Cholera

1. Cholera Between Life and Death Fr. Scott Binet MD, MI CTF-SOS DRS Sao Paulo, Brazil - October 20, 2011

2. Cholera Between Life and Death Presentation Objectives Inform you about cholera and what the Camillians are doing to respond to the signs of the times through disaster relief Sensitize you to the suffering of those affected by man-made and natural disasters such as cholera Inspire you to get involved and dialogue amongst yourselves and with me about how we might collaborate in disaster relief

3. CholeraBetween Life and Death

4. CholeraBetween Life and Death Presentation Outline Summary of Cholera Introduction to the Camillian Task Force (CTF) A Convergence – Camillians, Disasters and Risk Disasters and Cholera - the World , Brazil Cholera – Cause, Symptoms, Treatment, Prognosis The Cholera Epidemic in Haiti Questions/Comments

5. Cholera - Summary • Cholera is an infection of the small intestine that is caused by the bacterium Vibrio cholerae. • Transmission occurs primarily when drinking water or food is contaminated by the diarrhea from an infected person or by the feces of an infected but asymptomatic person. • The main symptoms are profuse watery diarrhea and vomiting. The severity of the diarrhea and vomiting can lead to rapid dehydration and electrolyte imbalance. • Primary treatment is with oral rehydration solution (ORS) and if this is not tolerated, intravenous fluids. Antibiotics are beneficial in those with severe disease. • Worldwide it is estimated to affect 3–5 million people and causes 100,000–130,000 deaths a year as of 2010. Cholera was one of the earliest infections to be studied by epidemiological methods.

6. Responding to the Signs of the Times Camillians and Disasters

7. Camillian Task Force – A Network Ministers of the Infirm (Camillians) CTF Central SOS DRS *Missionaries of Mercy* Core Church and State Archdiocese of Miami, USA Caritas CRS Italian Episcopal Conference Missionaries of Charity ? ? Archdiocese of Port au Prince, Haiti Misericordiae

8. CTF - SOS DRS A Vision • To be Jesus’ merciful presence to the neediest of the needy who are suffering from man-made and natural disasters. • To respond globally through a community-based, Eucharist-centered, Marian-inspired disaster relief organization.

9. CTF - SOS DRS A Mission • To witness the merciful love of Christ for the poor and the sick in word, deed, and sacrament • To serve the medical, pastoral, educational and humanitarian needs of people affected by man-made and natural disasters regardless of race, religion, or ethnicity.

10. Camillian Task Force 1- [SOS DRS Office] 3 - Italy [CTF Central/Earthquake] 5 - Pakistan [Floods] 2 [Haiti - Earthquake, Cholera, Hurricane, Slum] 4 - Horn of Africa [Famine] 6 - Thailand [Floods]

11. Responding to the Signs of the Times Cholera A Convergence - Camillians, Disasters, Risk Camillians – A Family Ready to Respond

12. Responding to the Signs of the TimesCholera A Convergence - Camillians, Disasters, Risk People at Risk - Globally People are Underprepared for Disasters Urbanization Increasing Numbers of Slums Underdeveloped Social Factors Spiritual, Societal and Family Deterioration – Decreased Resilience, Man’s Inhumanity to Man Global Warming - Deteriorating Environment People Live in Risk by Necessity and By Choice Lack of Early Warning Signs and Unpredictable Weather Increasing Number of Refugees and Internally Displaced

13. The Signs of the Times People at Risk Urbanization - “ The United Nations projected that half of the world's population would live in urban areas or cities at the end of 2008” 2008 – 50%

14. The Signs of the Times People at Risk Increasing Numbers of Slums - The number of people living out their days in the squalor of a slum is almost one billion, the United Nations says - one-sixth of the world's population. By 2050, the UN says, there may be 3.5 billion slum dwellers, out of a total urban population of about six billion. Kibera Slum in Nairobi, Kenya

15. The Signs of the TimesPeople at Risk • Underdeveloped Social Factors - The earthquake in Chile was 1,000  times more powerful than that in Haiti where 230,000 people died, many more than in Chile. Social factors are much more important than geological when determining the vulnerability of people to a disaster like an earthquake . Haiti - January 12 – Presidential Palace Chile – February 27, 2010 – Pelluhue

16. The Signs of the TimesPeople at Risk Social factors include: • The economy of a country • The healthcare infrastructure • Presence of integrated emergency management system • Previous experience of handling disasters • Emergency plan • Educational level of the population • Availability of basic necessities: clean water, housing, etc. • The government – effectiveness, trustworthiness

17. The Signs of the TimesPeople at Risk People in Risk by Necessity and by Choice[:00-35; 6:15-7:10] Pakistan Floods – 2010

18. The Signs of the TimesPeople at Risk - Increasing Number of Refugees and Internally Displaced Tent City in the Slum of Solino, Port au Prince, Haiti

19. Responding to the Signs of the Times - Cholera A Convergence - Camillians and Disasters Increasing Incidence and Severity of Disasters Disaster A serious disruption of the functioning of a community or a society causing widespread human, material, economic, or environmental losses that exceed the ability of the affected community or society to cope using its own resources.

