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The recent cholera outbreak in Zimbabwe highlights failures in the global fight against an old enemy. The recent cholera outbreak in Zimbabwe is not only symptomatic of the breakdown of water and sanitation infrastructure, but also of the restricted availability of a simple life-saving treatment a€“ oral rehydration salts (ORS) solution.
In early January, 600 new cases of cholera were being reported daily with 5a€“8% of victims dying.
Credited with preventing an estimated 40 million deaths since it was formally endorsed by the World Health Organization (WHO) in 1978, ORS therapy is the cornerstone of case management for acute diarrhoea, and therefore for cholera. So why, 30 years after they became the essential element of cholera outbreak response, were ORS not made available for people to use at home in Zimbabwe? In early December 2008, WHO advised the Ministry of Health and Child Welfare to endorse the administration of ORS solution by people with no health-care training to treat diarrhoea in the home in line with WHO policy, according to Dr Custodia Mandlhate, WHO Representative in Zimbabwe.
Zimbabwea€™s initial reluctance to mount an effective response early on, or even to admit that an outbreak was occurring, is not unique. Two-year-old cholera patient Rafael being treated at the Beatrice Road Infectious Diseases Hospital in Harare. WHO estimates that about 120A 000 people died of cholera in 2007, while millions more were infected, numbers that are in stark contrast to official figures that countries report to WHO. Cholera-like diseases have been described in the ancient Chinese, Greek and Sanskrit literature.
The communities that have suffered the most from the devastating effects of this disease treat it like a fact of life and, even where simple, affordable treatment is available, the illness carries an immense stigma.
One of Europea€™s worst cholera years on record was 1854 when 23A 000 people died in Great Britain and Ireland alone. Despite the fact that ORS solution is an effective treatment for dehydration from the disease and despite the existence of a cholera vaccine a€“ albeit an unsatisfactory one due to its two-dose regimen, short shelf-life, high cost and need for cold chain distribution a€“ prevention must be at the heart of any effective long-term response. Checchi believes that many of the severe outbreaks of cholera that occurred recently have been caused by consumption of water from contaminated sources. More than one billion people in the world do not have access to safe drinking-water, while 2.5 billion lack adequate sanitation. The symptoms and signs of cholera are a watery diarrhea that often contains flecks of whitish material (mucus and some gastrointestinal lining [epithelial] cells) that are about the size of pieces of rice.
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By clicking Submit, I agree to the MedicineNet's Terms & Conditions & Privacy Policy and understand that I may opt out of MedicineNet's subscriptions at any time. If you live in a community that experiences cholera outbreaks, how do you prevent an infection? Symptoms and signs: Strong and frequent diarrhea which starts suddenly and is as much as a liter an hour.
Causes: Caught through contaminated food, dirty hands, and contaminated water on contact with an infected person. CholeraCholera, sometimes known as Asiatic or epidemic cholera, is an infectious gastroenteritis caused by enterotoxin-producing strains of the bacterium ''Vibrio cholerae''. While little can be done in the short term to improve access to safe water and appropriate sanitation, treatment with ORS solution for cholera a€“ an acute intestinal infection that causes severe diarrhoea a€“ has become more widely available to those afflicted. Dominique Legros, from the Disease Control in Humanitarian Emergencies (DCE) programme at WHO, said the government in Zimbabwe was promoting self-medication with home-made solutions of sugar and salt.
In conjunction with the Ministry, WHO has now established a Cholera Command and Control Centre, with a team of epidemiologists, logisticians, water and sanitation experts and health workers, with the aim of executing a coordinated response. Since the 19th century, cholera has been particularly associated with the fertile Ganges river delta, with its labyrinth of waterways and swamps. That was also the year that English physician John Snow first demonstrated the link between contaminated water supplies and the spread of cholera. In other words, the front line with cholera is the village latrine and drinking-water supply.
Given that the global situation is unlikely to change in the near future, WHO and its partners are left relying for the most part on surveillance, forecasting and responding to cholera outbreaks and monitoring hot spots, mainly in large parts of Africa, Bangladesh, China, India, Indonesia, Pakistan and the Philippines. Population shifts from rural to urban areas in low-income countries exacerbate the growth of shanty towns and slums where cholera thrives. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. Learn about transmission, symptoms, treatment and prevention for this potentially fatal viral infection that affects the liver.
