Guidelines for Cholera Control

National Department of Health
Directorate: Communicable Disease Control
Sub-Directorate: Emerging and Re-emerging Infectious Diseases

Pretoria, June 2001

TABLE OF CONTENTS

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PREFACE

Since the early 1970’s, cholera has been endemic in the Southern part of the African region. Since then, South Africa has been actively involved in the prevention, control and treatment of cholera. Cholera outbreaks in the early 1980’s were used as training grounds for the South African Health System in so far as prevention and control of infectious diseases is concerned. Various strategies and outbreak response mechanisms were employed at various levels of care.

The experiences learnt in the 1980’s provided a wealth of knowledge, which culminated into the compilations of guidelines for the control of cholera outbreaks not only in South Africa but also in other developing countries throughout the world. So as not to loose what was learnt in the 1980’s, the National Department of Health developed guideline on the control of cholera in 1998.

These guidelines had been revised following discussions with the cholera experts and epidemiologist from the World Health Organisation [WHO]. In this document are different policy guidelines and recommendations useful during and in the absence of cholera outbreaks. Issues on prevention of disease outbreak, control of cholera, treatment of patients, surveillance, equipment and supplies are also discussed.

It is hoped that these guidelines will enable everyone involved in the prevention of cholera, particularly the health care providers to identify cholera, manage patients, and report cases. Information collected and reported is useful in programme planning and informed decision-making.

This document aims at improving awareness of cholera, which would contribute to timeous and appropriate treatment of patients. A list of both National and Provincial Communicable Disease Coordinators and Outbreak Response Managers is also provided should readers require any assistance.

Acknowledgements

This document, "Guidelines for Cholera Control" was compiled by the Sub-Directorate: Emerging and Re-emerging Infectious Diseases, within the Cluster: Disease Prevention and Control of the National Department of Health. The guidelines were also compiled in collaboration with other key stakeholder in communicable diseases in South Africa.

The National Department of Health acknowledges the valuable inputs of the, National Communicable Diseases Co-ordinators and all the Communicable Disease Control Co-ordinators from all the Provinces throughout South Africa.

The Department would also like to extend its gratitude to all the members of the National Cholera Task Team whose inputs made this document a reality. Also acknowledged are both the National and Provincial Outbreak Response Teams, who provided their wealth of knowledge during the compilation of this document.

Cholera experts and epidemiologists from the World Health Organisation are held in greatest regards for guiding the National Department of Health, in guiding us during the compilation of these guidelines.

"A cholera death is a health programme failure. The reduction of cholera mortality depends upon the health service organisation, distribution of supplies, health worker training, and communication with the population to ensure that adequate case management (principally oral rehydration therapy) reaches cholera patients. These components form the elements of a successful diarrhoeal-disease control programme."

A.V. Bartiett - John Hopkins University (The Lancet, Vol. 338:Nov 9,1991)

1. INTRODUCTION

Cholera has been prevalent worldwide since the early 19th centuries. This disease has been prevalent also in Sub-Saharan African countries, including South Africa. The World Health Organisation (WHO) has confirmed that cholera had always been endemic but under control in South Africa, although the worst cholera epidemic was seen in the early 1980s, particularly in the rural areas.

Research has contributed a great deal in providing health practitioners with knowledge on the etiology and epidemiology of the disease, including the clinical management of patients. Both public and clinical research contributed the following light in understanding cholera:

• In approximately 90% of cholera cases, the disease is mild; and it is difficult to differentiate it from other diarrhoeal diseases;
• Oral rehydration therapy is important in case management and can reduce the case fatality;
• Vaccination and other chemoprophylaxis are ineffective in preventing and controlling cholera; and personal hygiene on drinking and eating habits, safe disposal of human waste have proven to be effective in controlling the disease.

Cholera epidemics are public health problems and could claim up to 50% of its victims. It is therefore important for all the stakeholders in cholera prevention and control to use correct intervention strategies useful in curbing the epidemic.

