Introduction:

Cholera
Ethiopian Public Health Institute
Public Health Emergency Management
Bacterial Diseases Surveillance and
Response

Mandefro k(BSC, MPH in Field Epi)

Naflate Hotel, Adama.

October 16 2023

Cholera Surveillance and Outbreak Response

 Outline

 What is Cholera?
 Etiology
 Reservoir
 Mode of transmission
 Risk factor
 Clinical characteristics

Cholera Surveillance and Outbreak Response

 Enabling Objective

After completing this chapter, participants will

be able to:
1) Describe cholera disease, etiologic agent,
and reservoir
2) Summarize cholera disease mode of
transmission
3) Identify risk factors and clinical features of
cholera disease

Cholera Surveillance and Outbreak Response

Activity 1.1. Self-reflection_15 minutes

Instruction: Read the following summary of

cholera report in Ethiopia and answer the
following questions (on your participant
manual page)
Question:
1.What comes in your mind when you hear
cholera?
2.Why do you think frequent occurrence of
cholera outbreak in Ethiopia?
3.Some districts experienced extended
period for cholera? WHY?

Cholera Surveillance and Outbreak Response 4

 Epidemiology of Cholera in
Ethiopia
 From 2015 to 2021, Ethiopia was affected by AWD/cholera outbreaks
every year.
 The first epidemic of this period started in late 2015 (in Oromia and
Somali Regions) and spread throughout the country in 2016.
 In 2016, a total of 30,718 suspected cases were reported across all
regions except Gambela. This epidemic continued into 2017 with a total
of 47,540 suspected cases, of which 75% of suspected cases were
reported from Somali Region.
 Following the massive epidemic in 2017, case numbers drastically
decreased, with 3,024 cases reported in 2018 (mostly in Afar and Tigray
Regions) and 2,535 cases in 2019 (primarily in Oromia and Afar
Regions).
 Case numbers again increased in 2020, with 14,612 cases reported that
year (77% of cases were reported from SNNP Region).
 In 2021, a total of 983 suspected cases were reported, with nearly all
cases reported from either Oromia or SNNP Regions.
Cholera Surveillance and Outbreak Response
 Cholera

 Cholera is a diarrheal disease caused by infection

of the intestine with the gram-negative bacteria
Vibrio cholerae, either type O1 or O139.
 Both children and adults can be infected.

 It is one of the key indicators of social development

 Become a challenge to low safe drinking water and

adequate sanitation access and utilization

Cholera Surveillance and Outbreak Response

 Cholera..

Etiology :
 There are over 100 vibrio species known but
only the “cholerae” species are responsible
for cholera epidemics.
 Vibrio cholerae species are divided into 2
serogroups
 Vibrio cholerae O1 &Vibrio cholerae O139
 Both biotypes subdivided into Classical and
El Tor biotypes

Cholera Surveillance and Outbreak Response

 Cholera
Species Vibrio cholera

Serogroup O139 O1

Biotype El Tor Classic

Hikojima Hikojima
Serotype
Ogwa Ogwa

Inaba Inaba

Cholera Surveillance and Outbreak Response

 cholera

 The three serotypes can co-exist during an

outbreak
This does not affect the epidemic pattern:
– Clinical features are similar, whatever the strain
– Regardless of the strain, the response is the same.
 Vibrios grow easily in saline water and
alkaline media.
 Survive at low temperatures but do not
survive in acid media

Cholera Surveillance and Outbreak Response

 Cholera

Reservoir:
 Humans are the main reservoir of vibrio
cholerae
 Water
– V. Cholerae can live for years in some aquatic
environments
 Some molluscs fish and
 Aquatic plants

Cholera Surveillance and Outbreak Response

 Cholera

 Transmission
– Cholera is transmitted by the fecal-oral route
– Contaminated water or food
– Corpses of cholera patients
– Cholera treatment centers can become main
sources of contamination if hygiene and isolation
measures are insufficient
– Fruit and vegetables grown at or near ground level
and fertilized with night soil (human excreta) and
then eaten raw!