The excrement (feces) is runny and grayish, without fecal odor, sometimes containing blood or pus.


Transmission to humans occurs through eating food or drinking water contaminated with ''Vibrio cholerae'' from other cholera patients. According to DrA Claire-Lise Chaignat, from WHOa€™s Global Task Force on Cholera Control, a possible 80% of those afflicted could have been treated successfully with oral rehydration therapy, which can nearly eliminate deaths.
Underreporting is the norm not only for cholera but for other diseases, including typhoid fever, shigellosis, leishmaniasis and yaws. Seven cholera pandemics a€“ large-scale epidemics affecting several countries a€“ have sent waves of the disease across the world since the 1800s.
Another milestone in the fight against cholera came in 1883 when German physician Robert Koch a€“ one of the first doctors to study bacteria a€“ first isolated Vibrio cholerae, the bacterium that causes cholera, while studying outbreaks of the disease in Egypt and India. Referring to improvements in drinking-water and sanitation in the mid-19th century in Europe after Snowa€™s discovery, Legros says: a€?The last cholera outbreaks in western Europe were in the 1860s.
Basic hygiene education, which may be as simple as teaching people the importance of hand-washing, is also needed. Some affected individuals have copious amounts of diarrhea and develop dehydration so severe it can lead to death.
Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina.
Most people who get the disease ingest the organisms through food or water sources contaminated with V.
People with severe cholera (about 5%-10% of previously healthy people; higher if a population is compromised by poor nutrition or has a high percentage of very young or elderly people) can develop severe dehydration, leading to acute renal failure, severe electrolyte imbalances (especially potassium and sodium), and coma. It is estimated that most cases of cholera are unreported due to poor surveillance systems, particularly in Africa. And the numbers are expected to increase.As of late April, at least 7,112 people had died and over 536,943 been made ill by the deadly water-borne disease first introduced to Haiti by Nepalese peacekeepers 17 months ago.
However, in Zimbabwe, little can be done in terms of improving access to safe water and appropriate sanitation in the short term. He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.
She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology. Although symptoms may be mild, some previously healthy people will develop a copious diarrhea within about one to five days after ingesting the bacteria.
Severe dehydration can often occur four to eight hours after the first liquid stool, ending with death in about 18 hours to a few days in undertreated or untreated people. Prompt replacement of water and electrolytes is the principal treatment for cholera, as dehydration and electrolyte depletion occur rapidly.
Hydration (usually by IV for the very ill) of the patient, and antibiotics in some individuals, is the key to surviving the severe form of the disease.The World Health Organization (WHO) has maps of current and past areas with cholera outbreaks (see WHO reference). In situations where commercially produced ORT sachets are too expensive or difficult to obtain, alternative homemade solutions using various formulas of water, sugar, table salt, baking soda, and fruit offer less expensive methods of electrolyte repletion (i.e.
And the Pan American Health Organization (PAHO) announced that between 200,000 and 250,000 more people will likely contract the disease during the course of 2012.Cholera has also spread to the neighbouring Dominican Republic. As of May 4, 23,347 had been infected and 399 had died.Despite the fact that all actors knew this year’s rainy season would bring increased cases, the number of CTCs has dropped precipitously since the outbreak. Outbreaks of cholera in 2015 include South Sudan, United Republic of Tanzania, Kenya, and most recently, 121 people diagnosed with cholera in Iraq, their first outbreak since 2012.The term cholera has a long history (see history section below) and has been assigned to several other diseases. In severe cholera cases with significant dehydration, the administration of intravenous rehydration solutions may be necessary.Antibiotics shorten the course of the disease, and reduce the severity of the symptoms. For example, fowl or chicken cholera is a disease that can rapidly kill chickens and other avian species rapidly with a major symptom of diarrhea.
However, the disease-causing agent in fowl is Pasteurella multocida, a gram-negative bacterium. The French organisation has fielded about one-third of all cases since the outbreak began, according to their figures.Many of the NGOs who first heeded the call when the disease struck are today long gone. Similarly, pig cholera (also termed hog or swine cholera) can cause rapid death (in about 15 days) in pigs with symptoms of fever, skin lesions, and seizures. Neither one of these animal diseases are related to human cholera, but the terminology can be confusing.What are cholera symptoms and signs?
