NEW: Cholera Information for Healthcare Providers Going to Haiti

This document is intended to provide a brief overview of the current outbreak situation, basic epidemiology, diagnosis and management of patients with cholera, and prevention and infection control guidance for healthcare providers traveling to Haiti.  For more complete training on cholera, please refer to: http://www.cdc.gov/haiticholera/training/hcp_materials.htm.

An outbreak of cholera was confirmed in Haiti on October 21, 2010.  The outbreak strain has been identified as Vibrio cholerae serogroup O1, serotype Ogawa, biotype El Tor.  Previous to this outbreak, cholera had not been documented in Haiti for decades. For a cholera outbreak to occur, two conditions have to be met: (1) there must be significant breaches in the water, sanitation, and hygiene infrastructure used by groups of people, permitting large-scale exposure to food or water contaminated with V.cholerae organisms; and (2) cholera must be present in the population. While it is unclear how cholera was re-introduced to Haiti, both of these conditions now exist.

Mode of Transmission

Toxigenic V.cholerae are free-living organisms found in fresh and brackish water Cholera infections are most commonly acquired from drinking water in which V. cholerae is found naturally or into which it has been introduced from the feces of a symptomatic or asymptomatically infected personOther common vehicles include contaminated fish and shellfish, produce, or leftover food  that have not been properly reheated Transmission from person-to-person, including to healthcare workers during epidemics, has rarely been documentedCholera infection is most often asymptomatic or results in a mild gastroenteritis Approximately one in 20 (5%) infected persons will have severe disease characterized by acute, profuse watery diarrhea, described as “rice-water stools,” and vomiting, leading to dehydration Signs and symptoms of dehydration include tachycardia, loss of skin turgor, dry mucous membranes, hypotension, and thirst. Additional symptoms, including muscle cramps, are secondary to the resulting electrolyte imbalances If untreated, volume depletion can rapidly lead to hypovolemic shock and deathA suspected case of cholera is defined as profuse, acute watery diarrhea in a patient Laboratory testing is not required once an outbreak has been confirmed  Drink and use safe waterDrink only bottled, boiled, or chemically treated water and bottled or canned carbonated beverages. When using bottled drinks, make sure that the seal has not been broken. Use safe water to brush your teeth, wash and prepare food, and make ice. Piped water sources or tap water and drinks sold in cups or bags may not be safe and should be boiled, treated with chlorine, or avoided.  Ice should be avoided unless is known to have been made from safe water.To be sure water is safe to drink and use: Boil it or treat it with a chlorine product or household bleach. If boiling, bring your water to a complete boil for at least 1 minute. To treat your water with chlorine, use one of the locally available treatment products such as Aquatabs®, Dlo Lavi, Gayden Dlo, or PuR® and follow the instructions. If a chlorine treatment product is not available, you can treat your water with household bleach. Add 8 drops of household bleach for every 1 gallon of water (or 2 drops of household bleach for every 1 liter of water) and wait 30 minutes before drinking. If chlorine treatment is not available, you can treat your water with ½ an iodine tablet per liter of water.Always store your treated water in a clean, covered container. Wash your hands often with soap and safe water. Before you eat, prepare food, feed others, and after using the toilet.Before and after caring for someone ill with diarrhea, including patients.If no water and soap are available, use an alcohol-based hand cleaner (with at least 60% alcohol). If soap and alcohol-based hand cleaner are not available, scrub hands often with ash or sand and rinse with safe water.Use latrines or bury your feces; do not defecate in or near any body of water.Use latrines or other sanitation systems, like chemical toilets, to dispose of feces. Wash hands with soap and safe water after defecating. Clean latrines and surfaces that may have been fecally contaminated using a solution of 1 part household bleach to 9 parts water.What if I don’t have a latrine or chemical toilet? Defecate at least 30 meters away from any body of water and then bury your feces. Dispose of plastic bags containing feces in latrines, at collection points if available, or bury them in the ground. Do not put plastic bags in chemical toilets. Dig new latrines or temporary pit toilets at least a half-meter deep and at least 30 meters away from any body of water. Cook food well, keep it covered, eat it hot, and peel fruits and vegetables yourself.Boil it, cook it, peel it, or leave it. Be sure to cook seafood, especially shellfish, until it is very hot all the way through.Avoid raw foods other than fruits and vegetables you have peeled yourself. Clean up safely – in the kitchen and in places for bathing and washing clothes.Wash yourself, your children, diapers, and clothes 30 meters away from drinking water sources. Chemoprophylaxis with antibiotics is not indicated for healthcare providersHand washing with soap and clean water should be done before and after each patient contact If no water and soap are available, use an alcohol-based hand cleaner (with at least 60% alcohol) Several chlorine solutions are used for disinfection (solution calculations are based on using unscented household bleach with 5–6 % active chlorine): 2% chlorineMade using 3 parts water and 2 parts bleachUsed for disinfecting vomit, feces, and corpses0.5% chlorineMade using 9 parts water and 1 part bleachUsed for foot baths, cleaning floors, bedding, latrines0.05% chlorineMade using 9 parts water and 1 part 0.5% chlorine solutionUsed for bathing soiled patients, hand washing, rinsing dishes, laundry

At this time, CDC does not recommend cholera vaccines for travelers, including healthcare providers, since their risk of contracting the disease is extremely low.

