Global Health Issues: Cholera

Carime Gordon

Alexandria Henry

Andrew Hendrix

Jordon Garman

Cholera Overview

• Acute, diarrheal illness caused by infection of the intestine with the bacterium Vibrio cholera.

• Usually found in

• water or food sources that have been contaminated by feces from an infected person.

• places with poor water treatment, sanitation, and hygiene.

• brackish rivers and coastal waters.

• raw or undercooked shellfish

• Areas stricken by natural disaster

Effective Killer.

Signs & Symptoms• profuse watery diarrhea,

• vomiting,

• leg cramps

• Severe dehydration

• Rapid heartbeat

• Low blood pressure

• Restlessness or irritability

• Loss of skin elasticity

Characteristics• short incubation period of two hours to five

days

• Symptoms typically appear in 2-3 days.

• present in feces of infected for 7–14 days after infection and shed back into the environment.

• If left untreated can cause acute renal failure, severe electrolyte imbalances and coma.

• Severe dehydration can rapidly lead to shock and death.

History

• In the U.S., cholera was prevalent in the 1800s but water-related spread has been eliminated by modern water and sewage treatment systems.

• During the 19th century, cholera spread across the world from its original reservoir in the Ganges delta in India.

• The current (seventh) pandemic started in South Asia in 1961, and reached Africa in 1971 and the Americas in 1991.

• Cholera is now endemic in many countries.

• Estimated 3–5 million cholera cases and 100,000–120,000 deaths due to cholera every year.

Diagnosis and Detection

• Some Cholera patients are asymptomatic, and as many as 20% have only a mild to moderate diarrheal illness.

• Approximately 5% will develop the classic symptoms and signs of severe cholera

• Cholera can be detected by:

• culture of a stool specimen (gold standard for the laboratory diagnosis of cholera).

• Crystal VC® rapid test kits (useful in epidemic settings but should not be used for routine testing).

Origination of Cholera

• India: Ganges Delta River 1817

• 19th Century-Spread to Europe, Asia, North America, and Africa.

• First reported in 1991 near Lima, Peru.

• Disease spread throughout many South and Central American Countries

Outbreaks

• ECUADOR

• First case reported February 28, 1991 a few weeks after Peru declared a cholera epidemic

• Ecuadorian fisherman traveled to Peru and was exposed to cholera. The disease spread rapidly leading to an epidemic.

• Epidemic reached beyond the Andean Mountains to the Amazon River and spread throughout the rainforest

Outbreaks (Continued)• HAITI

• First detected October 21, 2010

• Haitian Ministry of Health surveillance and reports from Pan American Health Organization (PAHO) and other partners indicated an upsurge of Cholera cases and deaths in parts of Haiti.

• Cases seen in Departments of South-East, Grand-Anse, South and West

• 684,085 Cases and 8,361 deaths have been reported

• 380,846 (55.4%) were hospitalized

Current Outbreaks & Issues

• Haiti Sues United Nations for Cholera outbreak

• http://www.cnn.com/2013/10/09/world/americas/haiti-un-cholera-lawsuit/

• The epidemic is thought to have been brought to Haiti by U.N. troops from Nepal.

• Several scientific and medical investigators concluded that a likely source of the outbreak was sewage leaking from a UN base housing Nepalese peacekeepers.

• July 23, 2012-Democratic Republic of Congo (DRC), Africa

• The number of cholera cases has increased in the armed conflict area of North Kivu. The most affected areas include Birambizo, Goma, Karisimbi Kiroshe, Mutwanga, Mweso, and Rwanguba

Current Outbreaks & Issues (Continued)

• October 8, 2012-Sierra Leone, Africa

• Ministry of Health and Sanitation (MOHS) continues to work closely with partners at the national and international levels to step up response to the ongoing cholera outbreak.

• 12 of the 13 districts in Sierra Leone have been affected since the beginning of the year.

• October 28, 2013-Mexico

• The Ministry of Health in Mexico has reported an additional five cases of infection with Vibrio cholerae O1 Ogawa toxigenic.

