Introduction

Cholera is a severe diarrheal condition caused by consuming food or water tainted with harmful pathogens. It stands as a significant public health risk worldwide, particularly in less developed regions plagued by poor water and sanitation infrastructure.^1,2 Each year, UNICEF reports roughly 4 million cholera cases and around 143,000 fatalities, noting children under five as exceptionally vulnerable.³

With children having the highest incidence of cholera and contributing to almost half the death cases, it is reasonable to protect them from this disease.

Epidemiology 

In terms of geographical distribution, cholera is prevalent in the following continents:⁴

• Asian subcontinent (e.g., Indonesia, India, Bangladesh, and Vietnam)
• Africa (e.g., South Africa, Botswana, Zambia, Sierra Leone, and Nigeria)
• The Caribbean (e.g Haiti, Cuba, and the Dominican Republic)
  

Many countries do not report their cholera cases or deaths to avoid losses in tourism and exports and also to prevent global panic.⁴ 

Aetiology 

Cholera is caused by the bacterium Vibrio cholerae, discovered by the German bacteriologist Robert Koch. The name “vibrio” was based on the fact that the organism appears to vibrate when moving.¹

These bacteria are found in water contaminated by faeces from an infected person, shellfish. It is likely to occur and easily spread in places where adequate water treatment, proper sanitation, and hygiene are difficult to maintain. Vibrio cholerae is also prevalent in places where brackish rivers and coastal water are present. Thus, it is a treatable and preventable disease.⁵

Transmission

Cholera can be transmitted by:^2,5

• Ingestion of food or water contaminated with the feces of someone who has cholera
• Inadequate access to clean water
• Improper treatment of sewage
• Raw or undercooked food especially shellfish 

Risk factors 

Several factors tend to increase children's risk of cholera. They are:^1,2,4,6,7

• Inadequate sanitation
• Contaminated drinking water 
• Poor food hygiene 
• Malnutrition increases susceptibility 
• Inadequate and overcrowded places like camps in times of humanitarian crisis
• Travelling to endemic areas
• Having family members who had cholera in the past week

Symptoms and complications

The signs and symptoms of cholera in children are:⁴

• Loose watery stool in the form of water that contains uncooked rice or has been used to wash rice (commonly known as “rice-water stool”)
• The stool has a fishy odour 
• Signs of dehydration:
  • Sunken eyes 
  • Dry mouth
  • Thirst 
  • Tiredness 
  • Fatigue 
  • Vomiting

Some of the complications of cholera are:⁴

• Kidney failure 
• Shock 
• Sepsis
• Death
• Hypoglycemia 
• Hypokalemia
• Malnutrition 
• Chronic enteropathy

Diagnosis 

Cholera can be diagnosed based on symptoms and confirmed through testing.⁴

• In a laboratory setting, a stool sample or rectal swab is done and then cultured to detect the presence of the bacterium Vibrio cholerae. This is the most preferred method and requires trained personnel 
• Without a developed healthcare setting, rapid diagnostic tests (RDTs) of stool samples can be performed, and this does not require special training 

Strategies for preventing cholera 

The main goal is to control cholera and to reduce deaths, especially among children since they are part of the high-risk group.¹ Below are the ways of preventing cholera:⁸

Personal and general strategies 

• Ensure there is free access to safe and clean water.
  • In the absence of none, bottled water, properly boiled water, chlorinated, or filtered water in brushing teeth, washing, and preparing food is recommended 
  • Do not use bottled water from a broken seal or water from pipes (the supply tank might harbor the bacteria)
  • Water for household use can be treated with chlorine products, boiled, bleached, or filtered

• Hands should be washed often with soap and safe water or alcohol-based hand sanitizer
  • Before, during, and after food preparation and consuming meals 
  • After the use of the toilet 
  • After cleaning the children’s buttocks after a poop
  • After taking care of someone who has diarrhea

• The use of toilets and other improved sanitation facilities should be encouraged. Ensure to wash your hands properly after use
• Wash and cook food properly and thoroughly by boiling it, especially shellfish, or washing fruits and vegetables very clean
• Clean and disinfect toilets and surfaces including, potties contaminated with feces regularly: clean with proper disinfecting agents such as bleach to avoid spread 
• In areas where sanitation facilities are unavailable, bathe and wash clothes 30 meters away from drinking water sources 
• Safely dispose of soapy water and dirty rags used for cleaning
• Always wash children’s hands with soap and water after cleaning or disinfecting 
• Beddings or clothes in contact with diarrhea should be removed and washed using warm or hot water or a washing machine 
• Infected children should avoid swimming until their symptoms are gone
• People caring for persons with cholera should not serve food or drinks to anyone not part of their household
• Children visiting households with infected persons should avoid touching contaminated surfaces and endeavor to wash their hands thoroughly before leaving

