* Available from IHPO, CDC, 1600 Clifton Road, MS F-03, Atlanta, GA 30333, 404-639-0308.
Epidemics
In the event of an outbreak of cholera, early case-finding will allow for rapid initiation of treatment. Aggressive case-finding by trained community health workers should be coupled with community education to prevent panic and to promote good domestic hygiene.
Treatment centers should be easily accessible. Most patients can be treated with ORS alone in the local clinic and still achieve a CFR less than 1%. If the attack rate for cholera is high, it may be necessary to establish temporary cholera wards to handle the patient load. Health centers should be adequately stocked with ORS, IV fluids, and appropriate antibiotics. Health workers must be trained in the management of cholera.
Surveillance should be intensified and should change from passive to active case-finding. The number of new cholera cases and deaths should be reported daily, along with other relevant information (e.g., age, sex, location in camp, length of stay in camp).
Treatment
The goal of cholera treatment is to maintain the CFR at less than 1%.
Rehydration therapy
Rehydration needs to be aggressive. However, careful supervision is necessary to prevent fluid overload, especially when children are rehydrated with IV fluids. Most cases of cholera can be treated through the administration of ORS solution (see "Patient Assessment" and "Guidelines for Rehydration Therapy". Persons with severe disease may require IV fluid, which should be administered following the guidelines outlined in "Diarrheal Diseases".
Antibiotics
Antibiotics reduce the volume and duration of diarrhea in cholera patients. Antibiotics should be administered orally. Doxycycline should be used when available in a single dose of 300 mg for adults and 6 mg/kg/day for children less than 15 years of age. Tetracycline should be reserved for severely dehydrated persons, who are the most efficient transmitters because of their greater fecal losses. Tetracycline should be administered according to the following schedule.
Epidemiologic investigation
Epidemiologic studies to determine the extent of the outbreak and the primary modes of transmission should be conducted so that specific control measures can be applied. The CFR should be monitored closely to evaluate the quality of treatment.
Case-control studies may be undertaken to identify risk factors for infection. Environmental sampling, examination of food, and the use of Moore swabs for sewage sampling may be useful to confirm the results of epidemiologic studies and define modes of transmission.
Control and prevention
Health education. The community should be kept informed as to the extent and severity of the outbreak, as well as educated on the ease and effectiveness of treatment. Emphasis should be placed on the benefits of prompt reporting and early treatment. The community should be advised about suspected vehicles of transmission. The need for good sanitation, personal hygiene, and food safety should be stressed. Health workers involved in treating cholera patients need to observe strict personal hygiene, by washing their hands with soap after examining each patient. Smoking should be prohibited in cholera wards and clinics.
Water supply. Any water supplies implicated through epidemiologic studies should be tested. Any contaminated water sources should be identified and access to those sources cut off. Alternative sources of safe drinking water should be identified and developed as a matter of urgency.
Food safety. Community members should be informed of any food item that has been implicated as a possible vehicle of transmission. Health education messages regarding food preparation and storage should be disseminated.
During an outbreak, feeding centers should be extremely vigilant in the preparation of meals because of the potential for mass infection. Food workers should have easy access to soap and water for handwashing. Food workers should always wash their hands after defecating, and any food worker who is experiencing diarrhea should be prohibited from working.
Chemoprophylaxis. Mass chemoprophylaxis is not an effective cholera control measure and is not recommended. Although the WHO Guidelines for Cholera Control suggest that chemoprophylaxis may be justified for closed groups (such as refugee camps), CDC studies indicate that focusing on other preventive activities (i.e., providing an adequate water supply, improving camp sanitation, and providing adequate and prompt treatment) results in a more effective use of resources. If resources are adequate and transmission rates are high (greater than 15%), consideration should be given to providing a single dose of doxycycline to immediate family members of diagnosed patients.
Vaccines. Currently available vaccines are not recommended for the control of cholera among refugee populations. The efficacy of these vaccines is low and the duration of protection provided is short. Vaccination campaigns divert funds and personnel from more important cholera control activities and give refugee and surrounding populations a false sense of security.