1. Treatment & Prevention in Sierra Leone Zainab Blell MPH Student
Cholera
Treatment & Prevention in Sierra Leone
Zainab Blell
MPH Student
Hello and welcome. You are attending an informational briefing on the training and prevention of Cholera in Sierra Leone. My name is Zainab Blell and I am a MPH student at Walden University.

2. Introduction 2012 Cholera Outbreak in Sierra Leone
Purpose for This Briefing
Learning Objectives for Today
In the introductory portion of the briefing, we’ll begin a summary of the current epidemic of Cholera in Sierra Leone followed by a discussion of the purpose of this briefing. Then we will wrap the introduction with a discussion of the learning objectives for today.

3. 2012 Cholera Outbreak
Global health issue affected thousands in Sierra Leone
Worst outbreak in Sierra Leone in 15 years
Highest impacts overcrowded communities and slum areas
Alarming because Cholera is a preventable and easily treatable disease.
Reference
Schlein, L. (2012). Sierra Leone's Cholera Epidemic Easing But Not Over. Voice of America.com. Retrieved from,
Cholera is a global Health issue that has affected thousands of Sierra Leoneans since the first cases were reported in February of this year. According to Schlein (2012), World Health Organization (WHO) reported that this outbreak in 2012 is the worst cholera outbreak in Sierra Leone in 15 years, because of the numbers affected (18,919 cases reported with 273 deaths).
As a citizen of this community I am concern about the alarming spread of this disease because it is both preventable and easily treated. I wish to provide key information to help raise awareness about treatment and prevention. This informational briefing will discuss what cholera is, the cause and symptoms of cholera, how it is spread as well as how to treat and prevent it. The presentation is geared towards the adult populace of Sierra Leone particularly those that live in overcrowded communities and slum areas, as well as traditional healers. Stakeholders include their development partners such as WHO, UNICEF, British Red Cross, and government officials at the Ministry of Health and Sanitation (MoHS) to name but a few.
Reference
Schlein, L. (2012). Sierra Leone's Cholera Epidemic Easing But Not Over. Voice of America.com. Retrieved from,

4. PURPOSE
To increase knowledge and reduce the impact or incidence of the disease on Sierra Leoneans
Continue sounding the alarm on the danger of cholera so government officials and their development partners will allot resources to educate communities that are highly susceptible
The purpose of this presentation is again to raise awareness and to educate the community on what actions needed to be taken to reduce cholera outbreaks and increase the resources to prevent it. We must take charge of our health by preventing and stopping this disease from killing us and our children. In order to accomplish this we must know how cholera is contracted and all the ways to prevent getting ill from its infection.
The government must live up to its responsibilities by providing disease treatment and prevention management. It should be educating communities about practices such as the importance of hand washing before and after caring for people that have been infected and providing proper infrastructure to keep the environment clean. In particular, people need access to clean water and sanitation management especially those in slum areas, urban areas and remote areas of rural communities. The government must stand firmly with the help of its development partners to improve case management in Freetown and in all the other 12 districts as well as strengthen case surveillance for early detection and treatment.

5. Learning Objectives What Cholera is About Cholera Global Epidemiology
Cholera Epidemic in Sierra Leone
How It’s Transmitted
Symptoms and Diagnosis
Treatment & Prevention
Additional Resources for More Information
In this presentation we will provide correct information on prevention and treatment of cholera. Our goal is to raise awareness and sensitize the people on this issue. We are educating adults in this presentation but we must make sure our young people are also aware of what to look for..
Let’s discuss our learning objectives for today. When we learn what cholera is, I will give you information about the global epidemiology of cholera because it is important to know the impact of cholera in other countries. We will learn more on how it has affected us here in Sierra Leone, and I will give you tips on how it is transmitted, what makes you susceptible to getting cholera, what signs and symptoms to look out for and the available treatments to include why vaccination is not an option.

6. About Cholera
General Information, Epidemiology, Cholera in Sierra Leone
In the next section we’ll provide basic information about what cholera is, its epidemiology as a global issue and specifically about the outbreak of cholera in Sierra Leone that has occurred this year.