2. THE ETIOLOGY OF CHOLERA

2.1 Infectious Agent

Cholera is cause by a bacterium called Vibrio Cholerae. There are more than 60 cholera bacteria, however, current outbreaks in Africa are caused by El Tor biotype of Vibrio cholera serogroup 01. The serotype of El Tor biotype prevalent in Africa is Inaba. Vibrio cholerae 0139 serovar is the major causative agent of epidemics in Asia.

2.2 Clinical Presentation of Cholera

Most cholera infections are asymptomatic or mild, and indistinguishable from other mild diarrhoea. In its severe form the following signs and symptoms characterise cholera:

• Onset is typically sudden,
• Diarrhoea is profuse, painless and watery, with flecks of mucus in the stool ("rice water" stools). The presence of blood in stools is not a characteristic of cholera,
• Vomiting may occur, usually early in the illness,
• Majority of patients are afebrile, children are more often febrile than adults,
• Dehydration occurs rapidly (up to 1000ml/hour of diarrhoea may be produced),
• All complications result from effects of loss of fluids and electrolytes in stool; and
• Vomitus; muscle cramps, acidosis, peripheral vasoconstriction, and ultimately renal and circulatory failure, arrhythmias and death may occur if treatment is not given timeously.

2.3 Reservoir

For practical purposes, cholera is restricted to humans. Faecally contaminated water is the most important reservoir of infection and vehicle of transmission, either directly or indirectly through contaminated food.

2.4 Mode of Transmission

Vibrio cholerae is spread mainly via the faecal-oral route. Some of the best-known sources of infection are as follows:

• Drinking water that has been contaminated at its source, during storage or usage,
• Contaminated foods, vegetables that have been fertilised with human excreta (nightsoil) or "freshened" with contaminated water,
• Soiled hands can also contaminate clean drinking water and food, and
• Fish, particularly shellfish taken from contaminated water and eaten raw or insufficiently cooked.

2.5 Incubation Period

The incubation period ranges form a few hours to 5 days, (usually 2 - 3 days).

2.6 Period of Communicability

Cholera is communicable in the duration of stool-positive stage. Asymptomatic carrier status may persist for several months.

2.7 Population at Risk

The people most at risk of contracting cholera are those who do not have access to piped safe water and adequate and proper sanitation.

3. EPIDEMIC PREPAREDNESS

A strong programme for the control of diarrhoeal diseases is the best preparation for a cholera epidemic. In the long term, improvements of safe water supply and adequate sanitation are the best means of preventing cholera. In an outbreak, the best control measures are the early detection of cases and treatment of patients; coupled with health education. In order to respond quickly to the cholera epidemic and to prevent deaths, health facilities must have access to adequate quantities of essential supplies, particularly oral rehydration solution and intravenous fluids.

During the outbreak of cholera, these supplies are needed in greater quantities than normal. To prepare for an outbreak, it is essential to maintain additional stocks at appropriate points in the drug delivery system. Small 'buffer stocks" should be placed at local health facilities, larger buffer stocks at district or provincial levels, and an adequate emergency stock at a central distribution point.

Refer to Annexure C for supplies and equipment needed in case of epidemic preparedness. Medical and paramedical personnel involved in the treatment of cholera should receive intensive and continuing training to ensure that they are familiar with the most effective techniques for the management of patients with cholera.

4. PREVENTION AND CONTROL

4.1 Preventive Measures

The community should be informed about sources of contamination and ways to avoid infection. Attention to sanitation can markedly reduce the risk of transmission of cholera including other intestinal pathogens. This is especially true where lack of good sanitation may lead to contamination of water sources. High priority should be given to observing the basic principles of sanitary human waste disposal and particularly the protection of water sources from faecal contamination.

The development of sanitary systems appropriate to local conditions should be facilitated and their siting in relation to water sources emphasised. Basic hygiene involving thorough hand washing following contact with excreta should be encouraged for adults, infants and children.

