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{{Cholera}}
{{Cholera}}
{{CMG}}
{{CMG}}; '''Associate Editors-In-Chief:''' [[Priyamvada Singh|Priyamvada Singh, MBBS]] [mailto:psingh13579@gmail.com]


==Overview==
==Overview==
Choleria is a severe bacterial gastrointestinal, diarrheal disease. In its most severe forms, cholera is one of the most rapidly fatal illnesses known. A healthy person may become [[hypotension|hypotensive]] within an hour of the onset of symptoms and may die within 2-3 hours if no treatment is provided. More commonly, the disease progresses from the first liquid stool to shock in 4-12 hours, with death following in 18 hours to several days without [[rehydration]] treatment.<ref name=McLeod_2000>{{cite journal |author=McLeod K |title=Our sense of Snow: John Snow in medical geography |journal=Soc Sci Med |volume=50 |issue=7-8 |pages=923-35 |year=2000 |pmid = 10714917}}</ref><ref> WHO Cholera [http://www.who.int/topics/cholera/control/en/index.html]</ref>
In most cases, cholera can be successfully treated with [[oral rehydration therapy]] (ORT), which is highly effective, safe, and simple to administer. In severe cases with significant dehydration, [[intravenous]] rehydration may be necessary. [[Ringer's lactate]] is the preferred solution, often with added potassium. Large volumes and continued replacement until diarrhea has subsided may be needed<ref name="pmid24379835">{{cite journal| author=Lankarani KB, Alavian SM| title=Lessons learned from past cholera epidemics, interventions which are needed today. | journal=J Res Med Sci | year= 2013 | volume= 18 | issue= 8 | pages= 630-1 | pmid=24379835 | doi= | pmc=3872598 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24379835  }} </ref><ref name="pmid11869639">{{cite journal| author=Hahn S, Kim S, Garner P| title=Reduced osmolarity oral rehydration solution for treating dehydration caused by acute diarrhoea in children. | journal=Cochrane Database Syst Rev | year= 2002 | volume=  | issue= 1 | pages= CD002847 | pmid=11869639 | doi=10.1002/14651858.CD002847 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11869639  }} </ref>. Ten percent of a person's body weight in fluid may need to be given in the first two to four hours. [[Antibiotic]] treatments for one to three days shorten the course of the disease and reduce the severity of the symptoms<ref name="pmid9203786">{{cite journal| author=Kabir I, Khan WA, Haider R, Mitra AK, Alam AN| title=Erythromycin and trimethoprim-sulphamethoxazole in the treatment of cholera in children. | journal=J Diarrhoeal Dis Res | year= 1996 | volume= 14 | issue= 4 | pages= 243-7 | pmid=9203786 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9203786  }} </ref>. People can recover even without them, if sufficient hydration and electrolyte balance is maintained. [[Doxycycline]] is typically used first line<ref name="pmid708024">{{cite journal| author=Sack DA, Islam S, Rabbani H, Islam A| title=Single-dose doxycycline for cholera. | journal=Antimicrob Agents Chemother | year= 1978 | volume= 14 | issue= 3 | pages= 462-4 | pmid=708024 | doi= | pmc=352482 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=708024  }} </ref>, although some [[Strain (biology)|strains]] of ''V. cholerae'' have shown [[Antibiotic resistance|resistance]]<ref name="pmid6975183">{{cite journal| author=Towner KJ, Pearson NJ, Mhalu FS, O'Grady F| title=Resistance to antimicrobial agents of Vibrio cholerae E1 Tor strains isolated during the fourth cholera epidemic in the United Republic of Tanzania. | journal=Bull World Health Organ | year= 1980 | volume= 58 | issue= 5 | pages= 747-51 | pmid=6975183 | doi= | pmc=2395989 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6975183  }} </ref>. Zinc supplementation has been shown to reduce stool output and reduces the duration and severity of symptoms.<ref name="pmid18184631">{{cite journal| author=Roy SK, Hossain MJ, Khatun W, Chakraborty B, Chowdhury S, Begum A et al.| title=Zinc supplementation in children with cholera in Bangladesh: randomised controlled trial. | journal=BMJ | year= 2008 | volume= 336 | issue= 7638 | pages= 266-8 | pmid=18184631 | doi=10.1136/bmj.39416.646250.AE | pmc=2223005 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18184631  }} </ref>
==Medical therapy==
 
