Cholera: A Waterborne Disease
Abstract
It is estimated “that there will be 3 to 5 million cases of
cholera this year and of that number at least 100, 000
people will die from the disease” (WHO, 2010, p.1).
But this health problem is treatable and preventable. If
local governments and members of any given
community will be made aware of the nature of the
cholera bacterium and how it is transmitted from
person to person then the morbidity and mortality rate
can be significantly reduced.
There must be greater cooperation among national
governments and those who are in authority must make
a commitment that no one should die from cholera. An
effective and efficient information dissemination
campaign is the first important step in order to arm and
equip people all over the world so that everyone can
help in eradicating the possibility of another cholera
outbreak.
Introduction
Hippocrates was born 500 years before Christ. He was
a Greek physician and considered to be the founder of
modern medicine. He was one of the first to
scientifically study cholera. This means that this deadly
malady was already present in ancient times. It is a
medical problem caused by a bacterium that releases
toxins that disrupts the natural functions of the human
body.
Because it is a well-known medical issue cholera
health experts were able to develop ways to prevent
outbreak and even lower mortality rates. Nevertheless,
in the 21st century a cholera pandemic is still possible
due to poverty and ignorance. This study will attempt
to know more about cholera in order to help in
disseminating the information that no one should die
from this disease because it can be treated and more
importantly it can be prevented.
Historical Perspective
The term “cholera” was first seen in the works of
Hippocrates and believed to have been derived from
the Greek word chole which means bile and the word
rein which means to flow (Barua & Greenough, 1992,
p.1). If taken together these terms would mean, the
flow of bile (Barua & Greenough, 1992, p.1). It can be
surmised that the ancients described the disease based
on the discharge that comes out from the human body.
In another version, cholera historians remarked that
Alexander Trallianus in 1622 who asserted that it came
from the word cholades which means intestines (Barua
& Greenough, 1992, p.1). It is easy to surmise why
Trallianus made this inference. This conclusion comes
from the observation that the disease is linked to the
bowels.
Another definition frames describes the sickness as “an
infection of the small intestine that causes a large
amount of watery diarrhea” (National Center for
Biotechnology Information, 2011, p.1). This
establishes the fact that whatever causes cholera targets
the intestines and as a result a watery discharge is the
common symptom.
As mentioned earlier cholera has existed since
antiquity and yet it did not spread across continents
until early 19th century (Suddath, 2010, p.1).
Nevertheless, cholera historians are in agreement that
cholera was present in ancient times in Asia and even
in Europe. Hippocrates recorded his findings and
provided modern day scientists a grim insight into the
virulence of this old nemesis of man and the father of
modern medicine wrote:
At Athens a man was seized with cholera. He vomited,
and was purged and was in pain, and neither the
vomiting nor the purging could be stopped; and his
voice failed him, and he could not be moved from his
bed, and his eyes were dark and hollow, and spasms
from the stomach held him, and hiccups from his
bowels.
But the purging was much more than the vomiting.
This man drank hellebore with juice of lentils; and he
again drank juice of lentils, as much as he could, and
after that he vomited. He was forced again to drink,
and the two (vomiting and purging) were stopped; but
he became cold (Barua & Greenough, 1992, p.3).
The grim pronouncement made by Hippocrates is
consistent with modern findings. Supported by the fact
that, “Cholera is an acute diarrheal disease that can kill
within hours if left untreated” (WHO, 2010, p.1). A
more in-depth and scientific study revealed that there
are two types of cholera according to health experts
these are the V. cholera 01 and the V. cholera 0139
(WHO, 2010, p.1). It has also been reported that
“Majority of the outbreaks in recorded history were
caused by the 01 type while the 0139 group was first
identified in Bangladesh in 1992 and confined to
South-East Asia” (WHO, 2010, p.1).
In another commentary, “The global spread of the
disease was attributed to the fact that infected travelers
carried it from India along trade routes until it reached
modern day Burma, Sri Lanka and then Indonesia”
(Suddath, 2010, p.1). At first people believed that
cholera was carried by the wind but later on it was
discovered that it is a waterborne disease. In the second
wave of pandemic that hit the globe, cholera spread far
and wide even to the point of reaching the United
States and in the process destroyed the lives of 5,000
people in New Orleans in one year alone (Suddath,
2010, p.1).
