MINI PROJECT ON CHOLERA

Introduction

Cholera is a disease within the small intestine that results from the bacterium, Vibrio cholerae. The effects of the disease have produced considerable impacts within the global society. Globally, the disease infects between three and five million people and leads to 100,000-130,000 deaths every year (Aberth, 2011). One of the largest groups affected by the disease is Children under 6 Years group. As such, it is important to develop a proposed health intervention that will mitigate the impact of cholera on children under 6 years (Vinten-Johansen, 2003: 36).

Causes of Cholera:-

In England, John Snow became the first individual to recognize contaminated water as the major cause of the disease in 1854 (Vinten-Johansen, 2003: 77). However, the proximate cause of the disease is the bacterium Vibrio cholerae. Causation usually occurs through faecal contamination of ingesting substances, mainly water and food. Interestingly the bacterium possesses the capability of living naturally in any type of surrounding regardless of the occurring nature (Skovgaard, 2008: 414). In an uninfected person, the fluid within foods and beverages moves from the lumen via the epithelial cells within the intestinal walls.

(Retrieved from <http://karengrepin.com/2009/10/promising-results-for-new-cholera.html/>)

(Retrieved from http://www.britannica.com/blogs/2011/08/origin-seventh-cholera-pandemic/)

Types of Cholera:-

Regardless of the fact that cholera arises from the bacterium Vibrio cholerae, more than 200 types of the bacterium exist. However, only two kinds of Vibrio cholerae affect humans. These bacteria include Vibrio cholerae O1 and Vibrio cholerae O139. In addition, the distinct types of cholera vibrios produce the same strain of the Classic Cholera type, which is the most common cholera infection within the human population. As such, two key serotypes of the cholera bacterium cause the classic cholera symptoms in humans. The main characteristics arising out of the disease comprise violent diarrhoea, extreme dehydration and severe nausea. In addition, extreme dehydration, if untreated for 24 hours in the development of the disease can lead to absolute death (McElroy & Townsend, 2009: 375).

Another type of cholera that affects human beings is the Cholera sicca. The Cholera sicca refers to the strain of cholera witnessed during epidemics. This type differentiates from the Classic Cholera type based on extremity of deprivation of fluids and electrolytes from the human body. Specifically, persons infected with the Cholera sicca infection experience an extreme outflow of electrolytes and fluids into the digestive system (Lee, 2003: 131).

Bacterium Vibrio cholerae

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Symptoms and Diagnosis:-

Most individuals exposed to Vibrio cholera do not exhibit any apparent symptoms of the disease and thus do not have information or knowledge of their infection. However, since the infected persons excrete faecal matter, which comprises the cholera bacteria, for one to two weeks, they are still able to contaminate other individuals via contaminated water or food. This represents the high percentage of infected individuals who are unaware of the infection, which comprises 75 percent (O’Neal et al, 2005: 1094).

Diarrhoea is one of the main symptoms that define cholera infections. For the infected victims, diarrhoea is sudden and rapidly leads to hazardous loss of fluids. This loss in fluids is nearly 9.5 litres of fluid loss for each hour. Usually, diarrhoea that arises out of cholera infections comprises an insipid, chalky appearance that bears similarities to water in which rice has been doused (Pauw, 2003: 821). The subsequent symptoms arising from cholera infection is Nausea and Vomiting. Extreme Dehydration is also another symptom that develops suddenly after the inception of the disease’s symptoms.

Usually, a deprivation of 10 percent of the sum weight of an individual depicts acute dehydration. Additionally, signs that illustrate the dehydration based on cholera infection comprise irritability, dryness in the mouth, severe thirst, gaunt eyes, asymmetrical heartbeats, decreased blood pressure, less or null urine output and lethargy. Apart from experiencing the same symptoms as adults, children may also experience fever, severe drowsiness or convulsions (Sack et al, 2004: 229).

Rice watery diarrhoea

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Lifecycle of Vibrio cholerae:-

(Retrieved from <http://research.pomona.edu/jane-liu/files/2012/08/Vibrio-cholerae.jpg/>)

Transmission of the cholera bacteria takes place through a pair of divergent life cycles. The first life cycle takes place through the environment. Usually, waterborne sources comprise the main form of transmission of the disease to human beings (Deen et al, 2008). Waste contaminated with cholera can taint sources of water, leading to a considerable spread of disease.

