oyna CHOLERA Clinical case description: Inanarea 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 (Severe dehydration- lethargy, altered conciousness, decreased urine). Inan area where cholera is endemic Acute watery diarrhea, with or without vomiting in a patientaged 5 years or more. Inan area where there is a cholera epidemic Any watery diarrhea, with or without vomiting, in any patient. Laboratory criteria for diagnosis Isolation of Vibrio cholera 01 or 0139 from stools in any patient with diarrhea Case Classification ‘Suspect case: Acase that meets the clinical case definition. Probable case: Asuspect case diagnosed as cholera by aMO. Confirmed case: Asuspect case thatis laboratory confirmed. * Endemicdisease «Larger endemic foci foundin Maharastra, Tamil Nadu, Kamataka, Delhi and Kerala, * Affects all ages and both sexes, attack rate is highestin children DIFFERENTAL Discos During epidemics diagnosis is easy, but sporadic cases must be differentiated from other diarrhea cases such as: + Bacillary dysentery ‘+ Typhoid and salmonellosis © Viral diarrhea (enteritis due to viruses) ‘© Amoebiasis and intestinal parasitism ‘+ Staphylococcal food poisoning * Chemical poisoning + Some strains of € coli and other enteric organisms [Mlonenosrc nena wvesrcarons, rearMeN & REFERRALERITERI Il LEVEL 1: AT SOLO PHYSICIAN CLINIC: Clinical Diagnosis : Incubation period usually 2-3 days (range few hours to 5 days), + Acute onset + Severe watery diarrhea = Vomiting + Signs of dehydration WPM imc ta}orn Assessment of diarrhoea patients for dehydration: LOOK AT: CONDITION Well, alert Restless, irritable Lethargic or unconscious EYES Normal ‘Sunken Sunken THIRST Drinks normally, Thirsty, drinks eagerly Drinks poorly, not thirsty, or not able to drink Rapid Pulse Fall in BP Decreased Urine FEEL: SKIN PINCH Goes back quickly Goes back slowly Goes back very slowly DECIDE The patient has Ifthe patient has two or Ifthe patients has NO SIGNS OF more signs in B, there is two or more signs in DEHYDRATION © SOME DEHYDRATION —_C, there is SEVERE DEHYDRATION Fluid deficit as <5% 510% >10% % of body weight Fluid deficit in ml/kg <5 mi/kg ‘50-100 mi/kg >100 mikg body weight TREAT Treat with home ORS. IV rehydration therapy fluids! ORS Investigations : The diagnosis would be mostly clinical, However samples of stool could be collected & sent for following lab investigations outside: ‘+ Direct Examination of Darting Motilty through hanging drop preparation + Stool culture Treatment Early treatment in most cases by oral rehydration therapy can reduce the case fatality of Cholera to less than 1% Guidelines for giving ORS With obvious signs of dehydration (moderate dehydration), water deficit is 50- 100mI/kg. Ifthe child's weight is known or can be taken, 75 mi/kg of ORS is given within first 4 hours. Thus, for a child weighing 10 kg; 10x 75= 750 mi. Adults can be given up to 750 ml per hour. If weight is not known, age may be used for calculation. Give ORS as long as the patient desires; his thirstis the best guideline to regulate the quantity. Give additional water, ifdesired. Amount of ORS, as per the age of the child Upto4months 200-400 ml Upto 12 months 400-600 mi 2nd year 600- 800 ml ‘3rd/4thyear 800-1200 ml Sth- 14th year up to. 2000 mi How to give ORS? The success of ORS depends on how it is given. It is more accepted when given a teaspoonful every 1-2 minutes. If he vomits, wait 10 minutes and reinstitute ORS at longer intervals e.g. 1 tsf every 2-3 minutes. Continue breast- fee WPM imc ta}Crear Other Fluids that can be given in stage A: Salted drinks (e.g. salted rice water or a salted yoghurt drink), vegetable or chicken soup with salt, Ahome-made solution containing 3gmitt of table salt (one level teaspoonful) and 18gmilt of common sugar (sucrose) in one litre of potable water is also effective, if ORS not available. How longto give? 1) Give ORS aslongas fluid diarrhea is continuing 2)Aslong as signs of dehydration are there. 