Where water supplies are at risk of contamination, households should be taught about the necessity and the techniques of sanitising water in the home. The simplest and most cost effective method is chlorination of water in the storage container using household bleach. Boiling is also effective. Filtration may be necessary in addition to boiling if the only water available contains much particulate matter. Chlorination alone is not sufficient in such circumstances. Even when drinking water is rendered safe, infection may still be transmitted by contaminated surface water used for bathing and for washing clothing, food or cooking utensils. In an outbreak situation all water sources with potential for contamination must be tested, rendered safe if contaminated or otherwise closed to usage and alternative sources provided.

Since food is an important vehicle for the transmission of enteric pathogens, attention to food safety is an essential preventive measure, which should be intensified when there is a threat of cholera. Street vendors and communal food sources will require particular attention, since they pose a special risk. Flies play a relatively small role in spreading cholera but their presence in large numbers indicates poor sanitary conditions, which favour transmission of the disease.

4.2 Public Awareness

In case of an outbreak, communities at risk should be sensitised through intensive health education; and encouraged to participate in the following activities:

• Water purification or ensuring a safe water supply by boiling or chlorination of domestic water using household bleach: Add 1 teaspoonful (5ml, or one capful if bottle has a screw cap) of household bleach to 20-25 liters of water. Thoroughly mix solution with the water and allow to stand for at least two hours (preferably overnight) before use.
• Sanitary disposal of human waste without contaminating water sources and control of flies.
• Food hygiene - avoid any potentially contaminated food especially raw or partially cooked fish and shellfish. Food of vegetable origin should be peeled or shelled. Boil or pasteurise of all milk.

Actively inform and educate health care workers and the community about the extent and severity of the outbreak and the effectiveness and simplicity of current treatment methods, and benefits of reporting cholera cases promptly. The free flow of information would prevent panic spreading through the community. Communities should also be involved in educating themselves through the use of various communication strategies. Street food-vendors and restaurants may contribute in the spread of the disease. Therefore, Environmental Health Officers need to be vigilant in inspecting food-handling practices, and should be authorised to stop street sales or close restaurants if insanitary practices are revealed.

Health education activities for food handlers in areas under the threat of cholera should stress the following:

• Exclude infected persons from handling food
• Wash vegetables and fruit in treated water before use
• Prepare and store food under proper hygienic conditions
• Cook food thoroughly in treated water and eat it while still hot, or reheat it thoroughly before eating
• Prevent contamination of food by contact with other contaminated raw food, contaminated surfaces or flies
• Wash hands thoroughly with soap after defaecation and before preparing or eating food
• Encourage individuals to use clean cutlery when eating
• Discourage the habit of several people eating simultaneously from a communal food container
• Left over food should be reheated before eating
• Encourage breast-feeding of infants.

It is very important to liaise with local media such as press, radio and television to ensure that correct health education messages are passed on to the general public.

4.3 Control of Patients, Contacts and Environment

An organised programme for the control of diarrhoeal diseases is the best preparation for a cholera outbreak. The best control measures are the early detection and effective treatment of infected persons allied to health education. The mortality is likely to be high among severe cases (up to 50%) in an unprepared community.

The basic requirements for preparedness include the establishment of a reliable surveillance and reporting system, ensuring the availability of essential supplies and the training of workers in the clinical management of acute diarrhoea.

5. SURVEILLANCE

5.1 Bacterial Surveillance

All proven cases must be reported immediately through the line listing form to the local authority who must report to the Provincial Communicable Disease Control Officer and the National Department of Health. An attempt must be made to establish a bacteriological diagnosis from rectal swabs or stool specimens; (see Annexure A) in cases of gastro-enteritis suspected of being due to or possibly due to cholera, presenting at hospitals/peripheral clinics or observed by mobile health teams and field workers in cholera designated areas.

5.2 Environmental Surveillance

Environmental surveillance forms one of the most important part in the control and preparedness of the cholera epidemic. The following are to be taken into consideration when conducting an environmental surveillance.