7. What Cholera is
An infection of the intestines with a bacteria called VIBRIO CHOLERAE
Bacteria occurs naturally in coastal waters and can attach to shellfish causing infection
Many can be infected by environmentally contaminated food
Diarrhea from infected individuals contain large amounts of the bacteria
In humans the incubation period for symptoms is 1-5 days
Infected patients can recover quickly if treated promptly
Let’s find out what cholera is! Cholera is an infection of the intestines with the bacterium VIBRIO CHOLERAE, which causes an acute diarrheal illness. The bacteria interrupts the normal flow of fluids particularly water and sodium in the intestine and that is what causes the large amount watery diarrhea that if not treated quickly it can lead to dehydration, electrolyte imbalance, shock, and death and that accounts for 25%-50% cases of fatality (CDC, 2011).
Most people infected by environmentally contaminated food do not become ill even though the bacteria can exist in the feces for 7-14 days. The bacterium, VIBRIO CHOLERAE can be found both in the environment, naturally occurring in coastal waters and can attach to the shells of shrimps or crabs which can infect humans when eaten raw or undercooked. In humans with an incubation period of 1-5 days a large amount of the bacteria is in the copious diarrhea that is produced by the infected persons that can infect others if ingested through contaminated food or water from fecal matter and causes more cases of infection. Infected patients can recover quickly when treated promptly and do not become carrier after the illness but they can be infected again if exposed to the bacteria (CDC, 2011).
Reference
CDC, (2010). Cholera. Retrieved from
CDC, (2011). Cholera: Epidemiology and Risk Factors. Retrieved from,
Reference
CDC, (2010). Cholera. Retrieved from
CDC, (2011). Cholera: Epidemiology and Risk Factors. Retrieved from,

8. EPIDEMIOLOGY
45 countries reported 221,226 cholera cases and 4,946 cholera death
Areas with poor resources continue to report the majority of the cases
Cholera remains endemic in Sub-Saharan Africa
The first number of cases reported in Sierra Leone were in and 1971
Most recent large outbreak was in 2007 and 2008
From an epidemiology perspective, cholera has always been an issue in Sub-Saharan Africa where clean water and sanitation are an ongoing problem. 99% of the countries reported cholera illness and death are in Africa. In 1854, cholera swept London and thanks to John Snow, the Modern Father of Epidemiology, the Mode of Transmission was discovered. Outbreaks in Africa typically occur during the rainy season (from May to October) due to the heavy rains that cause flooding and contamination of the water source. Worldwide floods account for 40 % of all natural disaster and floods often cause a lot of damage to houses which leads to overcrowded living conditions and as a result of the large collection of solid waste, blockages to sewage systems can occur and thus contaminate drinking water which increases the risk for water-borne infection and in our case cholera outbreak.
Here at home, in 1970 and 1971, number of cases reported was 293 and 211 respectively and in 2007 and 2008, cases reported were 219 and 62 with 84 and 1 death respectively.
Reference
CDC, (2011). Cholera: Epidemiology and Risk Factors. Retrieved from,
Schlein, L. (2012). Sierra Leone's Cholera Epidemic Easing But Not Over. Voice of America.com. Retrieved from,
World Health Organization, (2009). Cholera Country Profile: Sierra Leone. Retrieved from,
Reference
Schlein, L. (2012). Sierra Leone's Cholera Epidemic Easing But Not Over. Voice of America.com. Retrieved from,
World Health Organization, (2009). Cholera Country Profile: Sierra Leone. Retrieved from,

9. Timeline for 2012 Cholera Outbreak in Sierra Leone
February 27: MoHS reported outbreak in Kambia, PortLoko and Pujehun district
Growth of the outbreak spread rapidly once declared in Freetown
On August 16th, President Ernest Bai Koroma declared a national State of Emergency
As of September 20, 18,919 total cases were reported with 273 deaths
In terms of the number infected, WHO (2012), reported that the 2012 epidemic is worst outbreak in 15 Years. Outbreaks were reported as early as February 27 in the Kambia, PortLoko and Pujehun districts but once outbreak was declared in Freetown, there was steady and rapid spread. The president declared a national State of Emergency in August but there have been even more outbreaks since then. As of September 20, twelve of thirteen districts have reported cases and the total number of cases nearly hitting 19,000 with 273 deaths.
Reference
Schlein, L. (2012). Sierra Leone's Cholera Epidemic Easing But Not Over. Voice of America.com. Retrieved from,
World Health Organization, (2012). Cholera in Sierra Leone. Retrieved from
Reference
Schlein, L. (2012). Sierra Leone's Cholera Epidemic Easing But Not Over. Voice of America.com. Retrieved from,
World Health Organization, (2012). Cholera in Sierra Leone. Retrieved from

10. Cholera Transmission/Risk Factors
Where cholera is found, how it is transmitted, who is at risk for contracting cholera
Work as a community to combat cholera –see CDC’s link
Reference
CDC. (2012). Prevention & Control. Retrieved from
Now that we have some basic information about cholera and how widespread the outbreak is in Sierra Leone, let’s discuss who is at risk for contracting cholera, how it is transmitted and where it is found. It is also important to work as a community in order to fight the disease, please visit CDC’s link on how to work with others in the community when there is a cholera outbreak.

