Cholera: A Waterborne Disease

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Table of Contents

Abstract
Introduction
Historical Perspective
Population Affected
Environmental Issues
Morbidity and Mortality Patterns
Public Health Issues and Interventions
Conclusion
References

Abstract

It is estimated “that there will be 3 to 5 million cases of cholera this year and of that number at least 100, 000 people will die from the disease” (WHO, 2010, p.1). But this health problem is treatable and preventable. If local governments and members of any given community will be made aware of the nature of the cholera bacterium and how it is transmitted from person to person then the morbidity and mortality rate can be significantly reduced.

There must be greater cooperation among national governments and those who are in authority must make a commitment that no one should die from cholera. An effective and efficient information dissemination campaign is the first important step in order to arm and equip people all over the world so that everyone can help in eradicating the possibility of another cholera outbreak.

Introduction

Hippocrates was born 500 years before Christ. He was a Greek physician and considered to be the founder of modern medicine. He was one of the first to scientifically study cholera. This means that this deadly malady was already present in ancient times. It is a medical problem caused by a bacterium that releases toxins that disrupts the natural functions of the human body.

Because it is a well-known medical issue cholera health experts were able to develop ways to prevent outbreak and even lower mortality rates. Nevertheless, in the 21^st century a cholera pandemic is still possible due to poverty and ignorance. This study will attempt to know more about cholera in order to help in disseminating the information that no one should die from this disease because it can be treated and more importantly it can be prevented.

Historical Perspective

The term “cholera” was first seen in the works of Hippocrates and believed to have been derived from the Greek word chole which means bile and the word rein which means to flow (Barua & Greenough, 1992, p.1). If taken together these terms would mean, the flow of bile (Barua & Greenough, 1992, p.1). It can be surmised that the ancients described the disease based on the discharge that comes out from the human body.

In another version, cholera historians remarked that Alexander Trallianus in 1622 who asserted that it came from the word cholades which means intestines (Barua & Greenough, 1992, p.1). It is easy to surmise why Trallianus made this inference. This conclusion comes from the observation that the disease is linked to the bowels.

Another definition frames describes the sickness as “an infection of the small intestine that causes a large amount of watery diarrhea” (National Center for Biotechnology Information, 2011, p.1). This establishes the fact that whatever causes cholera targets the intestines and as a result a watery discharge is the common symptom.

As mentioned earlier cholera has existed since antiquity and yet it did not spread across continents until early 19^th century (Suddath, 2010, p.1). Nevertheless, cholera historians are in agreement that cholera was present in ancient times in Asia and even in Europe. Hippocrates recorded his findings and provided modern day scientists a grim insight into the virulence of this old nemesis of man and the father of modern medicine wrote:

At Athens a man was seized with cholera. He vomited, and was purged and was in pain, and neither the vomiting nor the purging could be stopped; and his voice failed him, and he could not be moved from his bed, and his eyes were dark and hollow, and spasms from the stomach held him, and hiccups from his bowels.

But the purging was much more than the vomiting. This man drank hellebore with juice of lentils; and he again drank juice of lentils, as much as he could, and after that he vomited. He was forced again to drink, and the two (vomiting and purging) were stopped; but he became cold (Barua & Greenough, 1992, p.3).

The grim pronouncement made by Hippocrates is consistent with modern findings. Supported by the fact that, “Cholera is an acute diarrheal disease that can kill within hours if left untreated” (WHO, 2010, p.1). A more in-depth and scientific study revealed that there are two types of cholera according to health experts these are the V. cholera 01 and the V. cholera 0139 (WHO, 2010, p.1). It has also been reported that “Majority of the outbreaks in recorded history were caused by the 01 type while the 0139 group was first identified in Bangladesh in 1992 and confined to South-East Asia” (WHO, 2010, p.1).

In another commentary, “The global spread of the disease was attributed to the fact that infected travelers carried it from India along trade routes until it reached modern day Burma, Sri Lanka and then Indonesia” (Suddath, 2010, p.1). At first people believed that cholera was carried by the wind but later on it was discovered that it is a waterborne disease. In the second wave of pandemic that hit the globe, cholera spread far and wide even to the point of reaching the United States and in the process destroyed the lives of 5,000 people in New Orleans in one year alone (Suddath, 2010, p.1).

