Cholera Cholera is an acute intestinal infection caused by ingestion of food or water contaminated with the bacteriumVibrio cholerae.

It has a short incubation period and produces an enterotoxin that causes copious, painless, watery diarrhoea that can quickly lead to severe dehydration and death if treatment is not promptly given. Vomiting also occurs in most patients. Most persons infected with V. cholerae do not become ill, although the bacterium is present in their feces for 7-14 days. When illness does occur, about 80-90% of episodes is of mild or moderate severity and are difficult to distinguish clinically from other types of acute diarrhea. Less than 20% of ill persons develop typical cholera with signs of moderate or severe dehydration. Cholera remains a global threat and is one of the key indicators of social development. While the disease no longer poses a threat to countries with minimum standards of hygiene, it remains a challenge to countries where access to safe drinking water and adequate sanitation cannot be guaranteed. Almost every developing country faces cholera outbreaks or the threat of a cholera epidemic. Cholera occurs in places with poor sanitation, crowding, war, and famine. Cholera is typically transmitted by either contaminated food or water. In the developed world, seafood is the usual cause, while in the developing world it is more often water. Cholera has been found in only two other animal populations: shellfish and plankton. People infected with cholera often have diarrhea, and if this highly liquid stool, colloquially referred to as "rice-water," contaminates water used by others, disease transmission may occur. The source of the contamination is typically other cholera sufferers when their untreated diarrheal discharge is allowed to get into waterways or into groundwater or drinking water supplies. Drinking any infected water and eating any foods washed in the water, as well as shellfish living in the affected waterway, can cause a person to contract an infection. Cholera is rarely spread directly from person to person. Both toxic and nontoxic strains exist. Nontoxic strains can acquire toxicity through a temperate bacteriophage. Coastal cholera outbreaks typically follow zooplankton blooms, thus making cholera a zoonotic disease.

SIGNS AND SYMPTOMS

Most people exposed to the cholera bacterium (Vibrio cholerae) don't become ill and never know they've been infected. Yet because they shed cholera bacteria in their stool for seven to 14 days, they can still infect others through contaminated water. Most symptomatic cases of cholera cause mild or moderate diarrhea that's often hard to distinguish from diarrhea caused by other problems. Only about one in 10 infected people develop the typical signs and symptoms of cholera, usually within a few days of infection.

Symptoms of cholera infection may include:

Diarrhea. Cholera-related diarrhea comes on suddenly and may quickly cause dangerous fluid loss as much as a quart (.95 liters) an hour. Diarrhea due to cholera often has a pale, milky appearance that resembles water in which rice has been rinsed (rice-water stool).

Nausea and vomiting. Occurring in both the early and later stages of cholera, vomiting may persist for hours at a time.

Dehydration. Dehydration can develop within hours after the onset of cholera symptoms. Depending on how many 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 irritability, lethargy, sunken eyes, a dry mouth, and extreme thirst, dry and shriveled skin that's slow to bounce back when pinched into a fold, little or no urine output, low blood pressure, and an irregular heartbeat (arrhythmia). Dehydration may lead to a rapid loss of minerals in your blood (electrolytes) that maintain the balance of fluids in your body. This is called an electrolyte imbalance.

Electrolyte imbalance An electrolyte imbalance can lead to serious signs and symptoms such as:

Muscle cramps. These result from the rapid loss of salts such as sodium, chloride and potassium.

Shock. This is one of the most serious complications of dehydration. It occurs when low blood volume causes a drop in blood pressure and a drop in the amount of oxygen in your body. If untreated, severe hypovolemic shock can cause death in a matter of minutes.

Signs and symptoms of cholera in children In general, children with cholera have the same signs and symptoms adults do, but they may also experience:

Extreme drowsiness or even coma Fever Convulsions The risk of cholera is slight in industrialized nations, and even in endemic

areas you're not likely to become infected if you follow food safety recommendations. Still, sporadic cases of cholera occur throughout the world. If you develop severe diarrhea after visiting an area with active cholera, see your doctor. If you have diarrhea, especially severe diarrhea, and think you may have been exposed to cholera, seek treatment right away. Severe dehydration is a medical emergency that requires immediate care regardless of the cause.
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001348/ http://www.mayoclinic.com/health/cholera/DS00579/DSECTION=symptoms

WHO: Number of Reported Cases of Cholera

LOCATION Afghanistan Angola Australia Austria Belgium Benin Botswana 2010 2369 1484 3 2009 662 2019 2008 4384 10511 2007 18422 3 (3) 2006 67257 3 (3) 2005 33 0 2 (2) 1 (1) 2 (2) 749 0 2004 2003 41 2002 3 5 (2) 1 (1) 434 270 2001 4499 2 (4) 0 3943

2 1 (1) 642

983

74 15

985 8

91 0

Brazil Burkina Faso Burundi Cambodia Cameroon Canada Central African Republic Chad China China, Hong Kong Special Administrativ e Region Colombia Comoros Congo Cte d'Ivoire Democratic Republic of the Congo Denmark Djibouti Dominican Republic Ecuador Equatorial Guinea Eritrea Ethiopia Finland France Gabon Gambia Germany Ghana Guatemala Guinea Guinea-Bissau Haiti Honduras India Indonesia Iran (Islamic Republic of) Iraq Japan

