Cholera Disease Outbreak

Epidemics of communicable diseases serve as sharp reminders of the delicate balance that exists between microbes and the complex social structures in human existence. From the strange threat of pandemics to the limited effects of epidemics, these outbreaks have a significant influence on economies, public health, and international stability. For these reasons, understanding the dynamics of communicable disease outbreaks is an important aspect of ensuring their prevention and management. This essay explores the multifaceted nature of communicable disease outbreaks and how this knowledge can be used to manage epidemics.

Infectious Disease Description

The selected disease for investigation is cholera. Cholera is a highly infectious diarrheal disease caused by the bacterium Vibrio cholerae. The disease can rapidly spread through contaminated water or food leading to diarrhoea, severe dehydration, and death if left untreated (Shah et al., 2022). The disease is most prevalent in areas with poor sanitation, inadequate clean water supply, and overcrowded living conditions. The reason for selecting this disease is because it affects populations globally. There are also historical implications of the disease like the outbreak that swept through London in 1854, South Asia in 1961, and America in 1991 (World Health Organization, 2023). Today, cholera remains a significant public health challenge, particularly in regions with poor infrastructure and limited access to healthcare. Although improvements in sanitation and healthcare management strategies have reduced mortality rates, outbreaks still occur making the disease investigation crucial to maintaining public health.

Cholera is a potentially life-threatening public health concern caused by a gram-negative rod-shaped bacterium known as Vibrio cholerae. The two main strains of the bacteria that cause outbreaks are 01 and 0139 whereby they produce cholera toxin which is responsible for observed characteristics (World Health Organization, 2023). The cholera toxin works by attaching itself to particular receptors on the surface of small intestine lining cells. After binding, the toxin enters the cell and causes cyclic AMP (cAMP) production, which causes the intestinal lumen to secrete water and chloride ions (Mogasale et al., 2020). These changes lead to diarrhea and dehydration in affected individuals. While many of the affected individuals can remain asymptomatic, others develop severe cholera with rapid onset of dehydration and electrolyte imbalance, potentially leading to shock and death if left untreated.

Public Health Implications

Cholera has significant public health implications due to its potential to cause large-scale outbreaks. The high mortality and morbidity associated with outbreaks make it important to investigate epidemics and instill proper management measures. For instance, deadly among vulnerable populations such as young children, the elderly, and individuals with weakened immune systems. The disease continues to affect at least 47 countries worldwide and reports estimate around 95,000 deaths per year (Shah et al., 2022). Secondly, cholera has the potential to spread rapidly leading to explosive outbreaks in unsanitary conditions or overcrowded areas. The cost associated with planning for treatment makes it necessary to take precautions and thorough treatment approaches.

Another implication is the disease’s impact on communities and economies. For example, an estimated $130 million was spent to manage cholera outbreaks in Africa in 2015 (Mogasale et al., 2021). Apart from outbreaks in African countries, cholera is common in Asia. The economic burden of cholera in several Asian countries was estimated at around $57.1 million in 2015 (Mogasale et al., 2020). There are also significant impacts on the aspects of lost productivity and premature deaths that are difficult to estimate. The stigma and discrimination that accompanies cholera outbreaks are another public health concern because of the marginalization that results from outbreaks. The fear of international spread and global health security demonstrates the importance of outbreak investigation, coordination, and cooperation in surveillance.

Epidemiology

The epidemiology of cholera involves understanding the distribution, patterns, and determinants of the disease within populations. Cholera is a disease that is prevalent in many parts of the World, especially parts of sub-Saharan Africa, South Asia, and parts of Latin America. The Centers for Disease Control and Prevention (CDC) estimates that 1.3 to 4 million people get cholera each year and about 143, 000 deaths occur (CDC, 2023). Cholera has been endemic in the large parts of Asia but it has recently established its roots in Africa and Haiti. For example, data collected from 2010 to 2015 shows 13 endemic cases reported in India. Yemen is another country in Asia that is affected by cholera with more than 364,000 suspected cases reported in 2020 (Deen et al., 2020). In Africa, there have been reported cases in the countries of Congo (DRC), Ethiopia, Nigeria, Somalia, South Sudan, Sudan, and Zambia. Inadequate water and sanitation combined with environmental challenges cause increased disease burden in these countries.