Afterwards the epidemic spread along the Mississippi until it reached Texas. However, cholera continued to affect the residents of New Orleans and in this city it continued to flare up until the year 1855 (Barua & Greenough, 1992, p.11). It must be remembered that New Orleans is easily accessibly by traders and travelers using boats and other sea vessels.

However, it was not only the coastal areas that was badly hit by the disease, “In 1849, a cholera outbreak killed 10 percent of the population of St. Louis, Missouri” (Coleman, 2009, p.89). This should have served as an eye-opener for 19^th century physicians that although dirty surface water is a crucial component in the transmission process, they should have considered that human interaction is the major root cause of spreading the disease.

Around the same time in the Middle-East, one can find that Egypt was seriously affected because of pilgrims returning from Mecca. In addition, the disease reappeared in Istanbul and spread to Syria, Palestine and neighboring areas (Barua & Greenough, 1992, p.11). It has become a pandemic.

In the spring of 1849 cholera broke out all over France, Italy, and North Africa. In England alone the disease claimed the lives of 53,283 people, “It is during this epidemic in London that one of the greatest discoveries in cholera epidemiology was made by John Snow, a London anesthetist and amateur epidemiologist who demonstrated the role of water in the transmission of cholera, long before the causative agent was discovered” (Barua & Greenough, 1992, p.11). This is a critical breakthrough because from this discovery researchers were able to develop preventive measures that significantly reduced the morbidity and mortality rate of cholera.

A third pandemic was observed between 1852 and 1859. As a result, “International cooperation in health began for fear of cholera… the first international meeting was held in Paris in 1851, followed by 14 international sanitary conferences between 1851-1938” (Barua & Greenough, 1992, p.11).

In addition, “An International Sanitary Convention was signed in Paris in 1903, according to which all signatories would inform each other of epidemics in their territories… in 1907, the Office International d’Hygiene, the first international health organization, was established in Paris” (Barua & Greenough, 1992, p.11). It is safe to say that cholera shaped the history of world health organizations and it could be argued that these meetings and alliances were the precursor to modern day institutions such as the World Health Organization.

In the 19^th century, it has become very much evident that national governments and their citizens were alarmed by the destructive nature of cholera. It was also very frustrating because it behaved like a plague, meaning no one knows where it came from, as if an invisible force that no one can deal with, it strikes without mercy over a huge portion of the population. The mere fact that death will occur a few hours after a patient is left untreated added a terrifying menace to the said disease. It seems that the only way to fight cholera was to lift up both arms in exasperation and flee.

But due to improved sanitation and modern medicine, the disease was eradicated from many parts of the world (Suddath, 2010, p.1). This can be explained by the fact that in 1920, the Health Organization of the League of Nations was established after the end of the First World War (Barua & Greenough, 1992, p.11).

In other words more and more people as well as teams of dedicated scientists were working hand-in-hand to discovery the mysterious power of the pathogen that caused cholera.

The scientific breakthroughs in the field of medicine as well as increased cooperation among various governments led to an improved strategy to combat cholera. As a result researchers were able to see a significant decline in the morbidity and mortality rate in the 20^th century as compared to how the disease leveled towns and cities in ancient and medieval times.

For instance, in the 19^th century, thousands of people died from the disease even in relatively affluent countries like the United States. But compared to cholera outbreaks that occurred a hundred years later, those that received treatment in time did not succumb to the deadly disease.

The resulting mortality rate was significantly lower. This is even true for countries that are not as progressive as the U.S. For example, in 1991, there was a cholera outbreak in Peru that affected 300,000 people, but of that number less than one percent of the infected died from the disease (Coleman, 2009, p.89). This is proof that vast improvements had been made in the battle against this deadly pathogen.

Scientific breakthroughs in the study of cholera must be leveraged in the creation of preventive measures that will help affected areas resist the destructive force of the said disease. In the case of wars and natural disasters, sometimes it is inevitable that people get sick from cholera but it is without excuse to find patients dies from the said disease. The preventable and treatable nature of cholera must serve as a warning and inspiration to many that even in the onset of infection there are therapies and medication that can be used to save the lives of patients.