Another way in which cholera traverses among people is through ingestion. When individuals consume cholera bacteria, they will not experience the symptoms of the infection resulting from the infection. Rather, the infected persons will act as hosts that transmit bacteria through their excrements (stool). If the supplies of water or food experience contamination from faecal matter, both can apply as the perfect rearing platforms for the cholera bacteria. (Pauw, 2003: 827).

Impact of Cholera:-

Cholera possesses significant and considerable impacts on the society and economy of a respective country. While adding on the effect of human suffering as a significant impact arising from the disease, cholera also possesses adverse effects related to the economic and societal wellness of a given community and state. Thus, for a prolonged outbreak, the economy of a state is likely to decline extremely if the endemic does not cease at the proper time (Pauw, 2003: 828).

On a societal level, a cholera epidemic can hinder the development of the affected community based on its effect on children under 6 years who are likely to experience high mortality rates that will hinder the growth of future labour that will develop the community and the country in common (Pauw, 2003: 829).

Retrieved from http://www.bbc.co.uk/scotland/education/int/geog/health/health/cholera/effects/

Distribution of Cholera cases in the world:-

Cholera is considerably prevalent in less developed nations across the globe. Therefore, nations within the African and Asian continent comprise the highest degree of cases associated with cholera infections. Additionally, such regions grant an endemic status to the disease in events that comprise civil strife such as wars and armed disputes and naturally occurring disasters. However, nations within the Europe and American continents report low cases of cholera infections unlike their neighbouring continents.

(Retrieved from <http://gamapserver.who.int/mapLibrary/Files/Thumbnails/Global_Cholera (WER)_2011.png/>)

The below graph represents the increasing number of cholera cases reported as of 2005. The graph is a histogram that illustrates the existing and future trend of cholera cases globally. The graph indicates the number of cases that countries report every year. The year 1999 represents the year in which most countries experienced cholera endemics, however, after that, the number of cholera cases has steadily declined over the years with no level reaching the 1999 level of cases globally.

(Retrieved from <http://www.who.int/wer/2006/wer8131.pdf/>)

Vulnerable Group of Cholera:-

During cholera outbreaks, children under the age of six are the most vulnerable, and they succumb to the disease at a faster rate compared to the rest of the population. In addition, children under the age of six residing in war torn regions especially those within Africa such as the sub-Saharan areas and the Democratic Republic of Congo are considerably prone to gain infection from the disease. For instance, approximately 500,000 individuals, including women and children, suffered a cholera endemic that took place between 1999 and 2005 in the African continent. Consequently, endemic regions possess the highest rates of infection for children under the ages of 6 years. However, in non-endemic vicinities, adults together with the children gain similar infection from the disease. Within the vulnerable group, male children gain infection disproportionably than female children. This is because of exposure to greater levels of water based on working patterns (Deen et al, 2008).

Public Health Significance:-

Cholera is a significant public health issue globally. Regardless of the effects of the disease, being undetected, considerable cholera infections such as the infections witnessed in Zimbabwe, Haiti and Vietnam that deplorably affected children under six years require mitigation. As such, avoiding such occurrences from happening requires the use of interventions that will focus on mitigating the effects of cholera infections on children under the age of 6 years (Breslow, 2002: 57).

Proposed Interventions:-

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Primary interventions:-

The objective of the primary intervention is to ensure that uninfected and healthy people do not get the disease. It is a preventive approach, which operates by ensuring that the healthy person can resist the disease. Primary intervention will include raising an awareness campaign aimed at educating people about cholera. This will include teaching people about how they can contract the disease and the strategies they can use to ensure that they minimize their chances of getting it.

The implementation of the awareness campaign requires the creation of a center that will assist in raising awareness regarding cholera, its aetiology, and epidemiology as well as possible treatments and prevention schema. For children in the 6-year age group, it will be advantageous to implement a Voluntary Cholera Center (VCC).

Furthermore, in educating the children about cholera, its transmission and its prevention, the Voluntary Cholera Center will educate the children by employing social activities such as friendly sport competitions that will focus on the objective of eradicating and preventing cholera. Additionally, schools located in the vicinity can inculcate studies or subjects based on cholera that can assist in teaching children important information regarding cholera as well as encourage simple preventive practices such as boiling water and washing fruits and vegetables before consumption. In addition, the Center will supply soaps, water dispensers and water treatment products that will assist in children in washing their hands and consuming clean water for prevention.