11. Cholera in the Environment
Cholera naturally lives in water for long period
Poor sanitation that’s aggravated by war, and natural disasters
Poor sewage systems
Overcrowded slums and waterfront
Cholera occurs naturally in the environment, specifically it lives in water for long periods of time and can contaminate wells. It can be transmitted through fecal contamination with food or water supplies, poor sewage systems can also cause well contamination. Wells with contaminated water are a large outbreak source. Poor sanitation and overcrowding contributes to the spread of disease that’s aggravated by war or natural disasters, like floods which can contaminate water sources.
The epidemic is highest in developing countries where poverty rate is highest and in our case, overcrowding of the Capital, Freetown where most of the cases occurred is partly due to the migration of people from the rural areas during the long years of war for safer haven and as a result the slums and waterfront are swell and clean water is scarce and toilets or lavatories are in few numbers. The heavy rainfall causes floods and thus increases the risk of water contamination with fecal matter, increasing the chances for water-borne infections.

12. Cholera in Food SHELL FISH shrimps crabs RAW FRIUTS AND VEGETABLES
lettuce
tomatoes
guavas
COOKED GRAINS
Cholera is also transmitted in food. V.Cholera can be found in the shells of shrimps, crabs in some areas and when eaten raw or undercooked can infect humans. Tainted water used for watering, processing and washing of fruits and vegetables can contaminate them and when eaten raw and unpeeled can expose humans to this bacteria. Sewage infested with V. Cholera used as manure or fertilizers on these produce can contaminate them as well. When rice, millet or other grains are contaminated and left out for several hours in room temperature it provides as a great source for the growth of the bacterium.

13. Symptoms of Cholera Copious watery stools Vomiting Rapid Heart rate
Loss of skin elasticity
Dry mucous membranes
Low blood pressure
Thirst
Muscle cramps
Restlessness and irritability
Cholera infection is mostly mild or exists without symptoms but it can sometimes be severe in 5-10% of infected people.
Symptoms of early stages of severe illness as described by Centers of Disease Control and Prevention (CDC, 2010) includes
Copious watery stools sometimes called “rice-water stool”
Vomiting
Rapid Heart rate
Loss of skin elasticity
Dry mucous membranes
Low blood pressure
Thirsty
Muscle cramps
Restless and irritability
The large amount of watery diarrhea if not treated quickly can lead to dehydration, electrolyte imbalance, and shock and death if left untreated and that accounts for 25%-50% cases of fatality (CDC, 2011).
Reference
CDC, (2010). Cholera. Retrieved from
CDC, (2011). Cholera: Epidemiology and Risk Factors. Retrieved from,
Reference
CDC, (2010). Cholera. Retrieved from
CDC, (2011). Cholera: Epidemiology and Risk Factors. Retrieved from,

14. Cholera Treatment Oral Rehydration Salts (ORS) Sugar Salt Solutions
Intravenous Fluids
Antibiotic therapy
Zinc treatment
what to do if you contract cholera-see link
Not everyone in Sierra Leone has close access to a clinic or medical treatment center. Therefore we are including a slide on detailed cholera treatment for traditional and community healers as well. Anyone showing the symptoms of cholera should report to the nearest clinic or medical facility for treatment. The good news is cholera is an easily treatable infection. Simple rehydration treatment can save the lives of our people but the key is diagnosis and treatment. Prompt treatment is imperative so physicians, nurses, traditional healers will start hydration to replace the loss of fluids from profuse diarrhea even before confirmation of the diagnosis through stools culture.
It is important to take immediate action to report of how you feel and what is happening with you, whether nausea, vomiting, diarrhea, fever to name a few and do not try to care for yourself because of lack of money for medical services because the sooner you see a nurse or a doctor the sooner they can start treatment to replace the fluid loss and then try to figure out the cause. It is going to also be important for them to monitor your blood pressure, heart rate, blood sugar and electrolytes level because it is essential to detect cases of severe symptoms for the doctor to treat you with the correct fluid.
Traditional healers all around the countries are been educated on how to treat people with these symptoms in their communities.
Fluid replacement is key and prompt treatment is importance to prevent complication that will lead to fatalities in a matter of hours. Infants must continue with breastfeeding for hydration and immunity. Severely dehydrated patients must receive intravenous fluids but these are expensive and difficult to administer. Oral Hydration Salts and Sugar Salt solutions can also be used to replace electrolytes and can be made by home healers. Proper hand washing must be done with clean water before mixing these fluids and after treating these patients.
According to CDC (2011),
ORS is to be mixed with one liter of boiled water.
Sugar salt solutions can be made at home when you mix 8 tablespoons of sugar and 1 tablespoon of salt mixed with 1 liter of boiled water. We are encouraging patients to drink lots of water, clean water after vomiting.
To replace electrolytes and fluid lost through copious diarrhea you must get intravenous fluids and this has to be given to you by a nurse or a doctor and also antibiotics can be given to reduce the duration of the illness and is indicated for severely ill patients. CDC (2011), mentioned that zinc treatment can help improve cholera symptoms in children. Prompt treatment is critical between life and death and please remember cholera is easily treatable when you seek help for quick rehydration. I added a CDC link that illustrates what to do if you or your loved ones contract cholera, just follow this steps for swift recovery.
Reference
CDC. (2011). Cholera- Treatment. Retrieved from,
Reference
CDC. (2012). Cholera, Prevention & Control. Retrieved from
CDC. (2011). Cholera- Treatment. Retrieved from,