Cholera Surveillance and Outbreak Response

 Feco-oral rout

Cholera Surveillance and Outbreak Response

 Cholera

Common source_ Water

– Contaminated at its source
– Shallow wells, surface water
– Contaminated in the home / after storage
– When inadequately washed hands come in contact
with stored water
– If wash utensils in contaminated water
– If bathe in contaminated water

Cholera Surveillance and Outbreak Response

 Cholera

 Common source_ food

 Moist grains served at room temperature or
lightly heated
 Moist food is excellent environment for
growth of V. Cholerae
 Acidifying foods inhibits growth of V. Cholerae
with lemons, tomatoes, yogurt or fermented
milk

Cholera Surveillance and Outbreak Response

 Cholera

Risk Factors
 Poor social and economic environment,
precarious (risky) living conditions associated
with:
– Insufficient water supply (quantity and quality)
– Inappropriate and poor sanitation and hygiene
practices
– Inadequate food safety (from preparation to table)
–- High population density: camps, slum
populations, internally displaced people (IDP) are
highly vulnerable.
–- Conflict/War affected
Cholera Surveillance areas
and Outbreak Response
 Cholera

 Risk factor
 Inadequate quantity and/or quality of water
 Inadequate personal hygiene
 Poor washing facilities
 Inappropriate or poor sanitation
 Inappropriate funeral services for cholera
corpus

Cholera Surveillance and Outbreak Response

Activity 1.3 Think Pair –Share(10m)

 Instruction: Think and

discuss the following
questions with your
neighboring trainee for 5
minutes and share your
ideas within 5 minute.
 Question:
 The incubation period of
cholera?
 Describe the sign and
symptoms of cholera
patient?
Cholera Surveillance and Outbreak Response 17
 Cholera

Clinical Features_ Pathogenesis:

 The large majority of ingested bacteria are destroyed
by stomach acidity
 surviving bacteria colonize intestinal cells, where
they multiply and produce a very powerful
enterotoxin
 That causes profuse watery diarrhea by a secretion
mechanism.
 The toxin adheres to intestinal cells and causes an
excretion of isotonic fluid in the intestinal lumen: it is
the enterotoxin that causes fluid loss and diarrhea.

Cholera Surveillance and Outbreak Response

 Cholera

 Incubation Period and Period of Infectivity

 The incubation period is usually 1 to3 days but
can range from several hours to 5 days.
 Symptoms usually last 2 to 3days, although in
some patients they can continue up to 5 days.
 Infected persons whether they are symptomatic
or not, can carry and transmit vibrios during 1
to 4 weeks
 Antibiotic therapy can decrease the duration of
symptoms and the period of infectivity.

Cholera Surveillance and Outbreak Response

 Cholera

 Signs and Symptoms

 Of the people infected with cholera
– Around 75% have no symptoms
– Around 20% have mild or moderate diarrhea
(which can produce dehydration)
– Around 5% have severe diarrhea, vomiting, and
severe dehydration

Cholera Surveillance and Outbreak Response

 Cholera

 The case-fatality rate in untreated cases may

reach 30–50% if there is not prompt
treatment.
 Treatment is straightforward (basically
rehydration)
 If treatment is applied appropriately the
case-fatality rate can be minimized to below
1%.

Cholera Surveillance and Outbreak Response

 Cholera

 Symptomatic cholera:
– Acute watery diarrhea(AWD)
– Profuse, "rice water" stools
– No fever, no abdominal cramps
– Vomiting and leg cramps common
– It is usually odorless or has a mild fishy smell.
– People with a severe case of cholera can pass one
liter of stool per hour or more, and leads to
dehydration.

Cholera Surveillance and Outbreak Response

 Dehydration
 Can lose up to 10% of body weight
 Fluid losses up to 1 liter / hour
 Must replace fluids and electrolytes to avoid
hypovolemic shock, renal failure and death.

Cholera Surveillance and Outbreak Response

 Figure 1. Signs of severe dehydration

 Sunken eyes, lethargy and slow recall of skin

Cholera Surveillance and Outbreak Response
 Cholera

“Rice water" stool

Cholera Surveillance and Outbreak Response
 Cholera

 Key cholera prevention and control

measure
 Surveillance:
– Early detection and containment of cases
– Risk factor identification ..
 Proper case management:
– Reduce CFR
– Establish CTC/CTU as soon as possible in affected
community
 Conduct OCV camping: helps in controlling
the outbreak
Cholera Surveillance and Outbreak Response
 Cholera

 Water and sanitation improvements

– Construct latrines
– Construct above-ground sewage tanks (e.g., in urban
areas)
– Distribute safe water (e.g., water delivery by truck)
– Distribute point-of-use water purification tools (e.g.,
AquaTabs)
– Improved water storage containers (e.g., containers with
narrow mouths or spigots)
– Flocculation-disinfectant powder sachets
– Filtered water using cloth, SODIS
– Monitor Free chlorin residual (FCR) at point of consumption

Cholera Surveillance and Outbreak Response

 Cholera

 Use community leaders, teachers,

broadcast and print media to tell
messages:
– Hand washing with soap after defecation or
cleaning an infant’s bottom
– Hand washing with soap before handling food,
eating, or breastfeeding
– Boiling water before drinking or using it in cooking
– Safe food preparation and storage practices
– Breastfeeding infants

Cholera Surveillance and Outbreak Response

Cholera Surveillance and Outbreak Response