Garispanduan Pengurusan Dan Pengendalian Peyakit · PDF fileDr. Wong Ke Juin Dr. Lai Zhun Neay...
Transcript of Garispanduan Pengurusan Dan Pengendalian Peyakit · PDF fileDr. Wong Ke Juin Dr. Lai Zhun Neay...
Garispanduan Pengurusan Dan
Pengendalian Peyakit Kolera
Jabatan Kesihatan Negeri Sabah
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Editors:
Dr. Maria Suleiman Dr. Fong Siew Moy Dr. Timothy William Dr. Soo Thian Lian
Dr. Kartina Md. Noor Dr. Matthew Chong Dr. Wong Ke Juin Dr. Lai Zhun Neay
Afiedah Munir Rashidah Mohammad
Jaimi Borubui Normah Untong
Advisors: Director of Sabah Health Department
Deputy Director of Health (Public Health) of Sabah Health Department
Published by:
Public Health Division Sabah State Health Department
Level 1, Rumah Persekutuan Jalan Mat Salleh, 88814, Kota Kinabalu
SABAH
Tel: 088-265960 Fax: 088-217740
August 2012
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KATA-KATA ALUAN PENGARAH KESIHATAN NEGERI SABAH Penyakit Kolera adalah penyakit bawaan makanan dan air yang dilaporkan setiap tahun di negeri Sabah. Sabah melaporkan kes kolera yang tertinggi di Malaysia. Kes yang tertinggi dilaporkan adalah pada tahun 2010 dengan 431 kes dengan insiden 13.8 setiap 100,000 penduduk. Pada tahun tersebut juga Sabah melaporkan kematian disebabkan oleh kolera dengan 10 kes. Masalah utama yang dikenalpasti adalah kekurangan pengetahuan dalam pengendalian rawatan kes-kes penyakit kolera. Sehubungan dengan itu, buku garispanduan pengurusan dan pengendalian kolera ini disediakan untuk membantu para professional, doktor dan paramedik dalam rawatan, diagnosa dan kawalan penyakit kolera. Dengan adanya buku ini, ia diharap dapat membantu dalam rawatan, diagnosa dan kawalan penyakit kolera yang lebih berkesan dan seterusnya mengurangkan komplikasi akibat penyakit kolera. DR. MOHD. YUSOF HJ. IBRAHIM PENGARAH JABATAN KESIHATAN NEGERI SABAH
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Content Page
EDITORS i
FOREWORD ii
CONTENT iii
LIST OF TABLES vi
LIST OF FIGURES vii
LIST OF APPENDICES viii
ACRONYM ix
1.0 Management of Cholera in Paediatric
1
1.1 Introduction 1
1.2 Assessment of Dehydration and Treatment Plan 1
1.3 Treatment of Dehydration in Cholera 2
1.3.1 Correction of Dehydration is Based On Clinical Assessment 2
1.3.2 Hyponatraemic Dehydration 5
1.3.3 Hypernatraemia Dehydration 6
1.3.4 Hypokalaemia 6
1.3.5 Metabolic Acidosis 6
1.3.6 Examples for Treatment of Dehydration and Correction of Electrolyte Imbalance
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1.4 Antibiotic Treatment for Cholera 8
1.5 Zinc Supplements 8
1.6 Monitoring 8
1.7 Criteria for Discharge 9
1.8 Infection Control Recommendation for Hospitalized Cholera Patients 9
2.0 Management of Cholera in Adult
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2.1 Introduction 10
2.2 Step 1: Assess for Dehydration 10
2.3 Step 2: Rehydrate the Patient, Monitor Frequently and then Reassess Hydration 10
Status
2.3.1 No Sign of Dehydration 10
2.3.2 Some Dehydration 10
2.3.3 Severe Dehydration 11
2.4 Step 3: Maintain Hydration 12
2.5 Step 4: Give an Oral Antibiotic to the Patient 12
2.6 Step 5: Feed the Patient 13
2.7 Monitoring 13
2.8 Complications 13
2.9 Criteria for Discharge 13
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2.10 Infection Control Recommendation for Hospitalized Cholera Patients
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3.0 Laboratory Diagnosis of Vibrio Cholera in Hospital
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3.1 Introduction 14
3.2 Specimens for Submission for Suspected Cholera 14
3.3 Sample of Case 14
3.4 Outbreak and Surveillance Samples 14
3.5 Laboratory Processing 14
4.0 Pengurusan Ujian Vibrio Cholera di Makmal Kesihatan Awam
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4.1 Pemprosesan Sampel untuk Ujian Makmal bagi Spesimen Wabak di Seksyen Penyakit Makmal Kesihatan Kota Kinabalu
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4.1.1 Pengambilan Sampel 17
4.1.2 Perlabelan dan Pengangkutan Sampel 18
4.1.3 Pengkulturan 18
4.1.4 Pendiagnosan Koloni 20
4.2 Pengurusan Sampel Makanan, Air dan Swab Persekitaran 20
4.2.1 Prosedur Pengurusan 20
4.2.2 Proses Penghantaran Sampel 20
4.2.3 Penerimaan Sampel 22
4.2.4 Pelaporan Keputusan Ujian dan jangka Masa 22
4.2.5 Pengambilan Sampel 22
4.2.6 Jenis Sampel 24
4.2.7 Analisa Sampel 24
4.2.8 Keputusan Ujian 26
5.0 Pengurusan Kolera di Bahagian Kesihatan Awam
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5.1 Notifikasi 29
5.2 Penyiasatan 29
5.3 Pengesanan Kes 29
5.3.1 Definasi Kes 29
5.3.2 Definasi Asimptomatik 29
5.3.3 Definasi Kontak 29
5.3.4 Definasi Disyaki 30
5.4 Pengistiharaan Wabak 30
5.5 Penubuhan Jawatankuasa Wabak 30
5.6 Kawalan dan Pencegahan 31
5.6.1 Disinfeksi 31
5.6.2 Pengesanan Kontak 31
5.6.3 Pengambilan Sampel Persekitaran 31
5.6.4 Peralatan 31
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5.7 Pengendalian Kes Kolera dan Kontak Positif serta Rawatan 32
5.7.1 Pengurusan Ke atas Kes Kolera 32
5.7.2 Pengurusan Ke atas Kontak Kolera yang Positif 32
5.7.3 Rawatan Prophylaxis 32
5.8 Laporan 32
5.9 Promosi / Pendidikan Kesihatan 34
REFERENCES 35
APPENDICES 37
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List of Tables
Page
Table 1 : Assessment of Dehydration and Treatment Plan 1
Table 2 : Fluid Replace 4
Table 3 : Fluid Maintenance 5
Table 4 : Oral Antibiotic for Cholera 8
Jadual 5 : Jenis Media Ujian, Suhu dan Tempoh Penghantaran 17
Jadual 6 : Waktu Penghantaran Sampel 21
Jadual 7 : Jenis Sampel dan Cara Pengendalian Sampel 21
Jadual 8 : Keputusan Ujian dan Jangka Masa 22
Jadual 9 : Jawatankuasa Kawalan dan Pencegahan Wabak 30
Jadual 10 : Jenis Peralatan Wabak Kolera 32
Jadual 11 : Senarai Borang-borang Laporan Pengendalian Kolera 33
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List of Figures
Page
Figure 1 : Flow Chart for Treatment of Dehydration in Cholera 3
Figure 2 : Flow Chart of Laboratory Test for Cholera 16
Rajah 3 : Carta Aliran Pengkulturan Vibrio Cholera 19
Rajah 4 : Carta Alir Analisa Sampel 28
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List of Appendices
Page
1. Management of Cholera 37
2. Antibiotics for Cholera 39
3. Cholera Observation Chart 40
4. Cholera Review Chart 41
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Acronym
ACD - Active Case Detection
APW - Alkaline Peptone Water
BD - Twice Daily
CPRC - Crisis Preparedness Resource Centre
DME - Direct Microscopic Examination
EES - Erythromycin
HDU - High Dependency Unit
ICU - Intensive Care Unit
IV - Intravenous
JKNS - Jabatan Kesihatan Negeri Sabah
K - Postassium
KCl - Potassium Chloride
LIA - Lysine Iron Media
MHA - Meuller Hinton Agar
MIO - Motility Indole Ornithine
MKAKK - Makmal Kesihatan Awam Kota Kinabalu
Mmol - milimol
Na - Sodium
NaCl - Sodium Chloride
OD - Once Daily
ORS - Oral Rehydration Salt
RRT - Rapid Response Team
RS - Rectal Swab
RSVC - Rectal Swab for Vibrio Cholerae
SOP - Standard Operating Precedure
Stat - Immediately
TAT - Turn Around Time
TCBS - Thiosulfate Citrate Bile Sucrose
TSI - Triple Sugar Iron
WHO - World Health Organization
ml - millilitre
g - gram
PKD - Pejabat Kesihatan Daerah
PKK - Pejabat Kesihatan Kawasan
MKAK - Makmal Kesihatan Awam Kebangsaan
PFGE - Pulsed Field Electrophoresis
PKP - Pegawai Kesihatan Persekitaran
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1.0 Management of Cholera in Paediatric
1.1 Introduction
Cholera is a diarrheal illness caused by gram-negative Vibrio Cholerae. Cholera is characterized by severe, watery diarrhea, which can lead to dehydration and death in untreated patients.