333 588 10759 2

355 39 804 2 (2)

0 234 0 1 (1)

365 10 1 (1)

0 886 922 2 (2)

5 1050 1309 2847 7 (7)

21 819 57 8005 3 (3) 1 432 207 5 (2) 577 66 4 (4)

7 477 1003 259 6 (6)

6395 157

67 85 174 (3)

0 168 (3)

0 1668 161

0 90 980 (4)

320 5531 244

55 223

5244 140

32

93 5

4 156 7

1555 7785 8

0 175 414

0 0 39 1343 0

2 (2) 2 1 105

2 (2) 56 1034 2727 2 1567 4188 3165 8

14 (14) 226 5912

13884 2047 191

22899

30150 1 (1)

28269 1087

20642

7665 1 (1)

5728

5 0 0 54070 2 (2) 0 0 1 (1) 3357 3242 37 6391 0 0 1 (1) 0 214 3166 3821 2511 1 3 (3) 407 1516 155 59 16

25

1682

31509 1 (1)

1 3862 1 (1) 2 (2) 2 1 1223 513 14323

119 24121 4 (4) 12 2 (2) 179 8546 153

629 1 (1) 204 1 6 290

1 (1) 6 1 (1) 3614 1 61 842

2 (2)

4 438

1294 42 5

1 (1) 5487 13 392

179379 5155 2680 1007 72 925 2635 19 (19) 4697 0 1939 3155 1338 1133 34 43 4695 2893 3455 1 4081 561 105 560 11

94 35 66

96 (4) 187 16

118 718 27

(28) Kazakhstan Kenya Lao People's Democratic Republic Liberia Madagascar Malawi Malaysia Mali Mauritania Mozambique Myanmar Namibia Nauru Nepal Netherlands Niger Nigeria Pakistan Papua New Guinea Philippines Qatar Republic of Korea Russian Federation Rwanda Sao Tome and Principe Senegal Seychelles Sierra Leone Singapore Somalia South Africa Spain Sudan Swaziland Sweden Thailand 3510 208 10520 13681 19 1974 315 1281 3907 (66) 5 (5) 17241 1 436 41643 0 2 (2) 30662 18 1 (1) 35 3188 11425 1 (1) 3091 1206 870

(33) 816

(55) 870

(14)

(12) 291

(22) 1 1001

237 1546 1070

201 1236

169 3063 4929 0 4148 237 7 25 6306 185 3823 0 1105 1178 4132 2226 0 2786 3474 0 5 2736 1455 34 1375 8 1115 27 3261 8 18 80 2437 5 1062 7219 2395 557 67

1155 443

5751 187

831 153

475 0 3

675 16 2839 2008 0

7430

19679 159

9087 45 3496

2622 14 264

8794

1790 1154 44456 164 8997 33

82 5 972 5410

13691

24 1661

3 (3) 1232 2028

4 (4) 553 4477

1 (1) 2178 3186

1 (1) 292 1933

1 (1) 236 5429

81 2312

1957 0 66

0 139 2 (2)

1 3 67 23 119 3 4 1283 0 62 1 (1) 1453 90 3984 178 2219 1 405 926 365 0 2560

533 1 (1) 10 (10) 1 (1) 586

174 1 (1) 138 (1) 53 157

89 1966 3171 9 0 6

12

1227 513 11 (1) 4490

1 1102 0 3901

2 (1) 2775 1000 4 1 (1) 134

8 2567 1061 59 1 (1) 5612

3503

2767

2 (2) 13731 0 1428

1075 1 (1)

32 1 (1)

Togo Uganda United Kingdom United Republic of Tanzania United States of America Viet Nam Yemen

72 2341 8

218 1095 16 (16)

(307) 397 3726 8 (8)

65 276 32 (32)

1159 5194 49 (49)

1320 4924

1080 3380 13 (13) 1031 9 5 (5)

384 4377 9 (9)

257 2274

2551 247

4469 15 606 300

7700 10 (8) 471 55

2911 5 (4) 853

1609 7 (4) 1946

14297 8 (4)

2945 12 (8) 0

710 2 (2)

1192 0 2 (2)

1300 4

1214 Zambia 6794 4712 2061 2286 5360 1503 9 1049 339 3109 Zimbabwe 951 68153 60055 65 789 516 119 1009 3125 650 http://apps.who.int/gho/indicatorregistry/App_Main/view_indicator.aspx?iid=42 (c) World Health Organization The information in this database is provided as a service to our users.The responsibility for the interpretation and use of the material lies with the user.In no event shall the World Health Organization be liable for any damages arising from the use of the information linked to this section.