15. Prevention and Control
Through Proper Sanitation & Food Preparation
Cholera is also preventable with the right resources including proper sanitation and food preparation. There is an immediate need to clean our communities, provide safe food and drinking water and provide proper sanitation for waste disposal especially when there is an outbreak. However, by doing so we must respect local beliefs about privacy and cleanliness. We must commend our President for adopting the public cleaning days and this must be continued.

16. General Sanitation Wash hands at all times with soap and clean water
If there is no soap, scrub hands with ash or sand and rinse with clean water
Keep kitchen and places where the family bathes and washes clothes clean and separate
The first step in prevention is washing your hands with soap and clean water. When I say clean water i mean, water that is boiled or chlorinated to be safe from contaminants. On the next slide we will talk more about safe water. If there is no soap, scrub hands with ash or sand and rinse with clean water. You should wash your hands before handling any food and after dealing with any bathroom activities including toilets, latrines and diaper changes and most importantly after caring for others with diarrhea. You will need to keep kitchen areas and places where the family bathes and washes clothes clean and separate. Children, clothes diapers must be washed 30 meters away from drinking water sources (CDC, 2012).
Proper hand washing with clean water is the first line of defense against infectious diseases. Please make it a daily and frequent practice, it is good for your well-being.
Reference
CDC. (2012). Prevention & Control. Retrieved from
Reference
CDC. (2012). Prevention & Control. Retrieved from

17. Use Safe Water Boil it to a complete boil for one full minute
Treat it with chlorine or household bleach
Use Safe Water For:
Drinking
Washing and preparing food, like fruits and vegetables
Brushing teeth
Cleaning kitchen utensil
Another key prevention task is the use of safe water for drinking, cleaning and food preparation. Safe water is water that has either been boiled for a full minute or treated with chlorine or household bleach. If you’re treating your water with bleach you will need to add 8 drops of bleach for every gallon of water and wait 30 minutes before drinking it (CDC, 2012). It is best to use safe water for :
Drinking
Washing and preparing raw fruits and vegetables
Brushing teeth
Cleaning kitchen utensils
Also you can follow the live link on CDC’s safe water system.
Reference
CDC. (2012). Prevention & Control. Retrieved from
Reference
CDC. (2012). Prevention & Control. Retrieved from

18. Proper Waste Management
Use toilets, latrines, plastics or bury your feces
Keep latrines and toilets clean at all times to prevent flies
If you do not have a toilet or latrine
Defecate 30 meters away from any type of water and bury the feces
Defecate in a plastic bag and dispose it in a latrine or bury it away from any water
Wash hands after defecating with safe water
Proper waste management is essential in preventing the spread of cholera. This means using formal toilets or latrines or burying fecal matter. It is especially important if you live in an area that does not have toilets or latrines not to defecate near any community water sources which are streams, rivers, or any type of water in the community. The defecation should be preferable into a container or plastic, then burying away from potential flood areas. As mentioned previously, you will need to clean any actual toilets and latrines and wash your hands with soap, ash or sand and rinse them with clean water after defecating.
Reference
CDC. (2012). Prevention & Control. Retrieved from
Reference
CDC. (2012). Prevention & Control. Retrieved from