The incubation period of cholera ranges from a few hours to five days, with most cases presenting within one to three days. Diarhoea may begin suddenly or gradually usually watery with flecks of mucous, hence the “rice water” stools description. The stools may have a mild fishy odor. Vomiting is common and patients may have abdominal cramping pain as well. Fever is uncommon in cholera patients.
Dehydration is the commonest presentation of cholera and it can be classified according to severity namely mild or no dehydration (< 5%), some or moderate dehydration (5-10%) or severe dehydration (>10%).
1.2 Assessment of Dehydration and Treatment Plan
Do assessment of dehydration and plan of treatment accordingly (Table 1).
Table 1: Assessment of Dehydration and Treatment Plan
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1.3 Treatment of Dehydration in Cholera
All children with suspected symptomatic cholera should be admitted. Most children infected with cholera have mild diarrhea. Oral Rehydration Salt (ORS) should be given immediately and child should be encouraged to drink. Correction of dehydration is based on clinical assessment ( Figure 1 & Appendix 1 ).
1.3.1 Correction of Dehydration is Based On Clinical Assessment
i. Plan A (Mild or No Dehydration)
Breast feeding should be continued. Formula fed children should receive their normal feeds. Older children can continue their normal diet. For each episode of diarrhea, replace with 10 ml/kg of ORS. ORS should be given as small sips from cup or spoon. If child vomits, wait
10 minutes, then continue but more slowly (i.e. 1 spoonful every 2-3 minutes).
ii. Plan B (Some or Moderate Dehydration)
Give ORS 75 ml/kg over 4 hours (even in hypernatraemia). For each episode of diarrhea, replace with 10 ml/kg of ORS. Reassess child every 1 to 2 hours until hydration is completed. After 4 hours, reassess the child and classify the child for dehydration and
select the appropriate plan to continue treatment Plan A, B or C. Resume feeding with normal diet when vomiting has stopped. Start with
small frequent feeds of milk, given with spoon. Encourage mother to continue breast feeding. Consider intravenous therapy if oral therapy fails, vomiting persist or there
is impending shock.
iii. Plan C (Severe Dehydration)
Severe dehydration can result in shock and require intravenous fluid therapy.
ORS can be continued if child is able to tolerate. Intravenous fluid therapy can be divided into 3 components: resuscitation,
deficit and maintenance. (a) Resuscitation
Resuscitation indicated if child is in shock.
Use normal saline or Ringer’s lactate solution 20 ml/kg over 1 hour in infant or 30 min in child > 1 year of age (Table 2). Repeat if necessary until blood pressure, pulse and perfusion, return to normal.
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Figure 1: Flow Chart for Treatment of Dehydration in Cholera
YES
Plan A (Mild or No dehydration) - Breast feeding should be
continued. - Formula fed children should
receive their normal feeds. - Older children can continue their
normal diet. - For each episode of diarrhea,
replace with 10ml/kg of ORS.
NO
Does the child have 2 or more of the following signs? The lack of water in his body result in:
- Sunken eyes - Absence of tear - Dry mouth and tongue - Thirty and drinks eagerly - Skin pinch goes back slowly
NO
Plan B (Moderate dehydration) - Trial ORS 75 ml/kg in 4 hours. - For each episode of diarrhea,
replace with 10 ml/kg of ORS. - Reassess child every 1 to 2
hours until dehydration is complete. If necessary, amount of ORS can be increased to achieve adequate hydration. Similarly, the amount of ORS can be decreased if hydration is achieved earlier than expected.
- Consider intravenous therapy if oral therapy fails, vomiting persist or there is impending shock.
YES
Plan C (Severe dehydration) 1. Put an IV drip. Use normal saline or Ringer’s lactate solution 20 ml/kg over 1 hour in infant
or 30 min in child > year. Repeat if necessary until blood pressure, pulse and perfusion, return to normal. Replace the deficit 100ml/kg over 12 hours using normal saline or Ringer’s lactate solution, together with maintenance fluid using 0.45 % saline 5% dextrose.
2. Reassess child every 1-2 hours and continue hydrating. If hydration is not improving, give 100 ml/kg normal saline or Ringers lactate divided as below:
Age
20 ml/kg normal saline or Ringers lactate
80 ml/kg normal saline or Ringers lactate
Infant (<1 year)
Over 1 hour Over 5 hours
Child (>1year) Over 30min Over 2 hours 30 min
Is the dehydration very severe? - The child is lethargic,
unconscious or floppy - Unable to drink - Pulses are weak
- Skin pinch goes back very slowly
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Table 2: Fluid Replacement
Age
Fluid Replacement : 20ml/kg normal saline or Ringers lactate
Fluid Replacement : 80ml/kg normal saline or Ringers lactate
Infant (<1 year)
Over 1 hour Over 5 hours
Child (>1year) Over 30min
Over 2 hours 30 min
(b) Deficit
Replace deficit 100 ml/kg over 8 to 12 hours using normal saline or Ringer’s lactate solution. Resuscitation boluses are actually part of deficit and should be deducted from the deficit if repeated boluses had been given.
Reassess child every 1-2 hours and continue hydrating. If hydration is not improving and child continues to have profuse watery diarrhoea with unstable vital signs, the deficit may need to be corrected more rapidly. Give 100 ml/kg normal saline or Ringers lactate in divided amount over time.
Reassess the child every 1 to 2 hours during this hydration. If child not responding, consider the possibility of an underlying disorder eg: septic shock and myocarditis.
Reassess after 6 hours and reclassify the hydration status.
Reclassify dehydration and choose the most appropriate plan (A, B or C).
Switch to ORS if adequate hydration is achieved and child can drink.
(c) Maintenance
Use 0.45% saline 4.3% dextrose for maintenance fluid for the current episode of diarrhea.
Maintenance fluid must be given concurrently as the fluid replacement for deficit. The maintenance fluid varies with age (Table 3).
Add 10 mmol KCL to each 500 ml of IV maintenance fluid after urine is passed.
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Table 3 : Fluid Maintenance
Age Fluid maintenance: ml/kg/24 hours
< 6/12 months 150 ml/kg
> 6/12 months to 1 year 120 ml/kg
> 1year old First 10 kg Second 10 kg Subsequent kg
100 ml/kg 50 ml/kg 20 ml/kg
(d) Sign for adequate hydration
skin goes back normally when pinched.
thirst has subsided.
urine has been passed.
pulse is strong.
Note: For severely malnourished patients, one should be more careful with the amount of fluid given as these patients may not be able to tolerate large amount of fluid rapidly (may develop heart failure). Give 15 ml per kg fluid over 1 hour for fluid bolus and reassess these patients frequently for signs of heart failure.
1.3.2 Hyponatraemic Dehydration
Extra Na is normally unnecessary unless the Na level is very low (<125 mmol/l) or the child is symptomatic. Do not increase serum Na more than 10 mmol/l/day. The amount of Na required for correction is as below:
Na deficit (mmol) = ( desired Na level measured Na level ) 0.6 body weight in kg
In symptomatic hyponatremia (Na <125 mmol/l) more aggressive correction is indicated for first 3-4 hours ( or until the symptoms resolve). A 3% NaCl may be used for this short period (every 2 ml 3% NaCl contains 1 mmol/l of sodium) to improve serum sodium up to 125 mmol/l.
A 1 g NaCl is equal to 17 mmol Na.
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1.3.3 Hypernatraema Dehydration
Serum Na > 150 mmol/l.
ORS is the method of choice and the safest.
If intravenous therapy is used, deficit fluid should be given over 48 to 72 hours.
Use 0.45% saline / 5% dextrose for maintenance fluid.
Do not reduce serum Na more than 10 mmol/day.
1.3.4 Hypokalaemia
Add 10 mmol KCl to each 500 ml of IV maintenance fluid after urine is passed.
Amount of KCl in IV maintenance fluid can be increased if serum K<3.0 mmol/l, as long as the K infusion rate is not more than 0.4 mmol/kg/hr and recheck serum K after 4 hours of infusion.
”fast correction” can be given if serum K <2.5 mmol/l. 0.4 mmol/kg of KCl can be given in 50 ml saline infused over 1 hour with continuous ECG monitoring. Recheck serum K after correction.
A 1 g KCl is equal to 13 mmol K.
1.3.5 Metabolic Acidosis
In most cases, the acidosis improves on its own when dehydration is corrected and improved.
In severely ill child with pH < 7.1 and serum bicarbonate < 15 mmol/l, intravenous correction with sodium bicarbonate is indicated. The amount of bicarbonate required for correction is as below:
Bicarbonate required (mmol) for correction = 1/3 base deficit body weight (kg)
Usually only half the above volume is given (half correction). 8.4% sodium bicarbonate is usually diluted to 4.2% sodium bicarbonate for correction, with the rate not more than 1-2 ml/kg/h.
