Health Nuggets: Cholera

Introduction:

Dear readers, welcome to the second edition of HEALTH NUGGETS with DR ANIEKEME ANIEFIOK UWAH. It’s a pleasure welcoming you again to this very highly educating and informative health column. To ensure that you are kept healthy by preventing the spread of infectious diseases, we will begin a series on the 41 priority diseases, conditions and events that have been listed for Integrated Disease Surveillance and Response (IDSR).

As highlighted in our first edition which was published last week, under the Integrated Disease Surveillance and Response (IDSR), the 41 diseases have been classified into three sub-groups;

Epidemic prone diseases, Diseases targeted for eradication and elimination and other major diseases, events or conditions of public health importance.

Under the epidemic prone diseases, the diseases include;
a. Cholera
b. Measles
c. Cerebrospinal meningitis
d. Viral Haemorrhagic Fever (VHF)
i. Lassa fever
ii. Ebola virus disease
e. Yellow fever
f. Highly pathogenic avian influenza: HPA I (human)
For the next 6 weeks starting from today, we will be looking at the epidemic prone diseases starting with cholera.

HISTORICAL PERSPECTIVES:
The first cholera pandemic emerged out of the Ganges Delta with an outbreak in Jessore, India, in 1817, stemming from contaminated rice. The disease quickly spread throughout most of India, modern-day Myanmar, and modern-day Sri Lanka by traveling along trade routes established by the Europeans.

It is called the blue death because people with very bad cholera can have so much diarrheoa that they do not have enough water and electrolytes (salts) left in their bodies to survive. Cholera has been nicknamed the “blue death” because a person dying of cholera may lose so much body fluids that their skin turns bluish-gray

BACKGROUND:

There were many outbreaks of cholera, and by the 16th century, some were being noted in historical writings. England had several in the 19th century, the most notable being in 1854, when Dr. John Snow did a classic study in London that showed a main source of the disease (resulting in about 500 deaths in 10 days) came from at least one of the major water sources for London residents termed the “Broad Street pump.” The pump handle was removed, and the cholera deaths slowed and stopped. The pump is still present as a landmark in London. Although Dr. Snow did not discover the cause of cholera, he did show how the disease could be spread and how to stop a local outbreak. This was the beginning of modern epidemiologic studies. Cholera causes over 100,000 deaths per year. It may produce rapidly progressive epidemics or world-wide pandemics. In endemic areas, sporadic cases(less than 5% of all non-outbreak related diarrhea cases) and small outbreaks may occur.

DEFINITION:

Cholera is an acute infectious disease caused by a bacterium, Vibrio cholerae (V. cholerae), which usually results in a painless, watery diarrhea in humans. Some affected individuals have copious amounts of diarrhea and develop dehydration so severe it can lead to death.

EPIDEMIOLOGY:

There has been a resurgence of cholera in Africa since the mid- 1980s, where over 80% of the world’s cases occurred in 1999, with majority of the cases occurring from January through April.

According to the World Health Organization (WHO), it is estimated that about 1.4 million to 4.3 million people are infected worldwide each year, with approximately 28,000-142,000 deaths per year. Only about one in 10 people infected with cholera develop the typical signs and symptoms. Outbreaks of cholera in 2015-2016 include South Sudan, United Republic of Tanzania, and Kenya, with over 216 deaths and most recently, 121 people diagnosed with cholera in Iraq, their first outbreak since 2012 and in Cuba, the first outbreak in over 130 years.

CAUSES:

Cholera is caused by the bacterium Vibrio cholerae. This bacterium is Gram stain-negative and comma-shaped. Although there are many V. cholerae serotypes that can produce cholera symptoms, the O groups O1 and O139, which also produce a toxin, cause the most severe symptoms of cholera. O groups consist of different lipopolysac charides-protein structures on the surface of bacteria that are distinguished by immunological techniques.

MODE OF TRANSMISSION:

The disease is transmitted mainly through eating or drinking contaminated food or water; that is, cholera is spread through the faeco –oral route.

SYMPTOMS/SIGNS:

The symptoms and signs of cholera-related disease are a watery diarrhea that often contains flecks of whitish material (mucus and some gastrointestinal lining [epithelial] cells) that are about the size of pieces of rice. The diarrhea is termed “rice-water stool” and smells “fishy.” Although many bacterial infections may cause diarrhea, the volume of diarrhea with cholera can be enormous; high levels of diarrheal fluid, such as 250 cc per kg or about 10 to 18 liters over 24 hours for a 154-pound adult, can occur. People may go on to develop one or more of the following symptoms and signs:

I. Watery diarrhea (sometimes in large volumes)
II. Rice-water stools
III. Fishy odor to stools
IV. Vomiting
V. Rapid heart rate
VI. Loss of skin elasticity
VII. Dry mucous membranes (dry mouth)
VIII. Low blood pressure
IX. Thirst
X. Muscle cramps (leg cramps, for example)
XI. Restlessness or irritability (especially in children)

Unusual sleepinessor tiredness. Other symptoms that may occur, especially with more severe disease, include the following:
• Abdominal pain (cramps)
• Rectal pain
• Fever
• Severe vomiting
• Dehydration
• Low or no urine output
• Weight loss
• Shock
• Death

RISK FACTORS:

I. Eating or drinking of contaminated food such as uncooked seafood or shellfish from estuarine waters.
II. Lack of continuous access to safe water and food supplies, attending large gatherings of people including ceremonies such as weddings or funerals, contacts with persons who died of cholera.

INCUBATION PERIOD:
Is from a few hours to 5 days, usually in the range of 2-3 days.

SURVEILLANCE GOAL:

I. To detect and respond promptly and appropriately to cases and outbreak of watery diarrhea promptly.
II. To confirm an outbreak, collect stool specimens transported in Cary-Blair medium.
III. Immediate case based reporting of cases and deaths when an outbreak is suspected.

CASE DEFINITION:
The Federal Ministry of Health (FMOH) and the World Health Organization (WHO) recommends that the surveillance case definition for cholera be used by all health facilities for reporting suspected cases to the Local Government Area (LGA) level.

SUSPECTED CASE;
‘Any person 5 years of age or more who develops severe dehydration or dies from acute watery diarrhea ‘OR ‘ Any patient above the age of 2 years with acute watery diarrhea in an area where there is an acute outbreak of cholera.’

CONFIRMED CASE;
‘A suspected case in which Vibrio cholera O1 or O139 has been isolated in the stool.’

CONCLUSION:
In conclusion, it’s our hope that the above information will lead to the prevention of cholera and more reports of cases to the nearest health facility in order to reduce the morbidity and mortality rates due to cholera in our communities.

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