• Identify communities at risk (unsafe water supplies or inadequate sanitation) and ensure that they are informed about sources of contamination and ways to avoid infection
• Investigate all bacteriologically proven cases to identify the sources of infection
• Monitor the spread of cholera in risk areas by periodically sampling strategic sewage effluent (hospitals, prisons, hostels, sewage purification works) as an early warning system (Annexure B).
• Surveillance using Moore pads should only be done in high-risk areas where there is a definite chance of cholera being identified. Selected sentinel sites should be monitored in large cities. Moore pads should be used to monitor the end on an epidemic. Vibrio cholerae isolated from Moore pads should be tested to determine whether they are indeed Vibrio cholerae 01 or not, since Vibrio cholerae 01 result in diarrhoea.

When such changes in the pattern of diarrhoeal illness occur the notification process should be activated immediately. When this information comes from an area where cholera has.not previously been confirmed, bacteriological and epidemiological investigations should be arranged promptly to establish the cause of the outbreak and epidemic control measures instituted, if indicated.

5.3 Reporting

When suspected cases of cholera are detected at a health facility, the nearest referral facility or designated local health officer should be notified immediately. The Provincial Department of Health should then be notified to investigate and confirm the diagnosis. Upon confirmation, the National Department of Health should be notified since cholera is a notifiable disease.

Either the Provincial or National Department of Health should proactively inform the community via the media, of the cholera threat and measures to be taken to prevent the outbreak from spreading.

The National Communicable Disease Officer should then inform the Senior Management of the outbreak of the disease and the steps being taken to contain and control the outbreak. The opportunity should be used to motivate for improved water and sanitation through provision of safe water supplies and the building of toilets or latrines.

5.4 Notification According to International Health Regulations

According to these regulations National Health Authorities should report the first suspected cases of cholera to the World Health Organisation as rapidly as possible. Laboratory confirmation should be obtained at the earliest opportunity and also reported to WHO. Weekly reporting is required where cholera is confirmed.

Reports should include the number of new cases and deaths since the previous report plus the cumulative totals for the current year by province or other applicable geographic division.

Additional demographic information should be provided, if available. Once the presence of cholera in an area has been confirmed it is not a requirement to confirm all subsequent cases.

Neither the treatment of individual cases nor the notification of suspected cases needs laboratory confirmation of the presence of Vibrio cholerae 01. Monitoring of an epidemic should include laboratory confirmation of a small proportion of cases on a continuing basis.

6. TREATMENT

Hospitalisation with enteric precautions is desirable for severely ill patients but strict isolation is not necessary. Less severe cases can be managed on an outpatient basis with oral rehydration. Crowded cholera wards can be operated without hazard to staff and visitors when effective hand washing and basic procedures of cleanliness are practiced. The only treatment needed is rehydration as soon as possible. It is essential that all cases presenting clinically as cholera cases, must be treated as such immediately.

6.1 Management of Cholera Patients

Recognition of cholera cases "rice water stools" is very important, and health workers need to start treatment as early as possible to reduce potential contamination of the environment and death. Cholera should be suspected when:

• A patient older than five years develops severe dehydration from acute watery diarrhoea (usually with vomiting.) or
• Any patient above the age of two years has acute watery diarrhoea in an area where there is an outbreak of cholera.

6.1.1 Rehydration

Dehydration, acidosis, and potassium depletion typical of cholera are due to loss of water and salts through diarrhoea and vomiting. Therefore rehydration, which consists of replacing water and salts, is necessary. Patients should be encouraged to seek medical attention from trained health workers as rapidly as possible to reduce the risk of shock. To follow are steps useful for the management of cholera patients.

6.1.2 Steps in the Management of Suspected Cholera

Step 1: Assess dehydration

Step 2: Rehydrate the patient, and monitor frequently, and reassess hydration status

Step 3: Maintain hydration: replace continuing fluid losses until diarrhoea stops.

Step 1: Assess the Patients for Dehydration

Use Table 1 to determine whether the patient has severe, some or no signs of dehydration.