20. Disasters – Increasing in Incidence and Severity

21. Cholera • Between Life and Death • Seven Cholera Pandemics • In the past 200 hundred years, seven cholera pandemics have killed millions across the globe. • The seventh pandemic is still going on since 1961, but advancements in medical science have greatly reduced the number of people who die from it. •  3. Modern-day sewage and water treatment systems have • largely eliminated cholera from developed countries. But • it continues to be a concern in the developing world, • especially in areas ravaged by war and natural disasters • such as earthquakes and hurricanes that leave people • without access to clean drinking water.

22. Cholera • Between Life and Death Brazil and Cholera • The first epidemic in Brazil? Black Death in Brazil - 1855-1856 (Part of the 3rd Cholera Pandemic) The last epidemic in Brazil? Cholera Strikes Brazil Again - 1991-1998 (Part of the 7th Cholera Pandemic)

23. Cholera – 1st Pandemic1817-1823 • 1817 – First known pandemic of cholera originated in the Ganges River delta in India. The disease broke out near Calcutta. Hundreds of thousands died.

24. Cholera – 2nd Pandemic1829-1849 • 1829 - The 2nd pandemic starts in India and reaches Russia by 1830 before continuing into Hungary (100,000 dead), Finland, Poland, Paris (100,000 dead). • 1831 -1849 Epidemic goes from Ireland to Quebec to the US to Mexico. Hundreds of thousands die.

25. Cholera – 3nd Pandemic1852-59 • 1852 - The third pandemic, generally considered the most deadly, originated once again in India. It devastated large swaths of Asia, Europe, North and South America and Africa – mainly affecting Russia with over 1 million deaths (1,000,000). • 1854 - British physician John Snow succeeded in identifying contaminated water as the transmitter of the disease • 1860 - Deaths in India between 1817 and 1860 are estimated to have exceeded 15 million people.

26. 3rd Cholera Pandemic Black Death in Brazil - 1855-1856 • Cholera Epidemic - Black Death in Brazil - 1855-1856 • This map represents the movement of the first terrible cholera epidemic in Brazil as it spread in 1855 and 1856.  • Red indicates confirmed areas of disease.

27. Cholera – 4th Pandemic1863-1879 • 1863 - The fourth pandemic began in the Bengal region of India from which Indian Muslim pilgrims visiting Mecca spread the disease to the Middle East, Russia, Europe, Africa and North America

28. Cholera – 5th Pandemic1881- 1896 • 1881 - The fifth pandemic originated in the Bengal region of India and swept through Asia [Russia, Japan], Africa, South America and parts of France and Germany. US and Britain Spared [Quarantine] • 1892 - Waldemar Haffkine, a Ukrainian bacteriologist who worked mostly in India, developed a human vaccine for cholera.

29. Cholera – 6th Pandemic1899-1923 • 1899- The sixth pandemic killed more than 800,000 in India before moving into the Middle East, northern Africa, Russia, parts of Europe and Asia. • 1910 – 11 - The last outbreak in the United States • 1917 – An estimated 23 million people in India died of cholera between 1865 and 1917. Russian deaths during a similar time period exceeded 2 million. • 1923 - Cholera had receded from most of the world, although many cases were still present in India.

