Definition

Cholera is a gastrointestinal tract infection characterized by severe diarrhea and can become life-threatening within a few hours if not treated promptly. It represents a significant global public health concern, often associated with economic and social inequality. Annually, there are reported cases ranging from 1.3 to 4 million worldwide, resulting in 21,000 to 143,000 deaths attributed to this infectious disease.

Causes

Cholera is an infection caused by the Vibrio cholerae bacteria, commonly found in water or food contaminated with infected fecal matter. It is frequently associated with:

• Water storage in a particular area.
• Ice cubes made from water stored in contaminated conditions.
• Food or drinks sold by unhygienic street vendors.
• Vegetables washed using water contaminated with human fecal matter.
• Raw or uncooked fish and seafood caught in seas contaminated with fecal matter.

Consuming water or food contaminated with cholera bacteria releases toxins in the intestine, resulting in diarrhea.

Risk factor

Everyone has a risk of being infected by cholera, except for babies who inherit immunity from their mothers. Several risk factors include:

• Poor Hygiene: Cholera thrives in areas with inadequate hygiene, particularly where obtaining a clean water source is challenging. This is often observed in refugee camps, impoverished regions, and areas affected by drought, war, or natural disasters.
• Low or Lack of Stomach Acid: Cholera cannot survive in an acidic environment, and stomach acid usually serves as a protective barrier. However, individuals with low stomach acid levels, such as children, the elderly, and those using stomach medicines, are more vulnerable to cholera.
• Household Exposure: If a household member has cholera, others in the same household are at risk of infection.
• Blood Type O: Although the exact mechanism requires further research, individuals with blood type O are reported to be twice as likely to get severe cholera symptoms compared to other blood types.
• Consuming Raw or Uncooked Seafood: Eating raw or uncooked seafood from water contaminated with cholera bacteria poses a significant risk of cholera infection.

Symptoms

The signs of cholera can manifest within several hours to 5 days after infection, ranging from mild to severe symptoms. Approximately 1 in 20 people infected may experience severe symptoms, including diarrhea resembling washed rice water accompanied by vomiting, leading to rapid dehydration. Dehydration can be identified by the following signs:

• Fast Pulse
• Loss of Skin Elasticity: The skin, when pressed, is slow to return to its normal state.
• Dry Throat, Nose, and Eyes: Children may not cry enough tears.
• Low Blood Pressure
• Thirst
• Muscle Cramps

Dehydration can disrupt the balance of minerals responsible for maintaining fluid equilibrium in the body, a condition known as electrolyte imbalance. Signs of electrolyte imbalance include muscle cramps, acute kidney failure, and shock. Shock, characterized by inadequate oxygen supply to body tissues, occurs in cholera due to fluid deficiency, resulting in low blood pressure and organ dysfunction. If left untreated, this condition can progress to coma and death.

Diagnosis

The diagnosis of cholera depends on the available examinations or tests in healthcare facilities. In settings where laboratory tests are inaccessible, the diagnosis can be based on signs, symptoms, and medical history. However, when adequate health facilities are present, laboratory tests become instrumental in confirming cholera.

A fecal sample is typically subjected to rapid diagnostic tests or Gram staining. Gram staining aims to identify specific bacteria in the sample suspected of contamination. The sample may also undergo culture or polymerase chain reaction (PCR) to detect the genetic material of the bacteria.

Once the diagnosis is confirmed, healthcare workers may conduct an investigation into the local water source to identify the origin of the infection, preventing further spread. It's important to note that even individuals with mild or asymptomatic cases can still contribute to disease transmission by contaminating water sources.

Management

Effective management of cholera is crucial to prevent rapid dehydration and potential fatalities. The initial step involves fluid therapy, using oral rehydration solution (ORS) following the WHO standard. A single ORS sachet is typically diluted in 1 liter of clean water and consumed accordingly. The required fluid volume depends on body weight and the severity of dehydration. In mild to moderate dehydration cases in adults, around 6 liters of water may be needed on the first day.

For individuals in shock, intravenous (IV) fluid therapy is administered. Antibiotics are also prescribed to shorten the duration of infection, reduce the need for replacement fluids, and lower the bacterial count in feces. 

Additionally, children with cholera may receive zinc supplements, which help decrease the duration of the illness and prevent further diarrhea. If the child is still breastfeeding, it is advisable to continue this practice.

Complications

Cholera, if not properly managed, can lead to severe complications, with the most critical being severe dehydration, shock, and death. Additionally, other health issues may arise, including:

• Hypoglycemia: Low blood sugar levels can occur in severely ill individuals, especially children, leading to seizures, unconsciousness, and potentially death.
• Low potassium levels: Potassium is an essential electrolyte for maintaining fluid balance in the body. Cholera-induced diarrhea results in the loss of minerals, including potassium, leading to potential heart rhythm and nerve conductivity disorders, which can be life-threatening.
• Kidney failure: Dehydration or shock in cholera patients can contribute to kidney failure. Kidney failure prevents effective blood filtration, leading to the accumulation of water and waste products in the body, posing a significant risk of fatality.

Prevention

Cholera prevention involves both individual practices and public health efforts. For individuals in endemic areas, the following measures can help prevent cholera:

• Regular Handwashing: Wash hands frequently with water and soap, especially after using the toilet and before handling food. Proper handwashing involves scrubbing with soap for at least 15 seconds and then rinsing. In the absence of water and soap, alcohol-based hand sanitizers can be used.
• Safe Water Consumption: Consume water from secure and trusted sources, such as bottled water, boiled water, or water treated with disinfectants. Water can be disinfected by boiling it for 1-3 minutes or using water filters. It is advisable to use bottled water for activities like tooth brushing. Hot drinks, canned water, and packaged water are generally safe, but caution should be taken to clean the containers before opening them. Adding ice cubes to drinks is not recommended unless the ice comes from a trusted and secure source.
• Food Safety: Eat cooked and hot food, avoiding raw or uncooked items. If raw food must be consumed, ensure it is properly cooked. It is recommended to avoid raw food and consume only drinks and vegetables that are processed or peeled personally. Street food that is raw or cannot be peeled, such as salads or certain fruits like berries or grapes, should be avoided.
• Cholera Vaccine: Vaccination can be an effective preventive measure. Cholera vaccines are typically administered orally and may require two doses. The specific recommendations for vaccination depend on the type of vaccine and the geographical area, with priority given to regions with a high incidence of cholera.

When to see a doctor?

If you experience severe diarrhea after visiting or while in an area with a high incidence of cholera, it is strongly recommended to seek medical attention promptly. Severe dehydration, which can result from cholera-induced diarrhea, is considered a medical emergency. Timely treatment is crucial to prevent the condition from worsening and potentially leading to shock or death.

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