Another intervention that will assist greatly in preventing the people from acquiring cholera is the use of vaccines. In this particular case, there will be two varieties of oral vaccines for preventing cholera in the children. Additionally, the Cholera Treatment Facilities, which comprise part of the intervention plan, will be in charge of vaccinating the children, through oral vaccination, in which the children under six years will take. Additionally, both vaccines will be whole-cell dormant vaccines. One vaccine will possess a B-sub unit. In addition, the vaccine will provide immunization against Vibrio cholerae O1 and O139 for children under the age of 6 years. (Aumatell et al, 2011: 157).

Two types of vaccines will be in use at the Treatment Center. The first vaccine will be the BivWC Vaccine. The BiVWC Vaccine deemed commonly as Shanchol destroys V. cholerae O1 and V.cholerae O139 cells. The cost of the vaccine is readily cheap considering its considerable use in low income and poverty stricken areas especially in areas such as India that have numerous cases of Cholera. However, the second type of vaccine, which is the WC-rBS deemed, as Dukorval is not readily available since it concentrates on destroying V. cholerae O1 cells.

Oral vaccination for children under six years

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The Shanchol Vaccine:-

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Vaccine schedules:-

(Retrieved from <http://www.nathnac.org/pro/factsheets/cholera.htm/>)

Secondary Interventions

Secondary interventions for the respective group in question will require the utilization of strategies that focus on providing effectual eradicating services for children already suffering from the disease in less than 24 hours. As such, one of the interventions that will focus on mitigating the symptoms the children have regarding cholera is oral rehydration. Since children are more likely to lose fluids than adults are, they will require the administration of fluids through their veins (Gurrant et al, 2003: 400).

As such, in order to undertake oral rehydration, it will be important to implement the specific facilities of treatment that will focus on ensuring oral rehydration. One intervention that supports this will be the implementation of an Infusion and Intravenous Treatment Center. Since oral rehydration requires intravenous treatment, then the Center will focus on providing state of the art infusion treatment facilities and will thus focus on providing the children with intravenous treatment regarding oral therapy.

Using intravenous treatment to suppress cholera in children below 6 years

(Retrieved from http://www.medindia.net/afp/images/India-health-cholera-7987.jpg)

Tertiary Interventions

The objective of tertiary intervention is to help people with health problems to manage and improve their health and reduce further deterioration. Some of the strategies implemented as a form of tertiary intervention will ensure that patients are able to recover their health fully, and they will not have to suffer from other diseases and health conditions such as malnutrition. Some doctors recommend zinc supplements to reduce diarrhea in children. Children who take the supplements reduce subsequent incidences of diarrhea for several months after gaining treatment of the disease. A significant intervention will be implementing Cholera Treatment Facilities (CTFs). The CTFs within the affected population will cater for children less than five years. In addition, the CTFs will provide the necessary vaccinations, antibiotics and medicines that for eradicating the disease among the children under the age of six years; however some doctors do not favor the use of antibiotics, to give the body a chance to get rid of the cholera bacterium (Deen et al, 2008).

Cholera treatment centres for children under five years

(Retrieved from <http://www.pih.org/blog/haiti-three-years-after-the-earthquake>)

Factors Affecting the Success of the Interventions:-

One of the compromising factors is opposition. Most children that acquire cholera at the age of five and below reside within war torn areas. As such, facilitating such interventions will be difficult based on the intrusion of factors such as rebel armies, who usually recruit children of the same age group and even higher for participation in their armies. For instance, areas within the Democratic Republic of Congo accommodate rebels who ward off any foreign assistance to the affected populations in the respective areas (Zuckerman et al, 2007: 525).

The financial aspects in some regions can also possess a pessimistic consequence on the intercession practices in rural areas. Rural regions possess insufficient treatment centres that are inaccessible and situated far from the homes of the locals. Because of this, the locals are susceptible to obtain unconventional medicines from other locations and thus ignore medicines from accredited health individuals. (Zuckerman et al, 2007: 526).

Evaluating the Success of the Interventions

In order to evaluate the success of the interventions, various procedures can be of use in assessing success of the prevention strategies. For instance, use of a statistical study regarding the transmission of cholera can assist greatly in evaluating whether the measures implemented reduce cholera infections. The study will utilise questionnaires and will inquire from each household within the vicinity affected most by cholera.