Rank #1 =2 =2 =2 =2 =2 =2 =8 =8 = 10 = 10 = 10 = 10 = 10 = 10

Countries Brazil: Argentina: Peru: Ecuador: El Salvador: Egypt: Venezuela: South Africa: Colombia: Belize: Nicaragua: Germany: Korea, South: Japan: United States: Total: Weighted average:

Amount 18 deaths 3 deaths 3 deaths 3 deaths 3 deaths 3 deaths 3 deaths 2 deaths 2 deaths 1 deaths 1 deaths 1 deaths 1 deaths 1 deaths 1 deaths 46 deaths 3.1 deaths

MANAGEMENT Tests and Diagnosis Although signs and symptoms of severe cholera may be unmistakable in endemic areas, the only way to confirm a diagnosis is to identify the bacteria in a stool sample. Rapid cholera dipstick tests are now available, enabling health care providers in remote areas to confirm diagnosis of cholera earlier. Quicker confirmation helps to decrease death rates at the start of cholera outbreaks and leads to earlier public health interventions for outbreak control. Prevention Although cholera may be life-threatening, prevention of the disease is normally straightforward if proper sanitation practices are followed. In developed countries, due to nearly universal advanced water treatment and sanitation practices, cholera is no longer a major health threat. The last major outbreak of cholera in the United States occurred in 19101911. Effective sanitation practices, if instituted and adhered to in time, are usually sufficient to stop an epidemic. There are several points along the cholera transmission path at which its spread may be halted: 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 antimicrobial agents. Sewage: antibacterial treatment of general sewage by chlorine, ozone, ultraviolet 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 boiling, chlorination, ozone water treatment, ultraviolet light sterilization (e.g. by solar water disinfection), or antimicrobial 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 antimicrobial filters, like those present in advanced individual water treatment hiking kits, are most effective. Public health education and adherence to appropriate sanitation practices are of primary importance to help prevent and control transmission of cholera and other diseases. Surveillance Surveillance and prompt reporting allow for containing cholera epidemics rapidly. Cholera exists as a seasonal disease in many endemic countries, occurring annually mostly during rainy seasons. Surveillance systems can provide early alerts to outbreaks, therefore leading to coordinated response and assist in preparation of preparedness plans. Efficient surveillance systems can also improve the risk assessment for potential cholera outbreaks. Understanding the seasonality and location of outbreaks provide guidance for improving cholera control activities for the most vulnerable. For prevention to be effective it is important that cases are reported to national health authorities. Vaccine A number of safe and effective oral vaccines for cholera are available. Dukoral, an orally administered, inactivated whole cell vaccine, has an efficacy of 85%, with minimal side effects. It is available in over 60 countries. However, it is not currently recommended by the Centers for Disease Control and Prevention (CDC) for most people traveling from the United States to the third world. 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.[18] However, as of 2010, it has limited availability. Work is under way to investigate the role of mass vaccination. 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. If people are immunized broadly, herd immunity results, with a decrease in the amount of contamination in the environment. Treatment Continued eating speeds the recovery of normal intestinal function. The World Health Organization recommends this generally for cases of diarrhea from whatever case. A CDC training manual specifically for cholera states: Continue to breastfeed your baby if the baby has watery diarrhea, even when traveling to get treatment. Adults and older children should continue to eat frequently. Fluids In most cases, cholera can be successfully treated with oral rehydration therapy (ORT), which is highly effective, safe, and simple to administer. Rice-based solutions are preferred to glucose-based ones due to greater efficiency. In severe cases with significant dehydration, intravenous rehydration may be necessary. Ringer's lactate is the preferred solution, often with added potassium. Large volumes and continued replacement until diarrhea has subsided may be needed. Ten percent of a person's body weight in fluid may need to be given in the first two to four hours. This method was first tried on a mass scale during the Bangladesh Liberation War, and was found to have much success. If commercially produced oral rehydration solutions are too expensive or difficult to obtain, solutions can be made. One such recipe calls for 1 litre of boiled water, 1/2 teaspoon of salt, 6 teaspoons of sugar, and added mashed banana for potassium and to improve taste. Electrolytes

As there frequently is initially acidosis, the potassium level may be normal, even though large losses have occurred. As the dehydration is corrected, potassium levels may decrease rapidly, and thus need to be replaced. Antibiotics Antibiotic treatments for one to three days shorten the course of the disease and reduce the severity of the symptoms. People will recover without them, however, if sufficient hydration is maintained. Doxycycline is typically used first line, although some strains of V. cholerae have shown resistance. Testing for resistance during an outbreak can help determine appropriate future choices. Other antibiotics that have been proven effective include cotrimoxazole, erythromycin, tetracycline, chloramphenicol, and furazolidone. Fluoroquinolones, such as norfloxacin, also may be used, but resistance has been reported. In many areas of the world, antibiotic resistance is increasing. In Bangladesh, for example, most cases are resistant to tetracycline, trimethoprim-

sulfamethoxazole, and erythromycin. Rapid diagnostic assay methods are available for the identification of multiple drug-resistant cases. New generation antimicrobials have been discovered which are effective against in in vitro studies.

DRUG STUDY
doxycycline (Adoxa, Monodox) or azithromycin (Zithromax, Zmax) NURSING CARE PLAN Fluid volume deficit Dehydration Impaired skin integrity