30. CholeraThe 7th Pandemic - 1961 to present • 1961 - The seventh pandemic originates in Indonesia, not India. • Vibrio Cholerae Biotype El Tor is the dominant strain/causative agent [ • El Tor first identified in El Tor, Egypt in 1905 and then again in 1937, but it does not produce an epidemic until 1961]. • El Tor is distinguished from the classic strain at a genetic level, although both are in the serogroup O1 and both contain Inaba, Ogawa and Hikojima serotypes. • El Tor is also distinguished from classic biotypes by the production of hemolysins and the fact that it can remain in the human system longer allowing for a longer carrier state. • 1971 - It ravaged populations across Asia and the Middle East, eventually reaching Africa by 1971. The 7th Pandemic - Cholera in the World 1970- 2010

31. Cholera in Brazil 1991-98 Cholera in Brazil (1991-1998) Socioeconomic Characterization of Affected Areas Cholera reappeared in Latin America in January 1991 and spread rapidly. Vibrio cholerae O1 El Tor caused the disease. Peru was the first country affected, with an explosive outbreak. The high incidence of cholera in the Peruvian rain forest area in 1991 was probably the cause of emergence of cholera in Brazil through this unexpected route. During this period in Brazil - 161,432 cases and 1,296 deaths from cholera were reported. The most severely-affected regions of the country were the North and Northeast regions, accounting, respectively, for 7.0% and 92.2% of the cases and 6.6% and 90.5% of the deaths. Both the regions presented similar case fatality rates (0.79% and 0.76% respectively). In both the regions, the most affected areas were small villages with a predominantly rural population, characterized by deprivation, low HDI ranking, poverty, high rates of infant mortality and illiteracy, and lack of sanitation . During 1991-1996, Latin America reported 1.4 million cases and nearly 10,000 deaths .

32. Cholera in Brazil 1991-98

33. During the first half of the nineteenth century, there is little evidence of major epidemic activity beyond smallpox, measles, and scarlet fever in Brazil. Much of South America appears to have been spared from the cholera and influenza pandemics that killed millions in Asia, Europe and North America. Yellow Fever ,Cholera, Small Pox, Bubonic Plague, Influenza…

34. Cholera • Between Life and Death – The Evolving 7th Pandemic • 1980s - in the early 1980s, death rates are believed to have been greater than 3 million a year. [Lancet - Cholera – 2004] • 1989 -2010 - Reported Cases - Cholera – Bar Graph – 1989-2010 • 2010 - It is estimated that cholera affects 3-5 million people worldwide, and causes 100,000-130,000 deaths a year as of 2010. [2010 WHO position paper] . This occurs mainly in the developing world. • 2010 - Number of reported cases - 317, 534 cholera cases were reported to WHO in 2010. • 2010 Number of reported deaths -7,543 deaths due to cholera were reported globally in 2010 This represents a 52% increase compared to 2009 • 2010 Reported case fatality rate - The overall case fatality rate for cholera was 2.38%

35. Cholera Cause – Organism –Etymology • Vibrio \Vib"ri*o\, noun; plural English Vibrios, from Latin expression Vibriones. [New Latin expression, from the Latin expression vibrare to vibrate, to move by undulations.]. • Cholera - The word cholera is from Greek:  χολέραkholera from χολή kholē "bile". Latin Cholera means “bilious disease”. Electron Microscopy Light Microscopy

36. CholeraCause – Organism – Groups, Strains: Biotypes and Serotypes Vibrio cholerae is a gram-negative, rod-shaped bacterium with a single, polar flagellum which renders them motile. and surface O antigens which form the basis of classifying the bacteria into more than 130 groups. Two of the groups, O1 and O139 (‘O’ for O antigen), have been known to cause epidemics of diarrhea. O1 causes the majority of outbreaks, while O139 – first identified in Bangladesh in 1992 – is confined to South-East Asia O1 strains fall into two biotypes (or biovars), called classical and El Tor, that are distinguished by their different hemolytic activity, relative resistance to the antibiotic polymyxin B, and their different susceptibilities to bacteriophage. The classical biotype is further divided into two serotypes (or serovars), based on the antisera that recognize them, and named after the place where they were first isolated: Inaba and Ogawa. Thus, any pathogenic strain of Vibrio cholerae has a name that reflects both the biotype and the serotype; for example, strain 569B has a classical biotype and the Inaba serotype.

37. Cholera Susceptibility – Societal and Individual Risk Factors Societal - Peri-urban slums Societal - Camps for IDPs or refugees Societal - Post-disaster disruption of water/sanitation Individual - Ingestion of 100,000,000 bacteria in healthy adult. Individual - Lower gastric acidity  Individual - Children two to four years of age Individual - O blood type Individual - Lower immunity (AIDS, malnourished children) Individual - Cholera workers/unprotected

38. Cholera Cause - Transmission • Transmission is primarily due to the fecal contamination of food and water due to poor sanitation. This bacterium can, however, live naturally in any environment, particularly water reservoirs.