* In adults and children older than 5 years, other *signs* for severe dehydration are *absent radial pulse* and *low blood pressure). The skin pinch may be less useful in patients with marasmus (severe wasting) or kwashiorkor (severe malnutrition with oedema), or obese patients. Tears are a relevant sign only for infants and young children

Step 2: Rehydrate the Patient, and Monitor Frequently, Reassess Hydration Status

1. For Severe Dehydration:

• Give IV fluid immediately to replace fluid deficit. Use Ringer's lactate solution or, if not available, normal saline.
• If the patient can drink give ORS by mouth simultaneously while the drip is being set up.
• For patients aged 1 year and older, give 100 ml/kg IV in 3 hours, as follows:

• 30 ml/kg as rapidly as possible (within 30 minutes); then
• 70 ml/kg in the next 2,5 hours

• For patients aged less than 1 year, give 100ml/kg IV in 6 hours, as follows:

• 30 ml/kg in the first hour; then
• 70 ml/kg in the next 5 hours

• Monitor the patient very frequently. After the initial 30 ml/kg have been given, the radial pulse should be strong and blood pressure should be normal: If the pulse is not yet strong, continue to give IV fluid rapidly
• Give ORS solution (about 5 ml/kg per hour) as soon as the patient can drink, in addition to IV fluid
• Reassess the patient after 3 hours (infants after 6 hours), using Table 1:

• If there are still signs of severe dehydration (this is rare), repeat the IV therapy
• If there are signs of some dehydration, continue as indicated below for some dehydration
• If there are no signs of dehydration, go on to step 3 to maintain hydration by replacing continuing fluid losses.

2. For Moderate Dehydration

• Give ORS solution in the amount recommended in Table 2. If the patient passes watery stools or wants more ORS solution than shown, give more.
• Monitor the patient frequently to ensure that ORS solution is taken satisfactorily and to detect patients with profuse and continuing diarrhoea who will require closer monitoring.
• Reassess the patient after 4 hours, using Table 1:

• If signs of severe dehydration have appeared (this is rare), treat as in step 1, above.
• If there is still Moderate dehydration, repeat the procedures for some dehydration, and start to offer food and other fluids.
• If there are no signs of dehydration, go on to Step 3 to maintain hydration by replacing continuing fluid losses.

* Use the patient's age only when you do not know the weight. The approximate amount of ORS requires (in ml) can also be calculated by multiplying the patient's weight (in kg) by 75

NB: Use nasogastric tube if patient cannot drink and IV therapy not possible at the facility. Regular urinary output (every 3-4 hrs) is a good sign that enough fluid is being given.

3. For No Sign of Dehydration

Patient observed to be without signs of dehydration could be treated at home.

• Give ORS packets to take home. Give enough ORS for 2 days.
• Instruct the patients or the care-giver to return if the patient develops watery stool, marked thirst, repeated vomiting, fever and bloody stool

 Step 3: Maintain Hydration, Replace Continuing Fluid Losses Until Diarrhoea Stops

The amount of ORS solution varies from one patient to another. The greatest amount of ORS solution is required within the first 24 hours, especially in patients with severe dehydration. In the first 24 hours, such patients require an average of 200 ml of ORS solution per kg of body weight.

Prompt fluid therapy with volumes of electrolyte solution, enough to correct dehydration, acidosis and hypokalemia is the cornerstone to cholera therapy. Oral administration of glucose-electrolyte solution (8 teaspoons sugar, half teaspoon salt, mixed with 1 liter safe water) to patients with diarrhoea, including patients with cholera, will save many lives.

Approximately 80 - 90% of patients can be successfully treated by oral rehydration. It should be emphasised that all cases of diarrhoea showing signs of dehydration must receive adequate oral rehydration immediately, before transportation to hospital.

NB: Patients should be properly fed after vomiting has stopped.

6.2 Antibiotics

6.2.1 Antibiotic Resistance

There is no evidence to support the suggestion that the use of antibiotics increase the chances of survival of cholera patients. Although its use has previously been shown to shorten the duration of the diarrhoea, current strains tend to be resistant. The use of antibiotics in mild cases can quickly use up supplies and hasten the development of antibiotic resistance among Vibrio cholerae and, STDs, Haemophilus and Pneumococci, not only to tetracycline but also to other antibiotics.

