‘Water, water, everywhere, Nor any drop to drink’ – Safe drinking water and Adequate sanitation are indispensable for eradicating Cholera

What has Cholera to do with environment? Absolutely everything!  In this post, we look at why clean water and safe sanitation is essential for eradicating this dreadful disease from our planet.

Access to clean drinking water and safe sanitation could eradicate cholera. (Image - Sam Stephen)

Cholera, an acute intestinal infection caused by ingestion of food or liquids contaminated with the bacterium Vibrio cholerae, elicits the same fear today, as it did in the past. Although cholera has affected populations throughout history, the first recorded pandemic was in 1817 starting from South East Asia where it had been endemic. From there it spread globally. A dangerous disease, it affects children and adults, killing patients within hours. Malnourished children or HIV infected individuals are at a greater risk of death if infected. WHO figures indicate 3–5 million Cholera cases per year and 100000–120000 deaths.  

A big concern during the recent earthquake in Nepal was that cholera could strike as it remains endemic in that country today. Elsewhere in the world, an outbreak of cholera has been ongoing in Haiti since the earthquake in  2010 where  it has killed over 8000 Haitians, and  resulted in hospitalizing of over  600,000s and has also spread to the neighbouring country of Dominican Republic. Although epidemics such as this gains media coverage, in many parts of the developing world cholera cases continue to be reported occasionally but in smaller numbers and goes unnoticed globally often peaking during favourable conditions such as rainy seasons and drought seasons. In the rainy seasons, water and food often gets contaminated with wastes that spill out from faulty sanitation systems. The drought season  brings a different set of problems - people have to survive on very limited water which is often contaminated. Additionally, people are malnourished which makes them more prone to infectious disease including cholera.

Profuse watery diarrhoea is the main symptom of cholera. Diagnosis is made by the presence of V. cholerae-like organisms microscopically with a conclusive diagnosis by isolation and identification of V. cholerae from stool samples. Once infected by cholera, the patient requires immediate treatment as time is of the essence between life and death. Treatment primarily includes prompt rehydration through which lost fluids and electrolytes are  replaced using an Oral Rehydration Solution (ORS).  Approximately half of the cholera patients could die without rapid rehydration. Although most people can be helped with this treatment alone, severely dehydrated people may also need intravenous fluids. In children suffering from cholera, zinc supplementation can significantly reduce the duration and severity of diarrhoea. Antibiotics are also recommended for all patients who are hospitalized and the medication choice determined based on local antibiotic susceptibility patterns where it is used in parallel with aggressive rehydration therapy.

Using the right antibiotic/antibiotics is very important as bacterial strains that are resistant to drugs have been reported. In a recent study, researchers studied all available Vibrio cholerae  isolates collected from major outbreaks in the Democratic republic of Congo  during 1997–2012, and found loss of sensitivity to leading antibiotics over time. Additionally they found spread of fluoroquinolone-resistant strains. In a 2013 article in the New England Journal of Medicine, Waldman, Mintz and Papowitz  offered recommendations on how cholera can be effectively controlled. Whilst giving due credit to the current developments in cholera control in the medical arena - use of  antibiotics, treatment procedure, and  use of an improved two-dose oral cholera vaccine which had success in pilot trials, they importantly presented  a lasting solution for  prevention of the disease taken from the pages of the history books - Safe sanitation and clean drinking water eliminated cholera in North America and Northern Europe and this is the route for eradication of the disease, the authors proposed.

The  United Nations Committee on Economic, Social and Cultural Rights - General Comment 15, para.2. says "The human right to water entitles everyone to sufficient, safe, acceptable, physically accessible and affordable water for personal and domestic uses". However, the problem is that what  most of us take for granted-clean water and access to sanitation, is inaccessible to  an estimated 1.8 billion people world-wide who  are forced to drink water that is faecally contaminated,  and 2.4 billion people  who do not have access to any type of improved sanitation facility (WHO/UNICEF Joint Monitoring Programme forWater Supply and Sanitation figures). Sources of water in many parts of the world are tainted often by human activities- climate change effects, environmental pollution, and lack of sanitation.

Guaranteeing clean water, and improved sanitation is a difficult proposal complicated by a glut of hurdles which are technological, societal, behavioural, political and economical to name the main ones. Cholera, Waldman et al  said in their NEJM article  ‘is as much a symptom as a disease’. It is ‘a symptom of insufficient investment' by the global development community in offering access to safe water and improved sanitation for the marginalised.  'Safe drinking water and adequate sanitation are crucial for poverty reduction, crucial for sustainable development and crucial for achieving any and every one of the Millennium Development Goals', Ban Ki-moon, UN Secretary General said in2007 referring to the global targets to slash poverty, illiteracy, disease and other social ills by 2015 collectively known as the Millenium DevelopmentGoals. It appears that we still have miles to go.

Note: This is an updated version of an article that was first published in  http://zellula.blogspot.co.uk/ entitled -The long term solution for controlling cholera extends beyond antibiotics and vaccines : History books provide answers.

References:

The Rime of the Ancient Mariner (originally The Rime of the Ancyent Marinere) by the Samuel Taylor Coleridge

http://www.who.int/mediacentre/factsheets/fs107/en/index.html

http://www.who.int/water_sanitation_health/hygiene/en/

http://www.who.int/water_sanitation_health/mdg1/en/index.html

http://www.un.org/waterforlifedecade/pdf/human_right_to_water_and_sanitation_media_brief.pdf

http://www.undp.org/content/undp/en/home/mdgoverview.html

http://dailypioneer.com/nation/99107-Cholera-makes-a-comeback-in-kerala.html
http://allafrica.com/stories/201401140827.html
http://www.irinnews.org/fr/report/99273/drought-contributes-to-cholera-outbreak-in-southern-angola
http://uk.reuters.com/article/2015/04/17/us-haiti-cholera-idUKKBN0N82O220150417

Miwanda B, Moore S, Muyembe JJ, Nguefack-Tsague G, Kabangwa IK, Ndjakani DY, Mutreja A, Thomson N, Thefenne H, Garnotel E, Tshapenda G, Kakongo DK, Kalambayi G, & Piarroux R (2015). Antimicrobial Drug Resistance of Vibrio cholerae, Democratic Republic of the Congo. Emerging infectious diseases, 21 (5), 847-51 PMID: 25897570 Waldman RJ, Mintz ED, & Papowitz HE (2013). The cure for cholera--improving access to safe water and sanitation. The New England journal of medicine, 368 (7), 592-4 PMID: 23301693