Another evaluation method that can be important is checking the number of persons visiting the Cholera Treatment Facilities in a certain period. This task will require the use of past historical information regarding the number of visiting patients at the beginning of the treatment and at the end. If the number seems to be increasing, then it will be evident that the interventions do not work.

Conclusion and Recommendations:-

Cholera is indeed an infection that affects the global society on a considerable scale. As time progresses and novel techniques are developed, the risk of cholera is decreasing in industrialized countries. Furthermore, the overall number of cholera cases is decreasing as seen in the rates of cholera cases by 2010. These have contributed to adverse effects on children less than six years leading to high mortality rates and subsequent deaths. As such, recommendations that will assist in protecting children less than six years include:

Educating parents of the children on the causation, washing hands before feeding child, symptoms and treatment procedures based on cholera infections.
The use of vaccines for cholera on both parents and children after a period of one to two years in order to lessen the risk of transmission from mother to child through contaminated practices.
Involving the community in efficient management of garbage and other minor wastes in order to create a better conducive environment for the children to participate without risk of contamination.
Government intervention that will be based on creation of a mini-sewage treatment facility that will focus on disposal and treatment of wastes in the community in order to make it safer for children under six years to consume foods without risking contamination.

References

Aberth, J 2011, Plagues in world history, Rowman & Littlefield Publishers, Lanham.

Aumatell, M C, J M Torrell & N J Zuckerman, 2011, ‘Review of oral cholera vaccines: efficacy in young children’, Infection and Drug Resistance, vol. 4, pp.155-60.

Breslow, L 2002, Encyclopedia of public health, Macmillan Reference, New York.

Chaignat, C, & M Victoria, 2007, “Use of oral cholera vaccine in complex emergencies: What next? Summary report of an expert meeting and recommendations of WHO”, The Journal of Health, Population and Nutrition, vol. 25, no.2.

Cliff, A & M Smallman-Raynor, 2013, Oxford textbook of infectious disease control: a geographical analysis from medieval quarantine to global eradication, Oxford University Press, Oxford.

Deen, L J, L Seidlein & D Sur, 2008, ‘The high burden of cholera in children: comparison of incidence from endemic areas in Asia and Africa’, PLOS Neglected Tropical Diseases, vol. 2 no. 2.

Gurrant, L R, A B Carneiro-Filho & A R, Dillingham, 2003, ‘Cholera, diarrhea, and oral rehydration therapy: triumph and indictment’, Clinical Infectious Diseases, vol. 37, no. 3, pp.398-405.

King A A, E L Ionides, J Luckhurst & M J Bouma, 2008, “Inapparent infections and cholera dynamics”, Nature, vol. 454, no. 7206, pp.877–80.

Lee, K 2003, Health impacts of globalization: Towards global governance, Palgrave Macmillan, Hampshire.

McElroy, A & P K Townsend, Medical Anthropology in Ecological Perspective, Westview, Boulder, 2009.

Moore, P 2007, The little book of pandemics: 50 of the world’s most virulent plagues and infectious diseases, Collins, New York.

O’Neal C, M Jobling, R Holmes & W Hol, 2005, “Structural basis for the activation of cholera toxin by human ARF6-GTP”, Science, vol. 309, no. 5737, pp.1093–96. Oxford.

Pauw, J 2003, ‘The politics of underdevelopment: Metered to death – how a water experiment caused riots and a cholera epidemic’, International Journal of Health Services, vol. 33, no. 4, pp.819-30.

Sack D A, R B Sack, G B Nair, and A K Siddique, 2004, “Cholera”, Lancet, vol. 363, no. 9404, pp.223-33.

Skovgaard, N 2008, “Vibrio cholerae, Genomics and Molecular Biology”, International Journal of Food Microbiology, vol.128, no. 2, pp. 414-15.

Vinten-Johansen, P 2003, Cholera, chloroform, and the science of medicine: A life of John Snow, Oxford University Press, Oxford.

Zuckerman, N J, L Rombo and A Fisch, 2007, ‘The true burden and risk of cholera: implications for prevention and control’, The Lancet Infectious Diseases, vol. 7, no. 8, pp.521-30.

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