Garispanduan Pengurusan Dan

Pengendalian Peyakit Kolera

Jabatan Kesihatan Negeri Sabah

i

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

7

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

10

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

iv

2.10 Infection Control Recommendation for Hospitalized Cholera Patients

13

3.0 Laboratory Diagnosis of Vibrio Cholera in Hospital

14

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

17

4.1 Pemprosesan Sampel untuk Ujian Makmal bagi Spesimen Wabak di Seksyen Penyakit Makmal Kesihatan Kota Kinabalu

17

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

29

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

1

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.

3

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

38

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

39

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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