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Cholera: Gaps and Opportunities for Public Health Systems in Developing Countries. Gabriele Rossi, MPH student Walden University PH 6165-1 Instructor: Dr. Shana Morrell Summer Quarter, 2009. Cholera: a Gap Indicator for Public Health Systems.

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cholera gaps and opportunities for public health systems in developing countries
Cholera: Gaps and Opportunities for Public Health Systems in Developing Countries

Gabriele Rossi, MPH student

Walden University

PH 6165-1

Instructor: Dr. Shana Morrell

Summer Quarter, 2009

cholera a gap indicator for public health systems
Cholera: a Gap Indicator for Public Health Systems
  • During the 2008 cholera epidemic in Zimbabwe the Ministry of Health admitted the powerlessness of the national health system by stating “our central hospitals are literally not functioning” (BBC, 2008).

BBC. (2008). Zimbabwe cholera “an emergency”. Retrieved from: http://news.bbc.co.uk/2/hi/africa/7764200.stm

what is cholera
What is Cholera?
  • Cholera (caused by Vibrio cholera) affects public health resources around the globe.
  • Associated with watery stools, vomiting, and dehydration
  • Spread by contaminated drinking water or food and poor sanitation

Heymann, D.L. (2008). Control of communicable diseases manual. 19th edition. Washington, DC: American Public Health Association.

Snow, J. On the mode of communication of cholera. 2nd ed. London, England: Churchill, 1855. Reprinted as Snow J. Snow on cholera. New York, NY: Hafner Publishing Co; 1965.

history of cholera
History of Cholera
  • Six pandemics occurred between 1817 and 1923, the first of which started from the Gange delta and were caused by Vibrio cholerae O1, classic biotype
  • The ongoing 7th pandemic is caused by Vibrio cholerae O1, El Tor biotype, which started in Indonesia in 1961, gaining ground in Africa in 1970. Twenty years later it reached the Americas (Heymann, 2008)
  • Cholera has become endemic in many parts of the world

Heymann, D.L. (2008). Control of Communicable diseases manual. 19th edition. Washington, DC: American Public Health Association.

serotypes

Species

Vibrio Cholerae

Serogroup

O139 (Bengal)

in 1992

Serogroup

O1

Biotype

Classic

Biotypes

El Tor

(1961)

Serotype

Hikojima

Serotype

Ogawa

Serotype

Inaba

Serotypes

WHO. (2009). Cholera: prevention and control. Retrieved from: http://www.who.int/topics/cholera/control/en/index.html

features
Features
  • Clinical manifestation: watery stool and vomiting
  • Reservoir: mainly human beings
  • Environmental and seasonal factors: onset at the end of the dry season/beginning of the rainy season

Heymann, D.L. (2008). Control of Communicable diseases manual. 19th edition. Washington, DC: American Public Health Association.

risk factors and transmission
Risk Factors and Transmission
  • Poor social and economic environment, with precarious living conditions and high population density (Brown et al, 2002)
  • Person to person transmission
  • Contaminated food and water

Brown, V., Jacquier, G., Bachy, C., Bitar, D., & Legros, D. (2002). Management of cholera epidemics in a refugee camp. Bulletin de la Société de pathologie exotique, 95, 351-354.

Heymann, D.L. (2008). Control of Communicable diseases manual. 19th edition. Washington, DC: American Public Health Association.

insufficient response in many under developed countries naidoo patric 2002
Insufficient Response in Many Under-developed Countries (Naidoo & Patric, 2002)
  • Lack of knowledge and capability to adequately respond to an emergency situation
  • Lack of education and resilience by the population
  • Lack of coordination of the relief efforts
  • Lack of sustainability of these efforts, over time

Naidoo, A., & Patric, K. (2002). Cholera: a continuous epidemic in Africa. The Journal of the Royal Society for the Promotion of Health, 122, 89-94.

cholera preparedness
Cholera Preparedness
  • The country’s government and its Ministry of Health represent the key subjects to be empowered, in order to bring solutions to the cholera’s continuous epidemics outraging Africa and other very poor countries all over the world
solutions knowledge and prompt medical response during an outbreak
Solutions:Knowledge and Prompt Medical Response During an Outbreak.
  • Confirming the diagnosis by laboratory test (WHO, 2009) by
    • Confirming cholera by using 5 to 10 stool or vomit samples
    • Identify the strain
    • Assess antibiotic sensitivity

WHO. (2009). Cholera: prevention and control. Retrieved from: http://www.who.int/topics/cholera/control/en/index.html

outbreak investigation
Outbreak Investigation

Establishing and disseminating a case definition depends on the context…

  • Unknown in the area: severe dehydration or death from acute watery diarrhea in a patient aged 5 or more
  • Epidemic for cholera: acute watery diarrhea with or without vomiting in any patient
  • Endemic for cholera: acute watery diarrhea with or without vomiting in a patient aged 5 or more

WHO. (2009). Cholera: prevention and control. Retrieved from: http://www.who.int/topics/cholera/control/en/index.html

data collection
Data Collection
  • Describe the situation, by collecting data by person, time, and place
    • Calculation of incidence rate
    • Calculation of attack rate
    • Calculation of case fatality rate
  • Analyzing and interpret the data, for a meaningful action (WHO, 2009): distinguish between close (slum in the town) and open (rural area) settings where epidemics can take place

WHO. (2009). Cholera: prevention and control. Retrieved from: http://www.who.int/topics/cholera/control/en/index.html

solutions meaningful actions and intervention strategy who 2009
Solutions: Meaningful Actions and Intervention Strategy (WHO, 2009)
  • Reducing mortality
  • Ensuring effective sanitation
  • Reducing the epidemic spread

WHO. (2009). Cholera: prevention and control. Retrieved from: http://www.who.int/topics/cholera/control/en/index.html

reducing mortality
Reducing Mortality
  • Cholera is an emergency and is highly contagious
  • It is important to set up treatment centers, for the most severe cases to be isolated and treated (MSF, 2004)
  • Approach may be different, depending on the setting (urban vs rural) (Brown et al, 2002)

Brown, V., Jacquier, G., Bachy, C., Bitar, D., & Legros, D. (2002). Management of cholera epidemics in a refugee camp. Bulletin de la Société de pathologie exotique, 95, 351-354.

