Cholera Treatment Centres Research Articles

Community Mortality from Cholera: Urban and Rural Districts in Zimbabwe

In 2008-2009, Zimbabwe experienced an unprecedented cholera outbreak with more than 4,000 deaths. More than 60% of deaths occurred at the community level. We conducted descriptive and case-control studies to describe community deaths. Cases were in cholera patients who died outside health facilities. Two surviving cholera patients were matched by age, time of symptom onset, and location to each case-patient. Proxies completed questionnaires regarding mortality risk factors. Cholera awareness and importance of rehydration was high but availability of oral rehydration salts was low. A total of 55 case-patients were matched to 110 controls. The odds of death were higher among males (adjusted odd ratio [AOR] = 5.00, 95% confidence interval [CI] = 1.54-14.30) and persons with larger household sizes (AOR = 1.21, 95% CI = 1.00-1.46). Receiving home-based rehydration (AOR = 0.21, 95% CI = 0.06-0.71) and visiting cholera treatment centers (CTCs) (AOR = 0.07, 95% CI = 0.02-0.23) were protective. Receiving cholera information was associated with home-based rehydration and visiting CTCs. When we compared cases and controls who did not go to CTCs, males were still at increased odds of death (AOR = 5.00, 95% CI = 1.56-16.10) and receiving home-based rehydration (AOR = 0.14, 95% CI = 0.04-0.53) and being married (AOR = 0.26, 95% CI = 0.08-0.83) were protective. Inability to receive home-based rehydration or visit CTCs was associated with mortality. Community education must reinforce the importance of prompt rehydration and CTC referral.

Cholera Epidemic in Guinea-Bissau (2008): The Importance of “Place”

BackgroundAs resources are limited when responding to cholera outbreaks, knowledge about where to orient interventions is crucial. We describe the cholera epidemic affecting Guinea-Bissau in 2008 focusing on the geographical spread in order to guide prevention and control activities.Methodology/Principal FindingsWe conducted two studies: 1) a descriptive analysis of the cholera epidemic in Guinea-Bissau focusing on its geographical spread (country level and within the capital); and 2) a cross-sectional study to measure the prevalence of houses with at least one cholera case in the most affected neighbourhood of the capital (Bairro Bandim) to detect clustering of households with cases (cluster analysis). All cholera cases attending the cholera treatment centres in Guinea-Bissau who fulfilled a modified World Health Organization clinical case definition during the epidemic were included in the descriptive study. For the cluster analysis, a sample of houses was selected from a satellite photo (Google Earth™); 140 houses (and the four closest houses) were assessed from the 2,202 identified structures. We applied K-functions and Kernel smoothing to detect clustering. We confirmed the clustering using Kulldorff's spatial scan statistic. A total of 14,222 cases and 225 deaths were reported in the country (AR = 0.94%, CFR = 1.64%). The more affected regions were Biombo, Bijagos and Bissau (the capital). Bairro Bandim was the most affected neighborhood of the capital (AR = 4.0). We found at least one case in 22.7% of the houses (95%CI: 19.5–26.2) in this neighborhood. The cluster analysis identified two areas within Bairro Bandim at highest risk: a market and an intersection where runoff accumulates waste (p<0.001).Conclusions/SignificanceOur analysis allowed for the identification of the most affected regions in Guinea-Bissau during the 2008 cholera outbreak, and the most affected areas within the capital. This information was essential for making decisions on where to reinforce treatment and to guide control and prevention activities.

(A165) Red Cross Health Erus, a Modular Approach to the Challenge of Evolving Emergencies

