Cholera

Introduction

Cholera can produce watery diarrhea that is very profuse and this can rapidly lead to severe dehydration and death. Transmission is usually from contaminated water and direct person-to-person transmission is rare. The disease is endemic to parts of Africa, Asia (including India and Bangladesh), the Middle East and South America. Large outbreaks are common after natural disasters or in populations displaced by war, where there is inadequate sewage disposal and contaminated water. Although cholera is not reported in Sri Lanka since 2003, it is a notifiable disease in our country and surveillance is done.

Causative Agents

Cholera is caused by infection with the bacterium called Vibrio cholera.

Pathogenesis/ Action in the Body

A person can get infected by eating or drinking contaminated food or water. Most people who are infected with cholera do not become ill although they may be excreting the organism for 7 to 14 days from there excreta. Symptoms of cholera are similar to the usual gastroenteritis and only 10% who are infected will develop the severe illness with characteristically profuse diarrhea.

Symptoms and Signs

Symptoms of cholera include diarrhea (frequent passage of loose or watery stools), vomiting and abdominal pain. Sometimes fever may develop. Cholera has a higher incidence for dehydration than other forms of gastroenteritis. Risk of dehydration is significantly more in children.

Signs of dehydration are;

·         Thirst

·         Reduction of urine output

·         Dry tongue

·         Tears absent when crying

·         In infants a depression is formed in the soft area on top of the skull (anterior fontanelle)

·         Loss of elasticity of skin – when the skin is pinched usually it goes back rapidly but when there is dehydration it goes back slowly
When there is severe dehydration the patient becomes restless or weak. Breathing become rapid and hands and feet get cold and clammy. They can get drowsy or even semi-conscious. You should take your child to the nearest hospital if dehydration is getting worse.

Complications

Dehydration, malnutrition and even death

Management

The volume of fluid lost can be up to 20 liters a day. If not replaced, heavy fluid loss can rapidly lead to severe dehydration and patient can collapse.

Water and electrolytes lost during diarrhea should be replaced. Continue breast feeding and feeding with easily digestible nutritious food to maintain nutritional status. Giving your child rice kanji, pori kanji, yogurt, anamalu in addition to usual meals will help. If giving formula milk you should make it to half strength.

Give the child lots of fluids like king coconut water, young coconut water (kurumba), lime juice, salted rice water and soup. Sweetened artificial fruit drinks can make diarrhea worse.

Encourage the child to eat much as he wants. Mothers may withhold food thinking that this may stop the diarrhea. But it is very important to feed the child to prevent malnutrition. Small frequent feedings are the best. Avoid bulky, high fiber and fatty foods which are hard to digest. After diarrhea has stopped continue to give the child one extra meal daily for about 2 weeks to avoid malnutrition.

Giving ‘Jeewani’ (oral rehydration solution) which is available in pharmacies helps to replace the salt and water loss.

Investigations are not usually needed. But sometimes a medical practitioner may request a stool full report and a stool culture for management purposes.

How to Prepare and use Jeewani?

Dissolve the whole sachet in 1 liter (2 ½ elephant drink bottles or 1 liter bottles are available in the market) of clean water. This can be used for 24 hours. Give whenever the child feels thirsty or after each loose motion. If vomiting, get the child to sip the solution in small amounts. For infants use a spoon. Older child can drink with a cup. Throw away the remaining solution after 24 hours. If necessary a fresh solution should be prepared. Never attempt to feed when the child is asleep or unconscious.

Do not give anti-diarrheal medicine or antibiotics unnecessarily.

When cholera is confirmed certain antibiotics can be prescribed by a qualified medical practitioner.

Death from cholera is very rare now provided patients are rehydrated adequately.

Prevention and Promotion

Wash hands with soap and water especially before preparing food, eating and after using the toilet

Drink boiled and cooled water

Eat well cooked food

Protect cooked food from flies and cockroaches

Wash raw fruits, vegetables before cooking and leaves before consumption, avoid uncovered cut fruits

Ensure proper disposal of waste and human excreta - use of latrines and proper disposal of stools of young children

Consult a qualified doctor if diarrhea is associated with high fever, passage of blood with stool or intractable diarrhea

All travelers should take sensible precautions about food and water hygiene. An oral cholera vaccine is available for travelers to endemic countries.