===Summary of the treatment===
==Medical Therapy==
* Rehydrate with ORS or IV solution depending on the severity. Rehydration involves replenishment of the lost fluids and then maintenance of the fluid balance
===Summary of the Treatment===
* Maintain hydration and monitor frequently the hydration status
* Rehydrate with ORS or IV solution depending on the severity. Rehydration involves replenishment of the lost fluids and then maintenance of the fluid balance <ref name="pmid24379835">{{cite journal| author=Lankarani KB, Alavian SM| title=Lessons learned from past cholera epidemics, interventions which are needed today. | journal=J Res Med Sci | year= 2013 | volume= 18 | issue= 8 | pages= 630-1 | pmid=24379835 | doi= | pmc=3872598 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24379835  }} </ref><ref name="pmid11869639">{{cite journal| author=Hahn S, Kim S, Garner P| title=Reduced osmolarity oral rehydration solution for treating dehydration caused by acute diarrhoea in children. | journal=Cochrane Database Syst Rev | year= 2002 | volume=  | issue= 1 | pages= CD002847 | pmid=11869639 | doi=10.1002/14651858.CD002847 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11869639  }} </ref>
* Give antibiotics for severe cholera cases
* Maintain hydration and monitor frequently the hydration status<ref name="pmid24379835">{{cite journal| author=Lankarani KB, Alavian SM| title=Lessons learned from past cholera epidemics, interventions which are needed today. | journal=J Res Med Sci | year= 2013 | volume= 18 | issue= 8 | pages= 630-1 | pmid=24379835 | doi= | pmc=3872598 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24379835  }} </ref><ref name="pmid11869639">{{cite journal| author=Hahn S, Kim S, Garner P| title=Reduced osmolarity oral rehydration solution for treating dehydration caused by acute diarrhoea in children. | journal=Cochrane Database Syst Rev | year= 2002 | volume=  | issue= 1 | pages= CD002847 | pmid=11869639 | doi=10.1002/14651858.CD002847 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11869639  }} </ref>
===Management of cholera patients (table 1)===
* Give antibiotics for severe cholera cases<ref name="pmid21142691">{{cite journal| author=Nelson EJ, Nelson DS, Salam MA, Sack DA| title=Antibiotics for both moderate and severe cholera. | journal=N Engl J Med | year= 2011 | volume= 364 | issue= 1 | pages= 5-7 | pmid=21142691 | doi=10.1056/NEJMp1013771 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21142691  }} </ref>
* Zinc supplementation for reduction of stool output and improvement of symptom duration and severity<ref name="pmid18184631">{{cite journal| author=Roy SK, Hossain MJ, Khatun W, Chakraborty B, Chowdhury S, Begum A et al.| title=Zinc supplementation in children with cholera in Bangladesh: randomised controlled trial. | journal=BMJ | year= 2008 | volume= 336 | issue= 7638 | pages= 266-8 | pmid=18184631 | doi=10.1136/bmj.39416.646250.AE | pmc=2223005 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18184631  }} </ref>
 
