(916) 482-5200

The Cholera Epidemic In Haiti

Published: November 17, 2010

As the death toll from Haiti’s recent Cholera outbreak reaches 1000, health officials have reported at lease 73 cases in the nation’s capital, Port-au-Prince. With the disease rapidly spreading across the country, it was only a matter of time until outbreaks were recorded in densely populated capital. While the progression of the cholera epidemic is difficult to predict, officials are preparing for the worst. Cholera is highly contagious, and thrives in unsanitary conditions and contaminated water. The congested tent cities that sprung up around Port-au-Prince — the aftermath of a devastating earthquake last January — combined with access to limited sources of sanitary water from the recent flooding of Hurricane Tomas, provides an ideal breeding ground for the devastating disease. Health officials have declared that Haiti’s entire population, as well as people in the Dominican Republic are at risk from this epidemic.

Here in the states, we haven’t seen a cholera outbreak since 1911. For this reason many people might not be familiar with the specifics of this disease that afflicts 5 million people worldwide, and causes about 100,000 deaths per year. The symptoms of cholera include, fever, abdominal cramps, vomiting and severe diarrhea. Patients infected with the disease will loose up to thirty liters of body fluid over the course of the disease. This fluid loss results in severe dehydration and electrolyte imbalance that can kill within hours of the first symptoms.

The causative agent of Cholera is the bacterium Vibrio cholerae which lives on tiny waterborne crustaceans in contaminated water. When a person drinks this water, or eats food prepared with contaminated water, the Vibrio cholerae set-up shop in the person’s small intestine. Once they establish themselves in the GI tract, they begin producing a toxin. This toxin essentially reverses and then supercharges the function of our small intestines. Instead of slowly absorbing all of the liquid and electrolytes we eat and drink, the toxin causes our intestines begin rapidly and profusely expelling all of the fluid out of our body. Dehydration occurs quickly, and without rapid and appropriate treatment, a person with Cholera can die within hours. Fortunately, should the patient be able to remain hydrated, the bacteria and resulting toxins will be flushed from a person’s intestinal system within about four days.

Treatment of Cholera can come via intravenous Ringer’s lactate solution, or more easily through oral rehydration therapy (ORT). By ingesting a mixture of water, glucose, salt, sodium bicarbonate, and potassium chloride, ORT overcomes the effects of the toxins. This can be accomplished because the bacterial toxin doesn’t affect the uptake of glucose in our guts, so by piggybacking water and electrolytes to glucose, we can sneak this solution in the back door. Pre-mixed oral rehydration therapy packets are cheap and easy to make, costing approximately 12 cents per packet. The problem with oral rehydration therapy is access to clean water. Administering oral rehydration therapy with contaminated water will only prolong death. The morose reality is that, were access to clean drinking water available, Cholera wouldn’t be a problem.

Because treatment of cholera in areas lacking clean water is so circumstantial, prevention is the best method of controlling an epidemic. Currently world health officials are beginning a public health education campaign in Haiti, handing out fliers about methods to prevent the spread of the disease. The focus right now is on sanitation. It has to be remembered that enormous volumes of liquid will be lost from people suffering from the disease. It is essential that this contaminated liquid, along with the bodies of the unfortunate victims, be properly disposed of. Additionally, all sewage waste, even that from non-symptomatic people, must be properly handled during an outbreak. The reason for this is that Cholera will only make people sick when the bacteria congregate in a sufficient quantity. The bacterium itself is highly susceptible to stomach acid, and many who become infected by the bacteria will never contract the life threatening symptoms; however they can still pass these bacteria on through their excrement. For this reason proper sewage management is essential to controlling a cholera outbreak, and all the more difficult when that outbreak occurs in areas lacking sufficient infrastructure to do so, such as the earthquake ravaged country of Haiti.

Other practices essential to cholera prevention include the proper sanitization of drinking water. Anti-bacterial treatments include chlorine or iodine treatment, UV irradiation, or ozone treatment. The best way to ensure clean drinking water, however, is by boiling it. Unfortunately, areas stricken by cholera lack many methods of sanitizing water, including the wood or gas needed for boiling. Water filtration is cheap way of limiting an outbreak, but is by no means an acceptable way of sanitizing water. Filtration can catch the aquatic crustaceans that Vibrio cholerae colonizes, but the individual bacteria will pass through all but the most sophisticated (i.e. expensive) microfilters. In Bangladesh, where cholera is endemic and wood is scarce, cloth filtration is commonly used by the villagers. Those villages that use cloth filtration have about 40% fewer cases of cholera compared to villages that do not filter their water.

So now that you know about Cholera, what can you do? It should be obvious that Cholera is of no concern in industrialized nations. The last Cholera outbreak in London was in 1866, and the last one in the United States was in New York in 1911. However, travelers to nations where Cholera exists need to take precautions. Primarily, clean drinking water should always be obtained, whether it be bottled, boiled, or chemically treated. Avoid ice, as it is often made with untreated water, and avoid undercooked food which could contain live bacteria from the water used to prepare it. One interesting technique to avoid infection is to eat only small amounts of food at a time, allowing complete digestion. Remember that Vibrio cholerae is susceptible to stomach acid. If you limit your food intake, your stomach will process everything to a greater extent, reducing the chance that live bacteria will manage to hide inside an undigested morsel and make their way into your intestines.

For more information on the crisis in Haiti, and what you can do to help, visit http://www.doctorswithoutborders.org/ or http://new.paho.org/