Medecins Sans Frontieres. (2004). Cholera Guidelines.

epidemiological calculation of expected number of patients based on different settings msf 2004
Epidemiological Calculation of Expected Number of Patients, Based on Different Settings (MSF, 2004)

Medecins Sans Frontieres. (2004). Cholera guidelines.

ensuring effective sanitation who 2009
Ensuring Effective Sanitation (WHO, 2009)
  • Excreta disposal
  • Waste Water
  • Vector control

WHO. (2009). Cholera: prevention and control. Retrieved from: http://www.who.int/topics/cholera/control/en/index.html

reducing the epidemic spread
Reducing the Epidemic Spread
  • Ensuring access to water: quantity and quality
  • Enabling hygienic conditions
  • Promoting hygienic practices

WHO. (2006). Guidelines for drinking-water quality, third edition, incorporating first and second addenda. Retrieved from: http://www.who.int/water_sanitation_health/dwq/gdwq3rev/en/index.html

slide18

Promoting Hygienic Practices(picture used with the permission from Oxfam. Retrieved from:http://www.un.org.np/ocha-situation-updates/2008/Oxfam%20Sitrep%20Saptari%2013Sept08.pdf)

  • Promoting hygienic practices
multisectoral approach
Multisectoral Approach
  • WHO (2009) called for a national, coordinated, multisectoral approach to efficiently control cholera outbreak, and to more effectively rationalize the international aids

WHO. (2009). Cholera: prevention and control. Retrieved from: http://www.who.int/topics/cholera/control/en/index.html

inter regional committees are needed
Inter-regional Committees Are Needed
  • To ensure a rapid and coordinated response to the regional cholera situation
  • To improve the procurement and distribution of cholera supplies at a regional level
  • To agree to standardized effective prevention and treatment policies

Naidoo, A., & Patric, K. (2002). Cholera: a continuous epidemic in Africa. The Journal of the Royal Society for the Promotion of Health, 122, 89-94.

inter regional coordination naidoo patric 2002

1.Form coordination

committee at

interregionallevel

2.Prioritize

areas of high

risk

3. Mobilize

resources

4. Treat

people

5. Improve

water

quality

6. Conduct

awareness

Programs (1 m)

Within 2 months from the outbreak:

7. Establish program to

improve water quality and

waste disposal systems

in high-risk areas

8. Conduct a health and

hygiene education

campaign

9. Iniziate

a transmission

control program

10. establish a

monitoring system

Inter-regional Coordination (Naidoo & Patric, 2002)
cholera an opportunity according to the ecological model naidoo patric 2002
Cholera: An Opportunity, According to the Ecological Model (Naidoo & Patric, 2002)
  • Improve regional dialogue
  • Improve education
  • Improve water system and sanitation

Naidoo, A., & Patric, K. (2002). Cholera: a continuous epidemic in Africa. The Journal of the Royal Society for the Promotion of Health, 122, 89-94.

for further reading
For Further Reading
  • BCC History – John Snow. Retrieved from: www.bbc.co.uk/history/historic...snow_john.shtml
  • Cholera: traking the first truly global disease. Retrieved from: news.nationalgeographic.com/.../0614_040614_tvcholera.html.
  • Chambers, K. (2009). Zimbabwe’s battle against cholera. Lancet, 373, 993-994.
  • Mathematical model predicts cholera outbreaks. Retrieved from:
  • www.sciencedaily.com/.../02/070218135349.htm.
  • Prevention and control of cholera outbreaks: WHO policy. Retrieved from: www.emro.who.int/CSR/Media/PDF/cholera_whopolicy.pdf.
  • Roberts, L., & Toole, M.J. (1995): Cholera deaths in Goma: Lancet, 346, 1431.
  • (Book) “Love in the Time of Cholera”, by Gabriel Garcia Marquez.
references
References

BBC. (2008). Zimbabwe cholera “an emergency”. Retrieved from: http://news.bbc.co.uk/2/hi/africa/7764200.stm

Brown, V., Jacquier, G., Bachy, C., Bitar, D., & Legros, D. (2002). Management of cholera

epidemics in a refugee camp. Bulletin de la Société de pathologie exotique, 95, 351-354.

Heymann, D.L. (2008). Control of Communicable diseases manual. 19th edition. Washington, DC: American Public Health Association.

Hunt, M.D., Woodward, W.E., Kewsick, B.H., & Dupont, H.L.(1988). Seroepidemiology of cholera

in Gulf coastal Texas. Applied and Environmental Microbiology, 54, 1673-1677.

Medecins Sans Frontieres. (2004). Cholera Guidelines.

Moeller, D. W. (2005). Environmental health (3rd ed.). Boston: Harvard University.

Naidoo, A., & Patric, K. (2002). Cholera: a continuous epidemic in Africa. The Journal of the Royal

Society for the Promotion of Health, 122, 89-94.

WHO. (2006). Guidelines for drinking-water quality, third edition, incorporating first and second

addenda. Retrieved from: http://www.who.int/water_sanitation_health/dwq/gdwq3rev/en/index.html

WHO. (2009). Cholera: prevention and control. Retrieved from: http://www.who.int/topics/cholera/control/en/index.html

the end
The End

Thanks!

Gabri