However, in severe metabolic acidosis slow bolus of 2 ml/kg 4.2% sodium bicarbonate can be given.
A 1 ml of 8.4% sodium bicarbonate is equal to 1 mmol bicarbonate.
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1.3.6 Examples for Treatment of Dehydration and Correction of Electrolyte Imbalance
i. A 20 kg boy with 10% dehydration
Deficit correction over 12 hours = (10 X 10 X 20) / 12 = 166.7 ml/h normal saline
Maintenance = (10 X 100 + 10 X 50) / 24 = 62.5 ml/h 0.45% saline D5%
ii. If child is not improving after 1 to 2 hours of hydration,
Give 20 X 20 = 400 ml normal saline over 30min
Followed by (80 X 20)/2.5 = 640 ml/h normal saline over 2 hours 30min
iii. If the serum Na is 120 mmol/l and symptomatic,
Na deficit (mmol) = ( 125-120 ) X 0.6 X 20 = 60 mmol
Correct sodium deficit 60 mmol with 3% NaCl (60X2=120 ml of 3% NaCl). Infuse 120 ml 3% NaCl over 3-4 hour for symptomatic patient. This is in addition to the ongoing maintenance and deficit fluid regimen.
iv. If the serum K is 2.2 mmol/l,
Give Potassium (K) 0.4 X 20 = 8 mmol = 0.6 g KCl
Add 0.6g KCl in 50ml normal saline and infuse over 1 hour. Recheck serum K after infusion.
v. If the base deficit is 15,
Bicarbonate required (mmol) for correction = 1/3 X 15 X 20 = 100 mmol
Only half correction of the above base deficit is given 50 mmol. In paediatric 8.4% sodium bicarbonate is further diluted to 4.2% sodium bicarbonate (total 100ml) infused over 20 ml/h (rate of 1mmol/kg/hour).
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1.4 Antibiotic Treatment for Cholera
Antibiotic treatment will reduce the volume and duration of diarrhea. Treatment with antibiotic is recommended for symptomatic patients particularly for those patients who continue to pass large volumes of stools during rehydration treatment and all hospitalized patients (Table 4 and Appendix 2).
Table 4 : Oral Antibiotics for Cholera
Antibiotic
Paediatric dose
Comments
Cotrimoxazole (TMP/STX)
5 mg/kg/dose 12 hourly for 3 days
Most cholera serotypes in Sabah are still sensitive to Cotrimoxazole
Erythromycin Azithromycin
12.5 mg/kg/dose 6 hourly for 3 days 20 mg/kg/dose (single dose)
Single dose azithromycin is preferred therapy
Doxycycline
2-4 mg/kg/dose (single dose)
Not recommended for children less than 8 years old
1.5 Zinc Supplements
It has been shown that zinc supplements during an episode of diarrhoea reduce the duration and severity of the episode. WHO recommends zinc supplements as soon as possible after diarrhoea has started. Dose up to 6 months of age is 10 mg/day, and age 6 months and above 20 mg/day, for 10-14 day.
1.6 Monitoring
Patient with signs of dehydration should be monitored closely; every 2-4 hourly with cholera observation chart (Appendix 3) and cholera review chart (Appendix 4).
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1.7 Criteria for Discharge Patient can be discharge once
i. No more diarrhea.
ii. No dehydration.
iii. 3 consecutive RSVC samples are negative.
1.8 Infection Control Recommendation for Hospitalized Cholera Patients
1.8.1 Infected persons are infectious during the acute stage and for a few days after recovery if untreated. By the end of the first week, 70% of patients are non-infectious. 1.8.2 Hospitalized patients should be isolated in standard isolation room and cared for using standard precautions. 1.8.3 Strict contact precautions especially hand hygiene should be used for diapered or incontinent persons for the duration of illness or to control institutional outbreaks. 1.8.4 Disinfection of linen and laundry of the isolated patient is required. 1.8.5 Faeces and vomitus can be disposed off into the toilet without preliminary disinfection in hospitals. 1.8.6 Terminal cleaning of hospital rooms and equipment is required.
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2.0 Management of Cholera in Adults
2.1 Introduction
Cholera should be suspected when: any patient has acute watery diarrhoea in an area where there is an outbreak of cholera. Management of suspected cholera are divided into 5 steps.
Step 1: Assess for dehydration.
Step 2: Rehydrate the patient, and monitor frequently. Then reassess hydration status.
Step 3: Maintain hydration: replace ongoing fluid losses until diarrhoea stops.
Step 4: Give an oral antibiotics ( Doxycyline 300 mg stat or Azithromycin 1 g stat or EES 800 mg bd for 3 days for pregnancy).
Step 5: Feed the patient.
2.2 Step 1: Assess for Dehydration
Determine whether the patient has dehydration and classify their status of dehydration (Table 1).
No signs of dehydration.
Some dehydration.
Severe dehydration.
2.3 Step 2: Rehydrate the Patient, Monitor Frequently and then Reassess Hydration Status
2.3.1 No Sign of Dehydration
Encourage the patient to drink ORS as much as wanted after every episode of diarrhoea about 2 litres of fluid per day.
2.3.2 Some Dehydration
Give ORS solution
A 15 years or older patient weight 30 kg or more should be given 2,200 – 4,000 mls of ORS. Use the patient's age only when you do not know the weight. The approximate amount of ORS required (in ml) can also be calculated by multiplying the patient's weight (in kg) with 75.
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Monitor the patient frequently to ensure that ORS solution is taken satisfactorily and to detect patients with profuse ongoing 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), rehydrate for severe dehydration.
If there is still some 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 ongoing fluid losses.
Most patients absorb enough ORS solution to achieve rehydration even when they are vomiting. Vomiting usually subsides within 2-3 hours, as rehydration is achieved.
Use a nasogastric tube for ORS solution if the patient has signs of some dehydration and cannot drink or for severe dehydration only if IV therapy is not possible at the treatment facility.
Urine output decreases as dehydration develops, and may cease. It usually resumes within 6-8 hours after starting rehydration. Regular urinary output (every 3-4 hours) is a good sign that enough fluid is being given.
2.3.3 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, begin giving oral rehydration salts (ORS) solution by mouth while the drip is being set up.
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 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/h as soon as the patient can drink, in addition to IV fluid.
Reassess the patient after 3 hours, using Table 1.
If there are still signs of severe dehydration (this is rare), repeat the IV therapy already given.
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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 ongoing fluid losses.
Inform physician on call and manage patient in the HDU or ICU.
2.4 Step 3: Maintain Hydration
Maintain hydration of patient who presented with severe or some dehydration and replace ongoing fluid losses until diarrhoea stops.
When a patient who has been rehydrated with IV fluid or ORS solution is reassessed, and has no signs of dehydration, continue to give ORS solution to maintain normal hydration. The aim is to replace stool losses as they occur with an equivalent amount of ORS solution.
The amount of ORS solution actually required to maintain hydration varies greatly from patient to patient, depending on the volume of stool passed. The amount required is greatest in the first 24 hours of treatment, and is especially large in patients who present with severe dehydration. In the first 24 hours, the average requirement in such patients is 200 ml of ORS solution per kg of body weight, but some may need as much as 350 ml/kg.
Continue to reassess the patient for signs of dehydration at least every 4 hours to ensure that enough ORS solution is being taken. Patients with profuse ongoing diarrhoea require more frequent monitoring. If signs of some dehydration are detected the patient should be rehydrated as described earlier, before continuing with treatment to maintain hydration.
A few patients, whose ongoing stool output is very large, may have difficulty in drinking the volume of ORS needed to maintain hydration. If such patients become tired, vomit frequently or develop abdominal distension, ORS solution should be stopped and hydration should be maintained intravenously with Ringer's lactate solution or normal saline, giving 50 ml/kg in 3 hours. After this is done, it is usually possible to resume treatment with ORS solution.
Keep the patient under observation, until diarrhoea stops, or is infrequent and of small volume. This is especially important for any patient who presented with severe dehydration.
2.5 Step 4: Give an Oral Antibiotic to the Patient
Doxycyline 300 mg stat (Appendix 2).
Azithromycin (preferred) 1g OD stat or EES 800 mg bd for 3 days for pregnancy.
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2.6 Step 5: Feed the Patient
Resume feeding with a normal diet when vomiting has stopped.
2.7 Monitoring
Patients with signs of dehydration should be monitored closely, 2-4 hourly with cholera observation chart (Appendix 3) and cholera review chart (Appendix 4).
2.8 Complications
Pulmonary oedema is caused when too much IV fluid is given, and especially when metabolic acidosis has not been corrected. The latter is most likely to occur when normal saline is used for IV rehydration and ORS solution is not given at the same time. When the guidelines for IV rehydration are followed, pulmonary oedema should not occur. ORS solution never causes pulmonary oedema. However, if it occurs treat it accordingly with frusemide 40 mg IV and consult the physician on call.