Cholera often exhibits seasonal patterns, with peaks occurring during warmer months or rainy seasons. Changes in water quality, rainfall, and temperature are observed to influence outbreaks in susceptible regions. For instance, the elimination of pandemic cholera from the regions of South America supports the significant role of climate and the presence of aquatic environments in cholera outbreaks (Deen et al., 2020). Regarding the risk factors for the disease, lack of access to clean water and sanitation, overcrowded living conditions, poverty, malnutrition, and inadequate healthcare infrastructure increase the chances of outbreaks (CDC, 2023). Vulnerable groups during outbreaks may include young children, the elderly, pregnant women, and individuals with underlying health conditions or compromised immune systems.

Clinical Features

Cholera is an infection, often mild or without clinical symptoms, but can be severe requiring hospitalization. According to the CDC, around 1 in 10 people affected by cholera gets sick and presents with key features like watery diarrhea (CDC, 2023). The disease causes abdominal upset characterized by vomiting and loss of body fluids. Severe loss of body fluids causes dehydration and shock can result leading to death. On assessment, individuals will have dry oral mucosa, cool skin, and decreased skin turgor (Montero et al., 2023). Apart from these key symptoms, patients may experience acidosis leading to hyperventilation and other features like Kussmaul breaths. Individuals take about 12 hours to 5 days to show symptoms of infection and the disease progresses fast.

Laboratory Confirmation

A review of clinical features from different patients during a suspected outbreak is used to guide the investigation for cholera. The gold standard laboratory investigation to diagnose cholera is isolation and identification of Vibrio cholerae serogroup O1 or O139 by culture of a stool specimen (CDC, 2022). In areas with limited or no lab testing, rapid tests are available to guide disease treatment. For instance, the Crystal VC dipstick rapid test can be used to provide early warning regarding cholera disease outbreaks. During testing, culture and PCR can be enhanced by the use of selective media with high PH which allows the bacteria to multiply rapidly. The WHO criteria for a confirmed case involves vibrio cholerae 01 or 0139 confirmed by culture or PCR (WHO, 2023). Reporting of suspected cases should be done to the CDC and case confirmation made by the state health department.

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Transmission and Acquisition

Cholera bacterium is usually found in areas with water or food that has been contaminated by the feces of a person with the disease. Data also indicates that the bacteria can be found in environments with brackish rivers or coastal waters (Maniam et al., 2020). The CDC explains that Shellfish eaten raw can be a source of infection in some areas. Overall, the primary mechanism of transmission is via the fecal-oral route that happens during the consumption of contaminated seafood or water (CDC, 2022). This route is effective given that profuse diarrhea allows for bacteria shedding that contaminates water. In an epidemic, the sources of cholera are usually contaminated by the feces of an infected person (Maniam et al., 2020). The disease is observed to spread rapidly in areas with inadequate water treatment. The incubation period is 12 hours to 5 days from the time of contamination because of the adaptive mechanisms of the human digestive tract.

Prevention

The prevention of cholera is dependent on access to clean water, adequate sanitation, and good personal hygiene (Buliva et al., 2023). Individuals should be aware of recent outbreaks to initiate precautions. Drinking bottled water or chemically treated water is among the key preventive strategies. Individuals should avoid tap water, fountain drinks, and ice cubes. Secondly, handwashing is an effective strategy to minimize transmission of the disease. Individuals should use soap and clean water, especially before drinking or food preparation. The CDC recommends the use of alcohol-based hand sanitizer with at least 60% alcohol (CDC, 2023). Eating foods that are freshly cooked or packaged is another way of preventing infection. Eating raw or unpackaged seafood and meat is prohibited. For healthcare providers, it is recommended to disinfect surfaces with 2% chlorine (Buliva et al., 2023). Lastly, a single dose of the Vaxchora (lyophilized CVD 103-HgR) vaccine is available for individuals aged 2 to 64 years (CDC, 2023). This vaccine is given to those traveling to areas with active cholera transmission.

