RUNNING HEAD: Cholera 1

Cholera
Stephaine Ryan
NURS 119

RUNNING HEAD: Cholera 2

Abstract
Individuals can get cholera from drinking contaminated water or using contaminated water to
prepare food. This paper discusses ways that cholera can be found in the environment, ways to
treat the disease and ways to prevent cholera. Some of the ways to treat that are discussed are
rehydration therapy, antibiotics and mineral supplementation. One of the ways to prevent cholera
that researchers are advocating for is using oral vaccinations. Cholera can be a very deadly
disease but can very easily be prevented. One of the solutions that have been advocated for
worldwide is proper sanitation and safe water for drinking.
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Even with the improvements of sanitation and having safe water to drink, there are still
many places in the world that have been struggling with cholera. Cholera is a condition
individuals get from drinking water or eating food cleaned with water contaminated with feces
infected with Vibrio cholera. Ways to treat cholera are to improve water purification, improve
sanitation, rehydrate the individual, possibly give antibiotics to the individual and give
vaccinations against cholera in areas where the disease is an epidemic. It is also advisable to give
the vaccination to the individuals that are going to these areas to help in the community or help
after a disaster to prevent the transmission all over the world.
Summary
Cholera is caused by Gram-negative bacterium called Vibrio cholera. This disease has
been documented in history back to the 5
th
century BC (Harris, etl., p.2466). Cholera only
existed on the Indian subcontinent for centuries then in 1817, cholera spread (Harris, etl.,
p.2466). It was then found in England and spread further to Asia, Africa and Latin America.
Most recently cholera has affected the country of Haiti. The increase of cholera happened after
the earthquake in 2010. The World Health Organization (WHO) estimates that 3-5 million cases
occur per year (Harris etl., p.2466). There are estimates that there are 1.4 billion people are at
risk of cholera (Martin, etl., para 1). This disease is a major cause of diarrhea in adults and listed
children and in the top five reasons of mortality of children in the world today.
Transmission/Isolation
Cholera is caused by V. cholerae that can be found in water. It grows in warm water that
contains nutrients of sufficient quantities to maintain life. The V. cholerae organism that causes
the epidemics are in the serogroups O1 and O139 (Harris, etl., p.2467) . Cholera is transmitted
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through water contaminated with feces. Individuals drink the contaminated water or use the
contaminated water to clean food.
Cholera can be shed in feces from a couple of days to up two weeks depending on
whether or not the individual infected with the disease is showing symptoms of the disease or
not. Those individuals showing no symptoms of the disease will shed the disease for only a
couple of days. Individuals showing symptoms of the disease will shed the cholera organism for
up to two weeks. As the organism is shed from a human, it takes on hyperinfectivity-that is, the
infectious dose is 10-100 times lower than for non-human-shed organisms (Harris, etl., p.2468).
This means that the organism that is shed from humans is more infective than those that are
found naturally in the environment. The hyperinfective organisms can be found in the water from
five to twenty-four hours after being shed.
Jason Harris (2012) states that the individuals with O type blood have been associated
with the severe cases of cholera in some populations. He also educates that those with first-
degree relatives of individuals with cholera have an increases risk of contracted the disease rather
than those individuals just living in close proximity to the individual. He states that this is
suggesting that additional genetic factors have a role in susceptibility (Harris, etl., p.2469).
Clinical Presentation
There are many ways that the disease can be presented. It can range from mild
gastroenteritis to severe diarrhea and dehydration. One symptom that may present is massive
watery diarrhea of up to one liter an hour. The large loss of fluids can cause hypotensive shock
and death quickly, sometimes within hours of the symptom onset. Other symptoms are rice water
stool (stool that looks like water that washed rice in it), vomiting, possible abdominal cramping
or pain, and rarely fever. If the individual is in a state of dehydration, he/she may present
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lethargic, with sunken eyes, dry mouth, cold clammy skin, decreased skin turgor, Kussmaul
breathing, and wrinkled hands and feet. With dehydration some additional signs can be a rapid,
thready pulse, decreased blood pressure, decreased urine output, muscle cramping, muscle
weakness, hypoglycemia, altered consciousness, seizures, and even coma (Harris, etl., p. 2470).