Rapid high-volume oral or intravenous rehydration will save lives Appropriate administration of antibiotics can reduce duration of illness and reduce spread of disease 

Cholera patients should be evaluated and treated quickly.  Early administration of oral rehydration salt (ORS) solution is the mainstay of cholera treatment and should begin as soon as symptoms develop, continue while the patient seeks medical care, and be maintained until hydration returns to normal in the health-care facility.  ORS solution, combined with intravenous rehydration for those with severe dehydration, has been shown to reduce mortality rates to <1%.  Healthcare facilities in Haiti will need considerable assistance in preparing their facilities to provide the rapid clinical assessment and aggressive rehydration treatment necessary to reduce the risk for death from severe cholera.

Symptoms of Moderate or Severe Cholera

Profuse, watery diarrhea Vomiting Leg cramps

Signs and Symptoms of Dehydration

Some dehydration

Severe dehydration

Restlessness and irritability Sunken eyes Dry mouth and tongue Increased thirst Skin goes back slowly when pinched Decreased urine Infants: decreased tears, depressed fontanels Lethargy or unconsciousness Very dry mouth and tongue Skin goes back very slowly when pinched (“tenting”) Weak or absent pulse Low blood pressure Minimal or no urine

Dehydrated patients who can sit up and drink should be given ORS solution immediately and be encouraged to drink. It is important to offer ORS solution frequently, measure the amount drunk, and measure the fluid lost as diarrhea and vomitus. Patients who vomit should be given small, frequent sips of ORS solution, or ORS solution by nasogastric tube.  ORS solution should be made with safe water.  Safe water means the water has been boiled or treated with a chlorine product or household bleach.

Guidelines for treating patients with some dehydration Approximate amount of ORS solution to give in the first 4 hours to patients with some dehydration. Use the patient’s age only when you do not know the weight:

The approximate amount of ORS (in milliliters) can also be calculated by multiplying the patient’s weight in kg by 75. A rough estimate of oral rehydration rate for older children and adults is 100 ml ORS every five minutes, until the patient stabilizes. If the patient requests more than the prescribed ORS solution, give more. For infants, encourage the mother to continue breast-feeding.

Notes:
1. The volumes and time shown are guidelines based on usual needs. If necessary, amount and frequency can be increased, or the ORS solution can be given at the same rate for a longer period to achieve adequate rehydration. Similarly, the amount of fluid can be decreased if hydration is achieved earlier than expected.
2. During the initial stages of therapy, while still dehydrated, adults can consume as much as 1000 ml of ORS solution per hour, if necessary, and children as much as 20 ml/kg body weight per hour.
3. Reassess the patient after 1 hour of therapy and then every 1 to 2 hours until rehydration is complete.
4. Resume feeding with a normal diet when vomiting has stopped.

Patients with severe dehydration, stupor, coma, uncontrollable vomiting, or extreme fatigue that prevents drinking should be rehydrated intravenously.

Plain glucose (dextrose) solution

*Acceptable in emergency, but does not correct acidosis and may worsen electrolyte imbalance

Guidelines for treating patients with severe dehydration
Start intravenous fluids (IV) immediately. If the patient can drink,
give ORS solution by mouth while the IV drip is set up.
Give 100 ml/kg Ringer’s Lactate Solution divided as follows:

* Repeat once if radial pulse is still very weak or not detectable.

Reassess the patient every 1-2 hours and continue hydrating. If hydration is not improving, give the IV drip more rapidly. 200ml/kg or more may be needed during the first 24 hours of treatment. Also give ORS solution (about 5 ml/kg per hour) as soon as the patient can drink. After 6 hours (infants) or 3 hours (older patients), perform a full reassessment. Switch to ORS solution if hydration is improved and the patient can drink.

Signs of adequate rehydration

Skin goes back normally when pinched Thirst has subsided Urine has been passed Pulse is strong

An antibiotic given orally will reduce the volume and duration of diarrhea.  Treatment with antibiotics is recommended for moderately and severely ill patients, particularly for those patients who continue to pass large volume of stools during rehydration treatment, and including all patients who are hospitalized.  Do not give antibiotics to asymptomatic persons.  Zinc given orally can reduce the duration of most infectious diarrhea in children. No drugs should be given for treatment of diarrhea or vomiting besides antibiotics and zinc.

Appropriate oral antibiotics (give one of these) ** ALL BY MOUTH**

These recommendations are based on the antibiotic resistance profile of V. cholerae isolates from the Haiti cholera outbreak, as reported on December 14, 2010, and local drug availability. Multiple first choice and second choice options are presented. Selection of antibiotics should be based on individual case consideration and available medications.

