W H O G L O B A L TA S K F O R C E O N C H O L E R A C O N T R O L

WHAT TO DO IF YOU SUSPECT AN OUTBREAK DON’T FORGET … THE FIRST TWO QUESTIONS ARE:
■ Inform and ask for help 1. Is this the beginning of an outbreak?

First steps
■ Protect the community 2. Is the patient suffering from cholera or shigella?
■ Treat the patients

1. Is this the beginning of an outbreak?

for managing
■ Inform and ask Check the supplies
PROTECT YOURSELF FROM CONTAMINATION Be
■ Wash your hands with soap before and after taking care of the patient prepared
for help
you have You might be facing an outbreak very soon if you have seen an
and record availab
le quantities ■ Cut your nails unusual number of acute diarrhoeal cases this week and the patients
The outbreak can evolve quickly ➥ IV fluids (Ringer Lac have the following points in common: to face a

an outbreak
tat e is the best)
and the rapid increase of cases ➥ Drips
ISOLATE CHOLERA PATIENTS
• they have similar clinical symptoms (watery or bloody diarrhoea) sudden
may prevent you from doing • they are living in the same area or location
your daily activities
➥ Nasogastric tubes
■ Stools, vomit and soiled clothes of patients are highly contagious • they have eaten the same food (at a burial ceremony for example) increase
➥ Oral Rehydration
• Inform your supervisor about the Salt (ORS)
■ Latrines and patients’ buckets need to be washed and disinfected with • they are sharing the same water source in number

of acute
➥ Antibiotics (see Tab • there is an outbreak in the neighbouring community
situation
➥ Soap
le 2) chlorine
or
of cases
• Ask for more supplies if needed ■ Cholera patients have to be in a special ward, isolated from other patients
➥ Chlorine or bleach You have seen an adult suffering from acute watery diarrhoea with
(see Box) ing powder
➥ Rectal swabs and severe dehydration and vomiting

diarrhoea
• Ask for help to control the transport medium
(Cary Blair or TCBS) for CONTINUOUS PROVISION OF NUTRITIOUS FOOD is important for all patients, If you have some statistical information from previous years or weeks verify if the actual
outbreak among and outside the stool especially for those with shigella dysentery
samples increase of cases is unusual over the same period of time.
community
➥ Safe water is need
ed to rehydrate ■ Provide frequent small meals with familiar foods during the first two days
patients and to wash rather than infrequent large meals
instruments
clothes and
■ Provide food as soon as the patient is able to take it
2. Is the patient suffering from cholera or shigella?
THIS LEAFLET AIMS AT GUIDING YOU THROUGH Acute diarrhoea could be a common symptom. Therefore it is important to differentiate
■ Breastfeeding of infants and young children should continue between shigella or cholera in order to improve case management and to estimate
THE VERY FIRST DAYS OF AN OUTBREAK needed supplies
• Establish a clinical diagnosis for the patient
Collect data on the patients you have seen (Table1) TABLE 1
Note carefully the following data that will help to investigate the outbreak • Do the same for the other family members Symptoms Cholera = Shigella =
Two types of emergencies regarding acute diarrhoea exist: acute watery acute bloody
who are suffering from acute diarrhoea
N° Name Address Symptoms Age Sex Date Outcome diarrhoea diarrhoea
Cholera = acute watery diarrhoea
(<5 or (male M) or of onset For more information: cholera@who.int • Try to take stool samples and send them Stool > 3 loose > 3 loose
>5 years) (female F) and for immediate analysis. If it is not possible stools per day, stools per day,
http://www.who.int/cholera to send the samples immediately, collect watery like with blood
Shigella dysentery = acute bloody diarrhoea rice water or pus
© World Health Organization 2010 All rights reserved stool specimens in Cary Blair or TCBS
Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva Both are transmitted by contaminated water, unsafe food, Fever No Yes
27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate
transport medium and refrigerate.
WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 dirty hands and vomit or stools of sick people. Abdominal
791 4806; e-mail: permissions@who.int). Don’t wait for laboratory results to start cramps Yes Yes
The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the Other causes of diarrhoea may produce severe illness treatment and to protect the community. Vomiting Yes a lot No
World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of
proprietary products are distinguished by initial capital letters. for the patient, but will not produce outbreaks which Not all the cases need to be laboratory Rectal pain No Yes
All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However,
represent an immediate threat to the community. confirmed.
the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation
and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.
WHO/CDS/CSR/NCS/2003.7 Rev.2

WHO • GLOBAL TASK FORCE ON CHOLERA CONTROL WHO • GLOBAL TASK FORCE ON CHOLERA CONTROL WHO • GLOBAL TASK FORCE ON CHOLERA CONTROL
 W H O G L O B A L TA S K F O R C E O N C H O L E R A C O N T R O L
WHAT TO DO IF YOU SUSPECT AN OUTBREAK DON’T FORGET … THE FIRST TWO QUESTIONS ARE:
■ Inform and ask for help 1. Is this the beginning of an outbreak?

