Republic of the Philippines

University of Northern Philippines

Tamag, Vigan City
2700 Ilocos Sur

COLLEGE OF HEALTH SCIENCES

Website: www.unp.edu.ph email: chs_unp@yahoo.com
Tel No.: +639177708873

CHOLERA
(A report paper presented to Fitz Gerald P. Castillo, RMT)

A. EPIDEMIOLOGY OF CHOLERA
Cholera is a Greek word meaning “ the gutter of the roof”. It is caused by the bacteria Vibrio
Cholerae – discovered in 1883 by Robert Koch during a diarrhea outbreak in Egypt.
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.
The seventh pandemic began in Indonesia (1961) and affected more countries and continents
than the previous 6 pandemics. It was caused by V. Cholerae El Tor.

October, 1992
- An epidemic of cholera emerged from Madras, India as a result of a new serogroup (0139).
- This Bengal strain has now spread throughout Bangladesh, India, and neighboring countries
in Asia.
Crowding and gathering of people during religious rituals enhance the spread of infection.
Index cases when travelled back to their homes may pass the organism to at risk individuals
leading to secondary epidemic or small scale infection.

B. PATHOPHYSIOLOGY
Caused by three serotypes namely the Inaba (AC) , Ogawa (AB) and Hikojima.

2 major biotypes of V. Cholerae

1. Classical
2. EI Tor – predominant cholera pathogen worldwide.

V. Cholerae is a comma-shaped, gram – negative, aerobic bacillus whose size varies from 1-3
mm in length by 0.5 – 0.8 mm in diameter.
Its antigenic structure consists of a flagellar H antigen and a somatic O antigen.
It produces an enterotoxin that promotes the secretion of fluid and electrolytes into the lumen of
the gut.
The result is watery diarrhea with electrolyte concentrations isotonic to those of plasma.
The enterotoxin acts locally and does not invade the intestinal wall. As a result few WBC and no
RBC are found in the stool.
Fluid loss originates in the duodenum and upper jejunum.
The colon is usually in a state of absorption because it is relatively insensitive to the toxin.
The larger volume of fluid produced in the upper intestine, however, overwhelms the absorptive
capacity of the lower bowel, which results in severe diarrhea.

C. CASE DEFINITION
A case of Cholera should be suspected when:

CHOLERA (“THE GUTTER OF THE ROOF”) DAN CHRISTIAN P. BLANCE

 Republic of the Philippines
University of Northern Philippines
Tamag, Vigan City
2700 Ilocos Sur

COLLEGE OF HEALTH SCIENCES

Website: www.unp.edu.ph email: chs_unp@yahoo.com
Tel No.: +639177708873

In an area where the disease is not known to be present, a patient aged 5 years or more develops
severe dehydration or dies from acute water diarrhea.
In an area where there is a cholera epidemic, a patient aged 5 years or more develops acute
watery diarrhea, with or without vomiting.

D. CLINICAL DESCRIPTION
Ranges from asymptomatic intestinal colonization to severe diarrhea.
Abdominal discomfort, borborygmi, and vomiting particularly in the early phase of the disease.
Substantial volume and electrolyte loss from diarrhea.
Fever is uncommon

E. CLINICAL MANIFESTATIONS
Organism can be seen in stool by direct microscopy after gram stain and dark field illumination
is used to demonstrates motility.
It can be cultured on special alkaline media like TCBS agar.
Serologic tests are available to define strains, but this is needed only during epidemics to trace
the source of infection.
Dehydration leads to high blood urea and serum creatinine.
Hematocrit and WBC will also be high due to hemoconcentration.
Dehydration and bicarbonate loss in stool leads to metabolic acidosis with wide-anion gap.
Total body potassium is depleted, but serum level may be normal due to effect of acidosis.

F. SPREAD OF INFECTION
If ingested with water the dose is in the order of 10 3 – 106 organisms. When ingested with food,
fewer organisms are required to produce disease, namely 10 2 – 104
V. Cholerae is a saltwater organism and its primary habitat is the marine ecosystem.
It has two main reservoirs, man and water. Animals do not play a role in spread of infection.
Any condition that reduced gastric acid production increases the risk of acquisition.

G. INCUBATION PERIOD
Incubation period is 24- 48 hours.

H. MODE OF TRANSMISSION

It is transmitted by the fecal-oral route through contaminated water and food.

Person to person infection is rare.

I. PERIOD OF COMMUNICABILITY
Patients are infectious from the onset of symptoms until 7days after resolution of diarrhea.
The carrier state may develop and persist for few months.
Very rarely, chronic biliary carriage can develop in adults with intermittent shedding can persist
for years.

CHOLERA (“THE GUTTER OF THE ROOF”) DAN CHRISTIAN P. BLANCE

 Republic of the Philippines
University of Northern Philippines
Tamag, Vigan City
2700 Ilocos Sur

COLLEGE OF HEALTH SCIENCES

Website: www.unp.edu.ph email: chs_unp@yahoo.com
Tel No.: +639177708873

J. LABORATORY TEST FOR DIAGNOSIS.

Isolation and identification of Vibrio Cholerae serogroup O1 or O139 by culture of a stool

specimen.
Cary Blair Media is ideal for transport, and the selective thiosulfate-citrate-bile salts agar
(TCBS) is ideal for identification.

K. SCREENING AND CONFIRMATORY TEST.

Name of the test: Rapid Dipstick Test (RDT)

About the test: Considered as Cholera detecting tool in diarrheal outbreak investigations.

Test principle: The test is based on immunochromatography an colorimetric reporting and detects VC O1
and O139 antigens binding to antibodies fixed on a nitrocellulose strip.

Intended use: A diagnostic assay designed for use at the point of care testing, and can be adapted for use in
low-resource settings specially in screening for VC O1.