Doxycycline: 300 mg by mouth in one dose

Azithromycin:1 gram in a single dose

Tetracycline: 500 mg 4 times a day for 3 days

Erythromycin: 500 mg 4 times a day for 3 days

Azithromycin: 1 gram in one dose

Erythromycin: 500 mg 4 times a day for 3 days

Children =12 months old and capable of swallowing pills and/or tables

Azithromycin: 20 mg/kg in one dose

Erythromycin: 12.5 mg/kg 4 times a day for 3 days

Doxycycline: 2-4 mg/kg in one dose*

Tetracycline: 12.5 mg/kg 4 times a day for 3 days

Children <12 months old and others unable to swallow pills and/or tablets

Azithromycin oral suspension: 20 mg/kg in one dose

Erythromycin oral suspension: 12.5 mg/kg 4 times a day for 3 days

Doxycycline oral suspension: 2-4 mg/kg in one dose*

Tetracycline oral suspension: 12.5mg/kg 4 times a day for 3 days

* Doxycycline is safe for treatment of cholera in children at the recommended dose. The Pan American Health Organization recommends doxycycline as a second-line choice because of limited regional availability and to avoid future overuse in children.

Zinc supplementation significantly reduces the severity and duration of most childhood diarrhea caused by infection. When available, supplementation (10-20 mg zinc per day) should be started immediately.
Videos on the assessment of dehydration and the treatment of cholera are available at:
http://www.cdc.gov/haiticholera/video/

If you get watery diarrhea within five days of returning from Haiti or the Dominican Republic, seek medical care right away.  Replacing the water and salt lost from your body is the most important part of cholera treatment.  Do not travel again until you are well.
For more information and tips about traveling to Haiti, visit www.cdc.gov/haiticholera.

View the original article here

NEW: Cholera Information for Healthcare Professionals

Here are Cholera resources for healthcare professionals addressing diagnosis, testing, treatment, patient care, and prevention. You will also find publications and patient education materials relevant to Cholera. Some of the resources included were developed for Cholera outbreaks in other areas but have relevant information that can be applied to the Haiti Cholera Outbreak response effort.

View the original article here

NEW: Consider Cholera: Information for U.S. Healthcare Professionals

There is an outbreak of cholera in Haiti.
Healthcare professionals in the United States need to be on the lookout for possible cases.

What is cholera?
Cholera is an acute bacterial enteric disease with sudden onset of profuse watery diarrhea and
vomiting. If severe, it can lead to severe dehydration, shock, acidosis, and death in hours.

When should I suspect cholera?
You should suspect cholera in any patient presenting with severe watery diarrhea and vomiting
with severe dehydration, particularly after recent travel from Haiti. The patient may complain of
painful cramping in the legs due to electrolyte disturbances. Clinical suspicion should be
increased, and milder diarrheal illnesses are more suspect, in persons returning from Haiti, or in
persons with a recent history of ingestion of raw seafood. The incubation period of cholera is
between two hours and five days.

How do I diagnosis cholera?
The diagnosis is made by culturing the organism from the stool. Notify your lab that you are
considering cholera so that they will culture on TCBS agar. However, you should not wait for a
positive culture before starting aggressive treatment.

How do I treat cholera?
The severe cholera patient may have lost more than 10% of body weight and needs swift volume
replacement. Cholera deaths can be prevented by the aggressive administration of fluids. This
will correct the dehydration, shock, and acidosis. Antibiotic treatment is less important, but will
decrease the duration of illness.

What fluids should I give?
This depends on the patient's condition. Patients with mild to moderate dehydration can be given
an appropriate oral rehydration salt solution such as Rehydralyte™ or WHO Formula Oral
Rehydration Salts (ORS). Only solutions that contain the proper balance of electrolytes should
be given.

Patients with severe dehydration or those with intractable vomiting need intravenous therapy
with Ringer’s lactate solution. Intravenous fluid should be given quickly to restore the
circulation, followed by oral fluids as soon as possible.

How much fluid should I give?
Fluid therapy needs to be individualized. Severely dehydrated adults may require several liters of
fluid immediately to restore an adequate circulating volume. Base your therapy on the degree of
dehydration. Remember that cholera patients will have significant on-going fluid losses that also
need to be measured and replaced.

What antibiotic should I use?
Based on antimicrobial susceptibility testing on strains from the ongoing cholera outbreak in
Haiti, the following antimicrobial regimens may be used to treat confirmed or suspected cases of
cholera possible linked to this outbreak. Note that oral suspensions of most of these medications
are available for young children.

Doxycycline
Adult (non-pregnant): 300 mg in a single dose
Child: 2-4 mg/kg in a single dose

Azithromycin
Adult: 1g in a single dose
Child: 20 mg/kg in a single dose

Tetracycline
Adult (non-pregnant): 500 mg, 4 times/day for 3 days
Child: 12.5 mg per kg,4 times/day for 3 days

Erythromycin
Adult: 500 mg, 4 times/day for 3 days
Child: 12 mg/kg, 4 times/day for 3 days

Clinical management guidelines including antibiotic treatment are also posted on CDC’s website
at http://www.cdc.gov/haiticholera/clinicalmanagement/

What else should I do?
All suspected or confirmed cases of cholera should be reported to your county or state health
department immediately. Do not swim while ill with diarrhea or for 2 weeks after resolution of
symptoms.

