 5. CA S E M A N A G E M E N T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 9 1. Active case finding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 2. Assessment of the patient's hydration status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 3. Rehydration therapy and monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 4. Antibiotic treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 5. Identifying and treating complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 6. Cholera and severe malnutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 7. Resumption of normal feeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 8. Other treatment procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 9. Discharging the patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
CH A P T E R 6. RE D U C I N G T H E S P R E A D O F T H E E P I D E M I C . . . . . . . . . . . . . . . . . . . 6 2 1. Ensuring access to water: quantity and quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 2. Promoting and enabling hygienic conditions and practices. . . . . . . . . . . . . . . . . . . 64 3. Ensuring Effective Sanitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 4. Public information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 5. Prioritisation of interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 6. Mass chemoprophylaxis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 7. Vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 8. Specific situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
CH A P T E R 7 . MO N I TO R I N G A N D E VA L U AT I O N . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 7 1. Practical points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 2. Results and interpretation in a treatment facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Key points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
CH A P T E R 8 . TH E E N D O F T H E O U B R E A K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 6 1. When to declare the end of the outbreak. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 2. When and how to close a CTC/CTU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
CH A P T E R 9. CH O L E R A P R E PA R E D N E S S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 6 1. Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 2. When is cholera preparedness appropriate? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 3. How to organize cholera preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Key points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Table…
© Médecins Sans Frontières – September 2004 All rights reserved for all countries. No reproduction, translation and adaptation
may be done without the prior permission of the copyright owner
Cholera Guidelines
2004
Authors Second Edition Ariane Bauernfeind, Alice Cro i s i e r, Jean-Francois Fesselet, Michel van Herp, Elisabeth Le Saoût, Jean Mc Cluskey, Welmoet Tuynman.
Contributors Dounia Bitar, Gerry Boots, Guy Jacquier.
Editorial committee Lucie Blok, Myriam Henkens, Eric Thomas.
Foreword Poor hygiene and economic environment and precarious living conditions are trigge- ring cholera outbreaks all over the world. Therefore, this guideline will give guidance towards strategies on reduction of mor- tality as well as of reduction of transmission. As one cannot exclude the other in order to be sufficient to tackle this disease. Nevertheless, if resources are limited, first priority will be given to case management and proper isolation of those ones. The implementation of the strategies will differ as well when be addressed to rural, urban or closed (camp settings) situations. This guideline is closing with cholera preparedness, which can be applied as well as first step before an outbreak occurs. Various practical tools are presented in the annexes. Those annexes and in addition training, health education material and data collection tools are available in the atta- ched CD-rom. The authors would welcome any remarks or critical comments from those using this guide, so as to allow revision in keeping with the realities of working in the field.
Comments should be addressed to: Medecins Sans Frontieres – Medical Department 8 rue St-Sabin – 75544 Paris Cedex 11 - FRANCE
Tel. : +33.(0)1.40.21.29.29 Fax : +33.(0)1.48.06.68.68
FO R E W O R D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
TA B L E O F C O N T E N T S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
CH A P T E R 1. FE AT U R E S O F C H O L E R A O U T B R E A K S . . . . . . . . . . . . . . . . . . . . . . . 1 2 1. Epidemiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 2. Transmission and immunity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 3. Clinical features of cholera infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Key points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
CH A P T E R 2. OU T B R E A K I N V E S T I G AT I O N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 9 1. Triggering the alert . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 2. Confirming the diagnosis by laboratory tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 3. Establishing and disseminating a case definition. . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 4. Describing the situation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 5. Assessing response capacity of the health system . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 6. Identifying priority areas for intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 7. Reporting and formulating recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Key points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
CH A P T E R 3. IN T E RV E N T I O N S T R AT E G I E S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2 1. Reducing mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 2. Reducing the epidemic spread . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 3. Coordination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
CH A P T E R 4. IN T E RV E N T I O N S TO R E D U C E M O RTA L I T Y . . . . . . . . . . . . . . . . . . . . . 3 6 1. Setting up treatment centres, multiplying their numbers and decentralising . . . . 37 2. Organization of cholera treatment facilities: example of a CTC. . . . . . . . . . . . . . . . 40 3. Human resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 4. Supplies in a cholera treatment facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Key points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
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Cholera guidelines
CH A P T E R 5. CA S E M A N A G E M E N T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 9 1. Active case finding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 2. Assessment of the patient's hydration status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 3. Rehydration therapy and monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 4. Antibiotic treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 5. Identifying and treating complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 6. Cholera and severe malnutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 7. Resumption of normal feeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 8. Other treatment procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 9. Discharging the patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
CH A P T E R 6. RE D U C I N G T H E S P R E A D O F T H E E P I D E M I C . . . . . . . . . . . . . . . . . . . 6 2 1. Ensuring access to water: quantity and quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 2. Promoting and enabling hygienic conditions and practices. . . . . . . . . . . . . . . . . . . 64 3. Ensuring Effective Sanitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 4. Public information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 5. Prioritisation of interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 6. Mass chemoprophylaxis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 7. Vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 8. Specific situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Key points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
CH A P T E R 7 . MO N I TO R I N G A N D E VA L U AT I O N . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 7 1. Practical points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 2. Results and interpretation in a treatment facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Key points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
CH A P T E R 8 . TH E E N D O F T H E O U B R E A K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 6 1. When to declare the end of the outbreak. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 2. When and how to close a CTC/CTU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
CH A P T E R 9. CH O L E R A P R E PA R E D N E S S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 6 1. Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 2. When is cholera preparedness appropriate? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 3. How to organize cholera preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Key points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
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