Cholera alert: Knocking at our doors
The existing surveillance system should be strengthened and expanded into hospitals and health care centers. The government should launch public awareness programs prior to cholera outbreaks
On 29 May, 2017, a 21-year female from Satdobato, Lalitpur with a complaint of watery diarrhea and vomiting was brought to the local polyclinic. Stool culture was found positive for Vibrio Cholerae, commonly known as “Cholera”. The result was reported to the Epidemiology and Disease Control Division (EDCD). Due to lack of stool sample, cholera could not be verified by EDCD. This is the first reported case of cholera this year in Nepal. Over the past few days, there has been a sharp increase in the number of diarrhea cases; most of the stool samples were watery in nature. Last year, a cholera case was first detected in late June. Early detection of cholera is a loud wake-up call for government-concerned bodies, including the general public. In Nepal, every year, cholera cases occur mainly during the monsoon season; it is, thus, expected that, sooner or later, more cholera cases will be detected in Kathmandu or elsewhere in Nepal.
Cholera is potentially more life threatening and more epidemic than diarrhea caused by other organisms, thus it remains among the most feared diarrheal illnesses and public health threats in many countries. It is estimated that each year 30,000-40,000 die due to diarrheal diseases in Nepal, of which the majority of deaths occur due to cholera. A toxin release by the bacterium Vibrio cholerae, causes severe diarrhea and vomiting leading to severe dehydration, shock and even death, if not treated immediately.
Death from severe diarrhea is extremely rare in Kathmandu city due to easy access to health care centers. However, beyond the capital, particularly in remote villages; deaths due to severe diarrhea may be more because of difficult geographic terrain, meaning inability to visit health care facilities, and owing to lack of adequate intravenous fluids that are essential for saving life. For example, in 2009 a total of 128 deaths, mostly due to cholera, were recorded in Jajarkot, and the main reason behind the deaths was found to be difficult terrain. Cholera could be life threatening and spread rapidly, even in the city areas, if a new strain of cholera is introduced into the population, because people are not immune to it, and available medicines may not work properly and effectively. Multi-drug resistance is another emerging new challenge and causes difficulty in treating the patient effectively. Appropriate antibiotics or multi drug resistance is determined by the culture method. My previous research showed that cholera having a new biotype is emerging in Nepal, indicating that the currently used medicines may not work properly in future. It is, however, not yet known how this new biotype will impact the community in the long run.
The incubation period (the period between infection and the appearance of signs of a disease) of cholera is from a few hours to 5 days. Even though patients do not develop symptoms but they contain bacteria in their feces for up to 10 days after infection and infecting other people. Cholera transmission occurs when water or food contaminated with feces is consumed by a healthy person. Profuse watery diarrhea, vomiting, low blood pressure, thirst, muscle cramps, abdominal pain are the main signs and symptoms of cholera. Only 5-10% of infected patients will have severe cholera.
Transmission can also occur from unwashed hands. Recent evidence shows that cholera is spreading through commercial bottled water such as jar water including tanker water, which is increasingly and widely used in Nepal. During the cholera outbreak in 2015, I found that more than 50% of the cholera patients consumed jar war (unbranded), while nearly 25% used tap water. Before 2015, people did not give attention to the purity of jar water.
Oral Rehydration Solution (ORS) and intravenous fluids are life saving medications for cholera patients. Thus these life saving drugs should be readily available at the primary health care level. Antibiotics can be used to treat cholera that can reduce duration and the volume of diarrhea. Selection of antibiotic is based on sensitivity testing method. Multi drug resistance is one of the main challenges of treating with appropriate antibiotics due mainly to antibiotic resistance and inappropriate use of antibiotics through use of self-medication, which is a common practice in Nepal. Antibiotic susceptibility testing is, therefore, needed in order to ensure correct antibiotic treatment and avoid unnecessary use of antibiotics. Thus, government should provide information regarding susceptibility of antibiotics to health care providers who are working in those areas so that they can treat cholera patients rapidly, accurately and effectively.
Cholera is already knocking at our doors this year. Given several limitations and issues, more cholera cases are expected to surge during the upcoming monsoon season. Thus, existing surveillance system should be strengthened and expanded into hospitals and health care centers. Likewise, the government should launch public awareness programs prior to cholera outbreaks. The government should release information about the outbreak through media on a daily basis in the Nepali language as well, in particular, so that patients can consult their doctors immediately, if they have signs and symptoms similar to cholera.
Dr Pun is Coordinator of the Clinical Research Unit, Sukraraj Tropical and Infectious Disease Hospital