B.

PHARMACY FINAL YEAR

SOCIAL AND PREVENTIVE PHARMACY

UNIT-II- CHOLERA- Preventive and Control

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INTRODUTION
• Cholera is an acute intestinal infection.

• In severe conditions, it becomes rapidly fatal.

CAUSATIVE AGENT:

Vibrios are Gram-negative, highly motile curved rods with a single polar
flagellum.
• It has two serotypes, i.e. Ogawa and Inaba.

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 Some vibrios that are biochemically identical from the above but do not
agglutinate in Vibrio O-group I antiserum, are also classified under the V.
cholera species.
• Such strains are often referred to as Non Agglutinating Vibrios (NAGs) or
Non-Cholera Vibrios (NCVs).
• Thre most common organism that has been currently isolated is El T or
Ogawa serotype.

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MODE OF TRANSMISSION:
• The most common contamination source is the faeces of an infected
person, which contaminates the water and food.
• The disease spreads rapidly in areas where proper treatment of sewage and
drinking water is not carried out.
• Cholera does not spread from one person to another, thus a healthy person
cannot become ill through a casual contact with an infected person.
• Previously it was believed that humans are the main reservoir of cholera
infection, but now significant facts have proved that aquatic environment
serve as the reservoirs of bacteria.

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SYMPTOMS:
• Symptoms appearing 1-3 days after infection range from mild,
uncomplicated diarrhoea to severe and potentially fatal disease.
• Some infected individuals do not experience any symptoms.
• Mostly, the infection is mild or asymptomatic but sometimes it can be
severe.

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Pathogenesis
• Cholera is transmitted by the fecal-oral route. Vibrios are sensitive to acid, and
most die in the stomach.
• Surviving virulent organisms may adhere to and colonize the small bowel, where
they secrete the potent cholera enterotoxin (CT, also called “choleragen”).
• This toxin binds to the plasma membrane of intestinal epithelial cells and releases
an enzymatically active subunit that causes a rise in cyclic adenosine 5 1-
monophosphate (cAMP) production.
• within the intestinal lumen, resulting in increased cAMP levels in intestinal
epithelial cells and pumping of Cl − (and therefore Na+ and H20) into the intestinal
lumen and secretory diarrhea. Total flushing of the intestinal tract leads to “rice
water” stool with a fishy odor
• The resulting high intracellular cAMP level causes massive secretion of
electrolytes and water into the intestinal lumen. 6
Symptoms of cholera include:
• Muscle cramps. These result from the rapid loss of salts such as sodium,
chloride and potassium.
• Shock. This is one of the most serious complications of dehydration. It
occurs when low blood volume causes a drop in blood pressure and a drop
in the amount of oxygen in your body. If untreated, severe hypovolemic
shock can cause death in minutes.

• Diarrhoea with a fishy odour,

• Excessive thirst,

• Tiredness,

• Vomiting.

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• Dehydration

• Dry mouth and skin,

• Low urine output

• Nausea

• Sunken eyes.

• Unusual sleepiness,

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 General Principles of Prevention Transmission of cholera can be
prevented as follows:
• Sterilisation: It is essential to dispose and treat the infected faecal waste water
products and all contaminated materials (e.g.. clothing, bedding, etc.) of cholera
patients.
• Materials in contact with the cholera patients should be properly sterilised by washing
in hot water added with chlorine bleach .
• The person, who handles cholera patients and their clothing, bedding should keep
his/her hands thoroughly cleaned and sterilised using chlorinated water or other anti-
microbial agents.
• Sewage: General sewage before entering the waterways or underground water supplies
should undergo anti-bacterial treatment with chlorine. ozone, UV light, or any other
effective agent.
• This prevents accidental spreading of the disease from undiagnosed patients.
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• Sources: Cautions about potential cholera contamination should be posted
around contaminated water sources along with directions that how the
water can be decontaminated (boiling, chlorination, etc.) for use.
• Water Purification: In areas where cholera infection is prevalent, the
water intended for drinking, washing, or cooking should be sterilised by
boiling, chlorination , ozone water treatment, UV light sterilisation, or anti-
microbial filtration.
• The least expensive and most effective methods of preventing the
transmission of cholera are chlorination and boiling.
• Public health education and practising proper sanitation habits are essential
for preventing and controlling the cholera transmission.