In very severe dehydration and under supervision of a medical doctor, antibiotics may be given in a hospital setting. The choice of antibiotics should take into account local patterns of resistance. Knowledge of antibiotic sensitivity patterns of recent isolates in the immediate area or in adjacent areas is therefore important. Antibiotic-resistant Vibrio cholerae 01 should be suspected if diarrhoea continues after 48 hours of antibiotic treatment.

6.3 Vaccines

Cholera vaccination is NOT recommended, and vaccines currently available DO NOT help in controlling cholera because of the following reasons:

• Vaccines lack the required potency and have low rate of protective efficacy
• Vaccines provide immunity of limited duration only
• They do not reduce the rate of asymptomatic infections, and prompt a false sense of security

6.4. Prophylaxis

Prophylaxis with antibiotics such as tetracycline is not recommended because of the high incidence of resistance. The best prophylaxis is clean water and toilets, together with hand washing before food handling. During a local cholera epidemic:

• Discourage community members from attending large communal gatherings e.g. beer drinking
• Furthermore attempting to limit travel across borders etc (e.g. "cordon sanitaire") diverts manpower and resources from more effective control activities and hampers collaboration between agencies and countries in joint efforts to control cholera outbreaks.
• Note: Travel and trade restrictions between countries or different areas of one country, cannot prevent the spread of cholera.

6.5 General Measures

• Start rehydration immediately and remove patient to a treatment center if diarrhoea and/or dehydration persists
• The patients' soiled clothes and linen should be thoroughly washed in strong hot soapy solution and hung out to dry in the sun.
• Do not wash soiled clothes or allow people to play or swim in communal drinking water sources, rivers, etc.
• Corpses should be transported in sealed fluid tight containers where possible.
• Strict hand washing must be practiced after using the toilet and before handling food.
• Promote the construction and use of clean toilets - there must be no faecal contamination of the environment (water and food sources),
• Promote the use of safe sources of water, and identify and eliminate breeding places of flies.

7. TRAINING

Since case fatality is largely determined by the urgency and adequacy of diarrhoeal management practices, prior training and continual supervision of health workers in the assessment of diarrhoea cases and the promotion and use of ORT and continued feeding during diarrhoeal illness are essential.

Effective rehydration practices cannot be assumed during an outbreak if they are not part of established daily routine practice. Such practice is the cornerstone of diarrhoeal disease control in the conditions that prevail throughout much of South Africa and each province should pay due attention to training in, and supervision of the practice of ORT at primary care.

It is therefore essential to educate all health workers regarding cholera and to create an awareness of possible cholera cases. All hospitals, clinics, mobile health teams and other field workers such as Health Inspectors and Health Assistants must be equipped with, or have ready access to, a "cholera pack" containing the following items:

• Screw top specimen bottles containing "single strength" alkaline peptone water
• Sterile rectal swabs and disposable gloves
• Laboratory request forms
• Instructions for collection and dispatch of specimens.

NOTE: If delay in transport to laboratory is anticipated to be >24 hours, use Cary-Blair transport medium instead: Instructions for the collection of stool specimens for cholera investigation are contained in Annexure B. It is suggested that individual hospitals, clinics and other health authorities consult with their respective laboratories in this regard.

8. INTERSECTORAL MOBILISATION

If a cholera outbreak occurs in an area where the peripheral health services are inadequate or have no experience in controlling the disease, mobile teams from national or provincial level may be called upon for assistance. These outbreak response teams should have intersectoral representation including members from the Department of Water Affairs and Forestry, the South African National Defence Force, Provincial and Local Government and provincial and national communicable disease officers, environmental health officers, communications and laboratory services. The members of each team should be brought together for briefing on emergency activities and their individual responsibilities

ANNEXURE A

INSTRUCTIONS FOR COLLECTION OF STOOL SPECIMENS FOR CHOLERA INVESTIGATIONS

General information:

1. Specimen labels must be properly filled in.
2. Specimens should be collected before antibiotic treatment.
3. Delays between collection of specimens and dispatch to the laboratory should be minimised.
4. Stools may be sent:

1. In normal specimen containers for isolation of all pathogens including Vibrio cholerae, or
2. In single strengths alkaline peptone water, specifically for accelerated Vibrio cholerae isolation. Dip a swab into the stool and express fluid against the inside of the bottle; repeat. Discard swab into disinfectant, or
3. If a delay of more than 24 hours is anticipated, the specimen should be submitted in Cary-Blair transport medium. Swabs should be plunged deeply into the medium, left in position for at least 30 seconds, then twisted gently and removed.