===Management of Cholera Patients (table 1)===
{| border="1" cellpadding="5" cellspacing="0" align="center" class="sortable"
{| border="1" cellpadding="5" cellspacing="0" align="center" class="sortable"
|-
|-
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   | Normal
   | Normal
   | Goes down quickly (spontaneously)
   | Goes down quickly (spontaneously)
   | No / Mild dehydration
   | No / [[Dehydration|Mild dehydration]]
   |
   |
* Child < 2 years: 50–100 ml (1/4–1/2 cup)ORS solution. Up to approximately 1/2 litre a day.
* Child < 2 years: 50–100 ml (1/4–1/2 cup)ORS solution. Up to approximately 1/2 liter a day.
* Child between 2 and 9 years: 100–200 ml. Up to approximately 1 litre a day.
* Child between 2 and 9 years: 100–200 ml. Up to approximately 1 liter a day.
* Patient of 10 years of age or more as much as wanted, up to approximately 2 litres a day.
* Patient of 10 years of age or more as much as wanted, up to approximately 2 liters a day.
|-
|-
   | Irritable
   | Irritable
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   | Drink eagerly
   | Drink eagerly
   | Goes back slowly (< 2 sec)
   | Goes back slowly (< 2 sec)
   | Some / Moderate dehydration (in case if 2 of the symptoms are present)
   | Some / [[Dehydration|Moderate dehydration]] (in case if 2 of the symptoms are present)
   |
   |
* Give Oral Rehydration Salt in the amount recommended in below in table 2
* Give [[oral rehydration salt]] in the amount recommended in below in table 2
* Nasogastric tubes can be used for rehydration when ORS solution increasesvomiting and nausea or when the patient cannot drink
* Nasogastric tubes can be used for re-hydration when [[ORS]] solution increases [[vomiting]] and [[nausea]] or when the patient cannot drink
* Monitor the patient frequently
* Monitor the patient frequently
|-
|-
   | Lethargic, unconscious or floppy
   | [[Lethargic]], unconscious or floppy
   | Sunken, absence of tears
   | Sunken, absence of tears
   | Drinks poorly
   | Drinks poorly
   | Goes back slowly (> 2 sec)
   | Goes back slowly (> 2 sec)
   | Severe dehydration (in case if 2 of the symptoms are present)
   | [[Severe dehydration]] (in case if 2 of the symptoms are present)
   |
   |
* Put an IV drip to start intravenous rehydration
* Put an IV drip to start intravenous rehydration
* In case this is not possible, rehydrate with ORS
* In case this is not possible, rehydrate with [[ORS]]
* Give IV drips of Ringer Lactate or if not available cholera saline (or normal saline)
* Give IV drips of [[Ringer's lactate]] or if not available cholera saline (or normal [[saline]])
* 100 ml/kg in three-hour period (in 6 hours for children aged less than 1 year)
* 100 ml/kg in three-hour period (in 6 hours for children aged less than 1 year)
* Start rapidly (30ml/kg within 30 min) and then slow down.
* Start rapidly (30ml/kg within 30 min) and then slow down.
Line 54: Line 58:
|}
|}


 
===Management of Patients with Moderate Dehydration (table 2)===
===Management of patients with some/moderate dehydration (table 2)===


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<br clear="left"/>


===Maintenance of Hydration and Monitoring the Patient===
Reassess the patient for signs of [[dehydration]] regularly during the first six hours:
* Number and quantity of stools and vomit in order to compensate for the loss of body fluids
* Radial pulse: if it remains weak, IV rehydration must be continued.


===Method to Prepare Home-made Oral Rehydration Therapy Solution===
* If [[ORS]] sachets are available, dilute one sachet in one litre of safe water
* Otherwise: Add to one litre of safe water:
** Salt 1/2 small spoon (2.5 grams)
** Sugar 6 small spoons (30 grams)
* Try to compensate for loss of [[potassium]] (for example, eat bananas or drink green coconut water)


