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Cholera

What Is Cholera? What Causes Cholera? (Medical News Today)

Cholera is a bacterial infection. It usually spreads by drinking water contaminated with vibrio
cholerae bacteria. It is also caused by eating food that has been in contact with contaminated
water. Cholera primarily affects the small intestine and the main symptoms include production of
profuse watery diarrhea and vomiting. This can lead to rapid dehydration (hypohydration) and
electrolyte loss. Left untreated, cholera can be fatal in a matter of hours.

According to Medilexicon's medical dictionary-

Cholera is "An acute epidemic infectious disease caused by the bacterium Vibrio cholerae. A
soluble toxin elaborated in the intestinal tract by the bacterium activates the adenylate cylase
of the mucosa, causing active secretion of an isotonic fluid resulting in profuse watery
diarrhea, extreme loss of fluid and electrolytes, and dehydration and collapse, but no gross
morphologic change in the intestinal mucosa."

Modern sewage and water treatment have virtually eliminated cholera in industrialized countries.
The last major outbreak in the United States occurred in 1911. However, cholera continues to be
a major cause of death in the world and is still present in Asia, the Middle East, Latin America,
India and sub-Saharan Africa.

The risk of cholera epidemic is highest when poverty, war or natural disasters force people to
live in crowded conditions without adequate sanitation.

Cholera can be easily treated. Death results from severe dehydration and shock (a sudden and
massive drop in blood pressure that starves the body of oxygen). This can be prevented with a
simple and inexpensive combination of antibiotics, fluids and oral rehydration solution.

How cholera is spread?

Around three-quarters of people who are exposed to cholera bacteria do not develop any
symptoms. However, these people can contaminate water by passing stools that contain bacteria
into water, or pass on the disease through poor food hygiene.

How common is cholera?

Cases of cholera are now largely confined to regions of the world with poor sanitation and water
hygiene, such as-
 sub-Saharan Africa (all the countries south of the Sahara desert)
 south and south-east Asia, particularly India and Bangladesh
 some parts of the Middle East
 some parts of South America

Even in these parts of the world, cholera remains relatively uncommon. However, mass
outbreaks can occur in times of natural disaster, war or civil strife, due to overcrowding of
people in poor living conditions, and lack of access to clean water.

For example, outbreaks of cholera occurred in some parts of Iraq in 2008 and in a number of
refugee camps in Zimbabwe in 2009.

What are the signs and symptoms of cholera?

A symptom is something the patient senses and describes, while a sign is something other
people, such as the doctor notice. For example, drowsiness may be a symptom while dilated
pupils may be a sign.

Many people exposed to the cholera bacterium (Vibrio cholerae) do not become ill. Some may
never know they have been infected. Yet because those people shed cholera bacteria in their
stool for seven to fourteen days, they can still infect others.

Most symptomatic cases of cholera cause mild or moderate diarrhea that is often hard to
distinguish from diarrhea caused by other problems.

The symptoms start suddenly, usually one to five days after infection, and are the result of a
toxin produced by the vibrio cholerae bacterium. Only about one in ten infected people develop
the typical signs and symptoms of cholera, such as-

 Severe, watery diarrhea. The incubation time for cholera is short. Usually one to five days
after infection, diarrhea comes on suddenly.

Diarrhea due to cholera is often voluminous, containing mucus and dead cells. It has a pale,
milky appearance that resembles water in which rice has been rinsed (referred to as "rice-water
stool"). What makes cholera diarrhea so deadly is the loss of large amounts of fluids in a short
time (as much as a quart (.95 liters) an hour). An untreated cholera patient may produce
several gallons of diarrheal fluid a day. If fluid is not replaced, the patient may die within
several hours.
 Nausea and vomiting. Occurring in both the early and later stages of cholera, vomiting may
persist for hours at a time.
 Muscle cramps. These result from the rapid loss of salts such as sodium, chloride and
potassium.
 Shock. Hypovolemic shock is one of the most serious complications of cholera dehydration. It
occurs when low blood volume causes a drop in blood pressure and a corresponding reduction
 in the amount of oxygen reaching the tissues. If untreated, severe hypovolemic shock can
cause death in a matter of minutes.
 Dehydration. This can develop far more quickly than in other diarrheal diseases, within hours
after the onset of cholera symptoms. Depending on how much body fluids have been lost,
dehydration can range from mild to severe. A loss of 10 percent or more of total body weight
indicates severe dehydration.

