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© 2004 Keni Soler
In 1817, a new and terrible disease moved out of Bengal and began to spread across the world. It caused profuse diarrhea and vomiting, and its sufferers died of profound dehydration, sometimes within a matter of hours. By the end of the nineteenth century it had killed many hundreds of thousands of people across Asia and then Russia, Europe, and the Americas. Like many diseases it was given a Greek name... cholera. The word means diarrhea.
Now, at the end of the 20th Century, the world is being circled by the seventh great pandemic of cholera. More than 60 countries report outbreaks each year. In recent years, Doctors Without Borders/Médecins Sans Frontières (MSF) teams have battled the disease in places as diverse as Guinea in West Africa, Guatemala and Peru in Latin America, and Bangladesh in southern Asia.
How cholera kills
The bacteria Vibrio cholerae is excreted by an infected person in the stools and vomit. It can then be spread directly to other people if they touch the patient and then fail to wash their hands before eating. The germ can also contaminate food or water supplies. In the latter case this will cause an explosive outbreak because many people will ingest the vibrion in a short period of time.
© 2004 Keni Soler
Once inside the intestine, the organism multiplies and produces a toxin. This toxin causes the cells lining the intestine to secrete massive volumes of fluid and leads to diarrhea and vomiting. A patient under treatment can lose more than 50 liters of fluid during a bout of cholera.
A person who is not treated will die of dehydration well before this. In fact, death usually occurs when 10 to 15 per cent of the total body weight is lost. In severe cases this may take only a couple of hours.
There is, at present, no effective vaccine against cholera. The only way to prevent its spread is to interrupt the fecal-oral cycle of contagion. The ways MSF teams do this include:
For example, during the floods in Bangladesh in 1998, many thousands of water wells across the country became contaminated by the rising waters. Cholera vibrios were washed down the pump shafts into the water table below. The greatest danger came after the flood waters started to recede, when people went home and began using their wells again. Part of the health education given by MSF teams to villagers was instruction on how to disinfect their wells.
How MSF teams treat cholera patients
Cholera is treatable. The main pathological process it causes is dehydration - therefore the treatment we use is simply to replace all the fluid being lost.
© 2003 Florence Gaty
MSF treats many patients using oral re-hydration solution, called ORS. This is a mixture of glucose and electrolytes (such as sodium and potassium). The solution is stirred into a liter of water and provides the correct balance of electrolytes to re-hydrate a cholera patient. It has been said that in global terms, ORS is the most important medical discovery since penicillin.
Many of our cholera patients vomit so profusely that they cannot drink ORS. MSF therefore treats serious cases by putting in intravenous drips. These IV infusions contain fluid and electrolytes. Some patients lose fluid so quickly that they need two drips, one in each arm. Treating serious cases requires a high degree of skill and experience. In most situations MSF teams are able to limit the case fatality rate to less than 1 per cent.