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

Graphene-based system could lead to improved information processing

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Nutritional information: Milk

Sales of whole milk in the United States made up about 70 percent of the market in the mid-1970s but have dropped dramatically since, while the sales of skim and 2 percent have risen. The most recent sales figures show:

- 2 percent at 40 percent of the market

- whole milk at 30 percent

- skim milk at 16 percent

- 1 percent milk at 14 percent

Note: Figures are from 2009, the last year for which data are available.

SOURCE: National Dairy Council; U.S. Department of Agriculture's Economic Research Service;

Nutritional information

No matter how much fat is in store-bought, conventionally farmed milk, one cup of it delivers roughly 30 percent of your daily calcium requirement, about a quarter of your Vitamin D and 8 grams of protein. But the calories and saturated fat contents vary:

Whole (3.25 percent milk fat)

146 calories per cup

5 grams saturated fat

Reduced fat (2 percent milk fat)

122 calories per cup

3 grams saturated fat Low fat (1 percent milk fat)

102 calories per cup

2 grams saturated fat

Nonfat/skim (less than 0.5 percent milk fat)

86 calories per cup

0 grams saturated fat

SOURCE: Self Nutrition Data

Online poll

What kind of milk to you prefer?

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Patients find plenty of health information on line, but not all of it is reliable

The Internet has no equal as an information storehouse. The trick is to know how to get right to a source of useful information and not waste time on Web sites that are biased, trying to sell you something or just plain wrong.

Marvin M. Lipman, Consumers Union's chief medical adviser, recalls having a patient who made a Google search and somehow settled on an abdominal aortic aneurysm (a worrisome bulge in the body's main blood vessel) as the logical explanation for his midback pain. No reassuring on Lipman's part eased the patient's apprehension. It took a sonogram to convince him he wasn't at death's door.

Lipman had another patient who was referred to him after her primary-care physician told her she had Graves' disease (an overactive thyroid). She arrived for her appointment armed with computer printouts of useful, accurate information and fully prepared to discuss the pros and cons of treatment options for her problem.

Lipman says that nothing has changed the doctor-patient relationship as radically during his career as the Internet. As recently as 1995, about one in 10 American adults had online access; today, about three of four adults and just shy of 100 percent of teenagers use the Internet to get information and communicate with others, according to the Pew Research Center. The one-way flow of health information from doctor to patient is now a dialogue, or even, at times, a debate.

Caveatemptor.com

Google and Yahoo are among the most-used search engines. But almost anyone can pay these Web sites to display advertisements, or "sponsored links." And anyone with something to sell can set up a Web site with few if any checks and balances on what it says.

While information sites such as AOL sometimes post paid links, many links are nothing more than ads for individual products. By searching Google for "flu symptoms," for example, ads may pop up for Kleenex, Tylenol and the homeopathic preparation called Oscillococcinum.

The top "natural" (i.e., unpaid) search results might also include some sites marketing a specific product. For instance, a recent Google search on "enlarged prostate" yielded information from the Mayo Clinic and the National Institutes of Health but also the Web site for an unproven herbal product.

The other dots

You can also find health information on the generally commercial-free government Web sites (with addresses that end in ".gov") and academic ones (".edu").

Some not-for-profit organizations run Web sites (".org") that are ad-free, including ConsumerReportsHealth.org, which charges for some of its information, and some take advertising. Others are littered with advertising, and some are fronts for industries or manufacturers with a commercial agenda.

Consumers visiting an unfamiliar site should always check the "About Us" section for clues about who is funding the content.

Figuring out the pecking order among Web sites requires narrowing the choices to those that provide up-to-date, reliable and understandable information. Many qualify. No doubt your doctors can recommend personal favorites. This is Lipman's current Top 5 list:

www.cancer.gov for information about cancer.

www.cdc.gov for information about infectious diseases, travel medicine and epidemiology.

www.fda.gov for information about drugs.

www.medlineplus.gov for information about diseases.

www.usp.org for information about medicine and nutritional supplements.

(c) Copyright 2011. Consumers Union of United States Inc.

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