Emergency Response Units (ERUs) were pioneered over a decade ago by the International Federation of Red Cross and Red Crescent Societies (IFRC), with the intention of providing a standardized, rapid global tool for response in disasters. Health ERUs are one example of several types of ERUs on stand-by in various countries around the world. Their tented infrastructure, basic medical equipment, and pre-trained personnel allow for the provision of surge medical capacity where it is needed. Commonly used set-ups include a Basic Health Care Unit and a Referral Hospital. The recently-introduced Rapid Deployment Emergency Hospital allows for a lighter, highly mobile infrastructure, with surgical and emergency medical capacity. The modular design of these ERUs allows for deployment with materials “tailored” to the disaster. Their flexibility has been demonstrated in public health emergencies such as the nation-wide cholera epidemic that occurred in Zimbabwe (2008) and more recently in earthquake-damaged Haiti (2010) and flood-affected Pakistan (2010). Health ERUs already on the ground in post-earthquake Haiti were able to re-organize equipment for use in cholera treatment units and centers, and additional ERUs were deployed specifically to set-up treatment centers. In Pakistan, a mobile clinic set-up was used to deliver primary health services to displaced populations, including psychosocial support initiatives and community health messages to minimize the emergence of communicable diseases. The Community Health module (CHM) is a new module in development since 2009. Experience has shown that disrupted health systems, combined with displaced populations can create a fertile environment for communicable disease outbreaks. The CHM addresses primary, secondary and tertiary prevention early in emergencies by engaging communities and more specifically National Society volunteers in epidemic control. The modular design of Health ERUs allow for a rapid and comprehensive approach to delivery of health care in a disaster, with a longitudinal perspective of population needs.

Investigation of a Cholera Outbreak in Ethiopia's Oromiya Region

In late June 2006, Ethiopia's Oromiya Region was affected by an outbreak of acute watery diarrhea, subsequently confirmed to be caused by Vibrio cholerae O1, a pathogen not known to be endemic to this area. Despite initial control efforts, the outbreak quickly spread to neighboring zones and regions. The Oromiya Health Bureau required public health assistance to investigate the outbreak, determine potential causes, and assess the adequacy of the response, particularly given the concern that the number of cases being reported by health care personnel might represent only a fraction of what actually existed in the community. A physician-epidemiologist-led team assessed the Guji, Bale, and East Shewa zones from September 15 to October 9, 2006. By using a purposive sample, we surveyed health bureau staff and cholera treatment center (CTC) staff and community members, assessed CTC sites, and interviewed key personnel of the various organizations responding to the outbreak. The cholera cases mapped along the Ganale River. The individual attack rates were low (ranging from ~ 0.03% to ~ 4.12%), as was the overall attack rate for all 3 zones (almost 0.50%). The individual CTC case fatality rates ranged from 0% to 6.4%, and the overall case fatality rate was 1.11%. There was a trend toward men being disproportionately affected. This outbreak resulted primarily from poor sanitation and insufficient access to clean water. In Oromiya, the outbreak was addressed by a prompt and effective response, which included village chairmen at the community level. The use of community-based workers was successful and likely contributed significantly to control of the outbreak. Future epidemics will undoubtedly occur unless basic water and sanitation deficiencies are properly addressed. This outbreak prompts the need for increased local public health capacity to apply prevention strategies and establish ongoing surveillance. Signatories to the World Health Organization International Health Regulations must report outbreaks of nonendemic diseases.

Cholera in Mozambique, Variant ofVibrio cholerae

Cholera in Mozambique, Variant of<i>Vibrio cholerae</i>

Clinical Concerns About Reduced-Osmolarity Oral Rehydration Solution

Demonstration of the benefits of oral therapy for cholera in 1968 soon led to application of the method to all forms of infectious diarrheal diseases. The original oral rehydration solution (ORS) formulation developed by the World Health Organization (WHO) struck a compromise between the ideal solutions for these diverse disorders to meet the programmatic goal of a single formulation and packaging for global use in cholera and noncholera diarrheas in both adults and children. Recently WHO recommended a new oral solution for all acute diarrheas including cholera. This new formula would replace the original ORS which saved millions of lives with a new formulation containing less sodium and glucose. This change was ostensibly to reduce gross stool volume and use of unscheduled intravenous therapy by lowering solution osmolarity. However the reduced-osmolarity formulation is particularly unsuitable for universal use because it contains an amount of sodium insufficient to maintain sodium balance in cholera patients in whom its use induces negative sodium balance and may lead to hyponatremia polyuria and a small but clinically significant risk of neurologic complications. The new reduced-osmolarity formulation stretches the original compromise to the breaking point. It may be time to promote use of different solutions for patients with cholera beginning in controlled settings such as cholera treatment centers and hospitals. (authors)

Cholera prevention with traditional and novel water treatment methods: an outbreak investigation in Fort-Dauphin, Madagascar.

Cholera prevention with traditional and novel water treatment methods: an outbreak investigation in Fort-Dauphin, Madagascar.