NOTE: This applies to plastic-stemmed swabs, if wooden-stemmed swabs are used, these can be broken off at the lip of the specimen container after plunging into the transport medium.

5. Specimen containers with alkaline peptone water and Cary-Blair transport medium may be ordered from the South African Institute for Medical Research Stores, Johannesburg or from the laboratory serving the respective hospital clinic.

ANNEXURE B

INSTRUCTIONS FOR COLLECTION AND SENDING OF SEWER PADS FOR CHOLERA DETERMINATION

1. Special wide-necked bottles containing (double strength) alkaline peptone water are obtainable from the SAIMR stores in Johannesburg and the SAIMR laboratory serving that area.
   
   
2. Commercially available plain sterile surgical gauze swabs measuring approximately 10cm square should be used. Tie one corner with a length of wire (or string if no rats present) and immerse the pad to hang below the surface of the effluent. The swab should remain in place for 24-72 hours, after which it should be pulled out.
   
   
3. Hold a 2-3m long piece of the swab with sterile forceps, cut it off with sterile scissors and place the piece in the peptone water bottle. Close the lid tightly.
   
   
4. Place the used instruments in a jar or flat container with methylated spirits. The instruments must be completely immersed. On arrival at the next sewer pad site, remove the instruments from the jar, close the jar and then hold a lighted match to the instruments to remove all traces of alcohol.
   
   
5. Complete the attached label and send the specimen to the laboratory serving the specific hospital, clinic, etc. Specimens should arrive at the laboratory within 6 - 12 hours of collection.

ANNEXURE C

SUPPLIES AND EQUIPMENT ESTIMATE: FOR THE FIRST WEEK OF THE CHOLERA EPIDEMIC

Buffer and emergency stocks of essential supplies should already be in place before an epidemic starts. It is essential to establish a system to monitor their use and ensure their prompt replacement. Emergency supply requirements should be determined and individuals assigned to coordinate their procurement and distribution. The supplies and equipment needed have been calculated on an attack rate of 0.2, that is 200 cases may be expected to occur in a population of 100 000. This is only for calculating initial stocks to cope with the beginning of an epidemic of cholera. A review based on weekly actual figures will help to reassess actual needs and prompt replacements

Estimated Minimum Supplies Needed to Treat 100 Patients During a Cholera Epidemic

 Rehydration Supplies

[The supplies are sufficient for IV fluids followed by Oral Rehydration Salts for 20 patients, and for Oral Rehydration Salts alone for the other 80 patients]

Using the above estimates for 100 patients and current population in an area and an attack rate of 0.02. The needs may be calculated for stocking of supplies in preparing for an epidemic for the first week. Reassessment on a weekly basis for actual attack rate must be done. It is essential to establish a system to monitor their use and ensure their prompt replacement.

Emergency supply requirements should be determined and individuals assigned to coordinate their procurement and distribution. The supplies and equipment needed have been calculated on an attack rate of 0.2 that is 200 cases may be expected to occur in a population of 100 000. This is only for calculating initial stocks to cope with the beginning of an epidemic of cholera. A review based on weekly actual figures will help to reassess actual needs and prompt replacements

NATIONAL AND PROVINCIAL COMMUNICABLE DISEASE CONTROL AND OUTBREAK RESPONSE CO-ORDINATORS

For more copies of this document, complete and send to:

Director-General
Directorate: Communicable Disease Control
Department of Health
Private Bag X 828
PRETORIA
0001

Tel: (012) 312-0091

Fax: (012) 323-8626

GUIDELINES FOR THE CONTROL OF CHOLERA IN SOUTH AFRICA

Directorate: Communicable Disease Control (Hallmark R 1807)