Fluoroquinolones such as norfloxacin also may be used, but resistance has been reported.Rapid diagnostic assay methods are available for the identification of multidrug resistant ''V. For example, at the only CTC for Gonaives, one of Haiti’s largest cities, 12 of 15 employees haven’t been paid in for the past four months.The budget for Haiti’s ministry of health is very small compared with its neighbours.
In 2009, the World Health Organization determined that total spending on health in Haiti per capita was 71 dollars.


If cholera patients are treated quickly and properly, the mortality rate is less than 1%; however, with untreated cholera the mortality rate rises to 50a€“60%.
OCHA asked international donors for 231 million dollars for humanitarian work in 2012, with about 70 million dollars slated for health, water and sanitation projects.
Treatment is usually started without or before confirmation by laboratory analysis of specimens.Stool and swab samples collected in the acute stage of the disease, before antibiotics have been administered, are the most useful specimens for laboratory diagnosis.
If an epidemic of cholera is suspected, the most common causative agent is ''Vibrio cholerae'' O1. However, if neither of these organisms is isolated, it is necessary to send stool specimens to a reference laboratory.Infection with ''V.
The associated diarrheal illness should be referred to as cholera and must be reported as a case of cholera to the appropriate public health authorities. The few bacteria that do survive conserve their energy and stored nutrients during the passage through the stomach by shutting down much protein production. When the surviving bacteria exit the stomach and reach the small intestine, they need to propel themselves through the thick mucus that lines the small intestine to get to the intestinal wall where they can thrive. The bacteria stop producing the protein flagellin, thus again conserving energy and nutrients by changing the mix of proteins that they manufacture in response to the changed chemical surroundings. Of particular interest have been the genetic mechanisms by which cholera bacteria turn on the protein production of the toxins that interact with host cell mechanisms to pump chloride ions into the small intestine, creating an ionic pressure which prevents sodium ions from entering the cell. The chloride and sodium ions create a salt water environment in the small intestines which through osmosis can pull up to six liters of water per day through the intestinal cells creating the massive amounts of diarrhea. The host can become rapidly dehydrated if an appropriate mixture of dilute salt water and sugar is not taken to replace the blood's water and salts lost in the diarrhea.By inserting separate, successive sections of ''V.
Researchers have discovered that there is a complex cascade of regulatory proteins that control expression of ''V. ToxT then directly activates expression of virulence genes that produce the toxins that cause diarrhea in the infected person and that permit the bacteria to colonize the intestine. Between these two extremes are the A and B blood types, with type A being more resistant than type B.About one million ''V. In this model, the genetic deficiency in the cystic fibrosis transmembrane conductance regulator channel proteins interferes with bacteria binding to the gastrointestinal epithelium, thus reducing the effects of an infection.
In the first world, due to nearly universal advanced water treatment and sanitation practices, cholera is no longer a major health threat.
During recent years, substantial progress has been made in developing new oral vaccines against cholera.
Two oral cholera vaccines, which have been evaluated with volunteers from industrialized countries and in regions with endemic cholera, are commercially available in several countries: a killed whole-cell ''V. 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. This will also aid in the developing indicators for appropriate use of oral cholera vaccine.
Cholera is transmitted from person to person through ingestion of water contaminated with the cholera bacterium, usually from faeces or other effluent.
The source of the contamination is typically other 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. Coastal cholera outbreaks typically follow zooplankton blooms, thus making cholera a zoonotic disease.Potential human contribution to transmissibilityCholera bacteria grown ''in vitro'' encounter difficulty subsequently growing in humans without additional stomach acid buffering. In a 2002 study at Tufts University School of Medicine, it was found that stomach acidity is a principal factor that contributes to epidemic spread. In their findings, the researchers found that human colonization creates a hyperinfectious bacterial state that is maintained after dissemination and that may contribute to epidemic spread of the disease. When these hyperinfectious bacteria underwent transcription profiles, they were found to possess a unique physiological and behavioral state, characterized by high expression levels of genes required for nutrient acquisition and motility, and low expression levels of genes required for bacterial chemotaxis.



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