Signs and symptoms of cholera dehydration include-

o an irregular heartbeat (arrhythmia)

o dry mouth
o dry, shriveled skin that is slow to bounce back when pinched into a fold
o extreme thirst
o irritability
o lethargy
o little or no urine output
o low blood pressure
o sunken eyes

Signs and symptoms of cholera in children

In general, children with cholera have the same signs and symptoms adults do.

They may also experience-

 Convulsions
 Extreme drowsiness or even coma
 Fever

The risk of cholera is slim in industrialized nations. In endemic areas there is little risk to become
infected if one follows food safety recommendations. However, sporadic cases of cholera occur
throughout the world.

Seek medical treatment right away if you have diarrhea, especially severe diarrhea, and if there
may have been exposure to cholera. Severe dehydration is a medical emergency that requires
immediate care.

What causes cholera?

The main source of cholera infection is contaminated water supplies. However, raw shellfish,
uncooked fruits and vegetables, and other foods also can harbor cholera bacteria.

The bacterium that causes cholera, Vibrio cholera, has two distinct life cycles-

 in the environment
 in humans

Environment

Cholera bacteria occur naturally in coastal waters. They attach to tiny crustaceans called
copepods. As many as 10,000 bacteria may adhere to a single crustacean. The cholera bacteria
travel with their hosts, spreading around the world as the crustaceans follow their food source.
Certain types of algae and plankton grow explosively when water temperatures rise.

Most cholera outbreaks occur in spring and fall when ocean surface temperatures and algae
blooms are at their maximum. More algae mean more copepods, and more copepods mean more
cholera bacteria.

People

People who have ingested cholera bacteria may not become sick. However, they still excrete the
bacteria in their stool and can pass cholera disease to others through the fecal-oral route. This
mainly occurs when human feces contaminate food or water supplies.

The source of the contamination is typically cholera patients when their untreated diarrhea
discharge is allowed to get into waterways or into groundwater or drinking water supplies. Any
infected water and any foods washed in the water, as well as shellfish living in the affected
waterway, can cause an infection.

More than a million cholera bacteria (approximately the amount found in a glass of contaminated
water) are needed to cause illness. For this reason, cholera is rarely spread directly from person
to person.

Common sources of cholera infection-

 Water. Cholera bacteria can lie dormant in water for long periods. Contaminated public wells
are frequent sources of large-scale cholera outbreaks. Cholera epidemics are most likely to
occur in communities without adequate sanitation and in areas affected by natural disasters or
war. People living in crowded refugee camps are especially at risk of cholera.
 Grains. In regions where cholera is widespread, grains such as rice and millet are a source of
cholera infection. They can be contaminated after cooking while allowed to remain at room
temperature for several hours. This becomes a medium for the growth of cholera bacteria.
 Raw fruits and vegetables. Raw, unpeeled fruits and vegetables are a frequent source of
cholera infection in areas where cholera is endemic. In developing nations, manure fertilizers
or irrigation water containing raw sewage can contaminate produce in the field. Fruits and
vegetables may also become tainted with cholera bacteria during harvesting or processing.
 Seafood. Eating raw or undercooked seafood (especially shellfish) that originates from certain
locations. Most cases of cholera occurring in the United States since the 1970s have been
traced to oysters and crab from the Gulf of Mexico and to seafood transported or smuggled
 from countries where cholera is endemic.

There is a higher risk with shellfish because they filter large amounts of water, concentrating
the levels of cholera bacteria.

Bacteria produce strong toxin

The deadly effects of the disease are the result of a potent toxin, the cholera toxin (called CTX or
CT). CTX binds to the intestinal walls. It interferes with the normal flow of sodium and chloride.
This causes the body to secrete enormous amounts of water, leading to diarrhea and a rapid loss
of fluids and salts (electrolytes).

What are the risk factors for cholera?

A risk factor is something which increases the likelihood of developing a condition or disease.
For example, obesity significantly raises the risk of developing diabetes type 2. Therefore,
obesity is a risk factor for diabetes type 2.

Everyone is susceptible to cholera. Some infants are the exception. They derive immunity from
nursing mothers who have previously had cholera. Certain factors can make some people more
vulnerable to the disease or more likely to experience severe signs and symptoms.