It is clear that a proper information dissemination campaign will go a long way in fighting this deadly scourge. The moment that a case of cholera has been reported it is also high time for the community or refugee camp to be alerted as to the presence of the pathogen. If this is done in conjunction with an information dissemination drive that was completed earlier then the people in that area will pay extra careful when it comes to dealing with human wastes and washing their hands before preparing and eating food.

Parents will also be alerted to the fact that they must pay careful attention to the whereabouts of their children especially those who are still attracted to play in puddles of dirty water that could have been contaminated with human fecal matter.

Population Affected

This medical phenomenon is not partial to geographical region or social status. Cholera can affect young and old, men, women, and children. The disease can strike anywhere but the bacterium prefers places where the following conditions are met because, “Cholera occurs in places with poor sanitation, crowding, war, and famine” (National Center for Biotechnology Information, 2010, p.1).

Some of the more common locations where an outbreak is usually expected are in countries located in the following regions: Africa; Asia; India; Mexico; South America; and Central America (National Center for Biotechnology Information, 2010, p.1). The common denominator in places where cholera is still a major health concern is war, refugee camps, and extreme poverty that resulted in non-access to safe drinking water and contaminated surface water due to the lack of government infrastructures.

Environmental Issues

As seen in the previous discussion cholera was once a global problem. But today, an outbreak is almost always limited to the “world’s most impoverished regions” (Briggs, 2003, p.19). There is also a need to highlight the fact that, “Communities most at risk are overcrowded urban areas in developing countries, where clean water and public sewage systems are in scant supply” (Bjorklund, 2011, p.51).

The reason why a cholera outbreak is common in these conditions can be attributed to the fact that the bacterium in cholera stays within the fecal matter of the patient. Thus, body wastes that are allowed to contaminate surface water is the leading source of infection.

In poor countries the spread of the disease can be explained through intrafamilial transmissions as described in the following: “Cholera usually acquired by the ingestion of water or food contaminated with cholera vibrios. Food and beverages, particularly when consumed outside the home and at feasts during festivals and funerals, have often been the source of infection; food-borne spread is facilitated by the growth of V. cholera 01 in foods kept at ambient temperature after cooking” (Barua & Greenough, 1992, p.337).

This means that the bacterium responsible for cholera can be easily transmitted if an infected person handled food or was in-charge of food preparation. In countries where not much thought is given to sanitary food preparation practices, the morbidity rate is observed to be much higher.

Morbidity and Mortality Patterns

It has been said that after the 1920’s the incidence of a cholera pandemic began to decline significantly. In highly industrialized societies the possibility of a cholera outbreak became very unlikely as doctors and health experts had already created such a high-level of a awareness about the disease that preventive measures had been in place for many years.

However, in less affluent countries where poverty and ignorance are the norm, cholera is still considered a deadly disease. It has to be pointed out that, “There are an estimated 3-5 million cholera cases and 100,000 – 120,000 deaths due to cholera every year” (WHO, 2010, p.1). Some of the more recent cholera outbreaks were reported to occur in poor countries such as in Africa, Asia, and even the Caribbean. Aside from poverty and lack of facilities such as adequate sewers and access to potable water, a cholera outbreak is also the result of war and natural disasters.

This is because war and natural calamities can easily destroy whatever system was in place to prevent cholera. For example in a hurricane strong winds and flooding can destroy pipes preventing the delivery of clean water to a particular area. Natural disasters can also easily displace families and force them to congregate in evacuation centers where there is not enough number or toilets or latrines to service a great number of people.

Thus, it is crucial to remember that cholera strikes in the aftermath of a disaster. In poor countries devastated by a hurricane, tsunami or earthquake, cholera often serves as “a cruel second calamity” (Suddath, 2010, p.1). The reason for this is simple to grasp, “Following a disaster, clean water and sewage treatment systems can break down” (Bjorklund, 2011, p.51). By doing so early responders will be trained to bring and provide the necessary food and equipment that can remedy the situation.