Renal failure may occur when too little IV fluid is given, when shock is not rapidly corrected, or when shock is allowed to recur, especially in persons above the age of 60. Renal failure is rare when severe dehydration is rapidly corrected and normal hydration is maintained according to the guidelines. If it does occur, to consult the physician on call.
2.9 Criteria for Discharge
Patient can be discharge once
i. No more diarrhoea.
ii. No dehydration.
iii. 3 consecutive RSVC samples are negative.
2.10 Infection Control Recommendation for Hospitalized Cholera Patients
2.10.1 Infected persons are infectious during the acute stage and for a few days after recovery if untreated. By the end of the first week, 70% of patients are non-infectious.
2.10.2 Hospitalized patients should be isolated in standard isolation room and cared for using standard precautions.
2.10.3 Strict contact precautions especially hand hygiene should be used for diapered or incontinent persons for the duration of illness or to control institutional outbreaks.
2.10.4 Disinfection of linen and laundry of the isolated patient is required.
2.10.5 Faeces and vomitus can be disposed off into the toilet without preliminary disinfection in hospitals.
2.10.6 Terminal cleaning of hospital rooms and equipment is required.
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3.0 Laboratory Diagnosis of Vibrio Cholera in Hospital
3.1 Introduction
Vibrio cholerae is a curved gram negative rod. It is similar to other members of the family Enterobacteriacea with a flagellar H antigen and a somatic O antigen. The O antigen further clasisify V cholera in serogroups O1 and non O1. Approximately 206 serogroups are identified but only serogroups O1 and O139 are associated with clinical cholera and have pandemic potential. Vibrio cholera O1 can be classified into three serotypes which are serotype Inaba, Ogawa and Hikojima. The serotyping is useful for epidemiological purposes and there is no evidence of different clinical spectra among these three serotypes.
3.2 Specimens for Submission for Suspected Cholera
Specimens for confirmation of cholera should be 1 ml of liquid stool in 10 ml of Alkaline Peptone Water (APW) or rectal swabs placed in 1 to 2 ml of APW.
Rectal swab or stool send in alkaline peptone water as enrichment transport medium. The high pH will inhibit overgrowth of many commensal intestinal flora.
3.3 Sample of Case
Sample of case to be send to the processing laboratory, Hospital Queen Elizabeth, Hospital Duchess of Kent, Hospital Tawau and Hospital Keningau on the same day if cholera is suspected.
3.4 Outbreak and Surveillance Samples
All outbreak and surveillance samples should be send to Makmal Kesihatan Awam Kota Kinabalu (MKAKK) as soon as possible. Samples submitted must be clearly labeled with the date and time of sampling so that the laboratory can determine the start of incubation.
3.5 Laboratory Processing
Day 1
The day the specimen is received
At the receiving counter, specimens are checked against the requesting form.
Samples are inoculated on the selective and differential media which is
thiosulfate citrate bile sucrose (TCBS) and incubated at 35⁰C - 37⁰C for 18 to
24 hours (Figure 2).
Day 2
V. cholerae will grow as smooth golden yellow colonies, 2 to 4 mm in diameter with an opaque centre and transparent periphery.
15
If no golden yellow colonies are identified, result will be released as no V. cholerae is isolated.
Any golden yellow colonies is suspected to be V. cholerae and polyvalent serotyping test is carried out.
If polyvalent serotyping test is negative, result is released as no V. cholerae is isolated. The negative result is dispatch to the respective hospital’s pigeon holes.
If polyvalent serotyping test is positive:
i. Cytochrome oxidase test is carried out. V. cholerae will give positive result.
ii. Biochemical test consist of Triple Sugar Iron (TSI), motility and urease are performed.
iii. Preliminary result will be informed by a microbiologist to the person in charge of the respective laboratory.
iv. Using pure V. cholerae colonies, antibiotic susceptibility test is performed on the Mueller Hinton Agar (MHA) against antibiotic Ampicillin, Trimethoprim-sulfamethoxazole and Tetracycline and the MHA plate is incubated for 24 hours.
Day 3
Positive cultures only
Antibiotic susceptibility test is read. Tetracycline result can be used to predict susceptibility of isolates to doxycycline.
Confirmation of identification is done based on biochemical reaction. Further specific serotyping for Inaba and Ogawa is carried out using colonies from MHA.
Full result will be dispatch after verification.
16
Figure 2: Flow Chart of Laboratory Test for Cholera
Negative
Positive
Microbiologist inform person in charge lab
Incubate for 18 hours
Specimen in APW
Inoculate on TCBS agar
Look for
suspicious colony
No suspicious colony.
Suspicious colony
Do polyvalent test
Do oxidase and
biochemical test.
Read biochem ical
reaction after 18 hrs
Subculture
on MHA
Antibiotic
susceptibility
test
Specific
serotyping
Dispatch Positive result
Dispatch
negative
result
6 to 8 hours
Incubate for 18 – 24 hours
17
4.0 Pengurusan Ujian Vibrio Cholera di Makmal Kesihatan Awam
4.1 Pemprosesan Sampel untuk Ujian Makmal bagi Spesimen Wabak di Seksyen Penyakit
Makmal Kesihatan Kota Kinabalu
4.1.1 Pengambilan Sampel
a) Sampel Najis
Sampel najis perlu dipungut pada fasa awal penyakit-penyakit enterik di mana
jumlah patogen adalah tinggi dan sebelum rawatan antibiotik dijalankan. Spesimen
tersebut perlu diambil pada waktu pagi supaya dapat dihantar ke makmal secepat
mungkin dan diproses pada hari yang sama. Sampel najis tersebut hendaklah
dielakkan daripada terkontaminasi dengan urin. Sampel najis adalah sampel yang
baik bagi pemencilkan mikroorganisma enterik tetapi jika sampel najis tidak dapat
sampai ke makmal dengan kadar segera, media pengangkutan (Cary-Blair, Stuart
or Amies) dan media pengkayaan (Alkaline Peptone Water 1% - Vibrio cholerae,
Selenite F – Salmonella spp.) boleh digunakan (Jadual 5).
Jadual 5 : Jenis Media Ujian, Suhu dan Tempoh Penghantaran
Nota: APW boleh digunakan sebagai media pengangkutan jika tempoh
pengangkutan tidak melebihi 10 jam (Proteus species akan tumbuh
di dalam medium).
b) Swab Rektal atau Swab Najis
Swab rektal dihantar ke makmal di dalam media pengangkutan dan media
pengkayaan. Media ini digunakan jika sampel najis tidak dapat dihantar ke makmal
dalam tempoh 2 jam dari masa pengambilan.
Medium Control Species Pengangkutan Tempoh
Penghantaran
Alkaline
Peptone Water
Menggalakkan pertumbuhan :
Vibrio species Merencat:
Escherichia coli
Proteus species
Suhu biasa/ suhu
bilik
6 – 8 Jam
Selenite F
Broth
Salmonella species 24 Jam
18
4.1.2 Perlabelan dan Pengangkutan Sampel
Sampel yang dihantar mesti dilabel jelas dengan tarikh dan masa pengambilan sampel
supaya pihak makmal boleh menentukan tempoh mula pengeraman. Setiap sampel
hendaklah disertakan dengan borang permintaan ujian dengan perincian yang lengkap
seperti :
a) Nama pesakit, umur pesakit, lokaliti kes dan institusi yang memohon.
b) Jenis spesimen, tarikh dan masa pengambilan.
c) Jenis ujian yang diminta.
d) Nota klinikal yang memberikan perincian tentang penyakit pesakit, diagnosis yang disyaki dan rawatan antimicrobial yang telah dijanlankan.
Sampel perlu dihantar pada suhu biasa dan elakkan daripada meletakkan sampel di
dalam ‘cool box’ semasa penghantaran.
4.1.3 Pengkulturan
Sampel swab rektal adalah sampel yang lazim diterima untuk pemencilan
mikroorganisma enterik di hantar ke makmal dalam tempoh 2 jam dari tempoh
pengambilan. Setelah diterima, swab rektal dikultur ke atas TCBS (Rajah 3).
4.1.3.1 Spesimen dalam Alkaline Peptone Water
Sebaik sahaja swab rektal diterima, sampel akan dieramkan dengan tutup
yang ketat pada suhu 35°C -37° selama 6 - 8 jam dari masa pengambilan.
Selepas cukup tempoh eraman, sampel disubkulturkan ke agar TCBS dengan
satu loop penuh daripada permukaan atas. Eramkan TCBS yang telah
diinokulasikan pada suhu 35°C - 37°C selama 16 - 18 jam.
Walaubagaimanapun, spesimen yang diterima selepas 6 jam pungutan
disubkulturkan ke dalam APW pada jam ke 18 dari tempoh pungutan dan
dieramkan selama 4 hingga 6 jam sebelum dikulturkan ke atas agar TCBS.
4.1.3.2 Sampel Swab Rektum dalam ‘Cary Blair‘
Sampel akan dikultur ke atas agar TCBS dan inokulasikan ke dalam APW
serta merta selepas diterima kemudian di eramkan pada suhu 35°C – 37°C
selama 4 – 6 jam. Kultur daripada media APW itu tadi diinokulasikan ke atas
agar TCBS dan eramkan pada suhu 35°C -37°C selama 16-18 jam.