Afterwards the epidemic spread along the Mississippi
until it reached Texas. However, cholera continued to
affect the residents of New Orleans and in this city it
continued to flare up until the year 1855 (Barua &
Greenough, 1992, p.11). It must be remembered that
New Orleans is easily accessibly by traders and
travelers using boats and other sea vessels.
However, it was not only the coastal areas that was
badly hit by the disease, “In 1849, a cholera outbreak
killed 10 percent of the population of St. Louis,
Missouri” (Coleman, 2009, p.89). This should have
served as an eye-opener for 19th century physicians
that although dirty surface water is a crucial
component in the transmission process, they should
have considered that human interaction is the major
root cause of spreading the disease.
Around the same time in the Middle-East, one can find
that Egypt was seriously affected because of pilgrims
returning from Mecca. In addition, the disease
reappeared in Istanbul and spread to Syria, Palestine
and neighboring areas (Barua & Greenough, 1992,
p.11). It has become a pandemic.
In the spring of 1849 cholera broke out all over France,
Italy, and North Africa. In England alone the disease
claimed the lives of 53,283 people, “It is during this
epidemic in London that one of the greatest discoveries
in cholera epidemiology was made by John Snow, a
London anesthetist and amateur epidemiologist who
demonstrated the role of water in the transmission of
cholera, long before the causative agent was
discovered” (Barua & Greenough, 1992, p.11). This is
a critical breakthrough because from this discovery
researchers were able to develop preventive measures
that significantly reduced the morbidity and mortality
rate of cholera.
A third pandemic was observed between 1852 and
1859. As a result, “International cooperation in health
began for fear of cholera… the first international
meeting was held in Paris in 1851, followed by 14
international sanitary conferences between 1851-1938”
(Barua & Greenough, 1992, p.11).
In addition, “An International Sanitary Convention was
signed in Paris in 1903, according to which all
signatories would inform each other of epidemics in
their territories… in 1907, the Office International
d’Hygiene, the first international health organization,
was established in Paris” (Barua & Greenough, 1992,
p.11). It is safe to say that cholera shaped the history of
world health organizations and it could be argued that
these meetings and alliances were the precursor to
modern day institutions such as the World Health
Organization.
In the 19th century, it has become very much evident
that national governments and their citizens were
alarmed by the destructive nature of cholera. It was
also very frustrating because it behaved like a plague,
meaning no one knows where it came from, as if an
invisible force that no one can deal with, it strikes
without mercy over a huge portion of the population.
The mere fact that death will occur a few hours after a
patient is left untreated added a terrifying menace to
the said disease. It seems that the only way to fight
cholera was to lift up both arms in exasperation and
flee.
But due to improved sanitation and modern medicine,
the disease was eradicated from many parts of the
world (Suddath, 2010, p.1). This can be explained by
the fact that in 1920, the Health Organization of the
League of Nations was established after the end of the
First World War (Barua & Greenough, 1992, p.11).
In other words more and more people as well as teams
of dedicated scientists were working hand-in-hand to
discovery the mysterious power of the pathogen that
caused cholera.
The scientific breakthroughs in the field of medicine as
well as increased cooperation among various
governments led to an improved strategy to combat
cholera. As a result researchers were able to see a
significant decline in the morbidity and mortality rate
in the 20th century as compared to how the disease
leveled towns and cities in ancient and medieval times.
For instance, in the 19th century, thousands of people
died from the disease even in relatively affluent
countries like the United States. But compared to
cholera outbreaks that occurred a hundred years later,
those that received treatment in time did not succumb
to the deadly disease.
The resulting mortality rate was significantly lower.
This is even true for countries that are not as
progressive as the U.S. For example, in 1991, there
was a cholera outbreak in Peru that affected 300,000
people, but of that number less than one percent of the
infected died from the disease (Coleman, 2009, p.89).
This is proof that vast improvements had been made in
the battle against this deadly pathogen.
Scientific breakthroughs in the study of cholera must
be leveraged in the creation of preventive measures
that will help affected areas resist the destructive force
of the said disease. In the case of wars and natural
disasters, sometimes it is inevitable that people get sick
from cholera but it is without excuse to find patients
dies from the said disease. The preventable and
treatable nature of cholera must serve as a warning and
inspiration to many that even in the onset of infection
there are therapies and medication that can be used to
save the lives of patients.