First steps
■ Protect the community 2. Is the patient suffering from cholera or shigella?
■ Treat the patients

1. Is this the beginning of an outbreak?

for managing
■ Inform and ask Check the supplies
PROTECT YOURSELF FROM CONTAMINATION Be
■ Wash your hands with soap before and after taking care of the patient prepared
for help
you have You might be facing an outbreak very soon if you have seen an
and record availab
le quantities ■ Cut your nails unusual number of acute diarrhoeal cases this week and the patients
The outbreak can evolve quickly ➥ IV fluids (Ringer Lac have the following points in common: to face a

an outbreak
tat e is the best)
and the rapid increase of cases ➥ Drips
ISOLATE CHOLERA PATIENTS
• they have similar clinical symptoms (watery or bloody diarrhoea) sudden
may prevent you from doing • they are living in the same area or location
your daily activities
➥ Nasogastric tubes
■ Stools, vomit and soiled clothes of patients are highly contagious • they have eaten the same food (at a burial ceremony for example) increase
➥ Oral Rehydration
• Inform your supervisor about the Salt (ORS)
■ Latrines and patients’ buckets need to be washed and disinfected with • they are sharing the same water source in number

of acute
➥ Antibiotics (see Tab • there is an outbreak in the neighbouring community
situation
➥ Soap
le 2) chlorine
or
of cases
• Ask for more supplies if needed ■ Cholera patients have to be in a special ward, isolated from other patients
➥ Chlorine or bleach You have seen an adult suffering from acute watery diarrhoea with
(see Box) ing powder
➥ Rectal swabs and severe dehydration and vomiting

diarrhoea
• Ask for help to control the transport medium
(Cary Blair or TCBS) for CONTINUOUS PROVISION OF NUTRITIOUS FOOD is important for all patients, If you have some statistical information from previous years or weeks verify if the actual
outbreak among and outside the stool especially for those with shigella dysentery
samples increase of cases is unusual over the same period of time.
community
➥ Safe water is need
ed to rehydrate ■ Provide frequent small meals with familiar foods during the first two days
patients and to wash rather than infrequent large meals
instruments
clothes and
■ Provide food as soon as the patient is able to take it
2. Is the patient suffering from cholera or shigella?
THIS LEAFLET AIMS AT GUIDING YOU THROUGH Acute diarrhoea could be a common symptom. Therefore it is important to differentiate
■ Breastfeeding of infants and young children should continue between shigella or cholera in order to improve case management and to estimate
THE VERY FIRST DAYS OF AN OUTBREAK needed supplies
• Establish a clinical diagnosis for the patient
Collect data on the patients you have seen (Table1) TABLE 1
Note carefully the following data that will help to investigate the outbreak • Do the same for the other family members Symptoms Cholera = Shigella =
Two types of emergencies regarding acute diarrhoea exist: acute watery acute bloody
who are suffering from acute diarrhoea
N° Name Address Symptoms Age Sex Date Outcome diarrhoea diarrhoea
Cholera = acute watery diarrhoea
(<5 or (male M) or of onset For more information: cholera@who.int • Try to take stool samples and send them Stool > 3 loose > 3 loose
>5 years) (female F) and for immediate analysis. If it is not possible stools per day, stools per day,
http://www.who.int/cholera to send the samples immediately, collect watery like with blood
Shigella dysentery = acute bloody diarrhoea rice water or pus
© World Health Organization 2010 All rights reserved stool specimens in Cary Blair or TCBS
Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva Both are transmitted by contaminated water, unsafe food, Fever No Yes
27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate
transport medium and refrigerate.
WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 dirty hands and vomit or stools of sick people. Abdominal
791 4806; e-mail: permissions@who.int). Don’t wait for laboratory results to start cramps Yes Yes
The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the Other causes of diarrhoea may produce severe illness treatment and to protect the community. Vomiting Yes a lot No
World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of
proprietary products are distinguished by initial capital letters. for the patient, but will not produce outbreaks which Not all the cases need to be laboratory Rectal pain No Yes
All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However,
represent an immediate threat to the community. confirmed.
the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation
and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.
WHO/CDS/CSR/NCS/2003.7 Rev.2

WHO • GLOBAL TASK FORCE ON CHOLERA CONTROL WHO • GLOBAL TASK FORCE ON CHOLERA CONTROL WHO • GLOBAL TASK FORCE ON CHOLERA CONTROL
■ Protect the community ■ Treat the patients B. Maintain hydration and monitor the patient
Summary of the treatment
80% of the cases can be treated using only Reassess the patient for signs of dehydration regularly during the first six hours:

A. Rehydrate with ORS or IV solution depending on the severity Oral Rehydration Salt (ORS) • Number and quantity of stools and vomit in order to compensate for the loss of body fluids
• Radial pulse: if it remains weak, IV rehydration has to be continued.
B. Maintain hydration and monitor frequently the hydration status
C. Give antibiotics for severe cholera cases and for shigella cases

HOW TO PROTECT THE COMMUNITY
■ Isolate the severe cases
■ Provide information
— on how to avoid cholera through
simple messages
— on the outbreak
■ Disinfect water sources with chlorine
■ Promote water disinfection at home
GIVE SIMPLE MESSAGES
TO THE COMMUNITY
To avoid cholera and shigella
■ Wash your hands with soap
— after using toilets and latrines
— before preparing food
— before eating
■ Boil or disinfect the water with
A. Rehydrate depending on severity C. Give antibiotics if needed
BOX 2. THERE IS NO SIGN OF DEHYDRATION
Is the patient dehydrated? When there is NO sign of dehydration: give ORS solution (see Box 1) When is it useful to give antibiotics?
• The patient is losing a lot of fluids because of
diarrhoea and vomiting.
after each stool ➥ For cholera cases with severe dehydration only.
• Does he have two or more of the following signs? • Child less than 2 years old: 50–100 ml (1/4–1/2 cup) ➥ Ideally for all of Shigella dysenteriae cases, but as a priority for the most
ORS solution. Up to approximately 1/2 litre a day.
The lack of water in his body results in: vulnerable patients: children under five, elderly, malnourished, patients
— sunken eyes with convulsions.
• Child between 2 and 9 years old: 100–200 ml.
— absence of tears If NO Up to approximately 1 litre a day.
— dry mouth and tongue THEN
There is NO dehydration:

▲
▲
— the patient is thirsty and drinks eagerly • Patient of 10 years of age or more as much as
chlorine solution Give Oral Rehydration
using chlorine — the skin pinch goes back slowly Salt (Box 2) wanted, up to approximately 2 litres a day.
TABLE 2. WHICH ANTIBIOTICS CAN BE GIVEN?
■ Avoid gatherings ■ Only eat freshly cooked food
Stool and vomit are highly ■ Do not defecate near the water ▲ Cholera

contagious sources
BOX 3. THERE IS SOME SIGN OF DEHYDRATION Doxycycline single dose 300 mg
■ Use latrines and keep them clean If YES, check if the dehydration is very severe
Approximate amount of ORS solution to give in the first 4 hours or tetracycline 12,5 mg/kg 4 time/day for 3 days
If NO
PRECAUTIONS FOR FUNERALS In case of acute diarrhoea Is the dehydration very severe? THEN There is some dehydration: Age Less than 4–11 12–23 2–4 5–14 15 years Young children: erythromycin 12,5 mg/kg 4 time/day for 3 days

▲
4 months months months years years or older

▲
When dehydration is very severe in addition to the • Give Oral Rehydration Salt
■ Disinfect corpses with chlorine ■ Start oral rehydration with ORS • for children below 6 months of age: 10 mg daily for 10 days
above mentioned signs: in the amount Weight Less than 5–7.9 kg 8–10.9 kg 11–15.9 kg 16–29.9 kg 30 kg add zinc
solution (2%) (see Boxes 1 and 2) before going to recommended in Box 3 5 kg or more
• The patient is lethargic, unconscious or floppy • for children 6 months to 5 years of age: 20mg daily for 10 days
the health centre • Nasogastric tubes can be
■ Fill mouth and anus with cotton • He is unable to drink
ORS solution in ml 200–400 400–600 600–800 800–1200 1200–2200 2200–4000
add zinc

wool soaked with chlorine solution ■ Go to the health centre as soon • His radial pulse is weak used for rehydration when
• The skin pinch goes back very slowly ORS solution increases Note : There is an increasing resistance to doxycycline, tetracycline and TMP-SMX.
as possible
■ Wash hands with soap after vomiting and nausea or
touching the corpse when the patient cannot
Shigella
drink
■ Disinfect the clothing BOX 1. HOW TO PREPARE HOME-MADE ORS SOLUTION
• Monitor the patient
BOX 4. THERE IS SEVERE DEHYDRATION
and bedding of the frequently Give IV drips of Ringer Lactate or if not available
Adults : ciprofloxacin 500 mg twice a day for 3 days
• If ORS sachets are available: dilute one sachet in one
deceased by stirring cholera saline (or normal saline)
litre of safe water Enfant : ciprofloxacin 250 mg/15 kg twice a day for 3 days
them in boiling water
• Otherwise: Add to one litre of safe water: • 100 ml/kg in three-hour period • for children below 6 months of age: 10 mg daily for 10 days
or by drying them If YES THEN

▲
There is severe dehydration (in 6 hours for children aged less than 1 year) add zinc
thoroughly in the sun — Salt 1/2 small spoon (2.5 grams)
• Put an IV drip to start intravenous rehydration • Start rapidly (30ml/kg within 30 min) and then • for children 6 months to 5 years of age: 20 mg daily for 10 days
— Sugar 6 small spoons (30 grams) slow down. add zinc
• In case this is not possible, rehydrate with ORS
And try to compensate for loss of potassium • In any case, refer the patient to the higher level and rehydrate as Total amount per day: 200 ml/kg during the first Note : Rapidly evolving antimicrobial resistance is a real problem.
(for example, eat bananas or drink green coconut water) shown in Box 4 24 hours Shigella is usually resistant to ampicillin and TMP-SMX.

WHO • GLOBAL TASK FORCE ON CHOLERA CONTROL WHO • GLOBAL TASK FORCE ON CHOLERA CONTROL WHO • GLOBAL TASK FORCE ON CHOLERA CONTROL WHO • GLOBAL TASK FORCE ON CHOLERA CONTROL
■ Protect the community ■ Treat the patients B. Maintain hydration and monitor the patient
Summary of the treatment
80% of the cases can be treated using only Reassess the patient for signs of dehydration regularly during the first six hours:

A. Rehydrate with ORS or IV solution depending on the severity Oral Rehydration Salt (ORS) • Number and quantity of stools and vomit in order to compensate for the loss of body fluids
• Radial pulse: if it remains weak, IV rehydration has to be continued.
B. Maintain hydration and monitor frequently the hydration status
C. Give antibiotics for severe cholera cases and for shigella cases