19
Rajah 3: Carta Aliran Pengkulturan Vibrio Cholerae
Terima swab rektum dalam APW 1%
Kultur ke atas TCBS
Pendiagnosan kultur
Pertumbuhan koloni kuning (yellow
lemon)
Selain daripada koloni kuning
Lapor : No Vibrio cholerae isolated
Uji dengan antisera V/C Polyvalent 01
untuk laporan segera
Aglutinasi Tiada aglutinasi
Kultur ke atas Blood Agar Uji dengan antisera
Ogawa, Inaba dll
Ujian Serotyping
dengan antisera
Polyvalent 01, Ogawa,
Inaba dll
Ujian Biokimia:
1. Ujian oksidase
2. TSI, LIA, MIO, Citrate
3. D’nase, Arginine
4. Disc 0129 10ug dan 150ug,
Polymycin B 50ug. Ujian Sensitiviti
Lapor: Culture : Vibrio cholerae Eltor Ogawa or Inaba
isolate
Lapor : Culture : Vibrio choleare
01 isolated Confirmation to
follow
Lapor kepada pihak kesihatan
Hantar ke MKAK untuk ujian
PFGE
20
4.1.4 Pendiagnosan Koloni
Selepas tempoh pengeraman, agar TCBS akan dicerap untuk ciri-ciri Vibrio cholerae
(koloni bersaiz 2-3mm dan sedikit leper berwarna kuning keemasan, legap dibahagian
tengah serta lut cahaya pada periferi koloni). Jika terdapat koloni yang di syaki, ujian
serotyping akan dijalankan ke atas koloni daripada agar TCBS dengan menggunakan
antisera polyvalent Vibrio cholerae 01. Jika terdapat aglutinasi, laporan ‘preliminary’
akan dikeluarkan kepada institusi pemohon sebagai disyaki Vibrio cholerae dalam
tempoh 24 jam supaya aktiviti penyiasatan dapat dijalankan dengan kadar segera.
Koloni yang disyaki tersebut akan diinokulasikan ke atas agar darah dan di eramkan
selama 16 -18 jam. Selepas cukup tempoh eraman, ujian penyaringan biokimia
dijalankan dengan menggunakan media TSI, LIA, MIO dan Sitrat untuk mengesahkan
ciri-ciri spesies Vibrio cholerae. Kemudian, koloni yang sama daripada agar darah tadi
diuji dengan Vibrio cholerae antiserum Ogawa dan Inaba untuk mengesahkan subtype
Vibrio cholerae yang menyebabkan wabak tersebut. Jika jenis koloni telah dikenalpasti,
ujian kepekaan antibiotik perlu dijalankan ke atas kultur tersebut. Keputusan
pengesahan mengambil masa selama 3 hari. Hanya sebanyak 30 %– 50 % isolat
positif sahaja akan di uji dengan ujian kerintangan antibiotik pada awal wabak bermula
untuk menentukan corak kerintangan antibiotik pada sesuatu wabak tersebut tetapi
pihak makmal akan membuat pemantauan secara berkala sepanjang wabak untuk
mengesan jika terdapat sebarang perbezaan corak kerintangan antibiotik yang telah
dicapai pada awal wabak tersebut.
Semua isolat positif yang dipencilkan perlu disubkulturkan ke atas agar nutrien untuk di
hantar ke Makmal Kesihatan Awam Kebangsaan Sungai Buloh bagi tujuan ujian
Pulsed Field Electrophoresis (PFGE).
4.2 Pengurusan Sampel Makanan, Air dan Swab Persekitaran
4.2.1 Prosedur Pengurusan
a) Semua sampel makanan, air dan swab persekitaran hendaklah dihantar ke Seksyen Makanan, Makmal Kesihatan Awam Kota Kinabalu untuk dianalisa.
b) Pihak Unit Kawalan Penyakit Berjangkit (CPRC) JKNS mesti
memaklumkan kepada Pengarah Makmal Kesihatan Awam Kota Kinabalu jika berlaku kejadian wabak.
4.2.2 Proses Penghantaran Sampel
4.2.2.1 Waktu Penghantaran
a) Penghantaran sampel mesti dilakukan mengikut Jadual Bertugas Wabak yang telah diedarkan berdasarkan tempoh masa bertugas harian wabak (Jadual 6).
21
Jadual 6: Waktu Penghantaran Sampel
Hari Tempoh Masa
Isnin hingga Jumaat 8 pagi hingga 5 petang
Hujung minggu dan pelepasan am 9 pagi hingga 2 petang
Nota: Kakitangan yang bertugas MESTI dihubungi sekiranya penghantaran dilakukan selain daripada waktu di atas.
b) Pada hujung minggu dan pelepasan am kakitangan yang menghantar sampel perlu mendaftar dan membuat panggilan melalui talian sambungan dari pondok pengawal ke makmal. Ini perlu dilakukan untuk mengatasi kesulitan disebabkan kewujudan sistem keselamatan imbasan kad keluar masuk.
4.2.2.2 Kriteria Penghantaran Sampel
a) Kriteria penghantaran sampel adalah berbeza mengikut jenis sampel dan cara pengendalian sampel sebelum penghantaran (Jadual 7).
Jadual 7: Jenis Sampel dan Cara Pengendalian Sampel
Bil. Sampel dan
Isipadu Pengangkutan dan
Penyimpanan Catatan
1. Semua jenis makanan ≈250g
Sampel makanan:
bungkusan steril (whirlpak) atau dalam bungkusan asal
suhu perlu dikekalkan dalam julat 0-4°C.
i. Sampel makanan mesti dihantar dalam coolbox
ii. Sampel makanan beku mesti dihantar dalam keadaan beku
iii. Sampel mesti dihantar dalam tempoh 24 jam
2. Air ≈100-200ml (paip, perigi, sungai dan lain-lain)
Sampel air
bungkusan(whirlpak)/ botol steril
suhu perlu dikekalkan dalam julat 0-4°C
i. Sampel dihantar dalam coolbox
ii. Sampel mesti dihantar dalam tempoh 24 jam
3. Swab persekitaran (tangan, peralatan makan, kawasan penyediaan makanan, persekitaran dan lain-lain)
Sampel swab dalam Alkaline peptone water (APW) pada suhu bilik
i. Elakkan daripada terdedah di bawah cahaya matahari secara langsung
ii. Sampel mesti dihantar dalam tempoh 6-8 jam
22
4.2.3 Penerimaan Sampel
a) Semua sampel akan diterima sekiranya kriteria penghantaran sampel dipatuhi.
b) Semua sampel akan diterima oleh kakitangan bertugas seperti yang
dinyatakan dalam Jadual Bertugas Wabak.
c) Sampel yang diterima akan disahkan dan didaftarkan oleh kakitangan bertugas. Penghantar perlu merekodkan penghantaran sampel pada buku rekod.
4.2.4 Pelaporan Keputusan Ujian dan Jangka Masa
a) Keputusan ujian akan dimaklumkan mengikut jangka masa atau Turn Around Time (TAT) yang telah ditentukan (Jadual 8).
b) Keputusan pengesahan akan dimaklumkan dalam bentuk bercetak (hard
copy) dan diletakkan dalam peti surat (pigeon-hole) yang berkaitan.
Jadual 8: Keputusan Ujian dan Jangka Masa
Jenis Sampel
Jangka Masa (TAT)
Cara Makluman Keputusan Keputusan
Awalan (Preliminary
Result)
Keputusan Pengesahan
(Confirmatory Result)
Semua Jenis Makanan
3 hari 7 hari i. Panggilan telefon ii. Keputusan bercetak iii. Kiriman faks iv. Kiriman e-mel
Air (paip, perigi, sungai dan lain-lain)
3 hari 7 hari
Swab persekitaran (tangan, peralatan makan, kawasan penyediaan makanan, persekitaran dan lain-lain)
1 hari 5 hari
Nota: i. Keputusan awal untuk semua jenis sampel akan dimaklumkan melalui
panggilan telefon.
ii. Jika sampel swab dihantar lebih dari tempoh 6-8 jam, keputusan akan dikeluarkan mengikut TAT sampel makanan / air.
4.2.5 Pengambilan Sampel 4.2.5.1 Sampel Makanan
a) Sampel makanan perlu diambil dengan cara yang steril dan dimasukkan
ke dalam whirlpack.
Kepada PKP
bertugas yang
berkaitan
23
b) Sampel perlu dihantar dan sampai di makmal dalam tempoh tidak melebihi 24 jam dari waktu pengambilan sampel.
c) Sampel dicadangkan disimpan dalam kotak penyejuk (coolbox) yang
mengandungi ais (jenis ais pecah kecil-kecil) untuk memastikan suhu penghantaran sampel dalam julat 0 – 4oC.
d) Sampel disusun dengan tidak bertindih di antara satu sama lain dan
tidak bersentuh dengan dinding kotak penyejuk.
e) Sampel rujukan (sampel air yang diliputi dengan ais) perlu ada bersama-sama dengan sampel makanan. Ini bertujuan untuk mengetahui suhu sebenar di dalam sampel semasa perjalanan dari tempat persampelan ke makmal.
f) Berat sampel tidak semestinya sebanyak 250 gram.