Risk factors for cholera include-

 Malnutrition. There is a connection between malnutrition and cholera. People who are
malnourished are more likely to become infected with cholera. Likewise, cholera is more
likely to flourish in places where malnutrition is common, such as refugee camps,
impoverished countries, and areas devastated by famine, war or natural disasters.
 Reduced or nonexistent stomach acid (hypochlorhydria or achlorhydria) . Cholera
bacteria cannot survive in an acidic environment. For this reason, ordinary stomach acid often
serves as a first-line defense against infection. But people with low levels of stomach acid lack
this protection therefore they are more likely to develop cholera and to have severe signs and
symptoms of the disease.
 Who has lower levels of stomach acid?

o children
o older adults
o people who have had gastric surgery
o people who have untreated Helicobacter pylori infection
o people who are taking antacids, H-2 blockers or proton pump inhibitors for ulcers

Antacids help neutralize stomach acid, and H-2 blockers and proton pump inhibitors reduce
the amount of acid the stomach produces.
 Compromised immunity. Individuals whose immune system is compromised for any reason,
are more susceptible to cholera infection.
 Household exposure. People who live with someone who has the disease are at significantly
increased risk of cholera.
 Raw or undercooked shellfish. Large-scale cholera outbreaks no longer occur in
industrialized nations. However, eating raw shellfish (particularly oysters) from waters known
to harbor the bacteria or shellfish transported by travelers from countries where cholera is
endemic greatly increases the risk.
 Type O blood. Recent epidemiologic research suggests that an individual's susceptibility to
cholera (and other diarrheal infections) is affected by their blood type- those with type O blood
are the most susceptible, while those with type AB are the most resistant. Reasons for this are
not entirely clear.

What are the complications of cholera?

Cholera can quickly become fatal-

 In the most severe cases, the rapid loss of large amounts of fluids and electrolytes can lead to
death within two to three hours.
 In less extreme situations, people who do not receive treatment may die of dehydration and
shock 18 hours to several days after cholera symptoms first appear.

The most devastating complications of cholera are-

 Shock
 Severe dehydration

But, other problems can occur-

 Low blood sugar (hypoglycemia). Hypoglycemia occurs when blood levels of glucose fall
abnormally low. It is the body's main energy source. Glucose is absorbed directly into the
bloodstream after eating and enters the cells through the action of the hormone insulin. With
severe cholera, people can become too ill to eat, and as a result do not get glucose from food.
This may lead to unusually low blood sugar levels, which can cause seizures, unconsciousness
and even death. This is a common cholera complication in children.
 Low potassium levels (hypokalemia). People with cholera lose large quantities of minerals,
including potassium, in their stools. Very low potassium levels interfere with heart and nerve
function and are life-threatening. Hypokalemia is especially serious in people whose
potassium stores have already been depleted by malnutrition.
 Kidney (renal) failure. This is a potentially life-threatening condition. When the kidneys lose
their filtering ability, excess amounts of fluids, some electrolytes and wastes build up in the
body. In people with cholera, kidney failure often accompanies shock.

How is cholera diagnosed?

 In epidemic situations, a clinical diagnosis is made by taking a history of symptoms from the
patient and by a brief examination only. Treatment is usually started without or before
confirmation by laboratory analysis of specimens. However, the only way to confirm a diagnosis
is to identify the bacteria in a stool sample.

Rapid cholera dipstick tests are now available. They enable health care providers in remote areas
to confirm diagnosis of cholera earlier. Earlier confirmation helps to decrease death rates at the
start of cholera outbreaks and leads to earlier public health interventions for outbreak control.

What are the treatment options for cholera?

Because the disease can cause death within hours, cholera requires immediate treatment. In most
cases cholera can be successfully treated with oral rehydration therapy (ORT). ORT is highly
effective, safe, and simple to administer- prompt replacement of water and electrolytes is the
principal treatment for cholera, as dehydration and electrolyte depletion occur rapidly. The
success of treatment is significantly affected by the speed and method of treatment. If cholera
patients are treated quickly and properly, the mortality rate is less than 1%; however, with
untreated cholera, the mortality rate rises to 50-60%.

 Rehydration. The goal is to replace fluids and electrolytes lost through diarrhea using a
simple rehydration solution, Oral Rehydration Salts (ORS). They contain specific proportions
of water, salts and sugar. The ORS solution is available as a powder that can be reconstituted
in boiled or bottled water. Without rehydration, approximately half the people with cholera
die.
 Intravenous fluids. In severe cholera cases with significant dehydration, the administration of
intravenous rehydration solutions may be necessary.
 Antibiotics. Recent studies show that a single dose of azithromycin (Zithromax, Zmax) in
adults or children with severe cholera helps shorten diarrhea duration and decreases vomiting.
Antibiotics shorten the course of the disease and reduce the severity of the symptoms;
however, oral rehydration therapy remains the principal treatment. Tetracycline is typically
used as the primary antibiotic.
 Zinc supplements. Research has shown that zinc may decrease and shorten the duration of
diarrhea in children with cholera.

