E-DRUG: Cholera: lessons from South Africa
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[Some time ago we had discussion on E-drug about the best
treatment of Cholera during the Mozambique floods.
{ HYPERLINK "mailto:mcdfam@iafrica.com" }
Clean water is the most essential drug!
Below some advice from Kwa Zulu Natal, a rural province of South
Africa where more than 4000 cases have been experienced in the
last months. Mortality was below 1%.
The drug and inventory lists are at the end.
Copied from AMILADOC, a South African email list, with thanks.
Sorry, long posting. WB]
CHOLERA: SOME LESSONS LEARNED
Background: When I started working in KwaZulu-Natal in 1985,
this region had just come through a major cholera epidemic. I was
aware of the epidemic because I had, for two years before that,
been involved in epidemiological work in the National Department of
Health in Pretoria, but once I got to working on the ground, cholera
seemed to be little more than a memory that everyone had
breathed a collective sigh of relief to have behind them. Nowhere
did I see any report on what had transpired or any guidelines as to
what should be done. I confess to not having looked too hard, but
knowing what I know now, I am surprised that nowhere in the
doctors� library or on the superintendent�s shelves was a fat file
marked �CHOLERA� in which all the pearls gleaned during the
cholera experience of the preceding years had been collected.
At the time such a file would have made little more than interesting
reading, but right now, if I could lay my hands on it, it may be worth
significantly more than the paper it was written on. To get to the
point, my colleagues and I in the Eshowe-Nkandla sub-district of
KwaZulu-Natal have been dealing with a cholera outbreak for four
weeks now and our neighbours in Empangeni, for a month more
than us. A lot of the time we have felt like we are finding our way in
unknown territory and have not known where to turn for support.
The purpose of my writing this document is to review where we
have got to thus far and hopefully, in the process to offer some
guidance to colleagues elsewhere who might soon be facing similar
problems, so that they are better prepared for the onslaught and
don�t lose too much time once the problem is already upon them.
What follows are some personal reflections on my experience over
the past four weeks and is not intended to be a definitive guideline
or final word on how to manage a cholera outbreak, but I trust that
someone, somewhere will find it useful.
Be Prepared: Take reports of cholera seriously. Watch the
papers, try to pre-empt the arrival of the disease in your area.
Ultimately, where there are unprotected water supplies and
inadequate sanitary arrangements, the spread of cholera is
inevitable unless there is a massive effort to educate people on how
to protect themselves against the disease by practising good
personal hygiene, treating any water from an unprotected source
before drinking it and ensuring that they know what foods to avoid
(or how to properly prepare potentially harmful food).
Network: Once cholera becomes established, major intersectoral
collaboration is required to co-ordinate efforts in getting the
message out, providing and maintaining safe water supplies and
treating affected individuals as early as possible. We have been
fortunate to have the relevant government departments working very
closely, and I would recommend identifying early who the relevant
role players are in your local Department of Water Affairs &
Forestry, Education, Defence and Local Government offices. Their
co-operation in addressing a potential cholera threat, or if it comes
to it, an outbreak, is vital and it helps immensely to have a good
working relationship before the need arises. Of equal importance
are NGOs and community based organisations which are very
valuable in providing links to the people most likely to be directly
affected by the epidemic. If you don't know who your local
NGO/CBO structures are, find out and start working with them as a
matter of priority.
It is also worthwhile identifying, within the Department of Health,
which directors and other senior officials are responsible for
communicable disease control and develop a list of names and
contact numbers. Environmental health officers at local and higher
levels are also important role players. Get to know who they are
and how they operate so that you can make use of their skills and
resources early on.