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• Vaccine: In some countries, cholera vaccines are available; however
Centres for Disease Control and Prevention (CDC) do not recommend
them routine use. Recently, significant progress has been made in
developing the cholera vaccines which can be administered orally.
• Two oral cholera vaccines. These two vaccines, namely kill whole-cell V.
cholerae 01 combined with purified recombinant B subunit and of cholera
toxin and a live-attenuated live oral cholera vaccine.

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General Principles of Control:
• The Guidelines for Cholera Control, as issued by the WHO, include
follower points:
• Verification of the Diagnosis: The epidemic of the disease should
confirmed as early as possible, and all the confirmed and even suspicious
diarrhoea cases should be properly investigated.
• Identification of V. cholera O1 in the stools of the patient is essential for
the specific diagnosis of cholera.

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• Notification: Any case of diarrhoea and vomiting that is being doubted as
cholera should be timely and immediately informed to the health authorities.
• After identifying an area as having cholera outbreak, related reports should
be forwarded to the associated authority on daily and weekly basis till the
area is declared free of cholera. This happens only after 10 days of death,
recovery or isolation of the last case.
• Establishment of Treatment Centres: Treatment of the cholera should be
started as soon as possible, and this is possible only if they easily accessible
treatment facilities in the community.

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 Mildly dehydrated patients accounting for over 99% of cases) should be
treated with car rehydration fluid at home while, severely dehydrated
patients intravenous fluids and thus should be transferred to the nearest tree
centres or hospitals.
• Such patients should be given oral rehydration on way to the hospital or
treatment centre.
• Rehydration Therapy: Now cholera can be treated effectively by giving
rehydration therapy via oral or intravenous route.This therapy has to the
mortality rate to less than 1%.
• Oral Rehydration Solutions (ORS) are given to the patients to prevent mild
to moderate fluid lost (5-10% dehydration) resulted due to diarrhoea or or
post-operative conditions or when food and liquid intake have been
stopped momentarily. ORS provides sodium. chloride, potassium,
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waterand other basic nutrients.
•Nacl- 2.6 gm
•Kcl-1.5gm
•Trisodium citrate-2.9gm
•Glucose-13.5gm
•Water-1L
Total osmalrity 245 Osm/L

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Adjuncts to Therapy:
• Once the patients stop vomiting, antibiotics should be started that is generally after
3-4 hours of oral rehydration therapy.
• Antibiotics can be easily given through oral route, thus using injectable antibiotics
have no special advantages.
• Examples of some antibiotics given to treat cholera are fluoroquinolones,
tetracyclines. azithromycin, ampicillin, Trimethoprim (TMP) and Sulfamethoxazole
(SMX).
• Other medicines like antidiarrheals, anti-emetics, antispasmodics, cardiotonics, and
corticosteroids, should not be given for cholera treatment.
• In the epidemic areas such antibiotics should be identified against which resistance
has developed in Vibrio cholerae O1.
• Antibiotics are suspected to develop resistance if diarrhoea remains even after 2 days
of antibiotic treatment.
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Sanitation Measures: The following sanitation measures should be
undertaken:
Water Control: There are various methods for supplying safe water
quickly and with limited resources.
•Appropriate water supply facilities should be selected and installed in the
given area and community.
•The major aim should be to maintain permanent supply of piped water and
to completely eliminate alternative unsafe water sources.
•In developing countries like India, such measures cannot be applied
immediately on a larger scale owing to financial limitations and other
priorities.