==Antibiotic regimen==
:* 1. '''WHO''' <ref>{{cite web | title = WHO. Cholera Outbreak: Assessing the Outbreak Response and Improving Preparedness.| url =http://www.who.int/cholera/publications/final%20outbreak%20booklet%20260105-OMS.pdf }}</ref> <ref>{{cite web | title = Prevention and control of cholera outbreaks: WHO policy and recommendations| url =http://www.who.int/cholera/prevention_control/recommendations/en/index4.html}}</ref>
:::* Note: [[Antibiotic treatment]] for [[cholera]] patients with [[severe dehydration]] only
:::* Adults
::::* Preferred regimen: [[Doxycycline]] 300 mg po single dose
::::* Alternative regimen: [[Tetracycline]] 12.5 mg/kg PO qid for 3 days
:::* Pediatric
::::* Under 12 years old
:::::* Preferred regimen: [[Erythromycin]] 12.5 mg/kg PO qid for 3 days
::::* Over 12 years old
:::::* Preferred regimen: [[Doxycycline]] 300 mg po single dose
:::::* Alternative regimen: [[Tetracycline]] 12.5 mg/kg PO qid for 3 days


:* 2. '''Pan American Health Organization''' <ref name="PAHO">{{cite web | title = PAHO. Recommendations for clinical management of cholera| url = file:///Users/censhanshan/Desktop/cholera_clin_management_ENG_rev_JUN%201.pdf }}</ref>
:::* Note: Antibiotic treatment for cholera patients with moderate or severe dehydration
:::* 2.1 '''Adult'''
::::* Preferred regimen: [[Doxycycline]] 300 mg po single dose
::::* Alternative regimen (1): [[Ciprofloxacin]] 1 g PO single dose 
::::* Alternative regimen (2): [[Azithromycin]] 1 g PO single dose
:::* 2.2 '''Pediatric'''
::::* 2.2.1 '''Children over 3 year, who can swallow tablets'''
:::::* Preferred regimen (1): [[Erythromycin]] 12.5 mg/kg/ PO qid for 3 days
:::::* Preferred regimen (2): [[Azithromycin]] 20 mg/kg PO in a single dose
:::::* Alternative regimen (1): [[Ciprofloxacin]] suspension or tablets 20 mg/kg PO single dose
:::::* Alternative regimen (2): [[Doxycycline]] suspension or tablets 2-4 mg/kg PO single dose
:::::* Note: Although doxycycline has been associated with a low risk of yellowing of the teeth in children, its benefits outweigh its risks
::::* 2.2.2 '''Children under 3 year, or infants who cannot swallow tablets'''
:::::* Preferred regimen (1): [[Erythromycin]] suspension 12.5 mg/kg/ PO qid for 3 days
:::::* Preferred regimen (2): [[Azithromycin]] suspension 20 mg/kg PO single dose
:::::* Alternative regimen (1): [[Ciprofloxacin]] suspension 20 mg/kg PO single dose
:::::* Alternative regimen (2): [[Doxycycline]] syrup 2-4 mg/kg PO single dose
:::* 2.3 '''Pregnancy'''
::::* Preferred regimen (!): [[Erythromycin]] 500 mg/ PO qid for 3 days 
::::* Preferred regimen (2): [[Azithromycin]] 1 g PO single dose


 
===Nutrition===
 
* Proper attention to nutrition is particularly important, as patients with [[cholera]] often ignore nutrition due to [[diarrhea]] and [[vomiting]]. This may lead to [[hypoglycemia]] and associated complications like [[seizure]], [[coma]], and even death in the pediatric population.
 
* Provide frequent small meals with familiar foods during the first two days rather than infrequent large meals.
====HOW TO PREPARE HOME-MADE ORS SOLUTION?====
* [[Breastfeeding]] of infants and young children should continue.
* If ORS sachets are available: dilute one sachet in one litre of safe water
* Otherwise: Add to one litre of safe water:
** Salt 1/2 small spoon (2.5 grams)
** Sugar 6 small spoons (30 grams)
* Try to compensate for loss of potassium (for example, eat bananas or drink green coconut water)


== References ==
== References ==
{{Reflist|2}}
{{Reflist|2}}


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Latest revision as of 20:55, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Priyamvada Singh, MBBS [2]