Get connected: It is also worth the effort to source as much
material on cholera as you can, in the form of guidelines, protocols,
health promotion pamphlets and reports on previous outbreaks as
you are able to lay your hands on. I found the internet particularly
useful and would recommend the following sites:
{ HYPERLINK http://www.who.int/chd/publications/cholera/cholguid.htm
}http://www.who.int/chd/publications/cholera/cholguid.htm
{ HYPERLINK http://www.who.int/inf-fs/en/fact107.html
}http://www.who.int/inf-fs/en/fact107.html
{ HYPERLINK http://www.whoafr.org/afropac/commondiseases/cholera.html
}http://www.whoafr.org/afropac/commondiseases/cholera.html
{ HYPERLINK http://www.whoafr.org/emc/cholera.html
}http://www.whoafr.org/emc/cholera.html
www.who.int/health-topics/cholera.htm
{ HYPERLINK http://www.cdc.gov/ncidod/dbmd/diseaseinfo/cholera_g.htm
}http://www.cdc.gov/ncidod/dbmd/diseaseinfo/cholera_g.htm
The Department of Health in KwaZulu-Natal also has a site which
can be accessed through www.health.gov.za (click on provincial
links and then click on KwaZulu-Natal) where some good cholera
references have been posted.
The Department of Health in KwaZulu-Natal also has a site which can be
accessed through { HYPERLINK "http://www.health.gov.za"
}www.health.gov.za (click on provincial links and then
click on KwaZulu-Natal) where some good cholera references have been
posted.
The National Department of Health in Pretoria has, in its CDC
office, large supplies of a locally produced booklet �Guidelines for
Cholera Control� available free of charge. While not as
comprehensive as some of the WHO guidelines, it is helpful
particularly if you do not have access to the internet. Direct your
requests to Dr Uma Nagpal at fax +27-12-323 8626
Train staff: It is most important that staff dealing with cholera
patients in hospital or in the field (clinics and rehydration centres),
have a clear definition of cholera and are able to distinguish it from
other diarrhoeas which are so prevalent today. Cholera patients
generally present with a profuse watery diarrhoea of recent onset,
do not have abdominal cramps and are usually not febrile. The
stool is white and watery (classically described as rice water) and
has a characteristic fishy odour. Blood and mucus is not found in
cholera stool. Patients may also complain of vomiting and apart
from the stool, the most important physical sign is dehydration.
Once health workers know how to recognise a cholera patient and
how to assess the severity of his/her condition, making a decision
about appropriate treatment is relatively simple.
Accurate diagnosis of cholera is important also in terms of
notification. Our experience has been that in their initial concern
not to miss a cholera patient, staff labelled almost all patients
presenting with diarrhoea in the early stages of the outbreak as
cholera and until we were able to rectify this, our notification figures
were somewhat inflated. Staff responsible for completing line lists
for epidemiological and case-finding purposes should be
particularly clear about this and it would help a great deal if such
staff could be well prepared before being summarily despatched to
run a field rehydration centre, (we are still playing catch up in terms
of appropriate orientation of field staff). Medical staff also need to
be clear on how to manage cholera patients, which intravenous
fluids to use, when, if at all, to use antibiotics and to avoid the use
of anti-diarrhoeal and anti-emetic agents. Providing treatment
protocols and allowing opportunities for discussion of the various
options is probably a good way to go. Personal input from a trainer
is much more effective than faxing documents here there and
everywhere, guidelines issued without follow-up all too often don�t
get read and thus don�t get implemented.
Keep people informed: As you are probably aware, cholera makes
headlines and because of the intense media interest that an
outbreak of this disease provokes, it can be beneficial to have
press statements prepared about what cholera is, how it can be
prevented, what people should do if they think they are at risk or
are worried they have caught the disease etc. That way you get
the press to do a lot of your information dissemination for you, (just
keep a check on the accuracy of what they put out). National
media are already on board with the current epidemic, but local
papers are helpful in dispelling fears and eradicating myths in
smaller, newly affected communities as long as their reporting is
reliable. Find members of your staff who are prepared to give
interviews to community radio stations or to make opportunities to
talk to groups of people in person and afford them the opportunity
to ask questions. Such groups might include community based
organisations, women�s organisations, church meetings, farmers
meetings, business organisations, school assemblies, etc. Local
schools were particularly appreciative of a small fact sheet I put
together about cholera which they could use as a guideline to
inform their learners about the disease.
The media like to get their hands on figures but these can be easily
distorted or confused. Your department probably has a media
liaison section, or a media policy about how such technical
information should be disseminated. Although it may seem
unnecessarily controlling, for such structures to be in place, they
are in fact, most helpful in ensuring that everybody gets the same
(hopefully correct) information about how many people have
become ill, how many have died and so on. Establish links with
your media person, find out what information they require and
establish the process through which information will be fed to them.