Blood test results may show renal compromise, hypocalcaemia, hypokalemia, and as previously
stated hypoglycemia. There are a couple of conditions that can present that are a result of
cholera. One is renal compromise and stroke from dehydration and the other is aspiration
pneumonia from vomiting.
Diagnosis
Immunoassays are used to detect V. cholerae. One test or dipstick for both O1-O139
associated cholera has a 97% sensitivity. Dipstick assays seem to be more sensitive for detection
of V. cholerae in patients previously treated with antibiotics than is culture (Harris, etl., p.
2469). It has also been suggested that anyone over the age of five years old and presents with
severe dehydration from watery diarrhea, cholera should be suspected. If dehydration is
suspected, blood tests to see if hypocalcaemia, hypokalemia and hypoglycemia are present may
be necessary.
Therapy
To help treat cholera, rehydration is essential. Intravenous fluids may be necessary if
severe dehydration is present. It is important to remember how quickly the fluids can be
replaced. Mr. Harris (2012) states that the most common error in caring for patients with
cholera is to underestimate the speed and volume of fluids required (p. 2470). It is stated that
the fluid replacement can range from 200mL/kg to 350mL/kg of fluids because the loss of fluids
could be more than 20mL/kg/hr (Harris, etl., p.2470). It may also be necessary to have the
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individual placed on Cholera Ccots which are cots that have plastic linings over the mattress to
help measure fluid output. Once oral solutions can be tolerated, oral rehydration is recommended
as well as a high energy diet (Harris, etl., p.2471). Supplementing Zinc into the diet will help
with episodes of diarrhea as well.
Antibiotics can be used in some cases of cholera but is not always recommended to
prevent organism resistance. Antibiotics have been shown to decrease the amount of time the
individual has diarrhea and decrease the amount of time the individual sheds the organism. Four
antibiotics have been proven to help treat cholera. Those are Tetracycline, Doxycycline,
Ciprofloxacin, Erythromycin, and Azithromycin. These can be used in both children and adults.
To prevent Cholera is to improve sanitation and improve the amount of safe drinking
water that is available for individuals to drink and use in meal preparation. Ronald Waldman,
M.D., M.P.H. (2013) educates that there are 2.5 billion people [that] still live without even
modestly improved sanitation facilities, such as a well-constructed privy (p.593). He also states
that only 63% of people who live in the least-developed countries around the world have access
to improved water supplies. The proportion in Africa is 61% (Waldman, p.593). Educating
individuals on the importance of using safe water is essential. Not only will that information help
reduce the amount of individuals affected by Cholera but will also decrease other diseases that
are spread by fecal-oral contamination.
Another way to prevent Cholera is by having individuals be vaccinated. There are two
oral vaccines that have been approved for use, Dukoral and Shanchol. These have to be given in
two or three doses depending on the age of the individual. These vaccines provide 60-85%
protective efficacy for 2-3 years, although protection among young children is of shorter
duration (Harris, etl., p.2472). It is thought that vaccinating even some of the population in
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epidemic areas can provide many more community members with protection. Mr. Harris (2012)
proves that vaccination of 50% of a population could result in a greater than 90% reduction in
cholera incidence in that population overall (Harris, etl., p.2472). Both of these vaccines are
consists of killed whole-cell cholera bacterium as this type of vaccine has been proven to provide
the best protection from the disease (Desai and Clemens, p.89). There has been some research on
developing a vaccine that uses a live bacterium and the vaccine is a single dose. But, this vaccine
failed in trials showing that individuals would still need to receive another dose and only it had a
79% reduction in cholera. (Desai and Clemens, p.88).
The WHO has approved to have some of each approved vaccine stored for use if there
was an emergency or additional outbreak of the disease after a disaster. According to Stephan
Martin, Alejandro Costa, and William Perea (2012) the WHO has agreed on storing two million
doses of the vaccine (para. 3). In order to use these stored vaccines, the area requesting the
vaccines must meet certain epidemiological requirements. Dr. Samuel Stratton, MD, MPH
(2013) believes that not only should those individuals living in the epidemic area should be
vaccinated, those responding to the disaster or going to help individuals after a disaster in the
area where cholera is at should be vaccinated as well (p.195). He states, no longer can it be
assumed that only endemic diseases should be expected in a disaster zone; rather expect that
disease can be imported and exported along with response efforts (Stratton, p.195).
