Introduction to

Cholera
Managing
Infectious Hazards

OpenWHO.org ©WHO2017 0
 Learning objectives

 Describe the case definition and

alerts for cholera
 Describe main transmission
routes
 List the key preventive actions
 Explain how cholera control is
multisectoral

OpenWHO.org ©WHO2017 1
 The disease

 Cholera is caused by the bacterium

Vibrio cholerae.
 It causes diarrhoea that can lead to
severe dehydration and death in
people of all ages.
 Untreated, the case fatality can be
as high as 50%.
 80% of all infected cases will only
have mild or no symptoms at all.

OpenWHO.org ©WHO2017 2
 History

 Cholera can cause explosive,

widespread epidemics.
 Humans carry and spread the
disease globally. We are currently in
the 7th pandemic. Cholera arrived in
Africa in 1971.

OpenWHO.org ©WHO2017 3
 Epidemiology

 Transmission via faeco-oral route,

contaminated water and food
 There are three epidemiological profiles:
 Epidemic
 Humanitarian crises
 Endemic

OpenWHO.org ©WHO2017 4
 Cholera in 2016

South Sudan: 4401 cases,

81 deaths in 2016

OpenWHO.org ©WHO2017 5
 Signs and symptoms

 Acute watery diarrhoea with or without vomiting

 Dehydration
 May also cause hypoglycaemia, hypokalaemia
 High risk of fetal loss in pregnant women with cholera (aggressive
rehydration current best practice)

OpenWHO.org ©WHO2017 6
 Diagnosis and treatment

Diagnosis:

 Clinical; action can begin

 Rapid diagnostic tests to
reinforce suspicion of
epidemic
 Stool culture for confirmation
 Polymerase Chain Reaction
(PCR) for confirmation

OpenWHO.org ©WHO2017 7
 Diagnosis and treatment

Treatment

 No or some signs of dehydration

 Rehydrate with Oral
Rehydration Salts (ORS)
 Severe dehydration
 IV rehydration with Ringer’s
Lactate.
 Antibiotics will help reduce
severity and duration of
disease

OpenWHO.org ©WHO2017 8
 Prevention

 Provide access to clean water

and sanitation
 Adopt hand washing and other
protective hygiene practices
 Engage communities
 Provide treatment structures and
services

OpenWHO.org ©WHO2017 9
 Vaccination

 Oral Cholera Vaccine (OCV)

 Shanchol™ and Euvichol®
 1 or 2 doses of vaccine given to
at risk populations above age 1
 Protection approximately 80% at
6 months, 65% at 3 years
 Longer duration of protection with
2 doses

OpenWHO.org ©WHO2017 10
 Accessing vaccine

 Global OCV Stockpile to facilitate access to vaccine

 For emergencies (outbreak response and humanitarian crises)
vaccine available via the International Coordinating Group (ICG)
 For integration in control programme for endemic areas vaccine
available via the Global Task Force on Cholera Control (GTFCC)
OCV working group
OpenWHO.org ©WHO2017 11
 Case definitions

Non-endemic area Endemic areas Epidemic area

a patient aged 5 any patient aged 2 any patient
years or more years or more presenting with
presenting with presenting with AWD or dies from
acute watery AWD or dies from AWD
diarrhoea (AWD) AWD
and severe
dehydration or dies
from AWD Note: children under 5 are
susceptible to cholera and
must be treated accordingly

OpenWHO.org ©WHO2017 12
 Alerts

 A death from AWD in a

patient aged 5 years or
more

Alerts
 A positive rapid
diagnostic test

OpenWHO.org ©WHO2017 13
 Alerts

 A cluster of cases of
AWD in patients aged
5 years or more in the  A doubling of cases
same week and from of AWD in patients
the same area aged 5 years or more
compared to the
previous week, for
Alerts two consecutive
weeks, in the same
geographic area
Note: in endemic areas, the
age limit used is 2 years
OpenWHO.org ©WHO2017 14
 Prevention and control

 Preparedness in identified high risk

areas with multisectoral plans using
measurable indicators including:
surveillance (epidemiological and
laboratory), case management,
WaSH and vaccination

 Rapidity and coordination of

multisectoral response

OpenWHO.org ©WHO2017 15
 Key concerns

 Need for analysis of data and

anticipation of spread of epidemics

 Laboratory capacity for confirmation

is weak in many countries and
should be reinforced

OpenWHO.org ©WHO2017 16
 WHO technical support and recommendations

 Cholera Coordination Mechanism

(CCM) is providing a coordinated effort
from everyone in emergencies to control
cholera.
 The Global Taskforce for Cholera
Control (GTFCC) is providing a
multisectoral platform for coordination
and guidance for cholera control.

OpenWHO.org ©WHO2017 17
 WHO technical support and recommendations

 New OCV Strategic Advisory Group of

Experts on Immunization (SAGE)
recommendations expected later this
year
 New Global WHO Strategy in
development looking beyond outbreak
response to long term cholera control

OpenWHO.org ©WHO2017 18
 WHO global strategy for cholera control

 Eliminate predictable  Respond to

cholera epidemics unpredictable epidemics

 Reduce the magnitude and severity of cholera during

humanitarian crisis

OpenWHO.org ©WHO2017 19
 WHO global strategy for cholera control

 Cholera occurrence can be  Cholera is unevenly

predicted in many settings distributed
 Be «pre-emptive»
 Focus on «hot spots»

 The long term solution for  Use OCV for large scale
cholera control is not in the  Immediate impact
health sector  Trigger mechanism for
 Be multisectoral long term control

OpenWHO.org ©WHO2017 20
 Research and development

 Areas of research on OCV, 1 vs 2

dose regimens, dose spacing and
out of cold chain use
 Continued work on WaSH practices
e.g. reduction of transmission in
high risk households
 Moving from response to control:
identifying best practices, strategies

OpenWHO.org ©WHO2017 21
 Key contacts

 Vincent Sodjinou: sodjinouv@who.int

(AFRO Focal Point)
 Dominique Legros: legrosd@who.int
(Focal point)
 David Olson: olsond@who.int (CCM and
Outbreaks)
 Lorenzo Pezzoli: pezzolil@who.int (OCV)
 Kate Alberti: albertik@who.int (Capacity
building)
 Johanna Fihman: fihmanj@who.int or
gtfccsecretariat@who.int
Photo credits:
WHO/C. Black; WHO/AMRO; WHO/E. Soteras Jalil; WHO/F. Thompson; WHO/L. Pezzoli
OpenWHO.org ©WHO2017 22