HOW TO PROTECT THE COMMUNITY
■ Isolate the severe cases
■ Provide information
— on how to avoid cholera through
simple messages
— on the outbreak
■ Disinfect water sources with chlorine
■ Promote water disinfection at home
GIVE SIMPLE MESSAGES
TO THE COMMUNITY
To avoid cholera and shigella
■ Wash your hands with soap
— after using toilets and latrines
— before preparing food
— before eating
■ Boil or disinfect the water with
A. Rehydrate depending on severity C. Give antibiotics if needed
BOX 2. THERE IS NO SIGN OF DEHYDRATION
Is the patient dehydrated? When there is NO sign of dehydration: give ORS solution (see Box 1) When is it useful to give antibiotics?
• The patient is losing a lot of fluids because of
diarrhoea and vomiting.
after each stool ➥ For cholera cases with severe dehydration only.
• Does he have two or more of the following signs? • Child less than 2 years old: 50–100 ml (1/4–1/2 cup) ➥ Ideally for all of Shigella dysenteriae cases, but as a priority for the most
ORS solution. Up to approximately 1/2 litre a day.
The lack of water in his body results in: vulnerable patients: children under five, elderly, malnourished, patients
— sunken eyes with convulsions.
• Child between 2 and 9 years old: 100–200 ml.
— absence of tears If NO Up to approximately 1 litre a day.
— dry mouth and tongue THEN
There is NO dehydration:

▲
▲
— the patient is thirsty and drinks eagerly • Patient of 10 years of age or more as much as
chlorine solution Give Oral Rehydration
using chlorine — the skin pinch goes back slowly Salt (Box 2) wanted, up to approximately 2 litres a day.
TABLE 2. WHICH ANTIBIOTICS CAN BE GIVEN?
■ Avoid gatherings ■ Only eat freshly cooked food
Stool and vomit are highly ■ Do not defecate near the water ▲ Cholera

contagious sources
BOX 3. THERE IS SOME SIGN OF DEHYDRATION Doxycycline single dose 300 mg
■ Use latrines and keep them clean If YES, check if the dehydration is very severe
Approximate amount of ORS solution to give in the first 4 hours or tetracycline 12,5 mg/kg 4 time/day for 3 days
If NO
PRECAUTIONS FOR FUNERALS In case of acute diarrhoea Is the dehydration very severe? THEN There is some dehydration: Age Less than 4–11 12–23 2–4 5–14 15 years Young children: erythromycin 12,5 mg/kg 4 time/day for 3 days

▲
4 months months months years years or older

▲
When dehydration is very severe in addition to the • Give Oral Rehydration Salt
■ Disinfect corpses with chlorine ■ Start oral rehydration with ORS • for children below 6 months of age: 10 mg daily for 10 days
above mentioned signs: in the amount Weight Less than 5–7.9 kg 8–10.9 kg 11–15.9 kg 16–29.9 kg 30 kg add zinc
solution (2%) (see Boxes 1 and 2) before going to recommended in Box 3 5 kg or more
• The patient is lethargic, unconscious or floppy • for children 6 months to 5 years of age: 20mg daily for 10 days
the health centre • Nasogastric tubes can be
■ Fill mouth and anus with cotton • He is unable to drink
ORS solution in ml 200–400 400–600 600–800 800–1200 1200–2200 2200–4000
add zinc

wool soaked with chlorine solution ■ Go to the health centre as soon • His radial pulse is weak used for rehydration when
• The skin pinch goes back very slowly ORS solution increases Note : There is an increasing resistance to doxycycline, tetracycline and TMP-SMX.
as possible
■ Wash hands with soap after vomiting and nausea or
touching the corpse when the patient cannot
Shigella
drink
■ Disinfect the clothing BOX 1. HOW TO PREPARE HOME-MADE ORS SOLUTION
• Monitor the patient
BOX 4. THERE IS SEVERE DEHYDRATION
and bedding of the frequently Give IV drips of Ringer Lactate or if not available
Adults : ciprofloxacin 500 mg twice a day for 3 days
• If ORS sachets are available: dilute one sachet in one
deceased by stirring cholera saline (or normal saline)
litre of safe water Enfant : ciprofloxacin 250 mg/15 kg twice a day for 3 days
them in boiling water
• Otherwise: Add to one litre of safe water: • 100 ml/kg in three-hour period • for children below 6 months of age: 10 mg daily for 10 days
or by drying them If YES THEN

▲
There is severe dehydration (in 6 hours for children aged less than 1 year) add zinc
thoroughly in the sun — Salt 1/2 small spoon (2.5 grams)
• Put an IV drip to start intravenous rehydration • Start rapidly (30ml/kg within 30 min) and then • for children 6 months to 5 years of age: 20 mg daily for 10 days
— Sugar 6 small spoons (30 grams) slow down. add zinc
• In case this is not possible, rehydrate with ORS
And try to compensate for loss of potassium • In any case, refer the patient to the higher level and rehydrate as Total amount per day: 200 ml/kg during the first Note : Rapidly evolving antimicrobial resistance is a real problem.
(for example, eat bananas or drink green coconut water) shown in Box 4 24 hours Shigella is usually resistant to ampicillin and TMP-SMX.

