Fatal disease cholera: An International perspective

Cholera is in an epidemic form of disorder observed by various physicians in the 16th century. A disease is the malfunctioning of the body organs due to several reasons. Cholera is classified as a communicable disease, which is caused due to pathogens, transmitted from one person to another.

Cholera is derivative of a Greek word, which means, "flow of bile". Robert Koch exposed V cholerae in 1883 during an eruption in Egypt. This comma-shaped, gram-negative aerobic bacillus organism varies in size from 1-3 mm in length by 0.5-0.8 mm in diameter. A flagellar H antigen and a somatic O antigen is the antigenic structure of this organism.

Cholera is caused due to strains of the bacterium. The bacterium appears as rod shaped under microscope. When a person is infected by V. cholerae, it occupies place in the small intestine and begins producing an enterotoxin that causes plentiful, painless, watery diarrhoea. This causes the body to discharge an abnormally bulky amount of water into the intestine. The incubation period of Cholera is short, from less than one day to five days.   It results in severe dehydration and death if prompt treatment is not provided. Patients show mostly symptoms of vomiting. Some V. cholerae infected person do not become ailing, even though the bacterium is present in their faeces for 7-14 days. It has been observed that when patient fell with cholera bacteria, more than 90% of cases are of mild or moderate severity and are difficult to distinguish clinically from other types of acute diarrhea. Less than 10% of ill persons develop typical cholera with signs of moderate or severe dehydration (World Health organization).

Cholera is one of the most deadly diseases in its intense manifestation. If instant treatment is not provided, a healthy person may become serious within an hour of the onset of symptoms and may die within 2-3 hours. Cholera is nearly unrivaled in terms of the speed with which it kills. Electrolytes such as   sodium chloride and water are absorbed through the intestines in human body. The Vibrio cholerae bacteria which produces toxin, paralyzes the gut in such a way that intestinal cells secrete water and electrolytes that results in diarrhea and extremely rapid dehydration. It is hard to survive for V cholerae bacteria in an acidic environment. Therefore, any condition that reduces the production of gastric acid increases the risk of acquisition. Although the pathophysiology is not understood, individuals with blood group O are more at risk of developing El Tor cholera.

Populace of world suffers from this disease. Since many decades, Cholera has emitted in a rampant fashion on the Indian subcontinent. Garcia del Huerto, a Portuguese physician at Goa, India, noticed epidemic cholera in 1563. Cholera is transmitted through water, has been proved by John Snow, a London physician in 1849. From the perspective of eagle-eyed observation it is clear that when, during the early 1820s in Russia and then in Western Europe a decade later, cholera first arrived in Europe, no one became aware of what was happening with them.

Cholera was hit with astounding fierceness, petrifying like plague and yellow fever before it, making its way from its origins in India by leaps and bounds along the main routes of commercial intercourse in an imprecise, yet identifiably northwesterly movement. The current seventh pandemic began in 1961 when the vibrio first appeared as a cause of epidemic cholera in Celebes (Sulawesi), Indonesia. After that the disease stretched out quickly to other countries of eastern Asia and reached Bangladesh in 1963, India in 1964, and the USSR, Iran and Iraq in 1965-1966. In 1970, cholera attacked West Africa, which had not suffered from the disease for more than 100 years. The disease speedily swelled to a number of countries and eventually became endemic in most of the continent. In 1991, cholera struck Latin America and was affected by it in many areas. Within the year it swelled to 11 countries, and afterward all through the continent. Until 1992, only V. cholerae serogroup O1 had caused epidemic cholera, large outbreaks of cholera began in India and Bangladesh that were caused by a previously unrecognized serogroup of V. cholerae, designated O139, synonym Bengal.

In Europe, the first wave of cholera had broken without warning, provoking at first reactions that was little more than the application of lessons learnt from past attacks of such kind of disease. In the second phase of cholera, the half-century from the late 1830s up through Koch's discovery of the comma bacillus as the disease's cause and the gradual acceptance in official circles of its preventive implications during the late 1880s and early nineties, a similar process of experimentation, trial and error and the accretion of experience continued. This increase in knowledge, though commonly shared among all nations, did not, however, lead in any automatic sense to uniform and concrete strategies. Different states continued to take divergent approaches to cholera and other contagious diseases. This had resulted into increased differences in national preventive tactics.