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In urban areas, well-treated drinking water having tree residual chlorine
should be supplied to all families as an emergency measure and this
supplied water should be stored in the houses in covered narrow- mouthed
containers.
In rural areas, water is boiled or chlorinated to make it fit for drinking.
• Excreta Disposal: A simple, cheap and effective excreta disposal system
(sanitary latrines) is a basic need of all human settlements.
•During the outburst of cholera, these facilities are essential.
Selection and construction of sanitary system should be done with
cooperation of the community, considering the customs and practices of the
population, the Existing terrain and geology, and the available resources.

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iii) Food Sanitation: As food is one of the important vehicles of infection is essential to
improve food sanitation, focusing more on selling food items under hygienic conditions.
Health education should food in importance of eating cooked. hot food and of proper
food handling techniques. After every use, the cooking utensils should be properly
cleaned and dried. Houseflies play a small role in cholera translate but their presence
indicates the level of sanitation.
iv) Disinfection: Disinfection procedure should be both concurrent and terminal. A
commonly used and most effective disinfectant is a coal Tar disinfectant having a Rideal-
Walker (RW) coefficient of 10 or more eg: cresol.

•During disinfection, focus should be given to the patient's stools, vomit, clothes, other
contaminated personal belongings; the latrine, and the house and neighbourhood.

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9) Chemoprophylaxis:
• The preferred drug for chemoprophylaxis tetracycline, which is given twice-
daily for 3 days in a dose of 500mg for adults, 125 mg for 4-13 years old
children, and 50mg for 0-3 years old children.
•If the prevailing strains are not resistant, doxycycline (long- acting tetracycline)
is an alternative choice for chemoprophylaxis, which is given a single oral dose
(300mg for adults and 6mg/kg for children under 15 years10).

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Vaccination: The production of live attenuated single-dose vaccine (CVD103-
HgR) for cholera has stopped. Now, the following two typesoral cholera vaccines
are available:
•i) Dukoral (WC-rBS): It is a monovalent vaccine based on formalin angheat-
killed Whole Cells (WC) of Vcholera O1 strain (classical and Tor, Inaba and
Ogawa) with recombinant cholera toxin B sebum Dukoral is given in 3ml of single-
dose vials, along with the bicarborg buffer (effervescent granules in sachets to
protect the toxin B subuni from gastric acid).
•For patients aged >5 years, vaccine and buffer mixed in 150ml of water (either
chlorinated or not): and for childrens aged 2-5 years, vaccine and buffer are mixed
in 75ml of water.
•At 2-8C temperature, Dukoral vaccine has a shelf-life of 3 years: while at 370
temperature, it has a shelf-life of 30 days.
•Vaccine Schedule and Administration:
• As per the guidelines of the manufacturer, primary immunisation includes 2 oral
doses given at >7days apart (but <6 weeks apart adults and children aged 26 years.
Children of 2-5 years age she receive 3 doses at 27 days apart (but 26 weeks apart).
•Before and after hour of vaccination, food and drinks should not be consumed.
Prime immunisation should be restarted in case the interval between primary
immunisation doses is delayed for >6 weeks.
•Protectie around I week is advised after the last scheduled dose. 21
• One booster dose is recommended by the manufacturer after 2 years for adults and
children aged more than 6 years.
• When the interval is >2 years, primary immunisation should be repeated.
• One booster dose is recommended every 6 months for children aged 2-5 years, and
primary immunisation should be repeated if the interval between primary immunisation
and the booster is >6 months.
• Shanchol and mORCVAX: These are bivalent oral cholera vaccines based on
serogroups O1 and O139.
• For individuals aged 2l year, these vaccines are given through oral route in two liquid
doses 14 days apart.

• A booster dose is given after 2 years.

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11) Health Education: It is the most effective way to prevent and cure the
transmission of cholera.
• Health education mainly includes the effectiveness and simplicity of oral
rehydration therapy, the benefits of early reporting for prompt treatment, food
hygiene practices, hand washing after defecation and before eating, and the
benefits of eating cooked, hot food, and drinking safe water.
• Because cholera is mainly associated with poor and deprived people, special
attention should be given to them and they should be attended first.

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THANK YOU

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