WHO • GLOBAL TASK FORCE ON CHOLERA CONTROL WHO • GLOBAL TASK FORCE ON CHOLERA CONTROL WHO • GLOBAL TASK FORCE ON CHOLERA CONTROL WHO • GLOBAL TASK FORCE ON CHOLERA CONTROL
■ Protect the community ■ Treat the patients B. Maintain hydration and monitor the patient
Summary of the treatment
80% of the cases can be treated using only Reassess the patient for signs of dehydration regularly during the first six hours:

A. Rehydrate with ORS or IV solution depending on the severity Oral Rehydration Salt (ORS) • Number and quantity of stools and vomit in order to compensate for the loss of body fluids
• Radial pulse: if it remains weak, IV rehydration has to be continued.
B. Maintain hydration and monitor frequently the hydration status
C. Give antibiotics for severe cholera cases and for shigella cases

HOW TO PROTECT THE COMMUNITY
■ Isolate the severe cases
■ Provide information
— on how to avoid cholera through
simple messages
— on the outbreak
■ Disinfect water sources with chlorine
■ Promote water disinfection at home
GIVE SIMPLE MESSAGES
TO THE COMMUNITY
To avoid cholera and shigella
■ Wash your hands with soap
— after using toilets and latrines
— before preparing food
— before eating
■ Boil or disinfect the water with
A. Rehydrate depending on severity C. Give antibiotics if needed
BOX 2. THERE IS NO SIGN OF DEHYDRATION
Is the patient dehydrated? When there is NO sign of dehydration: give ORS solution (see Box 1) When is it useful to give antibiotics?
• The patient is losing a lot of fluids because of
diarrhoea and vomiting.
after each stool ➥ For cholera cases with severe dehydration only.
• Does he have two or more of the following signs? • Child less than 2 years old: 50–100 ml (1/4–1/2 cup) ➥ Ideally for all of Shigella dysenteriae cases, but as a priority for the most
ORS solution. Up to approximately 1/2 litre a day.
The lack of water in his body results in: vulnerable patients: children under five, elderly, malnourished, patients
— sunken eyes with convulsions.
• Child between 2 and 9 years old: 100–200 ml.
— absence of tears If NO Up to approximately 1 litre a day.
— dry mouth and tongue THEN
There is NO dehydration:

▲
▲
— the patient is thirsty and drinks eagerly • Patient of 10 years of age or more as much as
chlorine solution Give Oral Rehydration
using chlorine — the skin pinch goes back slowly Salt (Box 2) wanted, up to approximately 2 litres a day.
TABLE 2. WHICH ANTIBIOTICS CAN BE GIVEN?
■ Avoid gatherings ■ Only eat freshly cooked food
Stool and vomit are highly ■ Do not defecate near the water ▲ Cholera

contagious sources
BOX 3. THERE IS SOME SIGN OF DEHYDRATION Doxycycline single dose 300 mg
■ Use latrines and keep them clean If YES, check if the dehydration is very severe
Approximate amount of ORS solution to give in the first 4 hours or tetracycline 12,5 mg/kg 4 time/day for 3 days
If NO
PRECAUTIONS FOR FUNERALS In case of acute diarrhoea Is the dehydration very severe? THEN There is some dehydration: Age Less than 4–11 12–23 2–4 5–14 15 years Young children: erythromycin 12,5 mg/kg 4 time/day for 3 days

▲
4 months months months years years or older

▲
When dehydration is very severe in addition to the • Give Oral Rehydration Salt
■ Disinfect corpses with chlorine ■ Start oral rehydration with ORS • for children below 6 months of age: 10 mg daily for 10 days
above mentioned signs: in the amount Weight Less than 5–7.9 kg 8–10.9 kg 11–15.9 kg 16–29.9 kg 30 kg add zinc
solution (2%) (see Boxes 1 and 2) before going to recommended in Box 3 5 kg or more
• The patient is lethargic, unconscious or floppy • for children 6 months to 5 years of age: 20mg daily for 10 days
the health centre • Nasogastric tubes can be
■ Fill mouth and anus with cotton • He is unable to drink
ORS solution in ml 200–400 400–600 600–800 800–1200 1200–2200 2200–4000
add zinc

wool soaked with chlorine solution ■ Go to the health centre as soon • His radial pulse is weak used for rehydration when
• The skin pinch goes back very slowly ORS solution increases Note : There is an increasing resistance to doxycycline, tetracycline and TMP-SMX.
as possible
■ Wash hands with soap after vomiting and nausea or
touching the corpse when the patient cannot
Shigella
drink
■ Disinfect the clothing BOX 1. HOW TO PREPARE HOME-MADE ORS SOLUTION
• Monitor the patient
BOX 4. THERE IS SEVERE DEHYDRATION
and bedding of the frequently Give IV drips of Ringer Lactate or if not available
Adults : ciprofloxacin 500 mg twice a day for 3 days
• If ORS sachets are available: dilute one sachet in one
deceased by stirring cholera saline (or normal saline)
litre of safe water Enfant : ciprofloxacin 250 mg/15 kg twice a day for 3 days
them in boiling water
• Otherwise: Add to one litre of safe water: • 100 ml/kg in three-hour period • for children below 6 months of age: 10 mg daily for 10 days
or by drying them If YES THEN

▲
There is severe dehydration (in 6 hours for children aged less than 1 year) add zinc
thoroughly in the sun — Salt 1/2 small spoon (2.5 grams)
• Put an IV drip to start intravenous rehydration • Start rapidly (30ml/kg within 30 min) and then • for children 6 months to 5 years of age: 20 mg daily for 10 days
— Sugar 6 small spoons (30 grams) slow down. add zinc
• In case this is not possible, rehydrate with ORS
And try to compensate for loss of potassium • In any case, refer the patient to the higher level and rehydrate as Total amount per day: 200 ml/kg during the first Note : Rapidly evolving antimicrobial resistance is a real problem.
(for example, eat bananas or drink green coconut water) shown in Box 4 24 hours Shigella is usually resistant to ampicillin and TMP-SMX.