View the original article here

New: Cholera Information for Healthcare Providers Going to Haiti

This document is intended to provide a brief overview of the current outbreak situation, basic epidemiology, diagnosis and management of patients with cholera, and prevention and infection control guidance for healthcare providers traveling to Haiti.  For more complete training on cholera, please refer to: http://www.cdc.gov/haiticholera/training/hcp_materials.htm.

An outbreak of cholera was confirmed in Haiti on October 21, 2010.  The outbreak strain has been identified as Vibrio cholerae serogroup O1, serotype Ogawa, biotype El Tor.  Previous to this outbreak, cholera had not been documented in Haiti for decades. For a cholera outbreak to occur, two conditions have to be met: (1) there must be significant breaches in the water, sanitation, and hygiene infrastructure used by groups of people, permitting large-scale exposure to food or water contaminated with V.cholerae organisms; and (2) cholera must be present in the population. While it is unclear how cholera was re-introduced to Haiti, both of these conditions now exist.

Mode of Transmission

Toxigenic V.cholerae are free-living organisms found in fresh and brackish water Cholera infections are most commonly acquired from drinking water in which V. cholerae is found naturally or into which it has been introduced from the feces of a symptomatic or asymptomatically infected personOther common vehicles include contaminated fish and shellfish, produce, or leftover food  that have not been properly reheated Transmission from person-to-person, including to healthcare workers during epidemics, has rarely been documentedCholera infection is most often asymptomatic or results in a mild gastroenteritis Approximately one in 20 (5%) infected persons will have severe disease characterized by acute, profuse watery diarrhea, described as “rice-water stools,” and vomiting, leading to dehydration Signs and symptoms of dehydration include tachycardia, loss of skin turgor, dry mucous membranes, hypotension, and thirst. Additional symptoms, including muscle cramps, are secondary to the resulting electrolyte imbalances If untreated, volume depletion can rapidly lead to hypovolemic shock and deathA suspected case of cholera is defined as profuse, acute watery diarrhea in a patient Laboratory testing is not required once an outbreak has been confirmed  Drink and use safe waterDrink only bottled, boiled, or chemically treated water and bottled or canned carbonated beverages. When using bottled drinks, make sure that the seal has not been broken. Use safe water to brush your teeth, wash and prepare food, and make ice. Piped water sources or tap water and drinks sold in cups or bags may not be safe and should be boiled, treated with chlorine, or avoided.  Ice should be avoided unless is known to have been made from safe water.To be sure water is safe to drink and use: Boil it or treat it with a chlorine product or household bleach. If boiling, bring your water to a complete boil for at least 1 minute. To treat your water with chlorine, use one of the locally available treatment products such as Aquatabs®, Dlo Lavi, Gayden Dlo, or PuR® and follow the instructions. If a chlorine treatment product is not available, you can treat your water with household bleach. Add 8 drops of household bleach for every 1 gallon of water (or 2 drops of household bleach for every 1 liter of water) and wait 30 minutes before drinking. If chlorine treatment is not available, you can treat your water with ½ an iodine tablet per liter of water.Always store your treated water in a clean, covered container. Wash your hands often with soap and safe water. Before you eat, prepare food, feed others, and after using the toilet.Before and after caring for someone ill with diarrhea, including patients.If no water and soap are available, use an alcohol-based hand cleaner (with at least 60% alcohol). If soap and alcohol-based hand cleaner are not available, scrub hands often with ash or sand and rinse with safe water.Use latrines or bury your feces; do not defecate in or near any body of water.Use latrines or other sanitation systems, like chemical toilets, to dispose of feces. Wash hands with soap and safe water after defecating. Clean latrines and surfaces that may have been fecally contaminated using a solution of 1 part household bleach to 9 parts water.What if I don’t have a latrine or chemical toilet? Defecate at least 30 meters away from any body of water and then bury your feces. Dispose of plastic bags containing feces in latrines, at collection points if available, or bury them in the ground. Do not put plastic bags in chemical toilets. Dig new latrines or temporary pit toilets at least a half-meter deep and at least 30 meters away from any body of water. Cook food well, keep it covered, eat it hot, and peel fruits and vegetables yourself.Boil it, cook it, peel it, or leave it. Be sure to cook seafood, especially shellfish, until it is very hot all the way through.Avoid raw foods other than fruits and vegetables you have peeled yourself. Clean up safely – in the kitchen and in places for bathing and washing clothes.Wash yourself, your children, diapers, and clothes 30 meters away from drinking water sources. Chemoprophylaxis with antibiotics is not indicated for healthcare providersHand washing with soap and clean water should be done before and after each patient contact If no water and soap are available, use an alcohol-based hand cleaner (with at least 60% alcohol) Several chlorine solutions are used for disinfection (solution calculations are based on using unscented household bleach with 5–6 % active chlorine): 2% chlorineMade using 3 parts water and 2 parts bleachUsed for disinfecting vomit, feces, and corpses0.5% chlorineMade using 9 parts water and 1 part bleachUsed for foot baths, cleaning floors, bedding, latrines0.05% chlorineMade using 9 parts water and 1 part 0.5% chlorine solutionUsed for bathing soiled patients, hand washing, rinsing dishes, laundry

At this time, CDC does not recommend cholera vaccines for travelers, including healthcare providers, since their risk of contracting the disease is extremely low.