A cholera outburst occurred among 90,000 Rwandan refugees residing in temporary camps in the Democratic Republic of Congo in April 1997. It took 1521 lives during the first 22 days. Mostly deaths were recorded outside of health-care facilities.

According to information obtained by UNICEF, nearly 80 per cent of the population in Sao Tome and Principe was at risk from a deadly cholera outbreak. As of today, 131 cases of cholera, including 57 among children, have been reported; three deaths have occurred. Young children are particularly vulnerable to cholera, which causes diarrhoea that can   lead to severe dehydration and even death (UNICEF ).

The disease cholera hit badly in the maze of rivers and thousands of large and small islands that form the delta region of the Orinoco River in eastern Venezuel and five hundred persons died in 1992-1993. According to report, Cholera is uncommon in the United States but frequently observed in Asia, Africa, and Latin America.

When Peru was hit by waves of cholera, it rapidly swelled to Ecuador, Colombia, Chile, other South American countries, and Mexico as well. With in six months more than 270,000 cases and almost 3,000 deaths were reported, mostly in shantytowns and poor communities.

Rich communities where proper sanitation and disposal of human waste is maintained remained relatively unharmed. It might be because they could afford the fuel and equipment to heat their food enough. An eruption of cholera came into view from Madras, India, as a result of a new serogroup, O139 (also known as Bengal) in October 1992. This Bengal strain has now extended all the way through Bangladesh and India and into neighboring countries in Asia. This was as an eighth pandemic according to some experts. So far 11 countries in Southeast Asia have reported isolation of this Vibrio serogroup. In 2002, all over the world, Cholera spread caused was by V cholerae 01 biotype El Tor. Same year, statistical data showed a total of 142,311 cases and 4564 deaths in 52 countries. It was doubled the cases reported as compared with 2001.

Angola was severely hit by cholera during June 2006 and reported a total of 46 758 cases including 1893 deaths. Fourteen out of 18 provinces were affected; of all cases, 49% have occurred in Luanda and 17% in Benguela provinces. Even though present trend illustrate a decline in most provinces, daily 125 cases are still being reported. Cholera persists as a severe health crisis in Africa, Asia and Latin America, with as many as 200,000-500,000 cases per year, and mortality rates reaching as high as 20-50%.  There are currently no effective prophylactics, and treatment by oral rehydration is often thwarted by the lack of clean water supplies. Usually, cholera outbreaks occur when the feces of an infected person contaminate the water supply. Others then contact with potentially life-threatening infection by drinking the water or eating tainted food.

Cholera through direct person-to-person contact is hardly ever observed. In extremely endemic areas, generally the disease infects young children.  Breastfeeding infants are safe. The aquatic environment is quite favorable for Vibrio cholerae. It is often associated with algal blooms (plankton), which are influenced by the temperature of the water. Human beings are also one of the reservoirs of the pathogenic form of Vibrio cholerae. Cholera patients show symptoms of diarrhea, vomiting, and leg cramps. In these persons, speedy loss of body fluids leads to dehydration and shock. The rapid dehydration makes cholera patients weak and thirsty, their arms and legs grow cold and clammy, and powerful cramps seem to shrivel their limbs and tie them in knots. The tips of their tongues and their lips turn blue, their eyes sink back into their sockets, and their skin hangs limply on their bodies. Unless the lost fluid is replaced, consciousness fades rapidly. The loss of fluid leads to anuria, acidosis and shock. The loss of potassium ions may result in cardiac complications and circulatory failure. If the patient is not treated, the person becomes dehydrated, which can lead to kidney failure, shock, and death.