4.2.5.2 Sampel Air
a) Sebanyak 100-200 ml sampel air dimasukkan ke dalam bungkusan (whirlpak) / botol yang steril.
b) Sampel perlu dihantar dan sampai di makmal dalam tempoh tidak
melebihi 24 jam dari waktu pengambilan sampel.
c) Sampel dicadangkan disimpan dalam kotak penyejuk (coolbox) yang mengandungi ais (jenis ais pecah kecil-kecil) untuk memastikan suhu penghantaran sampel dalam julat 0 – 4oC.
d) Sampel disusun dengan tidak bertindih di antara satu sama lain dan tidak
bersentuh dengan dinding kotak penyejuk.
e) Sampel rujukan (sampel air yang diliputi dengan ais) perlu ada bersama-sama dengan sampel air. Ini bertujuan untuk mengetahui suhu sebenar di dalam sampel semasa perjalanan dari tempat persampelan ke makmal.
4.2.5.3 Sampel Swab Persekitaran
a) Masukkan cotton swab ke dalam botol bijou yang mengandungi media APW.
b) Swab perlu dihantar dan sampai di makmal dalam tempoh tidak melebihi 6
jam dari waktu pengambilan sampel.
c) Swab perlu dielakkan daripada suhu yang terlalu panas.
24
4.2.6 Jenis Sampel
Jenis sampel dibahagikan kepada 3 jenis.
4.2.6.1 Sampel Makanan Lebihan
Sampel makanan diambil daripada makanan lebihan yang disyaki.
4.2.6.2 Swab Persekitaran
Sampel swab persekitaran semasa wabak / keracunan makanan diambil daripada swab peralatan, swab tangan, swab kawasan memasak dan lain-lain (kecuali bendalir badan, swab hidung, swab telinga, swab dubur dan swab kerongkong).
4.2.6.3 Swab Makanan Baru
Sampel makanan yang baru diambil berkaitan dengan wabak / keracunan makanan.
4.2.7 Analisa Sampel
Analisa sampel dibuat berdasarkan kepada jenis sampel (Rajah 4).
4.2.7.1 Sampel Makanan Lebihan i. Direct Microscopic Examination (DME)
DME dibuat secara pre analisa kepada semua jenis sampel. Sediakan sampel makanan homogenius dalam 1:10 dengan 0.1% Peptone water yang steril. Ambil beberapa titik sampel untuk mengenalpasti organism berdasarkan teknik berikut:
a) Hanging Drop
Titiskan setitik sampel homogenius ke atas slaid (khusus
untuk hanging drop).
Letakkan penutup di atas slaid.
Perhatikan pergerakan organisma dibawah cahaya
mikroskop.
b) Gram Staining
Titiskan setitik sampel homogenius ke atas slaid.
Keringkan filem dan awet dengan kepanasan yang sederhana dengan melayangkan slaid di atas api penunu Bunsen 3 hingga 4 kali.
25
Secara alternatif, keringkan filem dan awet dengan 70% methanol 1-2 min, buangkan methanol yang berlebihan dan panaskan.
- Nota: Ini adalah bersesuaian dengan makanan yang mempunyai paras gula yang tinggi.
Sejukkan pada suhu bilik sebelum pencelupan. Masukkan filem di dalam xylene atau ‘gram defferentiator’ 1-2 min untuk membuangkan lemak pada makanan. Cuci dengan 70% methanol dan keringkan.
Celup filem dengan prosedur ‘Gram Stain’ (Rujuk kepada kaedah pencelupan atau arahan pengeluar).
Lakukan ujian di penyaringan sekurang-kurangnya 10 kawasan dengan menggunakan objektif ‘oil emersion’ pada setiap filem dan laporkan keputusan.
c) Spore Staining
Sediakan calitan smear dan ‘heat-fix’ dengan api yang minima.
Letakkan slaid diatas air yang mendidih sehingga titisan air terhasil di bawah slaid.
Celupkan filem dengan prosedur ‘Spore-Staining’ (rujuk kepada kaedah ‘spore staining’ atau arahan pengeluar).
Periksa kehadiran ‘spore’ pada slaid dan laporkan.
ii. Kaedah ‘Direct’
Analisa sampel dengan ‘direct plating’ menggunakan piring agar yang bersesuaian bergantung kepada keputusan DME.
iii. Analisa Toksin
Buat analisa toksin sekiranya mengesyaki sampel yang berpunca daripada ‘Staphylococcal enterotoxin’ atau ‘Bacillius enterotoxin’.
iv. Kaedah ‘Indirect’
Teruskan dengan analisa sampel menggunakan kaedah yang terkini atau kaedah lain untuk parameter yang disyaki.
26
4.2.7.2 Swab Persekitaran
i. Quick Swab
‘Quick swab’ biasanya mempunyai 1 ml ‘diluent’ (100). ‘Vortex quick swab’ untuk menjadikan sampel homogenius.
Buatkan larutan yang berkala.
‘Direct streaking’ dengan piring agar yang terpilih.
Teruskan dengan kaedah ini.
ii. Carry Blair Swab
Pindahkan putik kapas ke dalam 9 ml 0.1% Peptone water.
Sampel dihomogenus dengan menggunakan “vertox apparatus’.
‘Direct streaking’ dengan piring agar yang terpilih.
4.2.7.3 Sampel Makanan Baru
Sampel haruslah dianggap sebagai sampel rutin.
Analisa menggunakan ‘current method’.
4.2.8 Keputusan Ujian
Keputusan analisa sampel wabak / keracunan makanan dilaporkan dan direkodkan.
4.2.8.1 Sampel Makanan Lebihan
‘Direct plating’: laporkan keputusan results seperti yang didapati.
‘Enumeration method’: laporkan results as cfu/ml, MPN/ml, cfu/g or MPN/g.
‘Detection method’: laporkan keputusan hasil siasatan.
4.2.8.2 Quick Swab
Direct streaking: laporkan keputusan.
Enumeration method: laporkan keputusan dalam segi cfu/ml or MPN/ml.
Detection method: laporkan keputusan per ml.
27
4.2.8.3 Carry Blair Swab
Direct streaking: laporkan keputusan.
4.2.8.4 Sampel Makanan Baru
Enumeration method: laporkan keputusan dalam cfu/ml, MPN/ml, cfu/g or MPN/g.
Detection method: laporkan keputusan per 25g atau 25ml.
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29
5.0 Pengurusan Kolera di Bahagian Kesihatan Awam
5.1 Notifikasi
Penyakit Kolera merupakan penyakit berjangkit yang wajib dinotifikasi di bawah subseksyen 10(2) Akta Pencegahan dan Pengawalan Penyakit Berjangkit 1988. Pengamal Perubatan wajib melaporkan dengan serta merta kejadian kes kolera (disyaki/kes) ke Pejabat Kesihatan Daerah terdekat melalui telefon seterusnya diikuti melalui internet (e-notifikasi) dan borang notis dalam masa 24 jam.
5.2 Penyiasatan
Penyiasatan dilaksanakan sejurus menerima notifikasi dengan menggunakan borang penyiasatan (FWBD/UMU/BG/007). Kes yang berlaku di luar dari kawasan operasi/daerah perlu dirujuk kepada pejabat kesihatan di kawasan tersebut untuk tindakan lanjut.
Sejarah pergerakan dan pengambilan makanan perlu diambil dalam masa inkubasi (5 hari sebelum onset hingga pesakit dikenalpasti menghidap kolera dan diasingkan). Semua kontak perlu dikenalpasti agar penyiasatan dapat dijalankan secara menyeluruh. Aktiviti pemetaan, bubble chart pergerakan pesakit dan hipotesis punca jangkitan perlu dikenalpasti.
5.3 Pengesanan Kes
Pengesanan kes perlu dilaksanakan dengan kadar segera untuk mengenalpasti punca jangkitan seterusnya memutuskan rantaian jangkitan.
5.3.1 Definisi Kes
Pesakit/kes yang mengalami gejala klinikal iaitu cirit-birit akut dengan atau tanpa muntah serta memenuhi kreteria makmal iaitu isolasi Vibrio cholera dari najis atau swab rectal dari pesakit.
5.3.2 Definisi Asimptomatik
Pesakit/kes yang tidak mengalami apa-apa gejala (tidak memenuhi kriteria klinikal) tetapi telah disahkan melalui ujian makmal (memenuhi criteria makmal).
5.3.3 Definisi Kontak
Kontak adalah mereka yang mempunyai hubungan dengan pesakit dalam tempoh inkubasi iaitu 5 hari sebelum onset hingga ianya dimasukkan ke wad atau diasingkan. Ianya melibatkan kontak keluarga, kontek sekerja, kontak sekolah, kontak social dan kontak di premis/tempat makan.
