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Cholera is an infection of the small intestine by the bacteria Vibrio cholerae.[1] Some people have no symptoms. Others may have few symptoms severe symptoms, or symptoms that are fatal.[2] The most common symptom is large amounts of diarrhea that lasts a few days.[3] Vomiting and muscle cramps can happen.[2][3] A person may have dark eyes and cold skin. Their skin changes and can be very wrinkled and look blue.[4][5] When a person becomes infected, the sickness can start very quickly and as soon as two hours. Symptoms could also take up to five days to begin.[2]

Government orgainizations try to count the people who have cholera. This helps to find the source of the sickness and correct that.[6][7]

Vaccines given by mouth for cholera are available.[8] Dukoral is one of these.[9]

It is spread mostly by unsafe water and unsafe food that has been contaminated with human feces containing the bacteria.[3] Undercooked seafood is a common source.[10] Only people get cholera - not animals. If a person does not drink safe and clean drinking water the person is more likely to get cholera. Cholera can be diagnosed by a stool test by a doctor or nurse.[3]

Preventing cholera is having clean water.[4] There is a cholera vaccine that is taken by m outh. It will protect a person for about six months. Once a person has cholera, they will become healthy by oral rehydration therapy. This is giving of fluids that are with slightly sweet and salty.[3] Rice-based liquids are good.[3][11] In people who are very sick, severe cases, intravenous fluids, may be required. Some and antibiotics may be helpful.

Three to five 3–5 million people get sick with cholera every year. Cholera causes 28,800–130,000 deaths a year.[3][12] Children have cholera more often that adults..[3][13] Cholera can can happen as a temporary disease in an area or it can be chronic in an area. Areas with an ongoing risk of disease include Africa and south-east Asia.

The primary symptoms of cholera are diarrhea and vomiting of clear water.[7] These symptoms usually start quickly.[14] Some people call the diarrhea "rice water" and the diarrhea can smell like fish.[7] A person can produce 10 to 20 litres (3 to 5 US gal) of diarrhea a day.[7] If a person gets no rehydration or medical treatment then a person has a 50% of dying. Cholera has been another name - the "blue death" because a person's skin may turn bluish-gray.[15]

Cholera does not cause fever. If a person has a fever then they have a different infection. People with cholera are tired. A person can have a, dry mouth, cold and wet, or wrinkled hands and feet. A person may not be breathing normally. A person will pass less urine, have muscle cramps and become unconsious.[7]

If a person has AIDS they may have a very severe case of cholera.[16]

One injectable vaccine was found to be effective for two to three years. The protective efficacy was 28% lower in children less than 5 years old.[17] However, as of 2010, it has limited availability.[3] Work is under way to investigate the role of mass vaccination.[18] The World Health Organization (WHO) recommends immunization of high-risk groups, such as children and people with HIV, in countries where this disease is endemic.[3] If people are immunized broadly, herd immunity results, with a decrease in the amount of contamination in the environment.[19]

Treatment and medications

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Cholera patient being treated by oral rehydration therapy in 1992

If a person eats while they have cholera, they will improve more quickly.[20] Breastfeeding a child with cholera is very good.[21] It is easy to forget how much fluid a person with cholera can lose when they have cholera.[22] Most people who have cholera can be treated with oral rehydration therapy with success. It is effective, safe and simple to take and simple to make.[19] And rice-based solutions are better than sugar liquids.[19] If someone is very sick with cholera they may need, intravenous fluids.[7][20] Large amounts of fluid is given until the diarrhea stops.[7] Ten percent of a person's body weight in fluid may need to be given in the first two to four hours.[7] Fruit juices and sodas like cola are not the best fluids to take during cholera.[23]

Medical treatment with fluids

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If commercially produced oral rehydration solutions are too expensive or difficult to obtain, solutions can be made. One such recipe calls for 1 liter of boiled water, 1/2 teaspoon of salt, 6 teaspoons of sugar, and added sweet, mashed banana for potassium and to improve taste.[24]

Antibiotics

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Antibiotic treatments for one to three days will shorten the sickness and reduce the severity of the symptoms.[7] Use of antibiotics also reduces fluid requirements.[25] People will recover without them, however, if sufficient hydration is maintained.[19] The World Health Organization only recommends antibiotics in those with severe dehydration.[26] The antibiotic doxycycline is usually given first. There are some cholera bacteria that resist this antibiotic.[7] Testing for resistance during an outbreak can help determine appropriate future choices.[7] Other antibiotics proven to be effective include cotrimoxazole, erythromycin, tetracycline, chloramphenicol, and furazolidone.[27] Fluoroquinolones, such as ciprofloxacin, also may be used, but resistance has been reported.[28]

Antibiotics improve outcomes in those who are both severely and not severely dehydrated.[29] Azithromycin and tetracycline may work better than doxycycline or ciprofloxacin.[29]

Zinc supplementation

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Giving zinc supplements shortens the time of the disease in children.[30] Zinc also helps in treating other types of diarrhea.[30][31]

Prognosis

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If a person with cholera is treated quickly with fluids, the rate of death is less than 1%. If cholera is not treated the rate of death is 50–60%.[7][32] For certain types of cholera that were in Haiti in 2010 a person can die in two hours.[33]

Sewage Treatment

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Hand bill from the New York City Board of Health, 1832—the outdated public health advice demonstrates the lack of understanding of the disease and its actual causative factors.

