Cholera Outbreak; a Pharmacy Student

Perspective
Vibrio cholerae is a fecal-oral organism that secretes deadly toxins in the intestine, and you
would not want to ingest any of these gram negative facultative bacteria. This organism is a
popular cause of cholera epidemics which is common in Nigeria and a person may be infected
with Cholera by consuming contaminated food and water.

A German bacteriologist Robert Koch (1843-1910), found a bacterium in the intestines of those
who had died of cholera in an epidemic in Egypt. He failed to isolate the organisms at the time.
But later in India he was able to isolate the organism and note that they thrive in damp dirty linen
and moist earth. This organism was V. cholerae which lives in shallow brackish water.

Toxic strains of cholera produce toxins that cause an extreme form of diarrhea. The presence of
the bacteria in populated areas can lead to sever epidemics. The outbreak can also come to an
abrupt end if there are weather changes, population decline or improved sanitation.

How does cholera cause death?

Cholera causes severe diarrhea and vomiting which leads to severe rapid dehydration as well as
extreme loss of electrolyte. This consists of a large reduction in both intracellular and
extracellular fluid volume. Clinical / symptomatic indication of dehydration is mostly due to the
depletion of intravascular volume within the body. Hypovolemic shock ultimately occurs and
leads to acute kidney injury, organ failure and ultimately death. Ok! In a much less physiology
jargon, cholera causes diarrhea which leads to extreme loss of body fluids and dehydration then
leads to organ failure and then death.

What are the symptoms of Cholera?

The symptoms are extreme nausea and vomiting, diarrhea and a drop in blood pressure combined
with a rapid heart rate.

What is the approved treatment for Cholera?

According to the World Health Organization (WHO), cholera is easily treatable and can be
treated with administration of oral rehydration solution (ORS). The WHO/UNICEF ORS
standard sachet is dissolved in 1 litre (L) of clean water. Adult patients may require up to 6 L of
ORS to treat moderate dehydration on the first day. Severely dehydrated patients may also need
the administration of intravenous fluids.

The WHO also recommends that these patients are given appropriate antibiotics to diminish the
duration of diarrhea, reduce the volume of rehydration fluids needed, and shorten the amount and
duration of V. cholerae excretion in their stool. Tetracycline and doxycycline are the common
first choice of treatment for all patients, ciprofloxacin or azithromycin are also used as
alternatives when there is doxycycline resistance.

The patients are expected to eat safely and maintain high hygiene after these. The WHO also
recommends that breast feeding is promoted.

Handling antimicrobial resistance and therapeutic failure

Like any other organism V. cholerae also evolves and eventually shows adaptation and resistance
to treatment. Antimicrobial resistance often develops due to exposure of the organism to an
antimicrobial drug which may then lead to a chromosomal mutation, or there could be
acquisition of resistant genes from other organism via mobile genetic elements.

Resistant strains cause increased difficulty of treatment and often lead to medication failure.
There is the need to change to a drug to shows susceptibility of the organism if a resistant strain
is encountered. Outbreak of a resistant strain is usually more bothering than a nonresistant strain
outbreak especially in developing countries.

Resistance to drugs like Trimethoprim, Sulphamethoxazole and streptomycin are common,

tetracycline resistance is less common. V. cholerae shows better susceptibility to doxycycline but
drugs like ciprofloxacin and azithromycin are administered in case of resistance.

What are the preventions and controls of cholera?

We all know that prevention is better than cure so it would be better for us to avoid getting
infected or getting others infected rather than getting treatments and cure. Surely this can also be
done by curtailing the spread of this organism in populated areas. A multifaceted approach is
necessary in the control of cholera. A combination of surveillance, water sanitation and hygiene,
social mobilization, treatment, and oral cholera vaccines are used.

There is also what you do as an individual to prevent cholera and keep yourself safe. The five
basic steps for prevention of cholera by the Center CDC is given for the safe drinking and use of
water, hand hygiene, use of toilets, food consumption and general hygiene.

All the important cholera prevention tactics expected of you as an individual are summarized in
the following bullet points:

 The use of water

 Use only bottled water with unbroken seal or water that has been properly boiled
chlorinated or filtered
 Treat drinking water with locally available chlorine containing treatments and
follow instructions on label
  If boiling, keep water at boiling temperature for up to a minute or more and safely
store in clean container.
 Hand hygiene; use not less than 60% alcohol sanitizer or wash with soap and safe
water…
 Before during and after preparing food
 Before and after feeding
 After toilet
 Toilet use
 Proper disposal of feces
 Do not poop in or near water bodies
 Bury plastic bags containing feces underground, (advice for those who love shot
put).
 Latrines and temporary pit toilets should be at least half a meter deep
 Food and cooking
 Eat foods that are thoroughly cooked while still hot. Buying cold food from
source that has hygiene that cannot be guaranteed can be dangerous.
 Peel fruits yourself when you are ready to eat them.
 Avoid eating raw vegetables that cannot be peeled
 General hygiene in preventing cholera
 Always clean and disinfect cooking environment, if possible
 Wash cutleries, dishes and cooking wares well.
 Do not wash or bathe near drinking water source
 Disinfect and clean toilet surfaces with hypochlorite diluted with 9 times its
volume of water

All these are important things to do to keep safe, and there are cholera vaccines that can be taken.

Outbreak in Nigeria

Epidemiological reports of the cholera give over 3million cases with diarrhea symptoms yearly
and over 100,000 deaths worldwide. All cases of infection with either toxic or non toxic strains
of Vibrio cholerae may not be reported.

In current outbreak in Nigeria, death toll has been on the rise. The number of deaths has been
recorded at 37 and counting as the outbreak has reached 30 states of the country including Lagos
and Ogun states. The Nigeria Center for Disease Control and Prevention, NCDC, reported that
from January 1 to June 11, 2024, over 1,141 suspected and over 65 confirmed cases of cholera,
resulting in over 30 deaths had been reported from 96 local government areas in 30 states.
Whereas Lagos state had just given reports of an increase in cases to 401 while 6 more deaths
were recorded.

Conclusion
Remember it is best to do everything in ones power to keep good health as nothing can be done
without health. There are many good motivational quotes out there about keeping good health;
one of such is the one by Kenneth H. Cooper that states “it is easier and more cost effective to
maintain good health, than to regain it once lost”. There are many more by different well
recognized people but what matters is not you reading all but being able to achieve the goal.
Maintain good health by avoiding cholera, maintaining good health and preventing the spread. I
guess you also know what to do if anyone has it? Rehydration!

Ojat
2024