19. Food Preparation Food must be cooked well especially seafood!
If you cannot Boil it, Cook it, or Peel it then Leave it!
Do not eat foods that are not washed and peeled or cooked thoroughly.
When preparing any food, you must wash your hands first in safe water AND ensure that the food is also washed or rinsed in safe water before consuming it. This is especially critical for raw foods, fruits and vegetables. Cooking foods all the way through is another way to ensure any bacteria is removed. This includes seafood. Any fruits and vegetables should be peeled and food kept covered in general. The CDC (2012) recommends that you only eat raw food you personally prepare but otherwise stay away from raw foods. Do not eat foods that are not washed and peeled or cooked thoroughly.
Reference
CDC. (2012). Prevention & Control. Retrieved from
Reference
CDC. (2012). Prevention & Control. Retrieved from

20. Review of Content Covered:
What is Cholera?
About Cholera Global Epidemiology
Cholera Epidemic in Sierra Leone
How It’s Transmitted/Risk Factors
Symptoms and Diagnosis
Treatment & Prevention
Additional Resources for More Information
Let’s review everything we’ve covered today with regards to Cholera. We took a look at
What Cholera is
The Cholera Global Epidemiology
The Cholera Epidemic in Sierra Leone
How Cholera is Transmitted
Cholera Symptoms and Diagnosis
Cholera Treatment & Prevention (both clinical and at home)
And Why Vaccination is Not an Option
We’ll conclude our presentation by providing you with some Additional Resources for More Information.

21. Additional Prevention Steps
Allocate resources to provide proper sanitation
Provide safe public wells and toilets
Promote rural migration
Improve case management skills
Strengthen surveillance system and epidemiology investigation
Promote community education on proper hygiene and sanitation all year round
There are a number of steps the government and health assistance stakeholders can take to prevent future outbreak. Although we are addressing the education need in this presentation that is not enough. Sierra Leone needs the MoHS to invest in a proper sewage, sanitation and water treatment facilities. Communities in urban and rural areas need safe public wells and toilets. Agriculture and trading and infrastructures must be developed in the rural areas to help promote rural migration.
Trained healthcare workers need to provide rural outreach to monitor and defeat outbreaks early. Early detection at all times not just during outbreaks is important through strengthening of our surveillance system and epidemiology investigation. Education efforts should be year-round and online as well as taken to all areas of Sierra Leone’s urban and rural communities.
Cholera is a preventable disease and when people are provided with safe water, proper sanitation, and access to basic health necessities, this will bring about health promotion and disease prevention.

22. A Note on Vaccination Offers incomplete, short-term protection
Mass vaccination or routine antibiotics will not prevent the spread of cholera
There are two oral cholera vaccines available:
Dukoral.
ShanChol,
You may be wondering why vaccination was not previously mentioned as part of either prevention or treatment. The available vaccines offer only incomplete protection for a relatively short period of time (CDC, 2012) and is not recommended to prevent the spread of cholera. There are two oral cholera vaccines available: Dukoral prequalified by WHO and licensed in over 60 countries and ShanChol, licensed in India and is pending WHO prequalification. Vaccination is available globally but it should not replace standard prevention and control measures and CDC does not recommend cholera vaccines for most travelers
Reference
CDC. (2012). Cholera: Prevention and Control. Retrieved from,
Reference
CDC. (2012). Cholera: Prevention and Control. Retrieved from,

23. Additional Resources
CDC. (2011). Cholera: General Information including Symptoms.
CDC. (2012). Cholera: Prevention and Control.
CDC Safe Water Website:
CDC. (2011). Cholera- Treatment.
For most individuals in Sierra Leone, the most important impact you can have in the fight against cholera is educating yourselves, your families and your communities on how to recognize, treat and prevent the disease. We’ve included four links you can use for future reference in this endeavor. If you have rural outreach, please print and distribute this information to communities that do not have ready access to the internet.

24. References
CDC. (2010). Cholera. Retrieved from
CDC. (2011). Cholera: Epidemiology and Risk Factors. Retrieved from,
CDC. (2012). Cholera: Prevention and Control. Retrieved from,
CDC. (2011). Cholera- Treatment. Retrieved from,
Mathiu, S. (2012). Retrieved from
Schlein, L. (2012). Sierra Leone's Cholera Epidemic Easing But Not Over. Voice of America.com. Retrieved from,
World Health Organization, (2009). Cholera Country Profile: Sierra Leone. Retrieved from
WHO, (2012). Cholera in Sierra Leone. Retrieved from
For your additional information, we’ve included a reference slide of all the information cited in this presentation.

25. Thank You for Attending!
Please Help Spread the Word!
This concludes our presentation on Cholera in Sierra Leone. Please help educate your neighbors by sharing with them the information you received today. Cholera is treatable and preventable. Let’s do our part in stamping it out of Sierra Leone.