Cholera is diagnosed by the identification of V cholerae in the stool. The organism can easily detected by dark-field microscopy examination of a wet mount of fresh stool; chaotic motility is observed. The serotype may be determined by immobilization with Inaba-specific or Ogawa-specific antiserum.

Cholera can be simply and effectively treated by instant substitute of the fluid and salts lost through diarrhea. Patients are advised to take orally rehydration solution, a prepackaged mixture of sugar and salts to be mixed with water and drunk in large amounts. rehydration therapy prevents dehydration. An ideal oral rehydration solution is the mixture of Sodium chloride 3.5 g, sodium bicarbonate 2.5 g, potassium chloride 1.5 g, glucose 20 g, and sucrose 40 g in one liter of water. This solution is used globally to arrest diarrhea. In Severe cases, intravenous fluid replacement is given. Most effective antibiotic to cure cholera is tetracycline. Antibiotics can shorten the duration and ease the severity of symptoms; rehydration is the crux of treatment. When cholera spreads in a community, the most important preventive measures are hygienic disposal of human faeces, an adequate supply of safe drinking water, and good food hygiene. Food must be well cooked and avoid raw fruits or vegetables unless they are first peeled. All members should wash their hands after defecation, and before taking meals or drinking water.  The publication "Guidelines for Cholera Control", available through WHO's Distribution and Sales Unit, states that " Vibrio cholera 01 can survive on a variety of foodstuffs for up to five days at ambient temperature and up to 10 days at 5-10 degrees Celsius". The organism can also survive at freezing low temperatures; however, this limits propagation of the organism and in turn prevents the level of infectivity from reaching an infective dose.

WHO considers that while importing food from cholera-affected areas, it is important to agree with food exporters, on good hygienic practices which need to be followed during food handling and processing to thwart, eliminate or minimize the threat of any possible contamination and to check thoroughly that these measures are satisfactorily carried out (WHO). To execute awareness program and imparting effective education in environmental control is critical to prevent cholera. Environmental control must focus on safe water supply and proper disposal of human wastes because the bacteria of cholera by nature survive in human excretion and infect the populace through the media of water.

There are proper arrangement of public health planning and in the engineering of water conservation and sewage disposal in developed countries. But developing countries are continuously facing hazards of contamination of water by human excrement due to poor sanitation and improper handling of public services worse the condition further. These populations are constantly experiencing a sequence of infection and excretion. They require effectual education about the sterilization of water and hand-washing techniques, but it is some times difficult because of their inherited bad habits. As a responsible and alert member of society, we must carefully watch and perform some important activities.

We must regularly listen for public health announcements and news and follow the instructions aired. Team of doctors, scientists and public health workers should consciously watch environmental illnesses that might contaminate the food supply. If there is a dilemma, they should conduct advisory session to make public awareness to protect members and their family. Time to time these health organization advertise that if some one is suffering from severe diarrhea or vomiting, he must contact doctor immediately. Whatever be the disease, these symptoms can lead to serious dehydration. To know about Cholera disease and prevent themselves from infection, people must be educated with primary observation in their environment. A suspected case of cholera can be any person with watery diarrhea and depressed eye. Extensive care should be given to such person by providing ORS urgently. Attendants must rush to nearest cholera treatment center. Continuous observation is done for all contacts and household members for any development of diarrhea. The most significant step is burial of persons deceased from cholera. Preferably trained person should perform it. It should be promptly buried after disinfections of the body, beddings and all personal belonging of the deceased.

It is a reality that a healthy person can harbor cholera germs and spread it to people or contaminate food and water when hygienic conditions are poor. After getting news of cholera, one should immediately start taking precautions at individual level, such as boiling water and using chlorine disinfectant in water to control the disease.

Cholera is a worldwide risk and is one of the major sign of societal disturbance.  The disease no longer poses a threat to countries with minimum standards of hygiene; Cholera is ruled as a deadly one in countries where there is improper sanitation and access to contaminated drinking water. Almost every developing country suffers cholera outbreaks or threat of a cholera epidemic. At global level, many regions like Asia, Africa, and South America do not have appropriate sanitation so the disease is still widespread.