Cholera affects an estimated 3–5 million people worldwide, and causes 58,000–130,000 deaths a year as of 2010.[3][34] This occurs mainly in the developing world.[35] In the early 1980s, death rates are believed to have been greater than 3 million a year.[7] It is difficult to calculate exact numbers of cases, as many go unreported due to concerns that an outbreak may have a negative impact on the tourism of a country.[19] Cholera remains both epidemic and endemic in many areas of the world.[7]

Lack of treatment of human feces and lack of treatment of drinking water greatly facilitate its spread. Large lakes, seas and oceans can contain cholera. Seafood can spread the disease.

History

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See also: Timeline of cholera
Map of the 2008–2009 cholera outbreak in sub-Saharan Africa showing the statistics as of 12 February 2009.
Signal flag "Lima" called the "Yellow Jack" which when flown in harbor means ship is under quarantine. A simple yellow flag (also called the "Yellow Jack") had historically been used to signal quarantine (it stands for Q among signal flags), but now indicates the opposite, as a signal of a ship free of disease that requests boarding and inspection.

Cholera was not known in the Americas for most of the 20th century, but it reappeared towards the end of that century.[36]he word cholera is from Greek: χολέρα kholera from χολή kholē "bile". Cholera likely has its origins in the Indian subcontinent as evidenced by its prevalence in the region for centuries.[7] Early outbreaks in the Indian subcontinent are believed to have been the result of poor living conditions as well as the presence of pools of still water, both of which provide ideal conditions for cholera to thrive.[37] The disease first spread by trade routes (land and sea) to Russia in 1817, later to the rest of Europe, and from Europe to North America and the rest of the world.[7] Seven cholera pandemics have occurred in the past 200 years, with the seventh pandemic originating in Indonesia in 1961.[38]

The first cholera pandemic occurred in the Bengal region of India, near Calcutta starting in 1817 through 1824. The disease dispersed from India to Southeast Asia, the Middle East, Europe, and Eastern Africa through trade routes.[39] The second pandemic lasted from 1827 to 1835 and particularly affected North American and Europe due to the result of advancements in transportation and global trade, and increased human migration, including soldiers.[40] The third pandemic erupted in 1839, persisted until 1856, extended to North Africa, and reached South America, for the first time specifically affecting Brazil. The fourth pandemic lasted from 1863 to 1875 spread from India to Naples and Spain. The fifth pandemic was from 1881-1896 and started in India and spread to Europe, Asia, and South America. The sixth pandemic started 1899–1923. These epidemics were less fatal due to a greater understanding of the cholera bacteria. Egypt, the Arabian peninsula, Persia, India, and the Philippines were hit hardest during these epidemics, while other areas, like Germany in 1892 and Naples from 1910–1911, also experienced severe outbreaks. The final pandemic originated in 1961 in Indonesia and is marked by the emergence of a new strain, nicknamed El Tor, which still persists today in developing countries.[41]

Since it became widespread in the 19th century, cholera has killed tens of millions of people.[42] In Russia alone, between 1847 and 1851, more than one million people perished of the disease.[43] It killed 150,000 Americans during the second pandemic.[44] Between 1900 and 1920, perhaps eight million people died of cholera in India.[45] Cholera became the first reportable disease in the United States due to the significant effects it had on health.[7] John Snow, in England, was the first to identify the importance of contaminated water as its cause in 1854.[7] Cholera is now no longer considered a pressing health threat in Europe and North America due to filtering and chlorination of water supplies, but still heavily affects populations in developing countries.

In the past, vessels flew a yellow quarantine flag if any crew members or passengers were suffering from cholera. No one aboard a vessel flying a yellow flag would be allowed ashore for an extended period, typically 30 to 40 days.[46] In modern sets of international maritime signal flags, the quarantine flag is yellow and black.

Historically many different claimed remedies have existed in folklore. Many of the older remedies were based on the miasma theory. Some believed that abdominal chilling made one more susceptible and flannel and cholera belts were routine in army kits.[47] In the 1854–1855 outbreak in Naples homeopathic Camphor was used according to Hahnemann.[48] T. J. Ritter's "Mother's Remedies" book lists tomato syrup as a home remedy from northern America. Elecampane was recommended in the United Kingdom according to William Thomas Fernie[49]

Cholera cases are much less frequent in developed countries where governments have helped to establish water sanitation practices and effective medical treatments.[50] The United States, for example, used to have a severe cholera problem similar to those in some developing countries. There were three large cholera outbreaks in the 1800s, which can be attributed to Vibrio cholerae's spread through interior waterways like the Erie Canal and routes along the Eastern Seaboard.[51] The island of Manhattan in New York City touched the Atlantic Ocean, where cholera collected just off the coast. At this time, New York City did not have as effective a sanitation system as it does today, so cholera was able to spread.[52]

Cholera morbus is a historical term that was used to refer to gastroenteritis rather than specifically cholera.[53]

Research

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Robert Koch (third from the right) on a cholera research expedition in Egypt in 1884, one year after he identified V. cholerae.
How to avoid the cholera leaflet; Aberystwyth; August 1849

The bacterium was isolated in 1854 by Italian anatomist Filippo Pacini,[54] but its exact nature and his results were not widely known.