3)As longas the patient demands. Reassess clinical condition every 1 -2 hours: if hydration is not improving start IV infusion and refer to the next higher level Referral crit ia + Severe dehydration + Hydration notimproving LEVEL 2: AT 6-10 BEDDED PRIMARY HEALTH CENTRE Clinical Diagnosis : Same as Level 1 fora fresh case reporting directly. Investigations: * SameasLevel 1 Treatment: + SameasLevel 1 + IV therapy may be required for clinically severe form of Cholera. IV fluids will be used for the rehydration of patients with severe dehydration, including those who are in shock. Ringer's lactate solution is the preferred fluid for intravenous rehydration. Normal saline solution is less effective for intravenous rehydration, but can be used if Ringer's lactate solution is unavailable. Plain glucose solutions are ineffective and should notbe used. Guidelines for intravenous treatment of children and adults with severe dehydration Start IV fluids immediately. If the patient can drink, give ORS by mouth until the drip is set up. Give 100 ml/kg Ringer's lactate Solution divided as follows: Infants (under12 months) 1 hour 5 hours Older 30 minutes: 2%hours: + Reassess the patient every 1-2 hours. If hydration is not improving, give the IV drip more rapidly. + After six hours (infants) or three hours (older patients), evaluate the patient using the assessment chart. ‘Then choose the appropriate treatment plan to continue treatment Referral criter © Hydration n improving ‘+ Complications of IV therapy. + Pulmonary oedema is caused when too much IV fluid is given, and especially when metabolic acidosis has not been corrected. The latteris mostlikely to occur when normal saline is used for IV rehydration and ORS solution is not given at the same time. When the guidelines for IV rehydration are followed, pulmonary oedema should not occur. + ORS solution never causes pulmonary oedema. aT WPM imc ta}CHOLERA ‘+ Renal failure may occur when too little lV fluid is given, when shock is notrapidly corrected, or when shock is allowed to recur, especially in persons above the age of 60 years . Renal failure is rare when severe dehydration is rapidly corrected and normal hydration is maintained according to the guidelines. LEVEL 3: AT 30-100 BEDDED COMMUNITY HEALTH CENTRE Clinical Diagnosis :Itis possible that the patient may have other causes of diarrhea as listed in the differential diagnosis. Cholera would be confirmed more or less without any doubt with sensitive & specific laboratory support available atthis level of care. Investigations: + Sameas Level2 fora fresh case reporting directly. Stool Culture/ rectal swab for culture. Immobilization test with anti-sera for identification of the sero type. * Blood Urea. * Serum Creatinine. Treatment: * Sameas Level 2 in case of uncomplicated Cholera + AFoley's catheter should be placed to facilitate monitoring of intravascular volume status, hourly urine measurements should be recorded: urine output should be not less than 0.5mi/kg/hour. * In severe cases, antibiotics can reduce the volume and duration of diarrhoea and can shorten the period during which the cholera vibrios are excreted. Antibiotics can be given orally as soon as vomiting stops, usually within 3-4 hours of starting rehydration. There is no advantage in giving injectable antibiotics which are expensive. Use of antibiotics for mild cases is not recommended. This will hasten the development of antibiotic resistant strains as well as exhaust supplies which may be needed for severe cases. Patients who benefit most from antibiotic treatmentare those with severe dehydration. Ciprofloxacin 500mg BD Or Doxycycline: 300 mg single dose or Tetracycline 500 mg 6 hourly for 48 hrs or 2 gm single dose No antidiarrhoeal, antiemetic, antispasmodic, cardiotonic or corticosteroid drugs should be used to treat cholera. Blood transfusion and volume expanders are not necessary. Referral criteria: ‘+ Undertake constant lab and clinical monitoring, If no signs of improvement in five days or complications not controlled by specialists at the centre, refer to nextlevel ‘+ Patienthaving coma orrenal failure LEVEL 4: AT 100 OR MORE BEDDED DISTRICT HOSPITAL Clinical Diagnosis : Usually the patient would be in advanced stage of the disease or with complications manifest by the time he reaches this level. Cholera would already have been diagnosed more or less without any doubt with sensitive & specific laboratory support available at Level 3 itself. This level essentially entails management of severe complications. WPM imc ta} "