Rapid high-volume oral or intravenous rehydration will save lives Appropriate administration of antibiotics can reduce duration of illness and reduce spread of disease 

Cholera patients should be evaluated and treated quickly.  Early administration of oral rehydration salt (ORS) solution is the mainstay of cholera treatment and should begin as soon as symptoms develop, continue while the patient seeks medical care, and be maintained until hydration returns to normal in the health-care facility.  ORS solution, combined with intravenous rehydration for those with severe dehydration, has been shown to reduce mortality rates to <1%.  Healthcare facilities in Haiti will need considerable assistance in preparing their facilities to provide the rapid clinical assessment and aggressive rehydration treatment necessary to reduce the risk for death from severe cholera.

Symptoms of Moderate or Severe Cholera

Profuse, watery diarrhea Vomiting Leg cramps

Signs and Symptoms of Dehydration

Some dehydration

Severe dehydration

Restlessness and irritability Sunken eyes Dry mouth and tongue Increased thirst Skin goes back slowly when pinched Decreased urine Infants: decreased tears, depressed fontanels Lethargy or unconsciousness Very dry mouth and tongue Skin goes back very slowly when pinched (“tenting”) Weak or absent pulse Low blood pressure Minimal or no urine

Dehydrated patients who can sit up and drink should be given ORS solution immediately and be encouraged to drink. It is important to offer ORS solution frequently, measure the amount drunk, and measure the fluid lost as diarrhea and vomitus. Patients who vomit should be given small, frequent sips of ORS solution, or ORS solution by nasogastric tube.  ORS solution should be made with safe water.  Safe water means the water has been boiled or treated with a chlorine product or household bleach.

Guidelines for treating patients with some dehydration Approximate amount of ORS solution to give in the first 4 hours to patients with some dehydration. Use the patient’s age only when you do not know the weight:

The approximate amount of ORS (in milliliters) can also be calculated by multiplying the patient’s weight in kg by 75. A rough estimate of oral rehydration rate for older children and adults is 100 ml ORS every five minutes, until the patient stabilizes. If the patient requests more than the prescribed ORS solution, give more. For infants, encourage the mother to continue breast-feeding.

Notes:
1. The volumes and time shown are guidelines based on usual needs. If necessary, amount and frequency can be increased, or the ORS solution can be given at the same rate for a longer period to achieve adequate rehydration. Similarly, the amount of fluid can be decreased if hydration is achieved earlier than expected.
2. During the initial stages of therapy, while still dehydrated, adults can consume as much as 1000 ml of ORS solution per hour, if necessary, and children as much as 20 ml/kg body weight per hour.
3. Reassess the patient after 1 hour of therapy and then every 1 to 2 hours until rehydration is complete.
4. Resume feeding with a normal diet when vomiting has stopped.

Patients with severe dehydration, stupor, coma, uncontrollable vomiting, or extreme fatigue that prevents drinking should be rehydrated intravenously.

Plain glucose (dextrose) solution

*Acceptable in emergency, but does not correct acidosis and may worsen electrolyte imbalance

Guidelines for treating patients with severe dehydration
Start intravenous fluids (IV) immediately. If the patient can drink,
give ORS solution by mouth while the IV drip is set up.
Give 100 ml/kg Ringer’s Lactate Solution divided as follows:

* Repeat once if radial pulse is still very weak or not detectable.

Reassess the patient every 1-2 hours and continue hydrating. If hydration is not improving, give the IV drip more rapidly. 200ml/kg or more may be needed during the first 24 hours of treatment. Also give ORS solution (about 5 ml/kg per hour) as soon as the patient can drink. After 6 hours (infants) or 3 hours (older patients), perform a full reassessment. Switch to ORS solution if hydration is improved and the patient can drink.

Signs of adequate rehydration

Skin goes back normally when pinched Thirst has subsided Urine has been passed Pulse is strong

An antibiotic given orally will reduce the volume and duration of diarrhea.  Treatment with antibiotics is recommended for moderately and severely ill patients, particularly for those patients who continue to pass large volume of stools during rehydration treatment, and including all patients who are hospitalized.  Do not give antibiotics to asymptomatic persons.  Zinc given orally can reduce the duration of most infectious diarrhea in children. No drugs should be given for treatment of diarrhea or vomiting besides antibiotics and zinc.

Appropriate oral antibiotics (give one of these) ** ALL BY MOUTH**

These recommendations are based on the antibiotic resistance profile of V. cholerae isolates from the Haiti cholera outbreak, as reported on December 14, 2010, and local drug availability. Multiple first choice and second choice options are presented. Selection of antibiotics should be based on individual case consideration and available medications.

