Diarrhea and Dehydration

Cholera is a disease caused by the toxin produced by Vibrio cholerae. It is an endemic infection in many parts of the world, including tropical and subtropical areas. Transmission of cholera in disaster situations most frequently involves contaminated water and increased fecal-oral spread related to environmental conditions. Vibrio cholerae can survive in water for 7 to 10 days. Contaminated food may also result in outbreaks.

It is important to identify outbreaks as early as possible and take preventive measures. Cholera is a public health emergency. The first suspected case of cholera in an area needs to be confirmed by culture, and public health authorities should be notified immediately.

Confirm the diagnosis with a qualified laboratory and determine antibiotic susceptibility. Once cholera is confirmed in an area, identification of subsequent cases can be based on clinical findings. Since diarrheal illnesses with significant dehydration are common among children, the first recognition of cholera in an area is usually based on the identification of an adult case. Suspect cholera in any adult presenting with severe profuse watery diarrhea and severe dehydration, particularly if the patient dies because of the illness.

Take measures to control the outbreak. Take action to identify milder cases in people who might not seek care. Community efforts should involve improving sanitation, educating families about personal hygiene and food safety, and ensuring a noncontaminated water supply. Occasionally household chlorination or boiling of water will be necessary.

Clinical manifestations of cholera include painless diarrhea without fever. The volume of stools can vary considerably. In severe cholera, stools have the appearance of rice water. The severe fluid loss can cause shock within the first 4 to 12 hours in untreated patients. Additional findings include anxiety, muscle cramps, weakness (related to electrolyte alterations and hypoglycemia), and altered mental status (Table 3).

From: Mandell, Douglas, Bennett. Principles and Practice of Infectious Disease. 3rd ed. New York, NY: Churchill Livingstone; 1990.

Management of Cholera

Treatment of patients with oral rehydration solution (ORS) by itself reduces the case fatality rate (CFR) to less than 1%. However, antibiotic therapy with doxycycline, tetracycline, TMP/SMX, erythromycin, chloramphenicol, or fluoroquinolones can reduce the volume and duration of diarrhea, thus helping to limit transmission (Table 4). Fluoroquinolones are indicated when there is multidrug resistance. Manage mental status alterations with glucose to correct possible hypoglycemia. Once cholera is confirmed in an area, monitor CFR to determine the adequacy/availability of rehydration therapy.

*Children >6 years