WHO • GLOBAL TASK FORCE ON CHOLERA CONTROL WHO • GLOBAL TASK FORCE ON CHOLERA CONTROL WHO • GLOBAL TASK FORCE ON CHOLERA CONTROL WHO • GLOBAL TASK FORCE ON CHOLERA CONTROL
■ Protect the community ■ Treat the patients B. Maintain hydration and monitor the patient
Summary of the treatment
80% of the cases can be treated using only Reassess the patient for signs of dehydration regularly during the first six hours:

A. Rehydrate with ORS or IV solution depending on the severity Oral Rehydration Salt (ORS) • Number and quantity of stools and vomit in order to compensate for the loss of body fluids
• Radial pulse: if it remains weak, IV rehydration has to be continued.
B. Maintain hydration and monitor frequently the hydration status
C. Give antibiotics for severe cholera cases and for shigella cases

HOW TO PROTECT THE COMMUNITY
■ Isolate the severe cases
■ Provide information
— on how to avoid cholera through
simple messages
— on the outbreak
■ Disinfect water sources with chlorine
■ Promote water disinfection at home
GIVE SIMPLE MESSAGES
TO THE COMMUNITY
To avoid cholera and shigella
■ Wash your hands with soap
— after using toilets and latrines
— before preparing food
— before eating
■ Boil or disinfect the water with
A. Rehydrate depending on severity C. Give antibiotics if needed
BOX 2. THERE IS NO SIGN OF DEHYDRATION
Is the patient dehydrated? When there is NO sign of dehydration: give ORS solution (see Box 1) When is it useful to give antibiotics?
• The patient is losing a lot of fluids because of
diarrhoea and vomiting.
after each stool ➥ For cholera cases with severe dehydration only.
• Does he have two or more of the following signs? • Child less than 2 years old: 50–100 ml (1/4–1/2 cup) ➥ Ideally for all of Shigella dysenteriae cases, but as a priority for the most
ORS solution. Up to approximately 1/2 litre a day.
The lack of water in his body results in: vulnerable patients: children under five, elderly, malnourished, patients
— sunken eyes with convulsions.
• Child between 2 and 9 years old: 100–200 ml.
— absence of tears If NO Up to approximately 1 litre a day.
— dry mouth and tongue THEN
There is NO dehydration:

▲
▲
— the patient is thirsty and drinks eagerly • Patient of 10 years of age or more as much as
chlorine solution Give Oral Rehydration
using chlorine — the skin pinch goes back slowly Salt (Box 2) wanted, up to approximately 2 litres a day.
TABLE 2. WHICH ANTIBIOTICS CAN BE GIVEN?
■ Avoid gatherings ■ Only eat freshly cooked food
Stool and vomit are highly ■ Do not defecate near the water ▲ Cholera

contagious sources
BOX 3. THERE IS SOME SIGN OF DEHYDRATION Doxycycline single dose 300 mg
■ Use latrines and keep them clean If YES, check if the dehydration is very severe
Approximate amount of ORS solution to give in the first 4 hours or tetracycline 12,5 mg/kg 4 time/day for 3 days
If NO
PRECAUTIONS FOR FUNERALS In case of acute diarrhoea Is the dehydration very severe? THEN There is some dehydration: Age Less than 4–11 12–23 2–4 5–14 15 years Young children: erythromycin 12,5 mg/kg 4 time/day for 3 days

▲
4 months months months years years or older

▲
When dehydration is very severe in addition to the • Give Oral Rehydration Salt
■ Disinfect corpses with chlorine ■ Start oral rehydration with ORS • for children below 6 months of age: 10 mg daily for 10 days
above mentioned signs: in the amount Weight Less than 5–7.9 kg 8–10.9 kg 11–15.9 kg 16–29.9 kg 30 kg add zinc
solution (2%) (see Boxes 1 and 2) before going to recommended in Box 3 5 kg or more
• The patient is lethargic, unconscious or floppy • for children 6 months to 5 years of age: 20mg daily for 10 days
the health centre • Nasogastric tubes can be
■ Fill mouth and anus with cotton • He is unable to drink
ORS solution in ml 200–400 400–600 600–800 800–1200 1200–2200 2200–4000
add zinc

wool soaked with chlorine solution ■ Go to the health centre as soon • His radial pulse is weak used for rehydration when
• The skin pinch goes back very slowly ORS solution increases Note : There is an increasing resistance to doxycycline, tetracycline and TMP-SMX.
as possible
■ Wash hands with soap after vomiting and nausea or
touching the corpse when the patient cannot
Shigella
drink
■ Disinfect the clothing BOX 1. HOW TO PREPARE HOME-MADE ORS SOLUTION
• Monitor the patient
BOX 4. THERE IS SEVERE DEHYDRATION
and bedding of the frequently Give IV drips of Ringer Lactate or if not available
Adults : ciprofloxacin 500 mg twice a day for 3 days
• If ORS sachets are available: dilute one sachet in one
deceased by stirring cholera saline (or normal saline)
litre of safe water Enfant : ciprofloxacin 250 mg/15 kg twice a day for 3 days
them in boiling water
• Otherwise: Add to one litre of safe water: • 100 ml/kg in three-hour period • for children below 6 months of age: 10 mg daily for 10 days
or by drying them If YES THEN