ORS sachets are available from many pharmacists, camping shops and travel clinics. If you are
travelling to regions of the world affected by cholera, take ORS sachets as a precaution. In
situations where commercially produced ORS sachets are too expensive or difficult to obtain,
alternative homemade solutions using various formulas of water, sugar, table salt, baking soda,
and fruit are less expensive methods.

Vaccination

There is a vaccine (given as a drink) that protects against cholera. It is estimated to be 85%
effective.
 Vaccination is usually only required for-

 people travelling in remote areas where cholera epidemics are occurring and there is limited
access to medical care
 those intending to visit high-risk areas such as refugee camps or war zones
 those taking part in disaster relief operations

These people include emergency relief workers, members of the armed forces and healthcare
workers.

Because travelers have a low risk of contracting cholera and because the traditional injected
vaccine offers minimal protection, no cholera vaccine is currently available in the United States.
Keep in mind that no country requires immunization against cholera as a condition for entry.

Prevention

Effective sanitation practices, if instituted and adhered to in time, are usually sufficient to stop an
epidemic-

 Sterilization- Proper disposal and treatment of infected fecal waste water produced by cholera
victims and all contaminated materials (e.g. clothing, bedding, etc.) is essential. All materials
that come in contact with cholera patients should be sterilized by washing in hot water using
chlorine bleach if possible. Hands that touch cholera patients or their clothing, bedding, etc.,
should be thoroughly cleaned and disinfected with chlorinated water or other effective anti-
microbial agents.
 Sewage- anti-bacterial treatment of general sewage by chlorine, ozone, ultra-violet light or
other effective treatment before it enters the waterways or underground water supplies helps
prevent undiagnosed patients from inadvertently spreading the disease.
 Sources- Warnings about possible cholera contamination should be posted around
contaminated water sources with directions on how to decontaminate the water (boiling,
chlorination etc.) for possible use.
 Water purification- All water used for drinking, washing, or cooking should be sterilized by
either- boiling, chlorination, ozone water treatment, ultra-violet light sterilization, or anti-
microbial filtration in any area where cholera may be present. Chlorination and boiling are
often the least expensive and most effective means of halting transmission. Cloth filters,
though very basic, have significantly reduced the occurrence of cholera when used in poor
villages in Bangladesh that rely on untreated surface water. Better anti-microbial filters like
those present in advanced individual water treatment hiking kits are most effective.

Advice for travelers

In the developed nations cholera is no longer a major health threat due to nearly universal
advanced water treatment and sanitation practices. The last major outbreak of cholera in the
United States occurred in 1910-1911. Cholera cases reported in the United States since 1995
 have been traced to sources outside the U.S. or to contaminated and improperly cooked seafood
from the Gulf Coast waters.

If travelling to parts of the world known to be affected by cholera, follow some basic
precautions-

 Wash hands. Frequent hand washing is the best way to control cholera infection. Wash hands
thoroughly with hot, soapy water, especially before eating or preparing food, after using the
toilet, and when returning from public places. Carry an alcohol-based hand sanitizer for times
when water is not available. Maintain good personal hygiene.
 Avoid untreated water. Contaminated drinking water is the most common source of cholera
infection. For that reason, drink only bottled water or boiled or disinfected water. Coffee, tea
and other hot beverages, bottled or canned soft drinks, wine and beer are generally safe.
Carefully wipe the outside of all bottles and cans before opening them and ask for drinks
without ice. Use bottled water to brush your teeth. Only drink water from a bottle that has been
properly sealed or carbonated.
 Eat food that is completely cooked and hot. Cholera bacteria can survive on room
temperature food for up to five days. They are not destroyed by freezing. It is best to avoid
street vendor food, but if it is the case, make sure the meal is cooked in your presence and
served hot. Do not buy ice cream, ice cubes or fruit juices from street vendors.
 Avoid sushi. Do not eat raw or improperly cooked fish and seafood of any kind, unless you
have complete faith in the establishment that is serving it to you.
 Caution with fruits and vegetables. When traveling, make sure that all fruits and vegetables
are cooked or have thick skins that you peel yourself. Avoid lettuce in particular because it
may have been rinsed in contaminated water.
 Be careful with dairy foods. Avoid ice cream, which is often contaminated and unpasteurized
milk.