30
5.3.4 Definisi Disyaki
Pesakit/kes yang mengalami gejala klinikal (memenuhi kriteria klinikal) tetapi tidak atau belum memenuhi kriteria makmal.
5.4 Pengisytiharaan Wabak
Wabak kolera dikatakan telah berlaku apabila satu atau lebih kes kolera dalam suatu lokaliti pada suatu masa. Wabak kolera dikatakan telah tamat jika tiada kes baru dilaporkan dalam masa 2 tempoh inkubasi (iaitu 10 hari) daripada tarikh onset kes terakhir di lokaliti berkenaan.
5.5 Penubuhan Jawatankuasa Wabak
Apabila berlaku wabak kolera, bilik gerakan kawalan dan pencegahan wabak perlu diaktifkan serta merta dan Jawatankuasa Kawalan dan Pencegahan wabak daerah perlu ditubuhkan (Jadual 9).
Jadual 9: Jawatankuasa Kawalan dan Pencegahan Wabak
Jawatan Pegawai Penyandang
Pengerusi : Pegawai Daerah
Timbalan Pengerusi : Penolong Pegawai Daerah (Pentadbiran)
Urusetia / Setiausaha : Pegawai Kesihatan Kawasan / Daerah
Ahli Jawatankuasa : Pengarah Hospital
Pegawai Pergigian
Pegawai Farmasi
Pegawai Promosi Kesihatan
Pegawai Teknologi Makanan
Penyelia Jururawat Kesihatan
Penyelia Penolong Pegawai Perubatan
Juruteknologi Makmal Perubatan Kanan
Jabatan Persekutuan atau Negeri yang berkenaan:-
- Pejabat daerah
- Dewan Bandaraya / Majlis Perbandaran / daerah
- Jabatan Penerangan daerah
- Jabatan Pelajaran daerah
- Jabatan Bekalan Air
- Jabatan Kerja Raya
- Polis
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Pasukan petugas (Pasukan Tindak Cepat – RRT) untuk aktiviti kawalan dan pencegahan juga perlu ditubuhkan yang meliputi :- 1. Pasukan Petugas Bilik Gerakan. 2. Pasukan Siasatan Kes. 3. Pasukan Kawalan dan pencegahan. 4. Pasukan Pengesanan Kes (ACD). 5. Pasukan Promosi Kesihatan 6. Pasukan Penguatkuasaan.
5.6 Kawalan dan Pencegahan
5.6.1 Disinfeksi
Disinfeksi dijalankan dengan tujuan untuk membasmi kuman kawasan/permukaan yang disyaki telah tercemar dengan kuman vibrio dari najis atau muntah pesakit/disyaki menghidap Kolera. Disinfeksi dijalankan ke atas tempat pembuangan sampah, sistem perparitan, tandas, tempat pembiakan lalat serta permukaan (lantai lantai, dinding atau apa-apa permukaan yang disyaki telah tercemar oleh najis/muntah kes/disyaki).
5.6.2 Pengesanan Kontak
Pengesanan kontak perlu dijalankan dengan kadar segera untuk memutuskan rangkaian jangkitan serta untuk memastikan agar perebakan wabak dapat dibendung sebelum menjangkiti ke kawasan yang lebih luas lagi. Kontak adalah mereka yang mempunyai kaitan epidemiologi dengan pesakit dalam masa inkubasi (5 hari sebelum onset sehingga ianya dimasukkan ke wad untuk pengasingan). Jika kontak memenuhi kriteria tanda-tanda klinikal ianya perlu dirujukkan sertamerta ke hospital untuk siasatan lanjut dan rawatan. Swab rectal perlu diambil dari semua kontak mengikut teknik/prosedur pengambilan rectal swab yang betul.
5.6.3 Pengambilan Sampel Persekitaran
Jenis sampel yang diambil adalah bergantung kepada sejarah kes. Antara sampel yang perlu diambil adalah sampel makanan, sampel air, swab permukaan, swab peralatan, swab efluen air limbah dan bilik mandi pesakit.
5.6.4 Peralatan
Untuk menjalankan aktiviti penyiasatan, kawalan dan pencegahan yang lengkap pasukan yang terlibat perlu dibekalkan dengan peralatan yang mencukupi (Jadual 10).
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Jadual 10: Jenis Peralatan Wabak Kolera
Bil. Jenis Peralatan
i Bag, hand gloves, rubber boots, torch light, apron dan face mask.
ii Rectal swab dan Water samples bottles with Alkaline Pepton Water.
iii Kapas, plastic bags dan orange stick.
iv Peralatan alat tulis ( termasuk kertas, masking tape, stapler, gun thacker).
v Borang Penyiasatan (Kes/disyaki/Kontak).
vi Borang pemohonan analisa sampel rectal swab, swab permukaan, air dan makanan.
vii Methyl spirit 70%, Sodium hypochlorite 1:10, Lysol 1:20 atau dettol.
viii Bahan Promosi (poster, risalah, bunting/banner).
ix Alat pandang dengar (Haller,Laptop, LCD dan PA system) jika perlu.
5.7 Pengendalian Kes Kolera dan Kontak Positif serta Rawatan
5.7.1 Pengurusan Ke atas Kes Kolera
Semua kes kolera wajib dimasukkan ke hospital untuk tujuan pengasingan dan rawatan lengkap. Kes hanya dibenarkan didiscaj dari hospital setelah swab rektal yang diambil dari kes adalah negatif dengan organisma Vibrio cholera selama 3 hari berturut-turut.
5.7.2 Pengurusan Ke atas Kontak Kolera yang Positif
Kontak kes kolera yang positif perlu dikesan dengan kadar segera untuk dimasukkan ke hospital bagi maksud pengasingan dan rawatan segera. Ianya hanya dibenarkan didiscaj dari hospital setelah swab rektal yang diambil dari kes adalah negatif dengan organisma kolera selama 3 hari berturut-turut.
5.7.3 Rawatan prophylaxis
Pemberian Kemoprofilaksis boleh diberikan kepada kontak jika perlu tetapi hanya kepada kontak terdekat dan pengendali makanan yang berkenaan sahaja. “Mass chemoprophylaxis” tidak digalakkan kerana boleh menjadi faktor kepada kekebalan terhadap antibiotik.
5.8 Laporan
Bila berlaku kes kolera PKD/PKK perlu mengemukakan Laporan Awal Penyakit Kolera ke Jabatan Kesihatan Negeri Sabah dalam tempoh 24 jam dari tarikh kes/wabak disahkan dengan laporan di e-wabak dan menggunakan Borang FWBD/UMU/BG/001 (Pindaan 2006) (Jadual 11). JKNS perlu mengemukakan laporan tersebut sampai ke Kementerian Kesihatan Malaysia dalam masa 24 jam.
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Dalam masa yang sama PKD/PKK perlu menghantar laporan harian aktiviti kawalan dan pencegahan Kolera ke JKNS sebelum jam 9.00 pagi dengan menggunakan format laporan standard (FWBD/CHO/GP/001 (pindaan 2006), FWBD/UMU/BG/002 (pindaan 2006), FWBD/UMU/BG/003 (pindaan 2006) dan FWBD/UMU/BG/004).
Bila wabak telah diisytiharkan tamat (tiada kes baru kolera yang dilaporkan dalam masa 10 hari dari onset terakhir), pihak PKD/PKK perlu menghantar laporan Laporan Akhir Penyakit Kolera ke JKNS dalam masa 21 hari dari tarikh wabak diisytiharkan tamat. JKNS pula akan menyemak, membuat pembetulan dan penambaikan serta perlu memastikan Laporan tersebut dihantar ke Kementerian Kesihatan Malaysia dalam tempoh 1 bulan dari tarikh wabak disahkan tamat.
Jadual 11: Senarai Borang-borang Laporan Pengendalian Kolera
Bil. Nama Borang Nombor Borang
i Borang Laporan Awal wabak penyakit bawaan makanan dan air di Malaysia.
FWBD/UMU/BG/001 (Pindaan 2006)
ii Senarai pesakit / asimptomatik / disyaki / kematian penyakit Kolera / tifoid / hepatitis A / disenteri mengikut hari di daerah.
FWBD/UMU/BG/002 (Pindaan 2006)
iii Kedudukan harian kes / asimptomatik / disyaki / kematian di dalam wad penyakit Kolera / tifoid / hepatitis A / disenteri mengikut hari di daerah.
FWBD/UMU/BG/003 (Pindaan 2006)
iv Laporan harian aktiviti kawalan wabak kolera / tifoid / hepatitis A / disenteri di daerah.
FWBD/UMU/BG/004 (Pindaan 2006)
v Borang Siasatan Kes Penyakit Bawaan Makanan dan Air.
(FWBD/UMU/BG/007)
vi Senarai pesakit / asimptomatik / disyaki / kematian penyakit kolera / tifoid / hepatitis A / disenteri mengikut hari di dalam wad.