Spanish physician Jaume Ferran i Clua developed a cholera inoculation in 1885, the first to immunize humans against a bacterial disease.[55]

Russian-Jewish bacteriologist Waldemar Haffkine developed the first cholera vaccine in July 1892.[56]

One of the major contributions to fighting cholera was made by the physician and pioneer medical scientist John Snow (1813–1858), who in 1854 found a link between cholera and contaminated drinking water.[37] Dr. Snow proposed a microbial origin for epidemic cholera in 1849. In his major "state of the art" review of 1855, he proposed a substantially complete and correct model for the cause of the disease. In two pioneering epidemiological field studies, he was able to demonstrate human sewage contamination was the most probable disease vector in two major epidemics in London in 1854.[57] His model was not immediately accepted, but it was seen to be the more plausible, as medical microbiology developed over the next 30 years or so.

Cities in developed nations made massive investment in clean water supply and well-separated sewage treatment infrastructures between the mid-1850s and the 1900s. This eliminated the threat of cholera epidemics from the major developed cities in the world. In 1883, Robert Koch identified V. cholerae with a microscope as the bacillus causing the disease.[58]

Robert Allan Phillips, working at the US Naval Medical Research Unit Two in Southeast Asia, evaluated the pathophysiology of the disease using modern laboratory chemistry techniques and developed a protocol for rehydration. His research led the Lasker Foundation to award him its prize in 1967.[59]

More recently, in 2002, Alam, et al., studied stool samples from patients at the International Centre for Diarrhoeal Disease in Dhaka, Bangladesh. From the various experiments they conducted, the researchers found a correlation between the passage of V. cholerae through the human digestive system and an increased infectivity state. Furthermore, the researchers found the bacterium creates a hyperinfected state where genes that control biosynthesis of amino acids, iron uptake systems, and formation of periplasmic nitrate reductase complexes were induced just before defecation. These induced characteristics allow the cholera vibrios to survive in the "rice water" stools, an environment of limited oxygen and iron, of patients with a cholera infection.[60]

Society and culture

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Health policy

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In many developing countries, cholera still reaches its victims through contaminated water sources, and countries without proper sanitation techniques have greater incidence of the disease.[61] Governments can play a role in this. In 2008, for example, the Zimbabwean cholera outbreak was due partly to the government's role, according to a report from the James Baker Institute.[62] The Haitian government’s inability to provide safe drinking water after the 2010 earthquake led to an increase in cholera cases as well.[63]

Similarly, South Africa’s cholera outbreak was exacerbated by the government’s policy of privatizing water programs. The wealthy elite of the country were able to afford safe water while others had to use water from cholera-infected rivers.[failed verification][64]

According to Rita R. Colwell of the James Baker Institute, if cholera does begin to spread, government preparedness is crucial. A government's ability to contain the disease before it extends to other areas can prevent a high death toll and the development of an epidemic or even pandemic. Effective disease surveillance can ensure that cholera outbreaks are recognized as soon as possible and dealt with appropriately. Oftentimes, this will allow public health programs to determine and control the cause of the cases, whether it is unsanitary water or seafood that have accumulated a lot of Vibrio cholerae specimens.[62] Having an effective surveillance program contributes to a government’s ability to prevent cholera from spreading. In the year 2000 in the state of Kerala in India, the Kottayam district was determined to be "Cholera-affected"; this pronouncement led to task forces that concentrated on educating citizens with 13,670 information sessions about human health.[65] These task forces promoted the boiling of water to obtain safe water, and provided chlorine and oral rehydration salts.[65] Ultimately, this helped to control the spread of the disease to other areas and minimize deaths. On the other hand, researchers have shown that most of the citizens infected during the 1991 cholera outbreak in Bangladesh lived in rural areas, and were not recognized by the government's surveillance program. This inhibited physicians' abilities to detect cholera cases early.[66]

According to Colwell, the quality and inclusiveness of a country's health care system affects the control of cholera, as it did in the Zimbabwean cholera outbreak.[62] While sanitation practices are important, when governments respond quickly and have readily available vaccines, the country will have a lower cholera death toll. Affordability of vaccines can be a problem; if the governments do not provide vaccinations, only the wealthy may be able to afford them and there will be a greater toll on the country's poor.[67][68] The speed with which government leaders respond to cholera outbreaks is important.[69]

Besides contributing to an effective or declining public health care system and water sanitation treatments, government can have indirect effects on cholera control and the effectiveness of a response to cholera.[70] A country's government can impact its ability to prevent disease and control its spread. A speedy government response backed by a fully functioning health care system and financial resources can prevent cholera's spread. This limits cholera's ability to cause death, or at the very least a decline in education, as children are kept out of school to minimize the risk of infection.[70]

Notable cases

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References

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