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
 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

 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
 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

 Started in Indonesia – spread to India, USSR,
North Africa, Italy, Japan and South Pacific.
 Eight “pandemic” – 1991 - 1994
 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
 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
 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
initiatives
 at NIH
National and Provincial Task Forces
 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
 at NIH
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. Nationwide monitoring
2. Technical support - guidelines, SOPs, trainings
and DEWS Tools
3. Response when called by respective
departments International collaboration
4. Disease Early Warning System
5. > 600 alert/outbreak responded since 1998

“National Disease Surveillance Mechanisms” A.Ikram AFIP,

M.Safdar NIH
 Disease Early Warning
System
 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

 Project Director: Dr.Iftikhar.uddin

 Donor Agencies: World Bank, UNICEF
USAID
 Technical Advisors WHO, CDC Atlanta
 Partners for BCC Bloomberg School of Public
Health John Hopkins
 Working partners 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.

 1. Ensuring safe drinking water
and proper
 BCCsanitation
for boiling offor alland
water the citizens of
proper
sanitation. Pakistan.
 School sessions
 Mass media
 Television
 Radio
 Newspaper
 Community sessions
 Installation of Filtration Plants
2. Early detection of an
outbreak
 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