Overview

In most cases, cholera can be successfully treated with oral rehydration therapy (ORT), which is highly effective, safe, and simple to administer. In severe cases with significant dehydration, intravenous rehydration may be necessary. Ringer's lactate is the preferred solution, often with added potassium. Large volumes and continued replacement until diarrhea has subsided may be needed[1][2]. Ten percent of a person's body weight in fluid may need to be given in the first two to four hours. Antibiotic treatments for one to three days shorten the course of the disease and reduce the severity of the symptoms[3]. People can recover even without them, if sufficient hydration and electrolyte balance is maintained. Doxycycline is typically used first line[4], although some strains of V. cholerae have shown resistance[5]. Zinc supplementation has been shown to reduce stool output and reduces the duration and severity of symptoms.[6]

Medical Therapy

Summary of the Treatment

  • Rehydrate with ORS or IV solution depending on the severity. Rehydration involves replenishment of the lost fluids and then maintenance of the fluid balance [1][2]
  • Maintain hydration and monitor frequently the hydration status[1][2]
  • Give antibiotics for severe cholera cases[7]
  • Zinc supplementation for reduction of stool output and improvement of symptom duration and severity[6]

Management of Cholera Patients (table 1)

Mental status Eyes Thirst Skin pinch Conclusions Management
Normal, Alert Normal, hydrated Normal Goes down quickly (spontaneously) No / Mild dehydration
  • Child < 2 years: 50–100 ml (1/4–1/2 cup)ORS solution. Up to approximately 1/2 liter a day.
  • Child between 2 and 9 years: 100–200 ml. Up to approximately 1 liter a day.
  • Patient of 10 years of age or more as much as wanted, up to approximately 2 liters a day.
Irritable Sunken Drink eagerly Goes back slowly (< 2 sec) Some / Moderate dehydration (in case if 2 of the symptoms are present)
  • Give oral rehydration salt in the amount recommended in below in table 2
  • Nasogastric tubes can be used for re-hydration when ORS solution increases vomiting and nausea or when the patient cannot drink
  • Monitor the patient frequently
Lethargic, unconscious or floppy Sunken, absence of tears Drinks poorly Goes back slowly (> 2 sec) Severe dehydration (in case if 2 of the symptoms are present)
  • Put an IV drip to start intravenous rehydration
  • In case this is not possible, rehydrate with ORS
  • Give IV drips of Ringer's lactate or if not available cholera saline (or normal saline)
  • 100 ml/kg in three-hour period (in 6 hours for children aged less than 1 year)
  • Start rapidly (30ml/kg within 30 min) and then slow down.

Total amount per day: 200 ml/kg during the first 24 hours

Management of Patients with Moderate Dehydration (table 2)

Age Less than 4 months 4–11 months 12–23 months 2–4 years 5–14 years 15 years
Weight Less than 5 kgs 5–7.9 kg 8–10.9 kg 11–15.9 kg 16–29.9 kg 30 kg or more
ORS solution in ml 200–400 400–600 600–800 800–1200 1200–2200 2200–4000



Maintenance of Hydration and Monitoring the Patient

Reassess the patient for signs of dehydration regularly during the first six hours:

  • Number and quantity of stools and vomit in order to compensate for the loss of body fluids
  • Radial pulse: if it remains weak, IV rehydration must be continued.

Method to Prepare Home-made Oral Rehydration Therapy Solution

  • If ORS sachets are available, dilute one sachet in one litre of safe water
  • Otherwise: Add to one litre of safe water:
    • Salt 1/2 small spoon (2.5 grams)
    • Sugar 6 small spoons (30 grams)
  • Try to compensate for loss of potassium (for example, eat bananas or drink green coconut water)

