Solution 1.

2
Problem:
A cholera epidemic has broken out spreading from a neighboring country and threatens
people living in rural villages close to the border of Equador. Approximately 200,000 people
have already been infected. How can the cholera epidemic be terminated?

Reframe:
How can 200,000 people be treated? What is the most effective intervention? How can new
cases be prevented? How can new epidemics be prevented in the future?

Objective:
The goal of the intervention is to reduce mortality and morbidity and to prevent the cholera
epidemic from spreading all over the country.

Alternatives:
Reasonable alternatives for intervention are vaccination, antibiotics, Oral Rehydration
Solution, clean water supply and education programs.

Consequences and Chances:

Vaccination may prevent some new cases during an epidemic, but there is no vaccination
available with long-term effects. Antibiotics may prevent severe cases, but is costly and
cholera may become resistent to antibiotics.
30% of the moderate cases respond well to ORS, which reduces mortality substantially.
Water supplies in urban area’s can easily be chlorinated, but rural area’s are difficult to reach
with this strategy. Education will have a long term effect, but it takes time before it will show.
Trade-offs:
Benefit Harm
Vaccination Prevent new cases Costly, short term effect
Antibiotics Prevent severe cases Costly, resistence
ORS Cure moderate cases Distribution is a challenge
Water supplies Prevent new cases Restricted to urban area
Education Prevent new cases Time consuming
(For practical reasons we here present the balance sheet with the alternatives in the rows,
and benefits and harms in the columns because there are so many options to consider).

Integrate:
Vaccination
Murray et al studied the cost-effectiveness of vaccination in a population at risk for endemic
cholera. They concluded that mass vaccination with BS-WC vaccine is the least cost-effective
intervention compared with the provision of safe drinking-water and sanitation or with
treatment of the disease. (Murray J, McFarland DA, Waldman RJ. Cost-effectiveness of oral
cholera vaccine in a stable refugee population at risk for epidemic cholera and in a population
with endemic cholera. Bull World Health Organ 1998;76(4):343-52)

Antibiotics
Khan studied the effect of tetracycline during the cholera epidemic of 1975 in Dacca. Two
doses of tetracycline were administered to all family contacts of index cases. The control
group of cholera cases did not receive the drug. It was found that the subsequent diarrhoea or
cholera cases occurring among the cholera contacts within 10-12 days were not different
between the treated (13.5%) and the untreated (14.4%) groups. The occurrence of severe
cases requiring hospitalization was, however, significantly reduced in the treated group (8.0%
to 4.5%). In view of the emergence of V. cholera strains resistant to tetracycline, antibiotic
sensitivity testing of epidemic strains would be needed before use of tetracycline for
protecting cholera contacts as an immediate control measure. (Khan MU. Efficacy of short
course antibiotic prophylaxis in controlling cholera in contacts during epidemic. J Trop Med
Hyg. 1982 Feb;85(1):27-9.)

Oral Rehydration Solution

Sircar et al studied the effectiveness of ORS during an extensive outbreak of acute
gastroenteritis in 1978 in the Central district of Manipur state. A total of 4469 cases occurred
during the period. 45.7% of diarrhoea cases sampled and 47.6% of water samples collected
from rivers were found to be positive for V.cholerae biotype EITor. Case fatality rate in this
epidemic was exceptionally low (0.8%) which was attributed to the early domiciliary use of
oral rehydration salt solution (ORS) in the affected villages. (Sircar BK, Saha MR, Deb BC,
Singh PK, Pal SC. Effectiveness of oral rehydration salt solution (ORS) in reduction of death
during cholera epidemic. Indian J Public Health 1990 Jan-Mar;34(1):68-70)

Water supply
Mid-1994, Ramakrishna investigated the public water supply in a medium-sized town in south
India during an epidemic of cholera due to Vibrio cholerae O139. Vibrio cholerae O139 was
isolated from the public water supply including one of the wells supplying the town, the central
overhead tank, and domestic taps connected to the public supply. Following chlorination, the
organism was no longer isolated from the water supply and the epidemic subsided. This
demonstration of V. cholerae O139 in the drinking water supply of a town underlines the need
for adequate treatment of the water supply. (Ramakrishna BS, Kang G, Rajan DP, Mathan M,
Mathan VI. Isolation of Vibrio cholerae O139 from the drinking water supply during an
epidemic of cholera. Trop Med Int Health 1996 Dec;1(6):854-8)

Education
To assess the effectiveness of the cholera prevention activities of the Peruvian Ministry of
Health, Quick et al conducted a knowledge, attitudes, and practices (KAP) survey in urban
and rural Amazon communities during the cholera epidemic in 1991. They surveyed heads of
67 urban and 61 rural households to determine diarrhoea rates, sources of cholera prevention
information, and knowledge, attitudes, and practices regarding ten cholera prevention
measures. Twenty-five per cent of 482 urban and 11% of 454 rural household members had
diarrhoea during the first 3-4 months of the epidemic. Exposure to mass media education was
greater in urban areas, and education through interpersonal communication was more
prevalent in rural villages. Ninety-three per cent of rural and 67% of urban respondents
believed they could prevent cholera. The mean numbers of correct responses to ten
knowledge questions were 7.8 for urban and 8.2 for rural respondents. Practices lagged
behind knowledge and attitudes (mean correct response to ten possible: urban 4.9, rural 4.6).
Seventy-five per cent of respondents drank untreated water and 91% ate unwashed produce,
both of which were identified as cholera risk factors in a concurrently conducted case-control
study. They concluded that cholera prevention campaign successfully educated respondents,
but did not cause many to adopt preventive behaviours. Direct interpersonal education by
community-based personnel may enhance the likelihood of translating education into changes
in health behaviours. (Quick RE, Gerber ML, Palacios AM, Beingolea L, Vargas R, Mujica O,
Moreno D, Seminario L, Smithwick EB, Tauxe RV. Using a knowledge, attitudes and practices
survey to supplement findings of an outbreak investigation: cholera prevention measures
during the 1991 epidemic in Peru. Int J Epidemiol 1996 Aug;25(4):872-8)

Value:
The most important decision criterion for the situation at hand is the minimization of mortality
and morbidity. ORS appears to be the option with the maximum expected value. For the
prevention of new cases an intervention should have a long term effect and should be cost-
effective. Chlorination of the water supply appears to be effective in urban area’s. Education
could be an effective strategy in the long run.

Explore and Evaluate:

If a new vaccin would be developed with long term effects, a vaccination program would be
the preferred strategy for the prevention of new epidemics.