Also make sure that once they start producing media releases
that you get a copy so that you can verify that they are getting their
facts straight.
Establish logistics: If faced with a cholera outbreak, your district or
hospital will be faced with a logistical challenge of significant
proportions. Not only will you need to bolster supplies of
intravenous fluids and oral rehydration preparations as well as the
means to administer these substances, but you will also need to
prepare for the possibility of establishing and staffing field
rehydration centres. Hospitals will need to prepare for an influx of
both in- and outpatients and admission policies may have to be
modified to provide capacity for this. Staff should be warned of
possible extended working hours and leave cancellation in the early
days of the epidemic. If staffing is a critical issue, help may have
to be sought outside of the institution and it is better to do this
early rather than late because such things can take time to
arrange.
The WHO document Guidelines for Cholera Control has a useful
list of minimum supplies needed to treat 100 patients during a
cholera outbreak which I shall append at the end of this document.
Should you be required to establish rehydration centres in the field,
it helps to know what is required to equip and run these and I shall
also append a list of equipment and supplies we developed to kit
out a tent 5m x 5m as a basic guideline, (you will need to decide
on yoour own quantities). We have found that 5x5 tents are a bit
small and it may be better to use something bigger if you have
access to it.
In discussion with the WHO team who recently visited to
investigate the cholera outbreak here, it was pointed out, that as far
as possible, cholera patients should not be moved over great
distances as this has the potential to spread the disease. Words
to the effect that 'cholera is a disease that should be treated in the
field and not in hospital' were used. They were therefore
advocating the setting up of field rehydration centres or the use of
clinics and community halls for this purpose.
Please be warned that a rehydration centre is of little use if it is not
provided with its own supply of safe water and safe toilets
(chemical toilets are good if you can access them and they can be
regularly serviced). This has proved to be a source of delay in
getting some of our points going properly and it would have helped
if we could have identified this and prioritised it beforehand.
Vehicles are another issue to consider in advance. Doing case
follow ups, getting staff and supplies to and from clinics,
transporting patients and investigating outbreaks requires wheels.
A careful assessment of what is available and how it can be
redeployed if necessary, as well as the procurement of additional
vehicles, needs to be done early on. Be sure also that you have
enough drivers and that they are prepared to work odd hours to
accommodate the needs of staff going on and off duty.
Concluding remarks: We have been fortunate that thus far the
mortality rate in the KZN epidemic has been low. It would seem
from the discussions going around that this has a lot to do with
early presentation of cases, so perhaps people�s memories are not
that short and the cholera of 1982 was remembered, recognised
and acted upon. If you do nothing else besides heighten
awareness of the possibility of a cholera outbreak and reinforce
how people should respond should it become a reality, you will
already have saved lives. For the long term, we have to continue to
lobby for safe water and sanitation in our rural communities and
use this outbreak of cholera as leverage to get things done. I end
with a quote from WHO: 'Cholera will ultimately be brought under
control only when water supplies, sanitation, personal hygiene and
food handling practices are safe enough to prevent the
transmission of Vibrio cholerae O1.'
Kevin McDonald Eshowe, October 2000.
P.S. If I can be of any assistance please contact me at E mail
mcdfam@iafrica.com or telephone 034 474 2071 (Work) or 035 474
2228 (Home before 21h00 please).
{ HYPERLINK "mailto:mcdfam@iafrica.com" }Annexure A
{PRIVATE}
Estimated minimum supplies needed to treat 100 patients
during a cholera outbreak
Rehydration supplies1
650 packets ORS (for 1 litre each)
120 bags Ringer's lactate solution2, 1 litre, with giving sets
10 scalp-vein sets
3 nasogastric tubes, 5.3 mm OD, 3.5 ID, (16 French), 50 cm long
for adults
3 nasogastric tubes, 2.7 mm OD, 1.5 ID, (8 French), 38 cm long for
children
Antibiotics
For adults:
60 capsules doxycycline, 100 mg (3 capsules per severely
dehydrated case)
OR 480 capsules tetracycline, 250 mg (24 capsules per severely
dehydrated case)
For children:
300 tablets trimethoprim-sulfamethoxazole, TMP 20 mg + SMX 100
mg (15 tablets per severely dehydrated case)
If selective chemoprophylaxis is planned, the additional
requirements for four close contacts per severely dehydrated
patient (about 80 people) are:
240 capsules doxycycline, 100 mg (3 capsules per person)
OR 1 920 capsules tetracycline, 250 mg (24 capsules per person)
Other treatment supplies
2 large water dispensers with tap (marked at 5- and 10-litre levels)
for making ORS solution in bulk
20 bottles (1 litre) for ORS solution (e.g. empty IV bottles)
20 bottles (0.5 litre) for ORS solution
40 tumblers, 200 ml
20 teaspoons
5 kg cotton wool
3 reels adhesive tape
1 The amount of supplies listed allows enough intravenous fluid
followed by ORS for 20 severely dehydrated
patients, and the exclusive use of ORS for the other 80 patients.