Antibiotic regimen

  • Preferred regimen: Doxycycline 300 mg po single dose
  • Alternative regimen: Tetracycline 12.5 mg/kg PO qid for 3 days
  • Pediatric
  • Under 12 years old
  • Preferred regimen: Erythromycin 12.5 mg/kg PO qid for 3 days
  • Over 12 years old
  • Preferred regimen: Doxycycline 300 mg po single dose
  • Alternative regimen: Tetracycline 12.5 mg/kg PO qid for 3 days
  • 2. Pan American Health Organization [10]
  • Note: Antibiotic treatment for cholera patients with moderate or severe dehydration
  • 2.1 Adult
  • 2.2 Pediatric
  • 2.2.1 Children over 3 year, who can swallow tablets
  • Preferred regimen (1): Erythromycin 12.5 mg/kg/ PO qid for 3 days
  • Preferred regimen (2): Azithromycin 20 mg/kg PO in a single dose
  • Alternative regimen (1): Ciprofloxacin suspension or tablets 20 mg/kg PO single dose
  • Alternative regimen (2): Doxycycline suspension or tablets 2-4 mg/kg PO single dose
  • Note: Although doxycycline has been associated with a low risk of yellowing of the teeth in children, its benefits outweigh its risks
  • 2.2.2 Children under 3 year, or infants who cannot swallow tablets
  • Preferred regimen (1): Erythromycin suspension 12.5 mg/kg/ PO qid for 3 days
  • Preferred regimen (2): Azithromycin suspension 20 mg/kg PO single dose
  • Alternative regimen (1): Ciprofloxacin suspension 20 mg/kg PO single dose
  • Alternative regimen (2): Doxycycline syrup 2-4 mg/kg PO single dose
  • 2.3 Pregnancy

Nutrition

  • Proper attention to nutrition is particularly important, as patients with cholera often ignore nutrition due to diarrhea and vomiting. This may lead to hypoglycemia and associated complications like seizure, coma, and even death in the pediatric population.
  • Provide frequent small meals with familiar foods during the first two days rather than infrequent large meals.
  • Breastfeeding of infants and young children should continue.

References

  1. 1.0 1.1 1.2 Lankarani KB, Alavian SM (2013). "Lessons learned from past cholera epidemics, interventions which are needed today". J Res Med Sci. 18 (8): 630–1. PMC 3872598. PMID 24379835.
  2. 2.0 2.1 2.2 Hahn S, Kim S, Garner P (2002). "Reduced osmolarity oral rehydration solution for treating dehydration caused by acute diarrhoea in children". Cochrane Database Syst Rev (1): CD002847. doi:10.1002/14651858.CD002847. PMID 11869639.
  3. Kabir I, Khan WA, Haider R, Mitra AK, Alam AN (1996). "Erythromycin and trimethoprim-sulphamethoxazole in the treatment of cholera in children". J Diarrhoeal Dis Res. 14 (4): 243–7. PMID 9203786.
  4. Sack DA, Islam S, Rabbani H, Islam A (1978). "Single-dose doxycycline for cholera". Antimicrob Agents Chemother. 14 (3): 462–4. PMC 352482. PMID 708024.
  5. Towner KJ, Pearson NJ, Mhalu FS, O'Grady F (1980). "Resistance to antimicrobial agents of Vibrio cholerae E1 Tor strains isolated during the fourth cholera epidemic in the United Republic of Tanzania". Bull World Health Organ. 58 (5): 747–51. PMC 2395989. PMID 6975183.
  6. 6.0 6.1 Roy SK, Hossain MJ, Khatun W, Chakraborty B, Chowdhury S, Begum A; et al. (2008). "Zinc supplementation in children with cholera in Bangladesh: randomised controlled trial". BMJ. 336 (7638): 266–8. doi:10.1136/bmj.39416.646250.AE. PMC 2223005. PMID 18184631.
  7. Nelson EJ, Nelson DS, Salam MA, Sack DA (2011). "Antibiotics for both moderate and severe cholera". N Engl J Med. 364 (1): 5–7. doi:10.1056/NEJMp1013771. PMID 21142691.
  8. "WHO. Cholera Outbreak: Assessing the Outbreak Response and Improving Preparedness" (PDF).
  9. "Prevention and control of cholera outbreaks: WHO policy and recommendations".
  10. [file:///Users/censhanshan/Desktop/cholera_clin_management_ENG_rev_JUN%201.pdf "PAHO. Recommendations for clinical management of cholera"] Check |url= value (help) (PDF).



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