Dr. Francis SANWO

Cholera is an acute diarrhoeal infection caused by ingestion of food or water contaminated with the bacterium Vibrio cholerae. Cholera remains a global threat to public health and an indicator of inequity and lack of social development. It can kill within hours if left untreated. The risk of a cholera epidemic is highest when poverty, war or natural disasters force people to live in crowded conditions without adequate sanitation.

The consequences of a humanitarian crisis – such as disruption of water and sanitation systems, or the displacement of populations to inadequate and overcrowded camps – can increase the risk of cholera transmission, should the bacteria be present or introduced. Uninfected dead bodies have never been reported as the source of epidemics.

The long-term solution for cholera control lies in economic development and universal access to safe drinking water and adequate sanitation. 

Cholera is an extremely virulent disease that can cause severe acute watery diarrhoea. It takes between 12 hours and 5 days for a person to show symptoms after ingesting contaminated food or water. Cholera affects both children and adults and can kill within hours if untreated.

Most people infected with V. cholerae do not develop any symptoms, although the bacteria are present in their faeces for 1-10 days after infection and are shed back into the environment, potentially infecting other people.

Most cases of cholera that cause symptoms cause mild or moderate diarrhea that's often hard to tell apart from diarrhea caused by other problems. Others develop more-serious signs and symptoms of cholera, usually within a few days of infection.

Symptoms of cholera infection can include:

Diarrhea. Cholera-related diarrhea comes on suddenly and can quickly cause dangerous fluid loss — as much as a quart (about 1 liter) an hour. Diarrhea due to cholera often has a pale, milky appearance that resembles water in which rice has been rinsed.

Nausea and vomiting. These occur especially in the early stages of cholera and can last for hours.

Dehydration. This can develop within hours after cholera symptoms start and range from mild to severe. A loss of 10% or more of body weight indicates severe dehydration.

Signs and symptoms of cholera dehydration include irritability, fatigue, sunken eyes, a dry mouth, extreme thirst, dry and shriveled skin that's slow to bounce back when pinched into a fold, little or no urinating, low blood pressure, and an irregular heartbeat.

Dehydration can lead to an electrolyte imbalance which can lead to muscle cramps as a result of the rapid loss of salts such as sodium, chloride and potassium. Shock is one of the most serious complications of dehydration. It occurs when low blood volume causes a drop in blood pressure and a drop in the amount of oxygen in your body. If untreated, severe hypovolemic shock can cause death in minutes.

The risk of cholera is slight in industrialized nations. Even in areas where it exists you're not likely to become infected if you follow food safety recommendations.

Rapid cholera dipstick tests enable doctors in remote areas to quickly confirm a cholera diagnosis. Quick confirmation helps to decrease death rates at the start of cholera outbreaks and leads to earlier public health interventions for outbreak control.

Causes and Risk factors. The toxin produce by the bacteria in  the small intestine causes the body to secrete enormous amounts of water, leading to diarrhea and a rapid loss of fluids and salts (electrolytes).

Contaminated water supplies are the main source of cholera infection. The bacterium can be found in: Surface or well water. Contaminated public wells are frequent sources of large-scale cholera outbreaks. People living in crowded conditions without adequate sanitation are especially at risk.

Seafood. Eating raw or undercooked seafood, especially shellfish that comes from certain places can expose you to cholera bacteria.

Raw fruits and vegetables. Raw, unpeeled fruits and vegetables are a frequent source of cholera infection in areas where there's cholera.

Grains. In regions where cholera is widespread, grains such as rice and millet that are contaminated after cooking and kept at room temperature for several hours can grow cholera bacteria.

 

Everyone is susceptible to cholera, with the exception of infants who get immunity from nursing mothers who have previously had cholera. Still, certain factors can make you more vulnerable to the disease or more likely to have severe signs and symptoms.

Risk factors for cholera include:

Poor sanitary conditions. Cholera is more likely to flourish in situations where a sanitary environment — including a safe water supply — is difficult to maintain. Such conditions are common to refugee camps, impoverished countries, and areas afflicted by famine, war or natural disasters.

Reduced or nonexistent stomach acid. Cholera bacteria can't survive in an acidic environment, and ordinary stomach acid often serves as a defense against infection. But people with low levels of stomach acid — such as children, older adults, and people who take antacids, H-2 blockers or proton pump inhibitors — lack this protection, so they're at greater risk of cholera.

Household exposure. You're at increased risk of cholera if you live with someone who has the disease.

Complications. Cholera can quickly become fatal. In the most severe cases, the rapid loss of large amounts of fluids and electrolytes can lead to death within hours.

Although shock and severe dehydration are the worst complications of cholera, other problems can occur, such as: Low blood sugar (hypoglycemia) can occur when people become too ill to eat. Children are at greatest risk of this complication, which can cause seizures, unconsciousness and even death. Low potassium levels  interfere with heart and nerve function and are life-threatening.

Kidney failure. When the kidneys lose their filtering ability, excess amounts of fluids, some electrolytes and wastes build up in the body — a potentially life-threatening condition. In people with cholera, kidney failure often accompanies shock.

 

Management and prevention.

Cholera is an easily treatable disease. The majority of people can be treated successfully through prompt administration of oral rehydration solution (ORS). The WHO/UNICEF ORS standard sachet is dissolved in 1 litre (L) of clean water. Adult patients may require up to 6 L of ORS to treat moderate dehydration on the first day.

Severely dehydrated patients are at risk of shock and require the rapid administration of intravenous fluids. These patients are also given appropriate antibiotics to diminish the duration of diarrhoea, reduce the volume of rehydration fluids needed, and shorten the amount and duration of V. cholerae excretion in their stool.

Rapid access to treatment is essential during a cholera outbreak. Oral rehydration should be available in communities, in addition to larger treatment centres that can provide intravenous fluids and 24 hour care. With early and proper treatment, the case fatality rate should remain below 1%.

Zinc is an important adjunctive therapy for children under 5, which also reduces the duration of diarrhoea and may prevent future episodes of other causes of acute watery diarrhoea.                                                                                                  Prevention.                                                                           Provision of safe water and sanitation is critical to prevent and control the transmission of cholera.

A multifaceted approach is key to control cholera, and to reduce deaths. A combination of surveillance, water, sanitation and hygiene (environmental and personal), social mobilization, treatment, and oral cholera vaccines are used. This involve government at various levels, communities, families and personal hygiene.

Wash your hands with soap and water frequently, especially after using the toilet and before handling food.

Drink only safe water, including bottled water or water you've boiled or disinfected yourself. Use bottled water even to brush your teeth. Don't add ice to your drinks unless you made it yourself using safe water. Eat food that's completely cooked and hot and avoid street vendor food, if possible. Take fruits and vegetables that you can peel yourself, such as bananas, oranges and avocados.

Community Engagement means that people and communities are part of the process of developing and implementing programmes.  Local culture practices and beliefs are central to promoting actions such as the adoption of protective hygiene measures such as handwashing with soap, safe preparation and storage of food and safe disposal of the faeces, funeral practices for individuals who die from cholera to prevent infection among attendees.

Community engagement continues throughout outbreak response with increased communication regarding potential risks, symptoms of cholera, precautions to take to avoid cholera, when and where to report cases and to seek immediate treatment when symptoms appear.

 

DR. FRANCIS SANWO                                                                                                                                      

MEDICAL DIRECTOR,                                                                                                                                                   

OUR LADY OF APOSTLE CATHOLIC HOSPITAL, OLUYORO OKE OFFA IBADAN.