Archive for January, 2009

Cholera and Diarrhea

January 1, 2009


At this very moment there is an outbreak of cholera in Zimbabwe– not a worldwide pandemic, but a localized epidemic. This is not a trivial point of interest, but a major news event that will not only have a dramatic impact on the population of Zimbabwe but also on the entire world as the aftermath of this epidemic will require international aid. Cholera will most likely kill thousands of people in Zimbabwe, impact tens of thousands of lives, and will continue to be a constant threat around the world and a very real concern for the adventurous and international travelers.

What is cholera?
Cholera, an acute infectious diarrheal illness that can cause death in less than 24 hours due to the profuse diarrhea, is caused by the bacteria, Vibrio cholera.  Spread by oral-fecal contamination of food or water supplies, it is highly contagious, as has been demonstrated by at least seven worldwide pandemics over the past several hundred years.

How does cholera cause illness?
When consumed, the cholera bacteria passes through the stomach, where, fortunately, most of the bacteria are killed by the gastric juices and acid. Once the surviving bacteria have made it into the small intestine, they invade the lining of the small intestine and begin to multiply. In the process the bacteria produce an enterotoxin, and it is this enterotoxin that is responsible for causing the profuse, watery diarrhea that results in large quantities of fluid and electrolyte loss.

How does cholera cause death?
Death is a result of hypovolemic shock brought on by the profound dehydration from the enterotoxin-induced diarrhea.  The very watery, grayish diarrhea is referred to as a rice water diarrhea. The victim of cholera can easily have massive diarrhea at a rate of 3 – 4 liters per hour or even more, literally dehydrating and shriveling up right before your eyes. Cholera is a very dehumanizing, debilitating disease.

What are the signs and symptoms of cholera?
Diarrhea – copious amounts of watery, rice water diarrhea.
Dehydration leading to hypovolemic shock – rapid, weak pulse; hypotension; rapid, shallow breathing; pale, cool, clammy skin; anxiety; and a sense of impending doom
Exhaustion and prostration
Possible nausea and vomiting

How is cholera treated?
Hydration, Hydration,Hydration
The initial goal, and that means IMMEDIATELY is to replace the lost fluids and electrolytes. Then continue to replace the fluids that are being lost as quickly as they are being lost. As long as these patients can drink, oral therapy works very well. However, you have to replace the electrolytes as well as the water that is being lost. Water alone will not improve their survivability.

Electrolytes are charged ions: sodium (Na+), chloride (Cl-), potassium (K+), and bicarbonate (HCO3-).  Glucose is also required to supply the energy that is needed to live. These electrolytes with the addition of glucose maintain the basic and vital functions on a cellular level to sustain life as we know it.

How do you make an Oral Rehydration Solutions (ORS)?
1. ORS can by made by mixing a commercially available ORS powder with water.
2. Home remedy can by made by simple adding sugar and salt to water.
1 liter of water + 1 teaspoon of salt + 8 teaspoons of sugar
3. Rice water is also a very effective ORS. It is made by cooking rice as usual.
1 liter of water + ½ cup of the cooked rice + 4 teaspoons of sugar + 1 teaspoon of salt. Stir to create a drinkable liquid.
The calories from sugar are very important. If sugar is not available you substitute molasses, brown sugar, fruit juice (contains glucose and fructose), or green coconut water. In fact molasses and brown sugar are better as they contain additional compounds that are also helpful.

Antibiotic Therapy:
Cholera is also caused by the bacteria, Vibrio cholera, and fortunately it is susceptible to several different antibiotic therapies.

Antibiotics that can be used to treat cholera:

Oral rehydration is the cornerstone of therapy. Antibiotics will shorten the course of the diarrhea and speed recovery. Following is a list of several antibiotics and their dosages that will help to eliminate the Vibrio cholera in the small intestine. There are several options, all are equally efficacious.

Single dose antibiotics:
Doxycycline: single dose – 7mg/kg up to 300mg.
Tetracycline: single dose – 25mg/kg up to 1000mg.
Ciprofloxacin: single dose – 30mg/kg up to 1000mg.