Surveillance

To measure changes in patterns of morbidity and mortality and to assess the burden of disease in any given setting, disease surveillance is crucial. The initial approach to cholera disease surveillance involves detecting outbreaks, measuring changes in mortality, and monitoring suitable responses (Ganesan et al., 2020). Cases should be suspected among individuals aged two years and older with watery diarrhea and severe dehydration. A rapid diagnostic test can be used during an outbreak to detect cases and confirmation of cases using PCR and culture findings of the bacteria from stool samples. During monitoring, cases should be reported to the local authorities and the CDC. The use of integrated disease surveillance and response (IDSR) programs in regions like Africa and Asia is often used to cover surveillance and reporting of cholera (Ganesan et al., 2020).

Steps in Outbreak Investigation

Cholera disease outbreak investigation begins with confirmation of an outbreak through reported cases (Fricker & Rigdon, 2020). The next step is verification of diagnosis through laboratory testing. The next step will involve case definition that entails person, place, and time, and defining the at-risk population. Descriptive epidemiology is the next step that deals with identifying demographics, exposures, and pertinent risk factors (Fricker & Rigdon, 2020). The next step will involve generating a hypothesis reflecting on the identified data. Testing the hypothesis through analytical epidemiology follows to assess cases against controls. The last step will of investigation is to evaluate control measures and recommending Control measures.

Conclusion

Infectious disease outbreaks are a significant threat to public health. During outbreaks, priorities like investigating the disease and implementing control strategies can help to reduce mortality and morbidity. Cholera disease outbreak is a common phenomenon that affects regions with inadequate access to safe water and basic sanitation. The disease causes acute diarrhoea and dehydration which can lead to fatal outcomes like death. It is important to confirm outbreaks using laboratory findings from stool samples and use surveillance approaches to detect, diagnose, and manage the illness. Prevention strategies often include sanitation, hand hygiene, and vaccination for those visiting endemic areas.  

References

Centers for Disease Control and Prevention. (2022). Cholera - Vibrio cholerae infection: Diagnosis and detection. https://www.cdc.gov/cholera/diagnosis.html#:~:text=Isolation%20and%20identification%20of%20Vibrio,ideal%20for%20isolation%20and%20identification.

Centers for Disease Control and Prevention. (2023). Cholera - Vibrio cholerae infection. https://www.cdc.gov/cholera/general/index.html#:~:text=An%20estimated%201.3%20to%204,but%20cholera%20can%20be%20severe.

Deen, J., Mengel, M. A., & Clemens, J. D. (2020). Epidemiology of cholera. Vaccine, 38, A31-A40. https://doi.org/10.1016/j.vaccine.2019.07.078

Fricker Jr, R. D., & Rigdon, S. E. (2020). Investigating a disease outbreak. Significance (Oxford, England), 17(2), 14. https://doi.org/10.1111%2F1740-9713.01372

Ganesan, D., Gupta, S. S., & Legros, D. (2020). Cholera surveillance and estimation of burden of cholera. Vaccine, 38, A13-A17. https://doi.org/10.1016/j.vaccine.2019.07.036

Mogasale, V., Mogasale, V. V., & Hsiao, A. (2020). Economic burden of cholera in Asia. Vaccine, 38, A160-A166. https://doi.org/10.1016/j.vaccine.2019.09.099

Mogasale, V., Ngogoyo, S. M., & Mogasale, V. V. (2021). Model-based estimation of the economic burden of cholera in Africa. BMJ Open, 11(3), e044615. https://doi.org/10.1136/bmjopen-2020-044615

Montero, D. A., Vidal, R. M., Velasco, J., George, S., Lucero, Y., Gómez, L. A., … & O’Ryan, M. (2023). Vibrio cholerae, classification, pathogenesis, immune response, and trends in vaccine development. Frontiers in Medicine, 10, 1155751. https://doi.org/10.3389/fmed.2023.1155751

Shah, H. D., Desai, B., Jadav, P., Shah, N., Kadikar, R., & Singh, A. J. (2022). An epidemiological investigation of a cholera outbreak in peri-urban slum settlements of Gujarat, India. Journal of Family Medicine and Primary Care, 11(10), 6061–6066. https://doi.org/10.4103/jfmpc.jfmpc_133_22

World Health Organization. (2023). Cholera. https://www.who.int/news-room/fact-sheets/detail/cholera#:~:text=Rapid%20diagnostic%20tests%20(RDTs)%20can,polymerase%20chain%20reaction%20(PCR).