Specimen type: Fecal specimen.

Test Interpretation and expected results: fecal specimens that test positive for VC 1 or O139 always be
confirmed using traditional culture-based methods suitable for the isolation and identification of VC.

Test Limitation: The test has poor specificity.

L. Treatment and medical management: Ringer lactate solution over normal saline, IV fluids, use of ORS,
Tetracycline, doxycycline, contrimoxazole, and ciprofloxacin tablets.

M. Infection control measures: handwashing with soap and clean water should be done before and after each
patient contact. If no water and soap are available, use 70% isopropyl alcohol. Several chlorine solutions can be used
for disinfection. Proper use of PPE must be observe.

Infection control protocol:

Important advices
The most important elements of these infection precautions are hand hygiene and protection of hand
and cloths (body) from the contact with vomit or stool. Use of glove and gown while providing care of all
cholera patients presenting extensive watery diarrhea and/or vomiting is recommended. Promotion of safety
climate is a cornerstone of prevention of transmission of pathogens in health care.

Environmental Control

CHOLERA (“THE GUTTER OF THE ROOF”) DAN CHRISTIAN P. BLANCE

 Republic of the Philippines
University of Northern Philippines
Tamag, Vigan City
2700 Ilocos Sur

COLLEGE OF HEALTH SCIENCES

Website: www.unp.edu.ph email: chs_unp@yahoo.com
Tel No.: +639177708873

Promptly clean and decontaminate spills of vomit, stools or other potentially infectious materials.
Use protective gloves and other PPE appropriate for this task.

Clean soiled and disinfect frequently touched surfaces regularly, including those that are in close
proximity to the patient (e.g., chairs, bed, over bed tables) and floor with bleach 0.1% a least twice a day.
Cleaning of the surface must precede the application of disinfectants. Concentrations for use in the hospital
area: 10,000 ppm = 1% = Concentration for disinfection of spills, following cleaning. 1,000 ppm = 0.1% =
Disinfection of critical areas, following cleaning.

Puncture resistant waste

Containers located at the point of use (e.g., sharps containers) are used as containment for discarded
slides or tubes with small amounts of blood, scalpel blades, needles and syringes, and unused sterile sharps.

To prevent needle stick injuries, needles and other contaminated sharps should not be recapped,
purposefully bent, or broken by hand.

Infection control precaution in cholera patients presenting vomits and profuse diarrhea in hospital
settings
Patient placement
• Place together in the same room (cohort) patients who are infected with the same pathogen and are
suitable roommates
• Ensure that patients are physically separated (i.e., >3 feet apart) from each other
• Change protective attire and perform hand hygiene between contact with patients in the same
room, regardless of whether one or both patients are on Contact Precautions Personal protective equipment
(PPE)
• Hand hygiene with soap and water or an alcohol-based hand rub
• For practical purposes, put on PPE upon room entry and discard before exiting the patient room
• Remove gown and gloves and observe hand hygiene before leaving the patient-care environment
Patient-care equipment and instruments/devices
• Common use of equipment for multiple patients, clean and disinfect such equipment (ej.
Thermometers, stethoscope and sphygmomanometer) before use on another patient
• Use 70% ethanol solution or 0.1% hypochlorite solution (for no metal equipments)
Medical Practitioners: Pathologists, Gastroenterologists, Medical Technologists, Medical Technicians, Nurses.

CHOLERA (“THE GUTTER OF THE ROOF”) DAN CHRISTIAN P. BLANCE

 Republic of the Philippines
University of Northern Philippines
Tamag, Vigan City
2700 Ilocos Sur

COLLEGE OF HEALTH SCIENCES

Website: www.unp.edu.ph email: chs_unp@yahoo.com
Tel No.: +639177708873

References

Bossak, B., Welford, M., & Yarbrough, R. (2012). P-128. Epidemiology, 23, 1. doi:

10.1097/01.ede.0000417132.33077.2f
Bottomley, G. (2000). What Is Cholera? Bmj, s3-2(91), 890–891. doi: 10.1136/bmj.s3-2.91.890-a
Noah, N. (2001). Communicable disease: epidemiology and control.Cholera (2nd ed., Vol. 2). Quezon,
Philippines: Wiley.
Chang, A. (2005). Magills medical guide. The Pathology and Physiology of Cholera (3rd ed.). Pasadena,
CA: Salem Press.
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American Medical Association, 264(4), 441–441. doi: 10.1001/jama.264.4.441
Akanda, A., Jutla, A., Gute, D., Evans, T., & Islam, S. (2012). Reinforcing cholera intervention through
prediction-aided prevention. Bulletin of the World Health Organization, 90(3), 243–244. doi:
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Rapid cholera dipstick test. (n.d.). Retrieved March 17, 2020, from
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Aarogya.com. (n.d.). Mode of Transmission of Cholera. Retrieved March 17, 2020, from
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Normandin, B. (2017, July 8). Cholera: Causes, Symptoms & Diagnosis. Retrieved March 17, 2020, from
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Guidelines for Cholera Control - CliniciansOfTheWorld. (n.d.). Retrieved March 17, 2020, from
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http://cliniciansoftheworld.org/WHO_Guidelines_Cholera_Control.pdf

CHOLERA (“THE GUTTER OF THE ROOF”) DAN CHRISTIAN P. BLANCE

 Republic of the Philippines
University of Northern Philippines
Tamag, Vigan City
2700 Ilocos Sur

COLLEGE OF HEALTH SCIENCES

Website: www.unp.edu.ph email: chs_unp@yahoo.com
Tel No.: +639177708873

CHOLERA (“THE GUTTER OF THE ROOF”) DAN CHRISTIAN P. BLANCE