Cholera

 Description

The acute enteric infection that has caused several outbreaks worldwide in the recent years is known ascholera, otherwise called as violent dysentery. It has widely affected those locations with less potable supply of water, or those with inaccessible basic needs, and most especially those crowded places with lack of sanitation and hygiene practices.

Cholera is transmitted through fecal- oral route, more likely the ingestion of directly or indirectly fecal contaminated water or food by soiled hands, utensils or mechanical carrier like flies. A person who is infected by this illness can transmit the organism through his feces or vomitus. So, obviously, the diagnosis for this enteric infection is through fecal analysis. But, presently, the availability of the new rapid diagnostic test (RDT)is a promising way of early diagnosis. However, it is still being verified by the WHO to be utilized.

The extremely short incubation period of cholera pertaining to a few hours to five days with average of 3 days has marked its deadly threat to those infected to it; considering that its mild form causes no symptomsat all. That is why it could result to severe dehydration, coma and death if left untreated.

The initial clinical manifestations of an individual infected with cholera are:

• Acute colicky pain of the abdomen
• Mild diarrhea with yellowish colored stools
• Headache and vomiting
• Fever, which may or may not be present
• Marked mental depression

Later on, if not treated right away it could get worse to more profuse watery diarrhea (grayish white or rice water colored stools), vomiting and severe or violent leg cramps – leading to mild up to severe dehydration.

Symptoms of dehydration may be manifested by:

Mild Dehydration	Moderate Dehydration	Severe Dehydration
Somewhat dry mucous membranes Pale, cool skin on arms & legs Slight tachycardia Increased capillary refill Anxiety	Dry mucous membranes Poor skin turgor Cool truncal skin Sunken fontanel/eyes Rapid, thread pulse Supine hypotension Increased thirst Restlessness, confusion, or irritability	Dry, cracked mucous membranes Very poor skin turgor Cold, mottled, or cyanotic skin Sunken fontanel/ eyes Marked tachycardia & hypotension Narrowed pulse pressure Delayed capillary refill Unconsciousnes

According to World Health Organization, there are 48 countries that had been affected by cholera in the past 3 years. The continents of Africa, Americas (Haiti), Asia, and Oceania were the ones which are mostly affected by this infection. Nevertheless, it has occurred an overwhelming 52% increase of reported cases last 2009 to 2010 in the countries globally and which did not spared 45% of lives from 32 countries with reported cases of deaths.

In May 2011, the re-emergence of its cases pushed through a more integrated and comprehensive management utilizing strong surveillance, early detection and control, and prevention strategies.

Prevention

• Provision or assisting the community to access to potable and clean water resource i.e. boiling water if not sure to be clean
• Teaching the community on proper sanitation practices, handling and preserving food
• Educating them of the importance of hand washing before handling or eating food, and after defecating
• Proper detection of cases as part of rigid surveillance.

(WHO Standard case definition) Cholera case is suspected if:

• in an area where the disease is not known to be present, a patient aged 5 years or more develops severe dehydration or dies from acute watery diarrhoea;
• in an area where there is a cholera epidemic, a patient aged 5 years or more develops acute watery diarrhoea, with or without vomiting.

Cholera Management and Control

Infants

• Emphasize to mother to continue breastfeed the baby
• If the baby is exclusively breastfeeding, give ORS or 100 to 200ml clean water in addition to breast milk
• If the baby is not exclusively breastfeeding, teach the mother to give food based fluids like rice water and soups or ORS
• Encourage the mother to give frequent small sips of clean water or ORS from a cup; the child vomits, tell to wait for at least 10 minutes and continue slowly
  • Rehydration is the main goal to compensate for the fluid loss from diarrhea and vomiting.
  • Clients are encouraged to take more fluids as much as possible or are given with ORS to replace electrolyte losses.
  • Children: 20ml/kg body weight per hour
  • Adult: 1000ml per hour, if necessary
  • If moderate to severe dehydration ensues, intravenous infusion with normal saline or Lactate ringer’s solution is main priority.
  • Administration of antibiotic is done to reduce the volume and duration of diarrhea. Meanwhile, Zinc supplement is given to children to reduce the duration of diarrhea and to minimize its successive episodes.
  • Parenteral vaccines and mass chemoprophylaxis are not recommended by WHO for its high rates of severe adverse reactions. The available Oral Cholera Vaccine (OCV) in the market is only limited but best suitable for travellers aging 2 years old and above.

References:
Critical Care Nursing Made Incredibly Easy 3rd Edition. (2012). Lippincott Williams & Wilkins.National Center for Infectious Diseases, Center for Disease Control. Defeating Cholera: Clinical Presentation and Management. Retrieved last July 24, 2012 from www.cdc.gov Health Organization. Prevention and Control of Cholera Outbreaks: WHO Policy and Recommendations. Retrieved last July 24, 2012 from http://www.who.int