2 If Ringer's lactate solution is not available, substitute normal
saline.
From : Guidelines for Cholera Control: World Health Organisation , 1994
(Please note that we have not been using the antibiotics recommended
above because of confirmed resistance and have been advised to use
Ciprofloxacin 1000 mg as a stat dose in patients who are not responding
to rehydration therapy as desired.) KMcD
Annexure B
REHYDRATION CENTRE: INVENTORY
Beds, Folding
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Bins, Black garbage
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Blankets
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Bowls, Plastic , 10 l
�������������������
Brooms
������������������������
Buckets, Plastic 20 l
������������������..
Chairs, Folding canvas
������������������
Cookers, Gas
����������������������
Cupboards, Steel
�������������������..
Cylinders, Gas
���������������������
Dispensers, Water
�������������������..
Generators, Petrol
�������������������..
Kettles
������������������������.
Lamps, Gas
����������������������.
Mops
�������������������������
Pillows
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Rods, Extension,
��������������������.
Tables, Folding
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Telephone, Cellular
�������������������
Scale, Bathroom
��������������������
Sphygmomanometer
������������������.
Stethescope
����������������������
REHYDRATION CENTRE: STOCK LIST
Aprons, Cloth ��
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���.
Aprons, Disposable
���������������������������...
Bags, Garbage
�����������������������������...
Bags, Catheter (Urine)
��...�����������������������...
Bottles, Specimen
����������������������������.
Catheters,
Intravenous18G�������������������������
Catheters, Intravenous, 20G
������������������������.
Catheters, Intravenous, 22G
������������������������.
Catheters, Intravenous, 24G
������������������������
Cloths, Face
������������������������������.
Containers, Sharps 5 l
��������������������������..
Dispensers, Soap (thumb operated)
���������������������.
Dispensers, Solution (trigger
spray)���������������������
Giving Sets, Intravenous 15 drops/ml
��.������������������
Giving Sets, Intravenous, 60
drops/ml��������������������
Gloves, Sterile, Disposable
������������������������..
Jugs, Plastic, 1500ml
���������������������������
Lighters, Gas
������������������������������
Linen-savers
������������������������������..
Matches
��������������������������������
Sachets, Hypochlorite (Biocide D)
���������������������..
Sachets, Rehydration (Sorol)
������������������������
Sheets, Disposable
����������������������������
Soap, Liquid antiseptic
��������������������������.
Solution, Hibitaine in Alcohol
�����������������������.
Solution, Hypochlorite, (Jik)
������������������������
Solution, Intravenous, Modified Ringers Lacate 1000ml
�������������
Solution, Intravenous, � Darrows-Dextrose, 500ml
���������������
Swabs, Cotton wool
���������������������������..
Tape, Adhesive, Elastoplast
������������������������.
Tape, Adhesive, Transpore
������������������������..
Thermometers
�����������������������������..
Toilet Rolls
������������������������������..
Towels, Hand (paper)
��������������������������..
Tumblers, Plastic
����������������������������..
REHYDRATION CENTRE: STATIONERY
Boards, Clip
������������������������������.
Books, Exercise, Hardcover
������������������������.
Books, Duplicate (100 page)
������������������������
Cards, Clinic
������������������������������.
Form, Tracing
�����������������������������...
Lists, Line
�������������������������������.
Pens, Ballpoint
�����������������������������.
Register, Clinic
�����������������������������.
Sheets, Time
������������������������������..
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