• From Sept. 9th to date, a total of 176 confirmed cases, including one death, has been reported in the country. This is the first local transmission of cholera recorded since the 1991-2001 cholera epidemic in Mexico.

Treatments for Cholera

• Oral rehydration salts for less severe patients.

• Oral rehydration solutions such as electrolytes based drinks.

• Intravenous fluids for more severe cases.

• Antibiotics such as doxycycline for adults and azithromycine for children are the most effective.

• Zinc therapy has also been shown to reduce duration and severity of cholera symptoms in children in the Bangladesh outbreak in 2011.

Clean water and uncontaminated food

• Clean uncontaminated water is a necessity to control outbreak numbers and manage dehydration in the effected population.

• Most common source is sealed bottled water but isn’t very cost effective

• Ways to treat contaminated water include methods such as

• Boiling water

• Chlorine treatment

• Bleach treatment ( 8 drops of household bleach per gallon and two drops of bleach per liter)

• Pur sachets (flocculant disinfectant powder), aquatabs, or waterguard

• solar disinfection

• ceramic filtration

• Slow sand filtration

Clean water and uncontaminated food

• Proper storage of clean water is also very important to maintain its drinkability.

• Store in container with small openings and ones that contain a lid or covering of some sort

• Container with spouts or spigots are preferable since they prevent people from reaching into the container

• For food items always make sure they are cooked and not consumed raw (especially so for seafood) and that food is eaten while still hot

• For fruit and vegetable, make sure they are washed in clean water and have a peel or are abled to be peeled.

Sanitation

• Burying and burning of waste products can also slow and prevent the spread of cholera.

• Building and implementation of use of latrines

• Cleaning of latrines is also vital for prevention of spreading cholera; Clean with bleach solutions (one part bleach to 9 parts water).

• If available use of chemical toilets for purposes of defecation

• If building of latrines are not an available option NO defecation should be done within 30 meters of any body of water or food supply.

• Feces should also be buried safely away from water and food supplies

Prevention

• Proper hand washing with clean treated water and soap.

• Use of the two dose cholera vaccines Dukoral and Shanchol

• Educating the community on proper hygiene, better sanitation practices, and how to prepare safe and useable water sources are the best cholera prevention measures.

• Some ways to educate the population include;

• Direct one on one or small group teaching.

• Use of pamphlets or public health announcements.

• Using community leaders and public figures to demonstrate safe cholera prevention practices.

Impact of Cholera Solutions

• Oral rehydration salts successfully treat about 80% of cases

• Two types of safe and effective oral cholera vaccines currently available on the market

• WC/rBS

• CVD 103-HgRp

• Limited duration of protection

• Sustained protection of over 50%

• Dukoral provides short-term protection

• The case fatality rate usually remain below 1% with proper treatment

Global Studies on Cholera Solutions

• Ecuador Studies

• Lack of efficiency

• In the three hospitals 45% of the observed cholera treatment costs were considered excessive

• Mozambique Studies

• Compared the characteristics of 43 case subjects with cholera and 172 matched controls

• 78 to 84 percent protection against cholera

• 72% of those over the age of 15 were effectively treated by the vaccine

• Bangladesh Studies

• Due to community immunity, if 70% of the population was vaccinated cholera could be eliminated

Global Studies on Cholera Solutions (Continued)

• Vietnam Studies

• The vaccine efficacy after 2 doses was 66% on a population of 334, 000 people

• India Studies

• 66, 900 participants

• An analysis after 2 years displayed that 2 vaccine doses brought an overall protective efficacy of 67% against cases of cholera that had already been confirmed

Impact of Cholera Solution: Cholera Treatment Side Effects

Side Effects

• 1/100-1,000 people were affected by:

• Headache, Diarrhea, Abdominal pain

• 1/1,000-10,000 people were affected by:

• Dizziness, loss of appetite, cough, nasal inflammation, congestion, nausea and vomiting, fever

• Less than 1 in 10,000 people were affected by:

• Rash, sweating, dehydration, drowsiness, insomnia, reduced sense of taste, sore throat, indigestion, fainting

Impact of Cholera Solution: Summary

• The known solutions are highly effective

• Rehydration salts

• Vaccines

• Those at risk for receiving cholera should seek treatment immediately

• With help from the U.N. the eradication of cholera is possible

• Taking the steps required to catch the first few cases of cholera in a country can stop an epidemic

ConclusionCholera is an acute disease that is predominantly found in areas that lack clean sources of water or that have been stricken by natural disaster. It has many symptoms from irritability to profuse watery diarrhea. Originating in India, throughout its history it has reached every continent on Earth and has killed about 100, 000 people a year on average. Cholera can be detected by culture of a stool specimens and Crystal VC® rapid test kits. From various outbreaks through the years we have learned there are many ways to combat cholera. The majority of the countries that face cholera epidemics rely on the United Nations for help. The only way to prevent cholera outbreaks is by spreading the knowledge we have gained over the years to those who are most likely to come in contact with the disease. In addition, the United Nations has to help with the funding for the treatments for cholera. With these components put into place, if someone in a population does become ill from cholera we can eradicate it and prevent the nasty history of this disease from repeating itself.

Citations

• Cerda, R., & Lee, P. T. (2013). Modern Cholera in the Americas: An Opportunistic Societal Infection. American Journal Of Public Health, 103(11), 1934-1937. doi:10.2105/AJPH.2013.3011567

• Health Promotion Materials. (2013, July 11). Centers for Disease Control and Prevention. Retrieved November 20, 2013, from http://www.cdc.gov/cholera/materials.html

• Household Water Treatment. (2012, March 21). Centers for Disease Control and Prevention. Retrieved November 20, 2013, from http://www.cdc.gov/safewater/household-water.html

• Ali, M., Lopez, A., Young Ae, Y., Young Eun, K., Sah, B., Maskery, B., & Clemens, J. (2012). The global burden of cholera. Bulletin Of The World Health Organization, 90(3), 209-218A.

• Cerda, R., & Lee, P. T. (2013). Modern Cholera in the Americas: An Opportunistic Societal Infection. American Journal Of Public Health, 103(11), 1934-1937.

Citations (Continued)

• Poirier, M. P., Izurieta, R., Malavade, S. S., & McDonald, M. D. (2012). Re-emergence of Cholera in the Americas: Risks, Susceptibility, and Ecology. Journal Of Global Infectious Diseases, 4(3), 162-171.

• Richardson, S. D., (2007). Water Analysis: Emerging Contaminants and Current Issues. National Exposure Research Laboratory, U.S. Environmental Protection Agency, Athens, Georgia 30605, 79(Chem.), 4295-4324.

• www.epa.gov/ safewater/arsenic

• Malavade, S. S., Narvaez, A. A., Mitra, A. A., Ochoa, T. T., Naik, E. E., Sharma, M. M., & ... Izurieta, R. R. (2011). Cholera in Ecuador: Current Relevance of Past Lessons Learnt. Journal Of Global Infectious Diseases, 3(2), 189-194.

• Jenson, D., & Szabo, V. (2011). Cholera in Haiti and Other Caribbean Regions, 19th Century. Emerging Infectious Diseases, 17(11), 2130-2135.

Citations (Continued)

• http://www.cdc.gov/haiticholera/pdf/haiticholera_trainingmanual_en.pdf

• http://www.scielosp.org/scielo.php?pid=S1020-49891999000200002&script=sci_arttext

• http://www.who.int/mediacentre/factsheets/fs107/en/

• http://www.nejm.org/doi/full/10.1056/NEJMoa043323#t=articleResults

• http://www.netdoctor.co.uk/travel-health/medicines/dukoral.html

• http://www.niaid.nih.gov/topics/cholera/research/Pages/treatments.aspx

• http://www.who.int/immunization/cholera_PP_slides_20_Mar_2010.pdf

• http://www.who.int/immunization/Cholera_PP_Accomp_letter__Mar_10_2010.pdf