Doxycycline: 300 mg by mouth in one dose

Azithromycin:1 gram in a single dose

Tetracycline: 500 mg 4 times a day for 3 days

Erythromycin: 500 mg 4 times a day for 3 days

Azithromycin: 1 gram in one dose

Erythromycin: 500 mg 4 times a day for 3 days

Children =12 months old and capable of swallowing pills and/or tables

Azithromycin: 20 mg/kg in one dose

Erythromycin: 12.5 mg/kg 4 times a day for 3 days

Doxycycline: 2-4 mg/kg in one dose*

Tetracycline: 12.5 mg/kg 4 times a day for 3 days

Children <12 months old and others unable to swallow pills and/or tablets

Azithromycin oral suspension: 20 mg/kg in one dose

Erythromycin oral suspension: 12.5 mg/kg 4 times a day for 3 days

Doxycycline oral suspension: 2-4 mg/kg in one dose*

Tetracycline oral suspension: 12.5mg/kg 4 times a day for 3 days

* Doxycycline is safe for treatment of cholera in children at the recommended dose. The Pan American Health Organization recommends doxycycline as a second-line choice because of limited regional availability and to avoid future overuse in children.

Zinc supplementation significantly reduces the severity and duration of most childhood diarrhea caused by infection. When available, supplementation (10-20 mg zinc per day) should be started immediately.
Videos on the assessment of dehydration and the treatment of cholera are available at:
http://www.cdc.gov/haiticholera/video/

If you get watery diarrhea within five days of returning from Haiti or the Dominican Republic, seek medical care right away.  Replacing the water and salt lost from your body is the most important part of cholera treatment.  Do not travel again until you are well.
For more information and tips about traveling to Haiti, visit www.cdc.gov/haiticholera.

View the original article here

NEW: Haiti Cholera Healthcare Provider Training Materials in English

This page is located at http://www.cdc.gov/haiticholera/training/hcp_materials.htm.

Sorry, I could not read the content fromt this page.

View the original article here

House Republicans sharpen attack on health-care reform in two Hill hearings

Republicans on Wednesday used their new majority in the House of Representatives to hold the first of what they promise will be a steady drumbeat of congressional hearings to denounce the new health-care law.

During a hearing before the House Ways and Means Committee, two business owners and a prominent economist testified that the law imposes crushing costs that hamper job creation. Republican members also grilled Austan Goolsbee, chairman of the White House Council of Economic Advisers, for nearly two hours, charging that his rosy assessment of the law's economic impact was based on accounting gimmicks.

At a separate, nearly simultaneous hearing before the House Budget Committee, Chairman Paul Ryan (R-Wisc.) heaped praise on his star witness, Rick Foster, chief actuary for Medicaid and Medicare, who has questioned some of the Obama administration's predictions of savings through the health-care law.

"Time and time again, Rick's unbiased actuarial reports have proved difficult to square with the claims made by the law's proponents," said Ryan, adding that such analyses "enabled us to unpack the law's budgetary smoke and mirrors and reveal its true impact."

The Obama administration responded with a public relations offensive of its own, releasing letters from high-profile economists who back the law, and holding a news conference at which Secretary of Commerce Gary Locke and Costco chief executive Jim Sinegal argued that the law is a lifesaver for U.S. businesses because it will curb skyrocketing premiums.

In a White House blog post, Stephanie Cutter, a top White House official, also took on Foster's conclusions, writing that his analysis "discounts proposals that other independent experts credit with getting at the root causes of health care cost growth."

The latest round of sparring largely reprised arguments made in both the lead-up to the law's adoption last March and the floor debate preceding the House's nearly party-line vote to repeal it last week. However, the vigor with which each side jumped into the fray suggests both are determined to continue attempting to shape public opinion on an issue over which Americans have remained stubbornly divided.

"The hearing today is just our first of many," said House Ways and Means Chairman Dave Camp (R-Mich.) at the outset. "It is my intention to give the American people and employers big and small the opportunity they never had when this law was being written to testify in an open hearing about the impact the law will have on them."

Scott Womack, owner of 12 IHOP restaurants in Indiana and Ohio, told the committee that the law's mandate that he begin purchasing health insurance for his workers in 2014 is simply unsustainable. It will cost him $7,000 per worker to comply, he said, "more money than we make."

The alternative, to pay a $2,000 penalty per worker, would still eat up 60 percent of his company's earnings, Womack added. As a result, he may be forced to forfeit an agreement to develop additional restaurants, for which he has already invested $360,000.

"The goal of providing health coverage is noble, but the restaurant industry can't afford the steep fines and mandates loaded upon us," Womack concluded. "The law is one-size-fits-all for employers, and restaurants don't fit."

Joe Olivo, co-owner of a printing business in Moorestown, N.J., was particularly critical of the so-called 1099 provision of the new health-care law - which requires businesses to substantially expand their reporting of purchases to the IRS. The aim is to help the agency identify tax cheats, but Olivo said with his profits already squeezed to 3 cents on every dollar earned, the cost of complying would be "huge."