Aside from being familiar with the root cause of the disease it is also important to understand the mode of transmission. It has to be pointed out that “Among people who develop symptoms, 80% have mild or moderate symptoms, while around 20% develop acute watery diarrhea with severe dehydration” (WHO, 2010, p.1). There is therefore the danger of complacency allowing the cholera bacteria to get the upper hand.

In the latter part of the 20^th century the whole world witnessed the re-emergence of the bacterium in places ravaged by wars and natural disasters. In the first Persian Gulf War in 1991 there was a cholera outbreak (Suddath, 2010, p.1). In the second Gulf War in 2003 another cholera outbreak was reported (Suddath, 2010, p.1).

This is a good example of how war can be the indirect hand in the creation of an epidemic. The reason of course can be understood if one can see it from the perspective of displaced people. Hundreds of families fleeing their residences and living in make-shift homes is a recipe for disaster. Once again this is due to fecal matter that easily contaminated the environment.

The same thing can be said when it comes to a refugee camp. Thousands of people forced to stay in one place. Again it is easy to understand why a cholera outbreak is common in refugee camps and this is explained by the fact that “Refugee camps are usually pulled together quickly, and they rarely have clean water supplies and waste disposal systems” (Bjorklund, 2011, p.51). There is not enough water to clean their utensils and their plates. In addition, human to human interaction such as the shaking of hands and touching can easily transmit the bacterium from person to person.

The prevalence of a cholera outbreak in the aftermath of a war can be seen in refugee camps because of the sudden influx of people ill-prepared to stay in one overcrowded location. One of the best examples is “the cholera outbreak in the Rwandan refugee camps in the Democratic Republic of Congo in 1994” (Suddath, 2010, p.1).

In that said outbreak 23,800 people were killed in just one month (Suddath, 2010, p.1). In this type of condition “local governments are overwhelmed” and it is the best time for international aid organizations to come in and help (Bjorklund, 2011, p.51). Local governments are usually not ready to deal with the consequences of a civil war or an intensified regional conflict. The lack of resources forces them to adapt ineffectively to a developing crisis.

Aside from wars and refugee camps, a cholera outbreak is common in impoverished locales wherein the government and the people have no idea what they are dealing with in the first place. One of the most recent examples of a cholera outbreak occurred in Zimbabwe in August of 2008. According to the said report there were a total of 1,224 cases that were confirmed and of that number there was a total of 42 deaths (The International Federation’s Disaster Relief Emergency Fund, 2008, p.1).

The early responders also reported that the outbreak “has hit the high density suburbs of Harare the capital city of Zimbabwe, border town Nyamapanda in Mashonaland Central Province and Kariba in Mashonaland West and provincial town of Chinhoyi also in Mashonaland West” (The International Federation’s Disaster Relief Emergency Fund, 2008, p.1). It is imperative for relief agencies to fly into isolated areas to bring medicine and to educate the people that cholera can be prevented.

In the aftermath of the Haiti earthquake of 2010 a cholera outbreak was also reported. In October of that year authorities worked feverishly round the clock to try to contain an outbreak that was dangerously close to becoming a full-scale epidemic (Suddath, 2010, p.1). In October 27, 2010, a morbidity and mortality report was released: “a total of 4,722 cases and 303 deaths” (Centers for Disease Control and Prevention, 2010, p.1). This should not be the case if relief efforts and government agencies were prepared to handle the calamity.

The senseless destruction of human lives could have been avoided if the morbidity and mortality patterns of cholera were understood by those who have the power and the authority to do something with the external factors. It must be said that it is easier to criticize the government and health workers who were unable to significantly alter the deadly turn of events but it must be acknowledged that in the same manner, local government officials can also be easily overwhelmed by the consequences of a natural calamity.

Public Health Issues and Interventions

The first line of defense should be an effective information dissemination campaign. According to a historian, “arrangements must be made, and maintained, for the dissemination of appropriate information that will motivate the members of the community to participate in control activities” (Barua & Greenough, 1992, p.337). The key word here is motivation. The people has to be motivated and the best way to inspire them is to give them ample warning that if cholera is not dealt head-on then the disease can easily destroy families and communities.

