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By Dr Amit Singh- Dean School of Medicine at Texila American University Zambia
Cholera is an acute diarrhoeal infection caused by ingestion of food or water contaminated with the bacterium Vibrio cholerae.
Cholera is an extremely virulent disease that can cause severe acute watery diarrhoea. There are many serogroups of V. cholerae, but only two – O1 and O139 – cause outbreaks. V. cholerae O1 has caused all recent outbreaks. V. cholerae O139 is limited to Asia only and was identified from Bangladesh in 1992.
It takes between 12 hours to 5 days for a person to show symptoms after ingesting contaminated food or water.
An estimated 1.3 to 4 million people around the world get cholera each year and 21,000 to 143,000 people die from it. People who get cholera often have mild symptoms or no symptoms, but cholera can be severe.
Approximately 1 in 10 people who get sick with cholera will develop severe symptoms such as watery diarrhoea, vomiting, and leg cramps. In these people, rapid loss of body fluids leads to dehydration and shock. Without treatment, death can occur within hours.
Cholera transmission is closely linked to inadequate access to clean drinking water and sanitation facilities. Typical at-risk areas include peri-urban slums, area having poor waste disposal facility, highly populated area with poor public health infrastructure.
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. The current (seventh) pandemic started in South Asia in 1961, reached Africa in 1971 and the Americas in 1991.
Cholera is now endemic in many countries. Zambia has experienced cholera outbreaks since 1977 and the country’s last major outbreak lasted from October 2017 to June 2018 with a total of 5,935 reported cases and 114 deaths.
An outbreak of Cholera was declared by the Ministry of Health, Zambia on January 26, 2023. The epidemic count of 31 cases registered from 21st to 4th February 2023 in the Vubwi district. Currently 5 cases are in admission and one death.
Zambia is a landlocked country bordered by five cholera-endemic countries in the Cholera belt in Africa. Malawi and Mozambique to the east, DRC and Tanzania to the north, and Zimbabwe to the south. All experiencing regular cholera outbreaks and some with an ongoing cholera outbreak.
The cholera bacterium is usually found in water or in foods that have been contaminated by faeces (poop) from a person infected with cholera bacteria. Cholera is most likely to occur and spread in places with inadequate water treatment, poor sanitation, and inadequate hygiene.
A person can get cholera by drinking water or eating food contaminated with cholera bacteria. Cholera does not spread directly from one person to another person.
In an epidemic, the source of the contamination is usually the faeces of an infected person that contaminates water or food. The disease can spread rapidly in areas with inadequate treatment of sewage and drinking water. Cholera cases are detected based on clinical presentations and symptoms in patients who present with severe acute watery diarrhoea, nausea, vomiting and mild to severe dehydration.
The suspicion is then confirmed by identifying V. cholerae in stool samples from affected patients. Cholera is an easily treatable disease. Most people can be treated successfully through prompt administration of oral rehydration solution (ORS).
The WHO/UNICEF ORS standard sachet is dissolved in 1 litre (L) of clean water. Adult patients may require up to 6 L of ORS to treat moderate dehydration on the first day.
Severely dehydrated patients are at risk of shock and require the rapid administration of intravenous fluids. Continue to drink ORS at home and while traveling to get medical treatment. If an infant has watery diarrhoea, continue breastfeeding.
Antibiotics are used for treatment, but they are not as important as rehydration. Zinc is an important adjunctive therapy for children under 5, which also reduces the duration of diarrhoea and may prevent future episodes of other causes of acute watery diarrhoea.
All visitors or residents in areas where cholera is occurring or has occurred should follow recommendations to prevent getting sick:
• Drink only bottled, boiled, or chemically treated water and bottled or canned beverages. When using bottled drinks, make sure the seal has not been broken. Avoid tap water, fountain drinks, and ice cubes.
• To disinfect the water, choose one of the following options:
o Boil it for 1 minute, or
o Filter it and add either ½ an iodine tablet or 2 drops of household bleach per litre of water, or
o Use commercial water chlorination tablets according to the manufacturer’s instructions.
• Wash your hands often with soap and clean water, especially before you eat or prepare food and after using the Toilet.
• Eat foods that are freshly cooked and served hot.
o Do not eat raw or undercooked meats and seafood, or raw or undercooked vegetables. Always clean the fruits under running water before consuming,
• Dispose of faeces in a sanitary manner to prevent contamination of water and food sources.
• Open defecation to be completely stopped.
• Immediately contact your nearest health facility, if you are having even a single episode of bulky watery diarrhoea.
Three oral cholera vaccines are approved by the World Health Organization (WHO) – Dukoral, ShanChol, and Euvichol-Plus/Euvichol. All three vaccines require two doses for full protection. Dukoral can be given to all individuals over the age of 2 years. Shanchol™ and Euvichol-Plus® are given to all individuals over the age of one year.
In 2019 the Zambian government committed itself to an ambitious target of eliminating cholera by the year 2025 ahead of the Global Taskforce on Cholera Control’s 2017 global strategy which aims to reduce cholera deaths by 90% and to eliminate cholera in as many as 20 countries by 2030. It can only be eliminated by social engineering and improved public health facilities.
The author is the Dean for the School of Medicine at Texila American University Zambia