It is clear that a proper information dissemination
campaign will go a long way in fighting this deadly
scourge. The moment that a case of cholera has been
reported it is also high time for the community or
refugee camp to be alerted as to the presence of the
pathogen. If this is done in conjunction with an
information dissemination drive that was completed
earlier then the people in that area will pay extra
careful when it comes to dealing with human wastes
and washing their hands before preparing and eating
food.
Parents will also be alerted to the fact that they must
pay careful attention to the whereabouts of their
children especially those who are still attracted to play
in puddles of dirty water that could have been
contaminated with human fecal matter.
Population Affected
This medical phenomenon is not partial to
geographical region or social status. Cholera can affect
young and old, men, women, and children. The disease
can strike anywhere but the bacterium prefers places
where the following conditions are met because,
“Cholera occurs in places with poor sanitation,
crowding, war, and famine” (National Center for
Biotechnology Information, 2010, p.1).
Some of the more common locations where an
outbreak is usually expected are in countries located in
the following regions: Africa; Asia; India; Mexico;
South America; and Central America (National Center
for Biotechnology Information, 2010, p.1). The
common denominator in places where cholera is still a
major health concern is war, refugee camps, and
extreme poverty that resulted in non-access to safe
drinking water and contaminated surface water due to
the lack of government infrastructures.
Environmental Issues
As seen in the previous discussion cholera was once a
global problem. But today, an outbreak is almost
always limited to the “world’s most impoverished
regions” (Briggs, 2003, p.19). There is also a need to
highlight the fact that, “Communities most at risk are
overcrowded urban areas in developing countries,
where clean water and public sewage systems are in
scant supply” (Bjorklund, 2011, p.51).
The reason why a cholera outbreak is common in these
conditions can be attributed to the fact that the
bacterium in cholera stays within the fecal matter of
the patient. Thus, body wastes that are allowed to
contaminate surface water is the leading source of
infection.
In poor countries the spread of the disease can be
explained through intrafamilial transmissions as
described in the following: “Cholera usually acquired
by the ingestion of water or food contaminated with
cholera vibrios. Food and beverages, particularly when
consumed outside the home and at feasts during
festivals and funerals, have often been the source of
infection; food-borne spread is facilitated by the
growth of V. cholera 01 in foods kept at ambient
temperature after cooking” (Barua & Greenough, 1992,
p.337).
This means that the bacterium responsible for cholera
can be easily transmitted if an infected person handled
food or was in-charge of food preparation. In countries
where not much thought is given to sanitary food
preparation practices, the morbidity rate is observed to
be much higher.
Morbidity and Mortality Patterns
It has been said that after the 1920’s the incidence of a
cholera pandemic began to decline significantly. In
highly industrialized societies the possibility of a
cholera outbreak became very unlikely as doctors and
health experts had already created such a high-level of
a awareness about the disease that preventive measures
had been in place for many years.
However, in less affluent countries where poverty and
ignorance are the norm, cholera is still considered a
deadly disease. It has to be pointed out that, “There are
an estimated 3-5 million cholera cases and 100,000 –
120,000 deaths due to cholera every year” (WHO,
2010, p.1). Some of the more recent cholera outbreaks
were reported to occur in poor countries such as in
Africa, Asia, and even the Caribbean. Aside from
poverty and lack of facilities such as adequate sewers
and access to potable water, a cholera outbreak is also
the result of war and natural disasters.
This is because war and natural calamities can easily
destroy whatever system was in place to prevent
cholera. For example in a hurricane strong winds and
flooding can destroy pipes preventing the delivery of
clean water to a particular area. Natural disasters can
also easily displace families and force them to
congregate in evacuation centers where there is not
enough number or toilets or latrines to service a great
number of people.
Thus, it is crucial to remember that cholera strikes in
the aftermath of a disaster. In poor countries devastated
by a hurricane, tsunami or earthquake, cholera often
serves as “a cruel second calamity” (Suddath, 2010,
p.1). The reason for this is simple to grasp, “Following
a disaster, clean water and sewage treatment systems
can break down” (Bjorklund, 2011, p.51). By doing so
early responders will be trained to bring and provide
the necessary food and equipment that can remedy the
situation.