The major hurdle when it comes to prevention and minimizing the impact of cholera is ignorance. Those who were infected had no idea that the Vibrio cholera bacterium is already multiplying in their system. According to prevention experts, “About 75% of people infected with V. cholera do not develop any symptoms, although the bacteria are present in their feces for 7-14 days after infection and are shed back into the environment, potentially infecting other people” (WHO, 2010, p.1).

They may not know that they are infected but infected body wastes can easily pollute water supplies and more importantly, “Cholera directly affects people who are in close contact with another” (Bjorklund, 2011, p.44). Thus, the first thing that these people have to learn is the ability to detect symptoms of cholera so that they can immediately seek treatment.

One can just imagine how the chain reaction of events that leads to a pandemic can easily occur in an impoverished population. In poor counties an infected person does not have access to clean water and latrines. Their makeshift toilets cannot handle human wastes. Moreover, the patient continues to interact with family members, unwashed hands are used to handle food or to share food to other family members.

It is therefore important to be aware of tell-tale signs that the bacteria is already in a person’s system. One of the things to look out for is of course watery diarrhea combined with the following symptoms: “abdominal cramps; dry mucus membrane; dry skin; excessive thirst; glass or sunken eyes; lack of tears; lethargy; low urine output; nausea; rapid dehydration; rapid pulse rate; unusual sleepiness; and vomiting” (National Center for Biotechnology Information, 2010, p.1).

The key to stopping cholera in its tracks can be summarized into this statement: “Effective control measures rely on prevention, preparedness and response” (WHO, 2010, p.1). This is easier said than done but those areas that are stricken with this deadly bacterium have no choice but to react swiftly and efficiently.

Another way to mitigate risk and prevent a full-blown epidemic is to make sure that “Carefully designed messages delivered through multiple channels (media, home visits, schools, religious leaders, etc.) should be used to keep the public informed about the extent and severity of the outbreak, the effectiveness and simplicity of the present methods of treatment, the benefits of early reporting for prompt treatment, and the usefulness of simple preventive measures” (Barua & Greenough, 1992, p.337). An information dissemination campaign must be initiated as well as effective networking and communication strategies must be developed.

Health experts assigned in refugee camps and the ground zero of natural disasters must be trained to teach refugees how to deal with the sanitation problems that they are faced day-to-day until the issue had been totally resolved. In refugee camps people are told to wash their hands after using the toilet and the children are told not to play in puddles of dirty water (Bjorklund, 2011, p.51). This is a good starting point.

A good example of how to combat this disease can be seen in how the United States reacted to a pandemic in 1866. There was an outbreak in New York City during that year and the immediate response was the creation of a board of health and it was the first time that such an organization was established in the U.S. (Suddath, 2010, p.1).

Nevertheless, it was one of the most effective steps made because the impact was immediately made evident sanitation was improved and the disease was neutralized. Prevention is key and it can be argued that there is no other step that is most effective in eradicating cholera other than the construction of pipes that will be able to deliver clean water to communities so that people can stop using surface water, water from unfiltered wells, and water taken directly from rivers and lakes (Bjorklund, 2011, p.56).

Last but not least, “Appropriate facilities for human waste disposal are a basic need for human settlements” this necessity is exacerbated in refugee camps and overcrowded places (Barua & Greenough, 1992, p.338).

According to health experts, “Whenever a person suspects he or she has been exposed to cholera, the individual must take very careful steps to avoid spreading the disease” (Bjorklund, 2011, p.44). For those who are serious in defeating cholera in refugee camps and war torn countries, the World Health Organization, World Vision, Red Cross and the UNICEF has created a cholera kit that they send to stricken places and this kit contains the following:

large tents that can accommodate up to fifty patients at a time;
refrigerators (for medicines);
portable generators;
cots;
portable toilets or latrines;
IV equipment;
rehydration solutions;
water tanks;
water purification tablets;
soap;
hand and foot baths (Bjorklund, 2011, p.53).

These items must be shipped immediately because in this type of emergency situations a short delay can mean the death of a human being.

The importance of fluid replacement was explained succinctly by a research scientist who said, “In spite of the vast improvements in our understanding of the molecular mechanisms of cholera virulence, and the adaptation of the cholera bacillus to life in two different environments, the major breakthrough in treatment once infection occurs remains fluid replacement” (Coleman, 2009, p.89). The rapid loss of fluids in the human body will immediately affect the normal functions of the body.