▲
There is severe dehydration (in 6 hours for children aged less than 1 year) add zinc
thoroughly in the sun — Salt 1/2 small spoon (2.5 grams)
• Put an IV drip to start intravenous rehydration • Start rapidly (30ml/kg within 30 min) and then • for children 6 months to 5 years of age: 20 mg daily for 10 days
— Sugar 6 small spoons (30 grams) slow down. add zinc
• In case this is not possible, rehydrate with ORS
And try to compensate for loss of potassium • In any case, refer the patient to the higher level and rehydrate as Total amount per day: 200 ml/kg during the first Note : Rapidly evolving antimicrobial resistance is a real problem.
(for example, eat bananas or drink green coconut water) shown in Box 4 24 hours Shigella is usually resistant to ampicillin and TMP-SMX.

WHO • GLOBAL TASK FORCE ON CHOLERA CONTROL WHO • GLOBAL TASK FORCE ON CHOLERA CONTROL WHO • GLOBAL TASK FORCE ON CHOLERA CONTROL WHO • GLOBAL TASK FORCE ON CHOLERA CONTROL
 W H O G L O B A L TA S K F O R C E O N C H O L E R A C O N T R O L
WHAT TO DO IF YOU SUSPECT AN OUTBREAK DON’T FORGET … THE FIRST TWO QUESTIONS ARE:
■ Inform and ask for help 1. Is this the beginning of an outbreak?

First steps
■ Protect the community 2. Is the patient suffering from cholera or shigella?
■ Treat the patients

1. Is this the beginning of an outbreak?

for managing
■ Inform and ask Check the supplies
PROTECT YOURSELF FROM CONTAMINATION Be
■ Wash your hands with soap before and after taking care of the patient prepared
for help
you have You might be facing an outbreak very soon if you have seen an
and record availab
le quantities ■ Cut your nails unusual number of acute diarrhoeal cases this week and the patients
The outbreak can evolve quickly ➥ IV fluids (Ringer Lac have the following points in common: to face a

an outbreak
tat e is the best)
and the rapid increase of cases ➥ Drips
ISOLATE CHOLERA PATIENTS
• they have similar clinical symptoms (watery or bloody diarrhoea) sudden
may prevent you from doing • they are living in the same area or location
your daily activities
➥ Nasogastric tubes
■ Stools, vomit and soiled clothes of patients are highly contagious • they have eaten the same food (at a burial ceremony for example) increase
➥ Oral Rehydration
• Inform your supervisor about the Salt (ORS)
■ Latrines and patients’ buckets need to be washed and disinfected with • they are sharing the same water source in number

of acute
➥ Antibiotics (see Tab • there is an outbreak in the neighbouring community
situation
➥ Soap
le 2) chlorine
or
of cases
• Ask for more supplies if needed ■ Cholera patients have to be in a special ward, isolated from other patients
➥ Chlorine or bleach You have seen an adult suffering from acute watery diarrhoea with
(see Box) ing powder
➥ Rectal swabs and severe dehydration and vomiting

diarrhoea
• Ask for help to control the transport medium
(Cary Blair or TCBS) for CONTINUOUS PROVISION OF NUTRITIOUS FOOD is important for all patients, If you have some statistical information from previous years or weeks verify if the actual
outbreak among and outside the stool especially for those with shigella dysentery
samples increase of cases is unusual over the same period of time.
community
➥ Safe water is need
ed to rehydrate ■ Provide frequent small meals with familiar foods during the first two days
patients and to wash rather than infrequent large meals
instruments
clothes and
■ Provide food as soon as the patient is able to take it
2. Is the patient suffering from cholera or shigella?
THIS LEAFLET AIMS AT GUIDING YOU THROUGH Acute diarrhoea could be a common symptom. Therefore it is important to differentiate
■ Breastfeeding of infants and young children should continue between shigella or cholera in order to improve case management and to estimate
THE VERY FIRST DAYS OF AN OUTBREAK needed supplies
• Establish a clinical diagnosis for the patient
Collect data on the patients you have seen (Table1) TABLE 1
Note carefully the following data that will help to investigate the outbreak • Do the same for the other family members Symptoms Cholera = Shigella =
Two types of emergencies regarding acute diarrhoea exist: acute watery acute bloody
who are suffering from acute diarrhoea
N° Name Address Symptoms Age Sex Date Outcome diarrhoea diarrhoea
Cholera = acute watery diarrhoea
(<5 or (male M) or of onset For more information: cholera@who.int • Try to take stool samples and send them Stool > 3 loose > 3 loose
>5 years) (female F) and for immediate analysis. If it is not possible stools per day, stools per day,
http://www.who.int/cholera to send the samples immediately, collect watery like with blood
Shigella dysentery = acute bloody diarrhoea rice water or pus
© World Health Organization 2010 All rights reserved stool specimens in Cary Blair or TCBS
Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva Both are transmitted by contaminated water, unsafe food, Fever No Yes
27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate
transport medium and refrigerate.
WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 dirty hands and vomit or stools of sick people. Abdominal
791 4806; e-mail: permissions@who.int). Don’t wait for laboratory results to start cramps Yes Yes
The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the Other causes of diarrhoea may produce severe illness treatment and to protect the community. Vomiting Yes a lot No
World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of
proprietary products are distinguished by initial capital letters. for the patient, but will not produce outbreaks which Not all the cases need to be laboratory Rectal pain No Yes
All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However,
represent an immediate threat to the community. confirmed.
the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation
and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.
WHO/CDS/CSR/NCS/2003.7 Rev.2

