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Concerns over sanitation and the return of cholera.



I must apologize for my absence in this month of May, in all truth it has been just a combination of school-finals and work related projects hitting all in this month.


I'm writing this article as to, hopefully, create some insight in the importance of field sanitation in populated areas. Anyone who knows me personally knows I hold a strange fascination for epidemiology, particularly bacterial epidemics. Recent events in India, Eastern Europe, and Vietnam have bothered me a bit, and the focal point of these worries are the growing numbers of cholera outbreaks.


For those who have not been exposed to what this diseases is, I will give a short summary.


Cholera is a bacterial disease that is transmitted from person to person by ingesting food or water that has been contaminated by cholera vibrios. This bacteria, produces massive amounts of toxin in the linings of the small intestine of the host, causing extremely-debilitating diarrhea in its victims. The most frightening parts about cholera is that it can be rapidly fatal if not treated (can be fatal in less than 24 hours if not treated) and how quickly it can spread in a less-than-perfect world.


In all honesty, the United States has not seen a serious cholera outbreak since the first decades of the 20th century. But with the downturn of the economy and Cold-War style thermonuclear rhetoric on the news all day, one can not rule out the possibility of our way of life changing drastically.




Symptoms of Cholera Infection:


Depending on the health of the individual infected, symptoms can begin to manifest between 12 and 48 hours after infection. Many of these symptoms are shared with many other gastro-intestinal infections, most notably salmonella.


- Rapid onset of diarrhea.

- Vomiting

- Muscle cramps.

- Fever.

- Reduced urine output.

- Some people experience increased heart-rate.


- Most notable symptom of Cholera infection is the appearance of the infected individual's stool, commonly called 'rice-water'. It will have a gray-ish appearance and lack little substance.




As scary as the symptoms sound, treatment for cholera infection is relatively simple, but is time consuming.


- The number one factor you must consider in treatment is your own personal protection. Cholera cannot be transmitted by inhalation, but by placing a disposable covering over your face is a very good idea for the simple fact that it will force you to not touch anywhere around your face. Non-latex gloves is another mandatory item, the bacteria cannot be absorbed into your skin by simple touch, but this will keep you from contaminating other items by touch. Personal protection is key.


- Second is controlling the spread of the infection. Sterilization is key here. In a household setting, plastic sheeting and lots of spare linens are ideal. Strip the current bedding from the resting area and lay down a layer of plastic sheeting, then the patient can use the spare linens for resting purposes. Any porous items (such as stuffed animals and the like) should be removed from the area unless they can easily be replaced. When a caretaker is changing the bedding, great care should be taken to bag and seal all items in question for disposal, burning is ideal...but items can be sterilized with non-potable water and chlorinated bleach.


- The main cause of widespread outbreak in the third world is the lack of adequate waste-water management. Fecal matter making its way into the water system is the main cause widespread infection. That being said, if modern plumbing is available, the patient using the normal toilet is fine as long as sanitation concerns are met. The toilet should be throughly cleaned using chlorinated bleach after use, the floors should be mopped and all touched surfaces should be wiped down as well. All toilet tissue used should be placed in a bag and sealed. After the 'episode' has passed, make sure the patient does not have any fecal matter on their backside, aid them in washing their hands properly before flushing and helping them back to the resting area.


**Side note, very important one. Anyone with a severe gastro-intestinal infection where extreme diarrhea is a factor, you should not leave the person alone in the restroom. Extreme diarrhea has been known induce hypotensive shock (sudden drop in blood pressure), which can lead a person to become disoriented and pass out...very bad thing as most restrooms have multiple hard surfaces and sharp corners. Individuals with high blood pressure, are taking blood-thinners, or blood pressure lowering medication should be aware the episodes of extreme diarrhea can increase the affects of sudden blood-pressure drops. Those individuals with those particular afflictions should be carefully observed.**


- With the sanitation concerns out of the way (safeguarding those in the household and community), now we get on to treating the patient, which is actually...the easy part. The human body can easily destroy the bacteria responsible for Cholera, the reason it is so deadly though is that the bacteria kills by attrition, quickly depleting the body of vital fluids and electrolytes. So in a situation where no medical care can be reached, cholera infection can be treated by treating the symptoms and letting the body do its work.


Oral re-hydration salts are a very good item to keep in your homes in large quantities because of the variety of uses, but here is a simple recipe for making your own (note, for type-I diabetics, simple salt water in the same proportions will suffice).


1 liter (1/3 of a gallon) of water.

8 teaspoons of sugar

1 teaspoon of salt

1/2 cup of orange juice (or a 1/3 of a banana potassium is what you're looking for)


- Keep the patient very WELL hydrated to replenish lost fluids due to the diarrhea, water and other juices are fine as long as the patient is taking in proper salts and sugars in their foods. Potassium intake is important to help with the abdominal cramps. It should be noted that urine output will be abnormally low during the worst of the infection and this is how you will tell when the worst has passed. If all goes well, the diarrhea episodes will drop in frequency after 2-3 days and urine output will increase. Patient sterilization and isolation practices should continue for up to 2 days after stool consistency and urine output returns to normal.


**A few notes to all this. This disease is especially dangerous for children under 5 years old, so special precautions should be observed if small children are at risk.


Severe cases of cholera infection may require IV intervention to assure fluid/nutrient replenishment and antibiotics many be needed (where the immune system may already be weakened).


During an infection, it is advised that the household should treat their water by normal chlorination treatment and/or boiling practices. **




Disposal/treatment of contaminated items:


Items that can be destroyed, should be destroyed by through incineration. But linens can be cleaned by being soaked in chlorinated water (copious amounts of chlorine can be used), then re-washed in standard treated water. This water should not be used for drinking afterward.






Remember that infection control is key when dealing with anyone suffering from the Cholera disease. Many people in the third world know how to treat cholera, but outbreaks still happen because proper sanitation is not observed. I've read first hand accounts of aid-workers who are observing family members, treating their loved ones, wash their hands in the same wells that everyone else in a village drinks out of...thereby spreading the infection. Poorly constructed outhouses leak into the drinking water system. When proper sanitation is practiced and these simple measures of treatment are practiced, Cholera drops from a 50-60% mortality rate to 1%.


In closing, be smart and be safe.

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