FWBD/UMU/BG/002(H) (Pindaan 2006)
vii Kedudukan harian kes / asimptomatik / disyaki / kematian di dalam wad penyakit Kolera / tifoid / hepatitis A / disenteri mengikut hari di negeri.
FWBD/UMU/BG/002(N) (Pindaan 2006)
viii Format Laporan akhir wabak / epidemik (Naratif).
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5.9. Promosi / Pendidikan Kesihatan
Promosi dan pendidikan kesihatan dijalankan dengan tujuan untuk meningkatkan kesedaran masyarakat tentang penyakit kolera dengan memberikan maklumat lengkap mengenai penyakit tersebut. Kumpulan sasaran termasuklah kes, asimptomatik, kontak, penduduk setempat, pengendali makanan, pengunjung/pesakit yang datang ke klinik-klinik, pemimpin setempat dan masyarakat umum.
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References:
1. Paediatric Protocols For Malaysian Hospital 2nd Edition.
2. WHO Management of the Child with Serious Infection or Severe Malnutrition.
3. Academy of Medicine CPG Acute Gastroenteritis in Children.
4. CDC Defeating Cholera: Clinical Presentation and Management for Haiti Cholera Outbreak, 2010.
5. Joan R Butterton et al. Overview of Vibrio Cholerae infection. 2011 UpToDate.
6. Islam MS, Midzi SM, Charimari L, et al. Susceptibility fo fluoroquinolones of Vibrio Cholerae 01 isolated from diarrheal patinets in Zimbabwe. JAMA 2009: 302:2321.
7. Fluid management guideline from The Royal Children’s Hospital Melbourne & NHS.
8. Endom E et al, Treatment of hypovolemia( dehydration) in children. 2011 Up to Date.
9. FDA, 1999. Bacteriological Analytical manual. 7th Edition.
10. Desmarchelier, P. M. 1997. Pathogenic Vibrios. In: Foodborne Microorganisms of Public Health Significance. 5th ed., AIFST (NSW Branch), Food Microbiology Group, North Sydney, NSW: 285-312.
11. Sousa, O. S., dos Fernandes Vieira, R. H. S., de Menezes, F. G. R. and dos Reis, C. M. F and Hofer, E. 2004. Detection of Vibrio parahaemolyticus and Vibrio cholerae in oyster, Crassostrea rhizophorae, collected from a natural nursery in the Coco River Estuary, Fortaleza, Ceara, Brazil. Revista do Instituto de Medicina Tropical de Sao Paola 46: 59-62.
12. Wong, H. C., Liu, S. H., Ku, L. W., Lee, I. Y., Wang, T. K., Lee, Y. S., Lee, C. L., Kuo, L. P., and Shih, D. Y. 2000. Characterization of Vibrio parahaemolyticus isolates obtained from foodborne illness outbreaks during 1992 through 1995 in Taiwan. Journal of Food Protection 63: 900-906.
13. Garis Panduan Umum Pengurusan Wabak Penyakit-penyakit Bawaan Makanan dan Air di Malaysia Jilid 1, Kementerian Kesihatan Malaysia Edisi Kedua 2006.
14. Garis Panduan Pengurusan Wabak Kolera di Malaysia Jilid 3, Kementerian Kesihatan Malaysia Edisi Kedua 2006.
15. Garispanduan Umum Pengurusan Penyakit-Penyakit Bawaan Makanan Dan Air Di Malaysia FWBD/UMU/GP/001 (pindaan 2006).
16. Kementerian Kesihatan Malaysia , Edisi Kedua , 2006 , MOH/EPI/23.00(GU).
17. Garispanduan Pengurusan Wabak Kolera FWBD/CHO/GP/001 (pindaan 2006).
18. Kementerian Kesihatan Malaysia, Edisi Kedua, 2006 , MOH/EPI/25.00(GU).
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19. FWBD/UMU/BG/002 (pindaan 2006) Senarai Pesakit/Pembawa/Disyaki Penyakit Kolera / Tifoid/ Hepatitis A/ Disentri di Daerah.
20. FWBD/UMU/BG/003 (pindaan 2006)Laporan Kedudukan Harian Kes/ Pembawa/ DiSyaki/
Kematian Di Dalam Wad Penyakit Kolera / Tifoid/ Hepatitis A/ Disentri.
21. FWBD/UMU/BG/004 Laporan Harian Aktiviti Kawalan Wabak Penyakit Kolera / Tifoid/ Hepatitis A/ Disentri.
22. Seksyen Penyakit MKA: PK (0).MKAKK.SP.01.L01 – Prosedur Penerimaan dan Pengendalian
Spesimen.
23. Seksyen Makanan MKAKK: SOP A03-026 – Analysis of Outbreak/ Food Poisoning Sample.
24. Seksyen Makanan MKAKK: Panduan Perkhidmatan Makmal Makanan, KKM Edisi Kedua 2011.
25. Seksyen Penyakit MKAKK: AK.MKAKK.SP.BAKTI.02 – Pemprosesan Tinja untuk Penyiasatan
Wabak Kolera.
26. Buku Panduan Perkhidmatan Makmal Makanan, KKM Edisi Kedua 2011.
Appendix 1
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Management of Cholera
Suspected cholera
All patients suspected to have cholera
RSVC must be taken
T. Doxycycline 300mg stat
Admitted to the hospital for isolation
Assess hydration and provide hydration as follow
Hydration assessment Management
No Dehydration
Well, alert EYES: Normal TEARS: Present MUCOSA: Moist SKIN TURGOR:Normal.
Snaps back rapidly No thirst
Oral Rehydration Sachet
Some Dehydration Management
2 or more of the following including 1 of the criteria in *
Oral Rehydration Sachet
*Restless, irritable EYES: Sunken TEARS: Absent MUCOSA: Dry SKIN TURGOR: *Skin
snaps back slowly THIRST: *Drinks eagerly
ORS 75ml/kg given over 4 hours Reassess hydration after 1-2 hours
Reassess after 4 hours Assess for level of dehydration If still some dehydrated repeat steps If hydration has improved proceed to management steps for some dehydration or no dehydration
Severe Dehydration Management
2 or more of the following including 1 of the criteria n bold
*Lethargic, unconscious or floppy
EYES:Very sunken and dry TEARS: Absent MUCOSA: Very Dry
SKIN TURGOR: *Skin
returns slowly
THIRST: *Not eager to drink or unable to drink
In Patients more than 5 years old, look for: Absent radial pulse Hypotension
Patients 1 year and older
100ml/kg in 3 hours 30ml/kg in 30 minutes in
the first hour then 70ml/kg in the next 2
hours Patients less than a year old
100ml/kg in 6 hours 30ml/kg in the first hour
then 70ml/kg in the following 5
hours
Reassess after initial 30ml/kg hydration Weak pulse Low blood pressure Repeat rapid fluid infusion until pulses and blood pressure are normal Reassess after 3 hours (6 hours for children) Assess for level of dehydration If still severely dehydrated repeat steps as above If hydration has improved proceed to management steps for some dehydration or no dehydration ORS 5ml/kg in addition to IV fluids
Appendix 1
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Maintenance of Hydration
Assessment of Dehydration
Review patients every 4 hours or more frequently if diarrhea is profuse
If patient remains dehydrated, rehydration should follow the steps mentioned above.
Discharge Once:
No More Diarrhoea No dehydration Three daily consecutive RSVC samples are negative
Appendix 2
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Antibiotics for Cholera
Start antibiotics for severely dehydrated patients and older than 2 years old.
Antibiotics will usually stop the diarrhea in 48 hours.
There is no advantage in injectable antibiotics
Feeding
Allow feeding once vomiting has ceased
Continue breast feeding in infants and children
APPENDIX 3
NAME:__________________
Cholera Observation Chart
ID :________________
DATE :_____________
TIME OF ADMISSION:___________
/ / / /
2 4 6 8 10 12 14 16 18 20 22 24
°C
40
39
38
37
36
140
130
120
110
90
80
70
60
50
40
RR
Pulse Volume
CRT
general condition
eyes sunken
Thirst
BO(frequency)
PU
Staff's Initial
40
Hour since
admissionTE
MP
ERA
TUR
E B
LOO
D P
RES
SUR
E P
ULS
E R
ATE
Pulse Volume - G - Good or W - Weak CRT: Capillary refill time ( in seconds) General condition: alert/irritable/lethargic
APPENDIX 4
Name :________________________________
Cholera Review Chart
ID:________________ Date :________________
Hour since
admission 0 2 4 6 8 10 12 14 16 18 20 24
general condition (alert/irritable/
lethargic*)
sunken eyes
thirst
unable to drink*
abdomen skin
turgor (normal/slow/ very
slow*)
Blood pressure
pulse rate (normal/
tachycardia*)
radial pulse volume
(good/ weak*)
urine output (ml)
(minimal/ no urine
output*)
BO watery
BO frequency
(since last review)
management :
Plan A/B/C
NOTE : patient with signs and symptoms highligthed with bold and asterix (*) is considered to have severe dehydration - need frequent monitoring and plan C
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