WHO • GLOBAL TASK FORCE ON CHOLERA CONTROL WHO • GLOBAL TASK FORCE ON CHOLERA CONTROL WHO • GLOBAL TASK FORCE ON CHOLERA CONTROL
 W H O G L O B A L TA S K F O R C E O N C H O L E R A C O N T R O L
WHAT TO DO IF YOU SUSPECT AN OUTBREAK DON’T FORGET … THE FIRST TWO QUESTIONS ARE:
■ Inform and ask for help 1. Is this the beginning of an outbreak?

First steps
■ Protect the community 2. Is the patient suffering from cholera or shigella?
■ Treat the patients

1. Is this the beginning of an outbreak?

for managing
■ Inform and ask Check the supplies
PROTECT YOURSELF FROM CONTAMINATION Be
■ Wash your hands with soap before and after taking care of the patient prepared
for help
you have You might be facing an outbreak very soon if you have seen an
and record availab
le quantities ■ Cut your nails unusual number of acute diarrhoeal cases this week and the patients
The outbreak can evolve quickly ➥ IV fluids (Ringer Lac have the following points in common: to face a

an outbreak
tat e is the best)
and the rapid increase of cases ➥ Drips
ISOLATE CHOLERA PATIENTS
• they have similar clinical symptoms (watery or bloody diarrhoea) sudden
may prevent you from doing • they are living in the same area or location
your daily activities
➥ Nasogastric tubes
■ Stools, vomit and soiled clothes of patients are highly contagious • they have eaten the same food (at a burial ceremony for example) increase
➥ Oral Rehydration
• Inform your supervisor about the Salt (ORS)
■ Latrines and patients’ buckets need to be washed and disinfected with • they are sharing the same water source in number

of acute
➥ Antibiotics (see Tab • there is an outbreak in the neighbouring community
situation
➥ Soap
le 2) chlorine
or
of cases
• Ask for more supplies if needed ■ Cholera patients have to be in a special ward, isolated from other patients
➥ Chlorine or bleach You have seen an adult suffering from acute watery diarrhoea with
(see Box) ing powder
➥ Rectal swabs and severe dehydration and vomiting

diarrhoea
• Ask for help to control the transport medium
(Cary Blair or TCBS) for CONTINUOUS PROVISION OF NUTRITIOUS FOOD is important for all patients, If you have some statistical information from previous years or weeks verify if the actual
outbreak among and outside the stool especially for those with shigella dysentery
samples increase of cases is unusual over the same period of time.
community
➥ Safe water is need
ed to rehydrate ■ Provide frequent small meals with familiar foods during the first two days
patients and to wash rather than infrequent large meals
instruments
clothes and
■ Provide food as soon as the patient is able to take it
2. Is the patient suffering from cholera or shigella?
THIS LEAFLET AIMS AT GUIDING YOU THROUGH Acute diarrhoea could be a common symptom. Therefore it is important to differentiate
■ Breastfeeding of infants and young children should continue between shigella or cholera in order to improve case management and to estimate
THE VERY FIRST DAYS OF AN OUTBREAK needed supplies
• Establish a clinical diagnosis for the patient
Collect data on the patients you have seen (Table1) TABLE 1
Note carefully the following data that will help to investigate the outbreak • Do the same for the other family members Symptoms Cholera = Shigella =
Two types of emergencies regarding acute diarrhoea exist: acute watery acute bloody
who are suffering from acute diarrhoea
N° Name Address Symptoms Age Sex Date Outcome diarrhoea diarrhoea
Cholera = acute watery diarrhoea
(<5 or (male M) or of onset For more information: cholera@who.int • Try to take stool samples and send them Stool > 3 loose > 3 loose
>5 years) (female F) and for immediate analysis. If it is not possible stools per day, stools per day,
http://www.who.int/cholera to send the samples immediately, collect watery like with blood
Shigella dysentery = acute bloody diarrhoea rice water or pus
© World Health Organization 2010 All rights reserved stool specimens in Cary Blair or TCBS
Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva Both are transmitted by contaminated water, unsafe food, Fever No Yes
27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate
transport medium and refrigerate.
WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 dirty hands and vomit or stools of sick people. Abdominal
791 4806; e-mail: permissions@who.int). Don’t wait for laboratory results to start cramps Yes Yes
The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the Other causes of diarrhoea may produce severe illness treatment and to protect the community. Vomiting Yes a lot No
World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of
proprietary products are distinguished by initial capital letters. for the patient, but will not produce outbreaks which Not all the cases need to be laboratory Rectal pain No Yes
All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However,
represent an immediate threat to the community. confirmed.
the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation
and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.
WHO/CDS/CSR/NCS/2003.7 Rev.2

WHO • GLOBAL TASK FORCE ON CHOLERA CONTROL WHO • GLOBAL TASK FORCE ON CHOLERA CONTROL WHO • GLOBAL TASK FORCE ON CHOLERA CONTROL