Democrats have long expressed willingness to remove the provision, and President Obama reiterated his support for doing so during his State of the Union speech Tuesday.

However, Camp was not mollified. Noting that Obama has called the provision "counterproductive," he said, "I have one simple question today: How is it that Congress passed a health-care bill that is 'counterproductive' to American employers - especially at a time when we need to be looking for solutions that encourage, not impede, job creation?"

Olivo, who currently offers health insurance to his 45 employees, also testified that - in contravention of the president's promise that people who liked their health plans would be able to keep them - his insurer has informed him that his plan will be discontinued. The reason, said Olivo, is that the plan does not offer the level of preventative care coverage required by the new law.

"After 20-plus years of voluntarily providing coverage for my employees, much of it at my own cost, I am now finding out this coverage is no longer acceptable according to the government," he said.

Rep. Bill Pascrell (D-N.J.) questioned Olivo's account, noting that many of the law's minimum requirements for plans do not apply to those already in existence before the law was passed. "It sounds like your carrier may have pulled a fast one on you," he said. "Obamacare was the perfect scapegoat before the law even went into effect."

Democrats also echoed Goolsbee's testimony that the law would prove a boon to businesses. The smallest firms can get tax credits to offset the cost of buying insurance for their workers, he said. Slightly larger companies will be able to buy insurance on state-run marketplaces that can offer the more stable premiums that big companies have long enjoyed, leveling the playing field. And all businesses will benefit from the anticipated curbing of health-care costs resulting from the drop in the large uninsured population - whose uncompensated health-care costs often get passed on to paying customers.

During the White House news conference later in the day, Sinegal said that those savings alone would make all the difference for his company. While Costco is committed to offering its roughly 96,000 U.S. employees generous health insurance benefits, Sinegal said, its ability to do so has been being seriously threatened by double-digit premium spikes each year.

"We either have to have some type of plan like this that helps us rein in costs or we're not going to be able to continue as a business," he said.

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Wisconsin's health-care fight illustrates challenges as states change leadership

MADISON, WIS. - Two weeks after President Obama signed the nation's health-care overhaul into law, then-Wisconsin Gov. Jim Doyle (D) issued an executive order creating an Office of Health Care Reform.

Over the next eight months, the Badger State made more headway than virtually anywhere else in the country at preparing to carry the statute out. It designed - and presented at the White House - the country's only prototype for how people and small businesses could navigate a new health insurance marketplace online. It produced a 205-page blueprint envisioning that marketplace as a "transformative force," steering people toward care of high quality and low cost.

Then, in late January, Doyle's Republican successor, Scott Walker, issued his own executive order, dissolving the health reform office and replacing it with the Office of Free Market Health Care.

"We view this as a fundamentally different approach than what the past [Wisconsin] administration was doing - and what . . . the Obama administration is pushing," Walker said in the first interview he has given about health-care reform since assuming office.

Wisconsin's U-turn, as sharp as anywhere in the country, illustrates how the views of state leaders are shaping the way the health-care overhaul envisioned by Congress will work on the ground. It illustrates, too, the treacherous terrain the Obama administration and congressional Democrats are walking by entrusting states to carry out major parts of the plan now that 29 governors are Republicans, including 18 who - like Walker - have taken office this winter. In Wisconsin, as in five other states, both chambers of the legislature also have just switched to GOP control.

"We've gone from one kind of boldness to another," said Robert Kraig, executive director of Citizen Action of Wisconsin and a leading liberal activist on health care in this university town with its granite-domed state Capitol.

But being dead set against the health law is not proving to be a simple matter of saying no to everything it contains. The new opposition is subtler but no less profound - a process of picking and choosing provisions to embrace or reject, of taking some grants offered by the federal government while spurning others, of striving to kill the law in Congress or the courts while preparing a conservative alternative.

Walker, best known for his effort to demolish rights to collective bargaining for government employees, thinks that the health-care statute is unconstitutional and that the government has no business influencing people's health-care choices. Doyle's aides estimated that the law would save Wisconsin $850 million by the end of the decade; Walker's estimate that it would cost $433 million.

Where Wisconsin is coming from

With states required by 2014 to carry out the law's core features - among them, widening access to private and public insurance - Wisconsin is in a more auspicious starting place than most. Just 6 percent of its residents lack health coverage, the second-lowest proportion in the country. And over the years, Wisconsin repeatedly has expanded Medicaid, called BadgerCare here, so that an unusually large share of people already has public insurance.

Those distinctions are part of the Walker administration's justification for resisting federal requirements. "Wisconsin . . . already has accomplished much of what [the law] aspires to do," said Dennis G. Smith, the new secretary of the state's Department of Health Services.

Smith, the driving force behind Wisconsin's about-face, arrived from Washington in January with a reputation as a mild-mannered, highly conservative thinker on health policy. Under President George W. Bush, he was in charge of Medicaid at the U.S. Department of Health and Human Services. More recently, he was at the Heritage Foundation, writing criticisms of the new federal law. He said in an interview that he did not have ties to Wisconsin or know Walker before mutual acquaintances, including Rep. Paul Ryan (R-Wis.), chairman of the House Budget Committee, suggested to both men that they should talk.