This can lead to complications. A weakened body is prone to other medical problems. It is therefore urgent to find a way for the patient to have access to clean water. This is also the most urgent action that a relief worker or humanitarian aid agency must consider before flying into a hotspot. Water is key and without it an expensive equipment and other materials are useless because the patient can die in less than a day if fluid replacement therapy is not successful.

It has to be made clear that water is not the only major consideration when it comes to fluid replacement. Aside from the water lost through diarrhea, it is also important to replace lost electrolytes, the ions dissolved in the liquids and the proper term to describe this process is fluid replacement therapy (WHO, 2010, p.1).

This is a critical step in the treatment process because it has been documented that the mortality rates of cholera patients ho received fluid replacement therapy dropped to about 30 percent compared to those that did not receive this kind of treatment (Coleman, 2009, p.89).Aside from fluid replacement therapy and the maintenance of fluid levels in the patient’s body there is also a need to use antibiotics and make sure that the patient has access to adequate nutrition (Suddath, 2010, p.1).

The World Health Organization recommends the following formulation for oral rehydration therapy: sodium chloride (90 mmol/liter); potassium chloride (20 mmol/liter); glucose (111 mmol/liter); and sodium bicarbonate (30 mmol/liter) or sodium citrate (10 mmol/liter), as the best way to replace lost fluids (coleman, 2009, p.91).

Aside from electrolytes cholera patients will also lose bicarbonate in their stools (Coleman, 2009, p.91). Thus, caregivers must be reminded that the diet of the patient must be reinforced with a supply of alkaline solution. In the past sodium bicarbonate was used. But it was discovered that this compound (bicarbonate solution) is easily degraded if stored in hot and humid tropical climates and so they found a substitute – sodium citrate (Coleman, 2009, p.91).

It has been noted that great strides had been made in the creation of modern medicine that help combat the spread of cholera. The oral rehydration therapy works wonders in stricken areas as well as the use of antibiotics that reduces the impact of infection due to complications that arise from watery diarrhea.

However, there is much more that is needed in order to prevent a pandemic, especially when it comes to Third World countries such as Southeast Asia, South America, and other African nations characterized by low income and low literacy rates. Nevertheless, the present century offers a great deal of hope for those who are committed to eradicate this ancient scourge.

According to experts modern technology is the main weapon against ignorance and the spread of the disease and they added this is necessary because it will take a unified effort “of all nations to manage cholera outbreaks and to prevent them from destroying lives” (Bjorklund, 2011, p.56). International cooperation is therefore a must.

Conclusion

In the 21^st century no one should die from cholera. It is true that this bacterium is virulent and that patients can die in a matter of hours if left untreated. However, the virulence of the bacterium can be easily neutralized with the use of fluid replacement therapy, the use of antibiotics and the careful monitoring of nutrition. More importantly the transmission of cholera can even be prevented.

Nevertheless, almost five million cases of cholera are reported every year and more than a hundred thousand people die from the disease on a yearly basis. It is time to eradicate cholera and it begins with an effective and efficient information dissemination campaign. This must be accomplished even in war torn areas and even in the immediate aftermath of a national disaster. Teams must be trained to share information to families and community leaders with regards to the epidemiology of cholera and how its spread can be prevented and at the same time how infections can be treated.

References

Barua, D. & Greenough, W. (1992). Cholera. New York: Plenum Publishing Corporation.

Bjorklund, R. (2011). Cholera. New York: Marshall Cavendish.

Briggs, C. (2003). Stories in the Time of Cholera: Racial Profiling During a Medical Nightmare. CA: University of California Press.

Centers for Disease Control and Prevention. (2010). Cholera Outbreak – Haiti, October 2010. Web.

Coleman, W. (2009). Cholera. New York: Chelsea House.

PubMed Health. (2011). Cholera. Web.

Suddath, C. (2010). Brief History: Cholera Outbreaks. Web.

The International Federation’s Disaster Relief Emergency Fund. (2010). Zimbabwe: Cholera Outbreak. Web.

World Health Organization. (2010). Cholera. Web.

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