1. 10 Key factors UNICEF West and Central Africa
Cholera Prevention
10 Key factors
UNICEF West and Central Africa

2. OBJECTIVE OF NORWAY INITIATIVE
Develop systems for cholera prevention and outbreak response and to extend the benefits over a longer time frame to reduce diarrhoeal disease incidence.

3. 1. What are the symptoms?
Very rapid onset of vomiting and diarrhoea with large volumes of very watery (rice water type) stools (>3 times a day)
Severe de-hydration, = low pulse, undetectable blood pressure, sunken eyes, wrinkled hands and feet
Slow recovery of shape after depression of skin
No urine output
Laboratory confirmation but count all suspected cases and treat

4. 2. How is it transmitted?
It is caused by a bacterium (Vibrio cholerae) which lives naturally in brackish/freshwater amoeba, and is transmitted through -:
Unsafe water (7/8 investigations in Latin America identified this as a major route)
Unwashed fruit and veg (or washed in bad water), left over rice not re-heated (3 investigations +Lusaka 2004),
Lack of handwashing (food preparation, hand shaking, childcare)
Cooked and uncooked sea food – vibrio survives light cooking (2 investigations)

5. 3. Who is most at risk?
Those living near lagoons / low lying areas with fresh/ brackish water/ fishing populations
With unsafe water sources
With poor faecal disposal practices
With poor personal hygiene
With poor food hygiene (esp. moist food of neutral acidity)
Close to cholera patients in early stages (hyper-infectivity) and dealing with bodies

6. 4. When does cholera become epidemic?
After heavy period of rainfall
When water temperatures rise
When normal diarrhoeal incidence increases
Endemic cholera with good sanitation needs permanent source of vibrio, but with poor sanitation higher secondary transmission can maintain endemic status

7. 5. How long does it take? Incubation period 2hrs-5 days
Infection 7-14 days, but most people do not become ill or show any symptoms
Only about 10-20% of infected people show moderate or severe symptoms.
Moderate symptoms difficult to differentiate from other types of acute diarrhoea
Group O blood group highest risk

8. 6. How is it treated?
Greatest risk in first 24 hours, so re-hydrate as soon as possible
Normally ORS (rice- rather than glucose-based reduces purge rate,- sodium = or > 75mmol/l)
If vomiting, give intravenous fluid replacement (eg Ringer’s lactate) –extreme cases.
Give food as soon as patient can take it
Extreme cases only should have 1-3 days antibiotic (esp doxycycline single dose) to shorten illness, when vomiting stops

9. 7. How is it prevented?
Blocking routes of transmission – water disinfection (source and /or household), hand washing, sanitation, good food hygiene and well-cooked
Cholera vibrio doesn’t like acid environment (block with acidic water eg. With citrus juice, healthy stomach acid levels, acid food)
Oral vaccine (Dukoral) only for IDP setting

10. 8. What proportion will die?
Most people who die, do so within the first day of symptoms appearing
Without any treatment about 50% of people survive
With adequate re-hydration less than 2% will die
With good surveillance, rapid establishment of re-hydration, and anti-biotics for worst cases, almost all deaths can be avoided (<0.2% die)

11. 9.Risky cultural practices/ beliefs
The following beliefs about causes of cholera may reduce effectiveness of key messages -:
Witchcraft, eye, wind, climatic change cause the sickness
Children’s stools are not dangerous
Soap is believed to wash away luck
The following practices increase risks
Anal washing is often not followed by hand-washing
Handshaking transfers bacteria directly from one person to the next
Burial ceremonies may spread disease

12. 10. What are Key Messages?
Bad water is one source of cholera (disinfect source or stored water) but others, especially contaminated food (clean and cook well) and associated lack of hand washing (essential times and methods for handwashing) should also be highlighted
Rapid transfer to clinics or use of ORT corners speeds up treatment and reduces cross infection.
Re-hydration as early as possible saves the most lives- water quality in OR is of little importance
Good surveillance systems can identify causes and reduce infection rates

13. Africa’s global dominance?

14. West Africa
League Table

15. Typical cholera curve
Endemic 1. Cholera reservoir, constant or sporadic few cases
Epidemic. Triggered by factors in 4. reaches peak and then preventive measures dominate
Endemic 2. Continued levels higher than endemic 1 while person to person infection continues