Cholera

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Cholera is an illness characterized by excessive diarrhoea and vomiting caused by the organism Vibrio cholerae. It is transmitted by the faecal-oral route.

Clinical features
The incubation period varies from a few hours to 6 days. Cholera may be present as a mild illness indistinguishable from diarrhoea due to other causes.
Classically, however, it has three phases:

  • Evacuation phase characterised by abrupt onset of painless, profuse watery diarrhoea associated with vomiting in severe forms. Stools may be rice-water.
  • Collapse phase is reached if appropriate treatment is not given. This is characterised by features of circulatory shock (cold clammy skin, tachycardia, hypotension and peripheral cyanosis) and dehydration (sunken eyes, hollow cheeks and diminished urine output. There may also be muscle cramps. Children may also have convulsions due to hypoglycaemia. Complications such as renal failure and aspiration of vomitus may occur.
  • Recovery phase occurs if the patient survives the collapse phase.

 

Diagnosis

  • Largely clinical
  • Stool and rectal swabs for culture

Treatment

Rehydration

  • Patients should be assessed for the degree of dehydration.

Management of mild dehydration
Give Oral Rehydration Salt (ORS) solution or any fluids after each loose stool.

ORS Dose
Age		 Amount after each loose stool

Less than 24 months


2-5 Years

50-100ml after each loose stool

 

100-200ml
10 years and above As much as the patient wants

ORS and other fluids should be continued until diarrhoea stops. Breast-fed children should continue to breastfeed normally. Encourage the patient to eat.

 

Management of moderate dehydration (some dehydration in children)

 

Give ORS in the first 4 hours as follows:

Age Less than 4 months 4-11 months 12-23 months 24-59 months 5-14 years 15 years and above
Weight Less than 5kg 5-10 kg 10-12 kg 12-19 kg 16-29 kg 30kg and above
Amount in ml (approx) 150ml per hour 400ml per hour 600ml per hour 1,500ml per hour 2000ml per hour 3,800ml per hour
  • Monitor the patient frequently
  • Reassess the patient after 4 hours using the classification of dehydration. If signs of (moderate) dehydration are still present, repeat the same management. If the patient shows signs of severe dehydration change management to that of severe dehydration.
  • Patients should be encouraged to eat and drink as much as they want.
  • If the child vomits, wait 10 minutes and then continue giving ORS slowly, i.e. every 2 – 3 minutes.
  • Encourage the mother to continue breastfeeding.
  • For infants less than six months who are not breastfed also give 100-200ml clean water during this period.

Management of severe dehydration


Start intravenous drip with Ringers Lactate or Sodium Chloride 0.9% w/v (normal saline) immediately (give ORS while drip is being set).

Patients below 1 year:

  • Give 100ml/kg in 6 hours as follows:
    30ml/kg in the first 1 hour then 70ml/kg in the next 5 hours.

Reassess the patient very frequently.

  • If the patient can drink, give about 5ml/kg per hour of ORS in addition to the IV fluid.
  • Assess the state of re-hydration after six hours using the classification of dehydration level chart; classify and manage accordingly.
  • If the patient shows no sign of dehydration after treatment with IV fluids or ORS, continue ORS as follows:
    • Less than 24-months old = 100ml after each loose stool
    • 2 – 9 years-old = 200ml after each loose stool
    • 10 years or more = as much as the patient wants (at least 300ml)

Patients 1 year and above:

  • Give IV fluids, 100ml/kg in 3 hours as follows: 30ml/kg as rapidly as possible (within 30 minutes), then 70ml/kg in the next 2.5 hours.

Reassess the patient very frequently.

  • If the patient can drink, give about 5ml/kg per hour of ORS in addition to the IV fluid.
  • Assess the state of rehydration after 3 hours using the classification of dehydration on treatment charts; reclassify and manage accordingly.
  • If the patients show no sign of dehydration after treatment with IV fluids or ORS continue ORS as follows:
    • 24 months old = 100ml after each loose stool
    • 2 – 9 years old = 200ml after each loose stool
    • More than 9 years = as much as the patient wants (at least 300ml)


Drugs


Medicines should only be given according to the sensitivity patterns.

RECOMMENDED ANTIBIOTICS CHILDREN ADULTS
Doxycycline
One single dose		 - 300mg
Tetracycline
4 times daily for 3 days		 (For children >12 years) 
12.5mg/kg		 500mg
Erythromycin
Adults: 4 times daily for 3 days
Children: 3 times daily for 3 days		 10mg/kg 250 mg

• Doxycycline is WHO antibiotic of choice for adults (except pregnant women) because only one dose is required.
• Erythromycin may be used when the other recommended antibiotics are not available, or where V. cholerae is resistant to them.

Prevention

  • Drink clean boiled/ chlorinated water
  • Good sanitation
  • Good personal hygiene and sanitation