Aside from being familiar with the root cause of the
disease it is also important to understand the mode of
transmission. It has to be pointed out that “Among
people who develop symptoms, 80% have mild or
moderate symptoms, while around 20% develop acute
watery diarrhea with severe dehydration” (WHO, 2010,
p.1). There is therefore the danger of complacency
allowing the cholera bacteria to get the upper hand.
In the latter part of the 20th century the whole world
witnessed the re-emergence of the bacterium in places
ravaged by wars and natural disasters. In the first
Persian Gulf War in 1991 there was a cholera outbreak
(Suddath, 2010, p.1). In the second Gulf War in 2003
another cholera outbreak was reported (Suddath, 2010,
p.1).
This is a good example of how war can be the indirect
hand in the creation of an epidemic. The reason of
course can be understood if one can see it from the
perspective of displaced people. Hundreds of families
fleeing their residences and living in make-shift homes
is a recipe for disaster. Once again this is due to fecal
matter that easily contaminated the environment.
The same thing can be said when it comes to a refugee
camp. Thousands of people forced to stay in one place.
Again it is easy to understand why a cholera outbreak
is common in refugee camps and this is explained by
the fact that “Refugee camps are usually pulled
together quickly, and they rarely have clean water
supplies and waste disposal systems” (Bjorklund,
2011, p.51). There is not enough water to clean their
utensils and their plates. In addition, human to human
interaction such as the shaking of hands and touching
can easily transmit the bacterium from person to
person.
The prevalence of a cholera outbreak in the aftermath
of a war can be seen in refugee camps because of the
sudden influx of people ill-prepared to stay in one
overcrowded location. One of the best examples is “the
cholera outbreak in the Rwandan refugee camps in the
Democratic Republic of Congo in 1994” (Suddath,
2010, p.1).
In that said outbreak 23,800 people were killed in just
one month (Suddath, 2010, p.1). In this type of
condition “local governments are overwhelmed” and it
is the best time for international aid organizations to
come in and help (Bjorklund, 2011, p.51). Local
governments are usually not ready to deal with the
consequences of a civil war or an intensified regional
conflict. The lack of resources forces them to adapt
ineffectively to a developing crisis.
Aside from wars and refugee camps, a cholera
outbreak is common in impoverished locales wherein
the government and the people have no idea what they
are dealing with in the first place. One of the most
recent examples of a cholera outbreak occurred in
Zimbabwe in August of 2008. According to the said
report there were a total of 1,224 cases that were
confirmed and of that number there was a total of 42
deaths (The International Federation’s Disaster Relief
Emergency Fund, 2008, p.1).
The early responders also reported that the outbreak
“has hit the high density suburbs of Harare the capital
city of Zimbabwe, border town Nyamapanda in
Mashonaland Central Province and Kariba in
Mashonaland West and provincial town of Chinhoyi
also in Mashonaland West” (The International
Federation’s Disaster Relief Emergency Fund, 2008,
p.1). It is imperative for relief agencies to fly into
isolated areas to bring medicine and to educate the
people that cholera can be prevented.
In the aftermath of the Haiti earthquake of 2010 a
cholera outbreak was also reported. In October of that
year authorities worked feverishly round the clock to
try to contain an outbreak that was dangerously close
to becoming a full-scale epidemic (Suddath, 2010, p.1).
In October 27, 2010, a morbidity and mortality report
was released: “a total of 4,722 cases and 303 deaths”
(Centers for Disease Control and Prevention, 2010,
p.1). This should not be the case if relief efforts and
government agencies were prepared to handle the
calamity.
The senseless destruction of human lives could have
been avoided if the morbidity and mortality patterns of
cholera were understood by those who have the power
and the authority to do something with the external
factors. It must be said that it is easier to criticize the
government and health workers who were unable to
significantly alter the deadly turn of events but it must
be acknowledged that in the same manner, local
government officials can also be easily overwhelmed
by the consequences of a natural calamity.