39. Cholera – Prevention Halting Spread, Surveillance, Vaccination, Preparedness to Respond • Cholera may be prevented by halting spread (remember diagram): • Disposal and treatment (fecal waste/contaminated materials) • Sterilization with bleach/hot water of contaminated materials • Sterilization of hands (antimicrobial soap, water); • Antibacterial treatment of sewage before it enters water supply • Post warnings about possible cholera contamination around contaminated water sources with directions on how to decontaminate the water (boiling, chlorination etc.) • Water purification: Water used for drinking, washing, or cooking should be sterilized by either boiling, chlorination, ozone water treatment, ultraviolet light sterilization or antimicrobial filtration. • Cholera Prevention - Animated Video

40. Cholera – Prevention Halting Spread, Surveillance, Vaccination, Preparedness to Respond Surveillance - Prompt reporting allows for containing epidemics Surveillance - Cholera is seasonal in many endemic countries (rainy) Vaccine - Is additional control in cholera-endemic countries Vaccine - High-risk such as 2-4 year olds, pregnant, HIV-infected, healthcare workers. Vaccine - Pre-emptive vaccination should be considered Vaccine - Two types of safe and effective oral vaccines that are whole-cell killed, one with a recombinant B-sub unit (Dukoral), the other without (Shanchol). Both have sustained protection of over 50% lasting for two years in endemic settings. Vaccine – Dukoral is WHO prequalified and licensed in over 60 countries. Dukoral has been shown to provide short-term protection of 85–90% against V. cholerae O1 among all age groups at 4–6 months following immunization. Vaccine – Shanchol provides longer-term protection against V. cholerae O1 and O139 in children under five years of age. Vaccine - Both vaccines are administered in 2 doses given between 7 days and 6 weeks apart. Dukoral is given in 150 ml of safe water. Vaccine – Immunization should be used in conjunction with the usually recommended control measures.

41. Cholera – Mechanism of Infection • Vibrio cholera bacteria are ingested and survive the acidity of the stomach. • The bacteria exit into the small intestine, produce protein flagellin to make flagella, Flagella that rotate allow the bacteria to propel themselves through the mucus of the small intestine. • Upon reaching the intestinal wall, V. cholerae stop producing flagellin and start producing the toxic proteins that give the infected person a watery diarrhea. • The cholera toxin (CTX or CT) is an oligomeric complex made up of protein subunits. Upon binding, the complex is taken into the cell via receptor-mediated endocytosis. This in turn leads to secretion of H2O, Na+, K+, Cl−, and HCO3− into the lumen of the small intestine and rapid dehydration. • The chloride and sodium ions create a salt-water environment in the small intestines, which through osmosis can pull up to six liters of water per day through the intestinal cells, creating the massive amounts of diarrhea. • The diarrhea carries the multiplying new generations of V. cholerae bacteria out into the drinking water of the next host if proper sanitation measures are not in place.

42. CholeraDiagnosis and Treatment “Rice Water Stools”

43. Cholera Diagnosis and Treatment • In epidemic situations, history and doing a brief examination are the basis for a clinical diagnosis. • Treatment is usually started without or before confirmation by laboratory analysis. • For laboratory analysis, stool and swab samples of diarrhea collected in the acute stage of the disease, before antibiotics have been administered, are the most useful specimens. • A rapid dip-stick test is available to determine the presence of V. cholerae.  In those that test positive, further testing can be done to determine antibiotic resistance. • A number of special media have been employed for the cultivation for cholera vibrios: Enrichment media and Plating media. • Direct microscopy of stool is not recommended, as it is unreliable. Microscopy is preferred only after enrichment, as this process reveals the characteristic motility of Vibrio and its inhibition by appropriate antisera. • Diagnosis can be confirmed, as well, as serotyping done by agglutination with specific sera. If an epidemic of cholera is suspected, the most common causative agent is Vibrio cholerae O1. If V. choleraeserogroup O1 is not isolated, the laboratory should test for V. cholerae O139.

44. Cholera Diagnosis and TreatmentFirst steps for Managing an Outbreak of Acute Diarrhea – The First Days THE FIRST TWO QUESTIONS ARE: 1. Is this the beginning of an outbreak? 2. Is the patient suffering from cholera or shigella? A. Is this the beginning of an outbreak? - You might be facing an outbreak very soon if you have seen an unusual number of acute diarrheal cases this week and the patients have the following points in common: 1. They have similar clinical symptoms (watery or bloody diarrhea) 2. They are living in the same area or location 3. They have eaten the same food (at a burial ceremony for example) 4. They are sharing the same water source 5. There is an outbreak in the neighboring community 6. You have seen an adult suffering from acute watery diarrhea with severe dehydration and vomiting 7. If you have some statistical information from previous years or weeks verify if the actual increase of cases is unusual over the same period of time.