In a primary example of obeying the law selectively, Walker and Smith said they will create, as the statute envisions, one or more marketplaces called exchanges to help individuals and small businesses buy insurance. But the exchanges will not do everything the law says. "We believe it's got to be free-market driven, not government driven," Walker said.

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Obama says he will support letting states opt out of health-care law earlier

President Obama told a group of governors Monday that he would support moving up the timetable in which states may opt out of the federal health care law, making a major overture to critics of the legislation.

In his speech to the governors, who were attending the winter meeting of the National Governors Association, Obama said he would approve of allowing states to opt out of the Affordable Care Act by 2014 if they could offer health-care coverage for as many people as they would under the law and not increase the deficit. Under the original law, states could not opt until in 2017. Still, 2014 is a critical year, as many of the most important provisions of the bill, including the mandate, go into effect.

The new opt-out provision was first proposed by a bipartisan group of senators that included Sen. Scott Brown (R-Mass.) and Ron Wyden (D-Ore.).

"I think that's a reasonable proposal. I support it," Obama told governors of both parties assembled in the State Dining Room. "It will give you more flexibility more quickly, while still guaranteeing the American people reform. If your state can create a plan that covers as many people as affordably and comprehensively as the Affordable Care Act does - without increasing the deficit - you can implement that plan. And we'll work with you to do it."

Obama's move comes as a number of states, nearly all with Republican attorneys general, have filed suit to invalidate the law, arguing that requiring all Americans to purchase health insurance is unconstitutional. Three federal courts have ruled that the current law is constitutional, while two have struck it down.

The flexibility on opting out could appeal to Republicans both in Congress and in statehouses, who have been the main critics of the legislation. And some more liberal states, such as Oregon, have said they might consider alternative ways to expand insurance.

The governors said Obama's willingness to support an earlier opt-out from the law was welcome, but they stopped short of fully embracing it.

"A number of our fellow governors would be very interested in supporting this," said Gov. Christine Gregoire (D-Wash.), the current NGA chair. "We need to talk to them to see if we can put our support behind that bill as the National Governors Association. But I can assure you there is conservable interest among the governors."

The more flexibility in managing health care the better, Gov. Mary Fallin (R-Okla.) said. But "we'll see if it's going to be flexible enough."

Mississippi Gov. Haley Barbour (R) was also cautious. "The devil's in the details," he said. "We have to learn more about it before we know."

Kansas Gov. Sam Brownback (R-Kan.) opposed the health-care law while he was still in the Senate. He said the president's proposal doesn't negate what he and other Republicans see as a fatally flawed law. "This offers a little bit of flexibility, which I think is a positive thing, but it doesn't change the overall objection to the bill."

Brownback said he and others who are challenging the law in court will "implement what we're required to do" while continuing to fight it.

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U.S. recovers $4 billion from health-care fraud cases

The government recaptured a record $4 billion last year from pharmaceutical companies, hospitals, doctors, nursing homes and other providers of care that defrauded federal health-care programs, the Obama administration reported Monday.

Administration officials also called attention to new federal rules intended to prevent fraud - or detect it early - that took effect Monday as a result of the law enacted last year to overhaul the health-care system.

The annual report arrives as the new Republican leaders in the House are planning congressional investigations, suggesting that the administration is not aggressive in pursuing government waste and fraud.

"We can save $125 billion in simply not giving out money to Medicare recipients that don't exist for procedures that didn't happen," Rep. Darrell E. Issa (R-Calif.), the new chairman of the House Oversight and Government Reform Committee, said this month. Facing a hostile climate in the House, several senior aides to President Obama heavily touted what Health and Human Services Secretary Kathleen Sebelius called "unprecedented work to safeguard taxpayer dollars."

During the fiscal year ended in September, the report says, the government recovered $4.02 billion from fraud cases completed during that year or in the past. That sum compares with $2.6 billion recovered in fiscal 2009 and slightly more than $2 billion in 2008. Nearly three-fourths of the total recouped last year was from fraud against Medicare, the federal health insurance for older Americans. The figures also show that the government won court judgments and out-of-court settlements last year amounting to $2.5 billion, although not all that money has been collected.

According to Justice Department statistics, the number of new criminal and civil investigations of potential health-care fraud, most involving Medicare, increased slightly last year. And the number of defendants convicted of such fraud grew to more than 700 in 2010 from fewer than 600 the previous two years.

Less than a week after the Republican-led House voted to repeal the new health-care law, administration officials continued to focus attention on provisions they think the public will like.

Sebelius pointed out that the new rules authorized by the law, which took effect Monday, require more thorough screenings for health-care workers, companies and institutions that want to participate in Medicare, Medicaid or the Children's Health Insurance Program. And if such participants are accused of fraud, government officials can stop payments to them while they conduct an investigation.

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