Multiple dose antibiotics:
Trimethoprim/sulfamethoxazole:  5-10mg/day, divided bid x 3 days, up to 320mg of the
trimethoprim/day and 1600mg of the sulfamethoxazole/day.
Ampicillin: 50mg/kg/day, divided qid x 3 days up to 2000mg/day.
Erythromycin: 40mg/kg/day, divided tid x 3 days, up to 1000mg/day.

How can the spread of cholera be prevented?

Cholera is spread by oral-fecal contamination of the food and water supplies that are then consumed by others causing further spread of the illness.
Therefore, drink only water that has been properly treated with iodine, chlorine, filtration, boiling, or UVC light.
Avoid ice as freezing does not sterilize water.
Eat only properly prepared foods:
Vegetables that can be peeled or cooked.
Well cooked meats and fish.
Avoid raw or undercooked meats.
Beware of sanitation practices, hand washing, and dirty dishes.
In addition, health care providers must take Body Substance Isolation (BSI) precautions and practice extremely safe hygiene when working with cholera patients.
Quick summary of Cholera and its influence on recent history:
1816-1826: Cholera Pandemic:
The outbreak began in Bengal and then spread across India. Approximately 10,000 British troops and countless Indians died during this pandemic.
1829-1851: Cholera Pandemic:
This outbreak lasted 22 years and extended initially from Russia into Europe. In London, the disease claimed close to 7,000 victims, and in Paris alone another 20,000 perished with approximately 100,000 deaths in all of France.
The epidemic reached Quebec, Ontario, and New York in 1832 and the Pacific coast of North America by 1834. The number of deaths appears to not have been recorded.  In 1848, a two-year outbreak occurred in England and Wales which claimed about 52,000 lives.
1849:  A second major outbreak spread in Paris and London. In London it claimed 14,137 lives, twice as many as the 1832 outbreak.
1849:  Cholera was responsible for 5,308 deaths in Liverpool, England, and 1,834 in Hull, England.
1849: Cholera spread into the Mississippi river system killing over 4,500 in St. Louis and over 3,000 in New Orleans, and thousands more in New York. Cholera also spread along the California and Oregon trails; hundreds died during the California Gold Rush.
1852-1860:  Cholera Pandemic:
The pandemic mainly affected Russia, with over a million deaths.
In 1853-1854, another London’s epidemic claimed 10,738 lives.
1854: An outbreak of cholera in Chicago killed about 3,500 people.
1863-1875:  Cholera Pandemic:
Occurring primarily in Europe and Africa, at least 30,000 of the 90,000 Mecca pilgrims died from cholera during their pilgrimage. Cholera also claimed 90,000 lives in Russia in 1866.
1866: A cholera outbreak took place in North America while at the same time in London where cholera killed 5,596. Also more than 21,000 people died in Amsterdam, The Netherlands.
1881-1896: Cholera Pandemic:
The 1883-1887 epidemic took 250,000 lives in Europe and at least 50,000 in America. Cholera claimed 267,890 lives in Russia, 120,000 in Spain, 90,000 lives in Japan, 60,000 in Persia, 58,000 in Egypt, and 8,600 in Germany.
1899-1923: Cholera Pandemic:
This pandemic killed more than 800,000 in India.
1961-1970s:  Cholera pandemic:
Beginning in Indonesia, this pandemic reached Bangladesh in 1963, India in 1964, and the USSR in 1966. From North Africa it spread into Italy by 1973. In the late 1970s, there were small outbreaks in Japan and in the South Pacific.
January 1991 to September 1994:
An outbreak in South America, beginning in Peru where there were 1.04 million identified cases and almost 10,000 deaths.
November 2008 – Doctors Without Borders, (Medicines Sans Frontiers) reported an outbreak in a refugee camp in the Congo.
November – December 2008
Is has been estimated that more than 11,000 people in the African nation of Zimbabwe are infected, and there have been more than 600 deaths.
Please note that these statistics come from a variety of resources. If you are interested, one of the most complete sources of the history of cholera pandemics can be found on Wikipedia by looking up cholera.

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