45. Cholera Diagnosis and TreatmentFirst steps for Managing an Outbreak of Acute Diarrhea – The First Days 2. Is the patient suffering from cholera or shigella? - If so, it is an emergency Cholera = acute watery diarrhea Shigella dysentery = acute bloody diarrhea • Both transmitted by contaminated water, unsafe food, dirty hands and vomit or stools of sick people. • Cholera and shigella produce outbreaks which represent an immediate threat to the community. • Symptoms/Signs differentiate them (stool [amount/character]; fever; abdominal cramps; vomiting; rectal pain] • Establish clinical diagnosis for patient, family members with acute diarrhea, take stool samples/send for analysis or refrigeration; Don’t wait for lab to start treatment; estimate supplies needed; protect community; collect patient data

46. CholeraDiagnosis and TreatmentFirst steps for Managing an Outbreak of Acute Diarrhea – The First Days What are the next 3 questions to ask if you suspect an outbreak? ■ Who do I inform and ask for help from? ■ How do I protect the community? ■ How do I treat the patients? What 3 things not to forget? 1. PROTECT YOURSELF FROM CONTAMINATION ■ Wash your hands with soap before and after taking care of the patient ■ Cut your nails 2. ISOLATE CHOLERA PATIENTS ■ Stools, vomit and soiled clothes of patients are highly contagious ■ Latrines and patients’ buckets need to be washed and disinfected with chlorine ■ Cholera patients have to be in a special ward, isolated from other patients 3. CONTINUOUS PROVISION OF NUTRITIOUS FOOD is important for all patients, especially for those with shigella dysentery ■ Provide frequent small meals with known foods during the first 2 days ■ Provide food as soon as the patient is able to take it ■ Breastfeeding of infants and young children should continue

47. CholeraDiagnosis and TreatmentFirst steps for Managing an Outbreak of Acute Diarrhea – The First Days Check the supplies you have and record available quantities ➥ IV fluids (Ringer Lactate is the best) ➥ Drips ➥ Nasogastric tubes ➥ Oral Rehydration Salt (ORS) ➥ Antibiotics (see Table 2) ➥ Soap ➥ Chlorine or bleaching powder ➥ Rectal swabs and transport medium (Cary Blair or TCBS) for stool samples ➥ Safe water is needed to rehydrate patients and to wash

48. CholeraDiagnosis and TreatmentFirst steps for Managing an Outbreak of Acute Diarrhea – The First Days PROTECT THE COMMUNITY: Stool and vomit are highly contagious ■ Isolate the severe cases ■ Provide information on how to avoid cholera through simple messages and on the outbreak ■ Disinfect water sources with chlorine ■ Promote water disinfection at home using chlorine ■ Avoid gatherings PRECAUTIONS FOR FUNERALS ■ Disinfect corpses with chlorine solution (2%) ■ Fill mouth and anus with cotton wool soaked with chlorine solution ■ Wash hands with soap after touching the corpse ■ Disinfect the clothing and bedding of the deceased by stirring them in boiling water or by drying them thoroughly in the sun GIVE SIMPLE MESSAGES TO AVOID CHOLERA/SHIGELLA ■ Wash your hands with soap: after using toilets and latrines; before preparing food; before eating ■ Boil or disinfect the water with chlorine solution ■ Only eat freshly cooked food ■ Do not defecate near the water sources ■ Use latrines and keep them clean In case of acute diarrhea ■ Start oral rehydration with ORS before going to the health centre ■ Go to the health centre as soon as possible

49. CholeraDiagnosis and TreatmentFirst steps for Managing an Outbreak of Acute Diarrhea – The First Days Summary of the treatment • Rehydrate with ORS or IV solution depending on the severity • Maintain hydration and monitor the hydration status • Give antibiotics for severe cholera cases and for shigella cases

50. CholeraDiagnosis and TreatmentFirst steps for Managing an Outbreak of Acute Diarrhea – The First Days BOX 1. HOW TO PREPARE HOME-MADE ORS SOLUTION • If ORS sachets are available: dilute 1 sachet in 1 liter of safe water • Otherwise: Add to 1 liter of safe water: — Salt 1/2 small spoon (3.5 grams) — Sugar 4 big spoons (40 grams) And try to compensate for loss of potassium - for example, eat bananas or drink green coconut water