Public Health Issues and Interventions
The first line of defense should be an effective
information dissemination campaign. According to a
historian, “arrangements must be made, and
maintained, for the dissemination of appropriate
information that will motivate the members of the
community to participate in control activities” (Barua
& Greenough, 1992, p.337). The key word here is
motivation. The people has to be motivated and the
best way to inspire them is to give them ample warning
that if cholera is not dealt head-on then the disease can
easily destroy families and communities.
The major hurdle when it comes to prevention and
minimizing the impact of cholera is ignorance. Those
who were infected had no idea that the Vibrio cholera
bacterium is already multiplying in their system.
According to prevention experts, “About 75% of
people infected with V. cholera do not develop any
symptoms, although the bacteria are present in their
feces for 7-14 days after infection and are shed back
into the environment, potentially infecting other
people” (WHO, 2010, p.1).
They may not know that they are infected but infected
body wastes can easily pollute water supplies and more
importantly, “Cholera directly affects people who are
in close contact with another” (Bjorklund, 2011, p.44).
Thus, the first thing that these people have to learn is
the ability to detect symptoms of cholera so that they
can immediately seek treatment.
One can just imagine how the chain reaction of events
that leads to a pandemic can easily occur in an
impoverished population. In poor counties an infected
person does not have access to clean water and latrines.
Their makeshift toilets cannot handle human wastes.
Moreover, the patient continues to interact with family
members, unwashed hands are used to handle food or
to share food to other family members.
It is therefore important to be aware of tell-tale signs
that the bacteria is already in a person’s system. One of
the things to look out for is of course watery diarrhea
combined with the following symptoms: “abdominal
cramps; dry mucus membrane; dry skin; excessive
thirst; glass or sunken eyes; lack of tears; lethargy; low
urine output; nausea; rapid dehydration; rapid pulse
rate; unusual sleepiness; and vomiting” (National
Center for Biotechnology Information, 2010, p.1).
The key to stopping cholera in its tracks can be
summarized into this statement: “Effective control
measures rely on prevention, preparedness and
response” (WHO, 2010, p.1). This is easier said than
done but those areas that are stricken with this deadly
bacterium have no choice but to react swiftly and
efficiently.
Another way to mitigate risk and prevent a full-blown
epidemic is to make sure that “Carefully designed
messages delivered through multiple channels (media,
home visits, schools, religious leaders, etc.) should be
used to keep the public informed about the extent and
severity of the outbreak, the effectiveness and
simplicity of the present methods of treatment, the
benefits of early reporting for prompt treatment, and
the usefulness of simple preventive measures” (Barua
& Greenough, 1992, p.337). An information
dissemination campaign must be initiated as well as
effective networking and communication strategies
must be developed.
Health experts assigned in refugee camps and the
ground zero of natural disasters must be trained to
teach refugees how to deal with the sanitation
problems that they are faced day-to-day until the issue
had been totally resolved. In refugee camps people are
told to wash their hands after using the toilet and the
children are told not to play in puddles of dirty water
(Bjorklund, 2011, p.51). This is a good starting point.
A good example of how to combat this disease can be
seen in how the United States reacted to a pandemic in
1866. There was an outbreak in New York City during
that year and the immediate response was the creation
of a board of health and it was the first time that such
an organization was established in the U.S. (Suddath,
2010, p.1).
Nevertheless, it was one of the most effective steps
made because the impact was immediately made
evident sanitation was improved and the disease was
neutralized. Prevention is key and it can be argued that
there is no other step that is most effective in
eradicating cholera other than the construction of pipes
that will be able to deliver clean water to communities
so that people can stop using surface water, water from
unfiltered wells, and water taken directly from rivers
and lakes (Bjorklund, 2011, p.56).
Last but not least, “Appropriate facilities for human
waste disposal are a basic need for human settlements”
this necessity is exacerbated in refugee camps and
overcrowded places (Barua & Greenough, 1992,
p.338).
According to health experts, “Whenever a person
suspects he or she has been exposed to cholera, the
individual must take very careful steps to avoid
spreading the disease” (Bjorklund, 2011, p.44). For
those who are serious in defeating cholera in refugee
camps and war torn countries, the World Health
Organization, World Vision, Red Cross and the
UNICEF has created a cholera kit that they send to
stricken places and this kit contains the following:
large tents that can accommodate up to fifty
patients at a time;
refrigerators (for medicines);
portable generators;
cots;
portable toilets or latrines;
IV equipment;
rehydration solutions;
water tanks;
water purification tablets;
soap;
hand and foot baths (Bjorklund, 2011, p.53).
