THE ADVOCATE Q1
From the Doctor’s Desk
By: By: Dr. Kim Panovka - Medical Director, CMN Inc.
Due to the recent outbreak of Cholera in Haiti and Dominican Republic it has become a very news worthy discussion.
I have extracted information from WHO (World Health Organization) Fact sheet on Cholera:
- Cholera is an acute diarrhoeal disease that can kill within hours if left untreated.
- There are an estimated 3–5 million cholera cases and 100 000–120 000 deaths due to cholera every year.
- Up to 80% of cases can be successfully treated with oral rehydration salts.
- Effective control measures rely on prevention, preparedness and response.
- Provision of safe water and sanitation is critical in reducing the impact of cholera and other waterborne diseases.
- Oral cholera vaccines are considered an additional means to control cholera, but should not replace conventional control measures.
Cholera is an acute diarrhoeal infection caused by ingestion of food or water contaminated with the bacterium Vibrio cholerae. The short incubation period of two hours to five days, enhances the potentially explosive pattern of outbreaks.
Cholera is an extremely virulent disease. It affects both children and adults and can kill within hours.
About 75% of people infected with V. cholerae do not develop any symptoms, although the bacteria are present in their faeces for 7–14 days after infection and are shed back into the environment, potentially infecting other people. Among people who develop symptoms, 80% have mild or moderate symptoms, while around 20% develop acute watery diarrhea with severe dehydration. This can lead to death if untreated. People with low immunity – such as malnourished children or people living with HIV – are at a greater risk of death if infected.
During the 19th century, cholera spread across the world from its original reservoir in the Ganges delta in India. Six subsequent pandemics killed millions of people across all continents. Cholera is now endemic in many countries.
Risk factors and disease burden
Cholera transmission is closely linked to inadequate environmental management. Typical at-risk areas include peri-urban slums, where basic infrastructure is not available, as well as camps for internally displaced people or refugees, where minimum requirements of clean water and sanitation are not met.
The consequences of a disaster – such as disruption of water and sanitation systems, or the displacement of populations to inadequate and overcrowded camps – can increase the risk of cholera transmission should the bacteria be present or introduced. Epidemics have never arisen from dead bodies.
Cholera remains a global threat to public health and a key indicator of lack of social development. Recently, the re-emergence of cholera has been noted in parallel with the ever-increasing size of vulnerable populations living in unsanitary conditions.
Prevention and control
A multidisciplinary approach based on prevention, preparedness and response, along with an efficient surveillance system, is key for mitigating cholera outbreaks, controlling cholera in endemic areas and reducing deaths.
Cholera is an easily treatable disease. Up to 80% of people can be treated successfully through prompt administration of oral rehydration salts (WHO/UNICEF ORS standard sachet). Very severely dehydrated patients require administration of intravenous fluids. Such patients also require appropriate antibiotics to diminish the duration of diarrhea, reduce the volume of rehydration fluids needed, and shorten the duration of V. cholerae excretion. Mass administration of antibiotics is not recommended, as it has no effect on the spread of cholera and contributes to increasing antimicrobial resistance.
In order to ensure timely access to treatment, cholera treatment centres (CTCs) should be set up among the affected populations. With proper treatment, the case fatality rate should remain below 1%.
Once an outbreak is detected, the usual intervention strategy is to reduce deaths by ensuring prompt access to treatment, and to control the spread of the disease by providing safe water, proper sanitation and health education for improved hygiene and safe food handling practices by the community. The provision of safe water and sanitation is a formidable challenge but remains the critical factor in reducing the impact of cholera.
Oral cholera vaccines
There are two types of safe and effective oral cholera vaccines currently available on the market. Both have sustained protection of over 50% lasting for two years in endemic settings.
One vaccine (Dukoral) is WHO prequalified and licensed in over 60 countries. Dukoral has been shown to provide short-term protection of 85–90% against V. cholerae O1 among all age groups at 4–6 months following immunization.
The other vaccine (Shanchol) is pending WHO prequalification and provides longer-term protection against V. cholerae O1 and O139 in children under five years of age.
Both vaccines are administered in two doses given between seven days and six weeks apart. The vaccine with the B-subunit (Dukoral) is given in 150 ml of safe water. WHO recommends that immunization with currently available cholera vaccines be used in conjunction with the usually recommended control measures in areas where cholera is endemic as well as in areas at risk of outbreaks. Vaccines provide a short term effect while longer term activities like improving water and sanitation are put in place. When used, vaccination should target vulnerable populations living in high risk areas and should not disrupt the provision of other interventions to control or prevent cholera epidemics. The WHO 3-step decision making tool aims at guiding health authorities in deciding whether to use cholera vaccines in complex emergency settings. The use of the parenteral cholera vaccine has never been recommended by WHO due to its low protective efficacy and the high occurrence of severe adverse reactions.
Travel and trade
Today, no country requires proof of cholera vaccination as a condition for entry. Past experience shows that quarantine measures and embargoes on the movement of people and goods are unnecessary. Isolated cases of cholera related to imported food have been associated with food in the possession of individual travellers. Consequently, import restrictions on food produced under good manufacturing practices, based on the sole fact that cholera is epidemic or endemic in a country, are not justified.
Countries neighbouring cholera-affected areas are encouraged to strengthen disease surveillance and national preparedness to rapidly detect and respond to outbreaks should cholera spread across borders. Further, information should be provided to travellers and the community on the potential risks and symptoms of cholera, together with precautions to avoid cholera, and when and where to report cases.