Analysis of the Evidence
The number of individuals that have been diagnosed with cholera has increased recently
Mr. Waldman (2013) states the annual number of cases reported to the World Health
Organization (WHO) has increased over the past few years to more than half a million cases and
7816 related deaths reported from all regions in 2011 (p.592). The amount of cholera in Haiti
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increased as well, especially in the aftermath of the earthquake in 2010. Ezra Barzilay, M.D. and
others (2013) states the cholera epidemic in Haiti accounted for 57% of all cholera cases and
53% of all cholera deaths reported to the World Health Organization in 2010 and 58% of all
cholera cases and 37% of all cholera deaths in 2011 (p.599). Not only are there many
individuals in Haiti affected by cholera but there are many around the world. Mr. Martin, Mr.
Costa, and Mr. Perea (2012) educates that estimates suggest that about 1.4 billion people are at
risk of cholera and that the risk is highest among children under five years of age. Annually 2.8
million cases and 91000 deaths from cholera occur in endemic countries; non-endemic countries
contribute another 87000 cases and 2500 deaths (para. 1).
Evidence has proven that rehydration of the individual decreases the chance of death in
those affected. The use of antibiotics can also decrease the death rate from the disease. Mr.
Harris (2012) proved that management of patients with cholera involves aggressive fluid
replacement; effective therapy can decrease mortality from more than 50% to less than 0.2%.
Antibiotic treatment decreases volume and duration of diarrhae [sic] by 50% and is
recommended for patients with moderate to severe dehydration (p.2466).
Factors and/or situations that may promote this emerging disease
The main way Cholera is spread is by fecal-oral transmission. Usually by the individual
drinking water contaminated by V. cholerae or using water to clean food the individual is
planning to eat. It has been shown that back in 1854; Dr. John Snow was convinced that cholera
was taking lives from contaminated water. He saw a high occurrence of cholera deaths around a
particular water pump, he saved countless lives and changed infection control practices forever
(Bates, p.25). He also proposed that cholera was a communicable disease and that stool
contained infectious material. He suggested that this infectious material could contaminate
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drinking water supplies, resulting in transmission of cholera (Harris, etl., p.2466). It has also
been shown that cholera is found around a continents rainy season. Mr. Harris and others
(2012), state that in Asia, cholera occurs seasonally before and after the monsoon rains
(p.2467). Warmer waters have been found to increase the amount of the cholera organism in
water. Cholera rates also increase substantially during floods compared with non-flood periods.
Natural disasters that disrupt public health facilities, such as cyclones and earthquakes, also
contribute to cholera epidemics (Harris, etl., p.2467).
As previously stated in this paper, an individual with the blood group O is more
susceptible to cholera. Also the individual that have a first degree relative that is affected by
cholera has a better chance of getting the disease. Thus having researchers believe that there are
some genetic involvement with the disease as well.
It has also been proven that a community without proper sanitation and water that is not
purified or coming from a safe source away from fecal contamination is another reason an
individual can contract the disease. If communities have access to safe water and a proper place
to use the restroom or a place for the sewage to go it will not only decrease the amount of cholera
but also other illnesses or diseases that are caused by fecal-oral contamination.
One of the ways to help prevent cholera by having individuals get vaccinated using an
oral vaccination. One reason that researchers are advocating for not only individuals that are
living in the area where cholera is an epidemic but also those individuals that are helping these
communities can bring the organism to the area with them to the area they are trying to help.
There is epidemiologic evidence [that] associates the cholera contamination of the Haiti water
supply with a visiting international peacekeeping force [that] arrived from southern Asia where
the strain of cholera that was introduced (Stratton, p.195).
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Cholera is a disease that is transmitted to humans via the fecal-oral route. The disease has
been around for many years. When it was first affecting individuals in the community
researchers of that time werent sure where the disease was coming from. They thought that it
was caused by contaminated food being eaten. Dr. John Snow did research that proved cholera
was caused by water being used out of a contaminated water pump. Since then, much research
has been done to help understand the disease such as, other ways the disease is transmitted, ways
to help treat individuals with the disease and ways to prevent the disease from affecting
communities and even spreading to multiple individuals in one single community.





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