These items must be shipped immediately because in
this type of emergency situations a short delay can
mean the death of a human being.
The importance of fluid replacement was explained
succinctly by a research scientist who said, “In spite of
the vast improvements in our understanding of the
molecular mechanisms of cholera virulence, and the
adaptation of the cholera bacillus to life in two
different environments, the major breakthrough in
treatment once infection occurs remains fluid
replacement” (Coleman, 2009, p.89). The rapid loss of
fluids in the human body will immediately affect the
normal functions of the body.
This can lead to complications. A weakened body is
prone to other medical problems. It is therefore urgent
to find a way for the patient to have access to clean
water. This is also the most urgent action that a relief
worker or humanitarian aid agency must consider
before flying into a hotspot. Water is key and without it
an expensive equipment and other materials are useless
because the patient can die in less than a day if fluid
replacement therapy is not successful.
It has to be made clear that water is not the only major
consideration when it comes to fluid replacement.
Aside from the water lost through diarrhea, it is also
important to replace lost electrolytes, the ions
dissolved in the liquids and the proper term to describe
this process is fluid replacement therapy (WHO, 2010,
p.1).
This is a critical step in the treatment process because
it has been documented that the mortality rates of
cholera patients ho received fluid replacement therapy
dropped to about 30 percent compared to those that did
not receive this kind of treatment (Coleman, 2009,
p.89).Aside from fluid replacement therapy and the
maintenance of fluid levels in the patient’s body there
is also a need to use antibiotics and make sure that the
patient has access to adequate nutrition (Suddath, 2010,
p.1).
The World Health Organization recommends the
following formulation for oral rehydration therapy:
sodium chloride (90 mmol/liter); potassium chloride
(20 mmol/liter); glucose (111 mmol/liter); and sodium
bicarbonate (30 mmol/liter) or sodium citrate (10
mmol/liter), as the best way to replace lost fluids
(coleman, 2009, p.91).
Aside from electrolytes cholera patients will also lose
bicarbonate in their stools (Coleman, 2009, p.91).
Thus, caregivers must be reminded that the diet of the
patient must be reinforced with a supply of alkaline
solution. In the past sodium bicarbonate was used. But
it was discovered that this compound (bicarbonate
solution) is easily degraded if stored in hot and humid
tropical climates and so they found a substitute –
sodium citrate (Coleman, 2009, p.91).
It has been noted that great strides had been made in
the creation of modern medicine that help combat the
spread of cholera. The oral rehydration therapy works
wonders in stricken areas as well as the use of
antibiotics that reduces the impact of infection due to
complications that arise from watery diarrhea.
However, there is much more that is needed in order to
prevent a pandemic, especially when it comes to Third
World countries such as Southeast Asia, South
America, and other African nations characterized by
low income and low literacy rates. Nevertheless, the
present century offers a great deal of hope for those
who are committed to eradicate this ancient scourge.
According to experts modern technology is the main
weapon against ignorance and the spread of the disease
and they added this is necessary because it will take a
unified effort “of all nations to manage cholera
outbreaks and to prevent them from destroying lives”
(Bjorklund, 2011, p.56). International cooperation is
therefore a must.
Conclusion
In the 21st century no one should die from cholera. It is
true that this bacterium is virulent and that patients can
die in a matter of hours if left untreated. However, the
virulence of the bacterium can be easily neutralized
with the use of fluid replacement therapy, the use of
antibiotics and the careful monitoring of nutrition.
More importantly the transmission of cholera can even
be prevented.
Nevertheless, almost five million cases of cholera are
reported every year and more than a hundred thousand
people die from the disease on a yearly basis. It is time
to eradicate cholera and it begins with an effective and
efficient information dissemination campaign. This
must be accomplished even in war torn areas and even
in the immediate aftermath of a national disaster.
Teams must be trained to share information to families
and community leaders with regards to the
epidemiology of cholera and how its spread can be
prevented and at the same time how infections can be
treated.
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