Community involvement in reducing cholera among children 

• Community involvement is highly crucial in reducing and preventing the spread of cholera. These are:¹¹
  • The creation of health education and awareness campaigns in schools, communities, and families 
  • Action to end the use of open defecation
  • Construction of latrines in areas that lack proper sanitation facilities
  • Encouraging the use of safe water and testing and monitoring the quality of water 
  • Proper management of faecal waste
  • Increasing access to and use of handwashing facilities, especially in schools and playground areas 
  • Awareness of the importance of treatment such as the oral rehydration solution should be encouraged, and training on how to make it for household use especially if symptoms occur at night should be done
  • Referral to a clinic or hospital should be encouraged for proper treatment. Do not self-medicate
  • Involve locally trusted leaders such as religious heads in promoting the use of vaccines by getting vaccinated and sharing their experience

Vaccination

This is another way of reducing the spread of cholera. W.H.O recommends that vaccines should be given under these circumstances:²

• In areas endemic to cholera 
• During outbreaks of cholera 
• In situations of humanitarian crises where there is an increased risk of cholera

There are three pre-qualified oral (given by mouth) vaccines for cholera. They are:

• Dukoral®
• Shanchol™
• Euvichol-Plus®

Each vaccine requires at least two doses for full protection.^2,9

The table above lists the vaccines available and their recommended doses.^2,9

Treatment and management 

• Rehydration is the key approach to managing patients with cholera. An oral rehydration solution is given to replace fluid losses and restore electrolyte balance. ORS should be prepared with safe and clean water¹⁰
• Antibacterials or antibiotics help to shorten the time and severity of disease and also the transmission. This is an adjunctive therapy^10,9
• Food high in energy is recommended. This prevents malnutrition and complications such as hypoglycemia
• Breastfeeding should be encouraged for infants in addition to ORS⁹ 
• For ages under 5 years, zinc supplementation can be used to reduce the incidence of subsequent episodes of diarrhea, according to WHO⁹

FAQs

How can children be protected from cholera?

Children can be protected from cholera by ensuring they practice good hygiene, such as

• washing their hands with soap and clean water frequently, particularly before eating and after using the toilet; drinking and using safe water
• eating food that is fully cooked and hot
• peeling fruits and vegetables themselves
• avoiding street food
• being breastfed if they are infants
• receiving the appropriate vaccinations where available
• and by educating them about the importance of cleanliness to prevent disease

It’s also essential to ensure a clean water supply and proper sanitation and waste disposal systems in the community.

How can we stop people from catching cholera?

Ensure individuals have access to clean, safe drinking water. Promote proper sanitation practices, including the use of toilets and handwashing with soap. Educate the community about cholera prevention and symptoms for early detection.

Implement wastewater treatment processes to prevent contamination of water sources. Encourage the preparation and storage of food in safe and hygienic conditions. Support vaccination campaigns in regions where cholera is endemic or outbreaks are frequent.

What causes children to be susceptible to cholera?

Children are more susceptible to cholera due to several factors including their underdeveloped immune system, higher risk of malnutrition, less stomach acid which can neutralize pathogens, and a tendency to play in unhygienic conditions which may expose them to contaminated water or food sources. Additionally, they may not understand the importance of good hygiene practices and are more likely to be unaware of the risks of cholera.

Can cholera be passed from parent to child?

Cholera is not typically passed directly from parent to child through genetic inheritance. It is an infection caused by the Vibrio cholerae bacterium and is spread mostly through contaminated water and food. The primary transmission route is the fecal-oral route, mainly from ingestion of contaminated water sources or foodstuff.

Direct person-to-person transmission is rare since it would require a significant amount of bacteria to be introduced into a healthy individual's digestive system. Standard hygiene practices and cooking food properly can prevent its spread within households, including from parents to children.

What are the symptoms of cholera?

The symptoms of cholera can range from mild to severe and typically include: watery diarrhea, vomiting, rapid heart rate, loss of skin elasticity, dry mucous membranes, low blood pressure, thirst, muscle cramps, and restlessness or irritability. In severe cases, these symptoms can lead to dehydration and electrolyte imbalances, which can be life-threatening without prompt treatment.

Summary 

Cholera remains a significant threat to children worldwide due to the consumption of contaminated food and water. It is caused by Vibrio cholerae, a bacteria commonly found in water polluted by the faeces of an infected person.^1,2 Cholera is prevalent in Africa, as well as in some countries in the Caribbean and Asia.⁴

To protect children from cholera, effective measures have been implemented, including ensuring proper access to clean water, promoting good sanitation practices, and implementing vaccination programmes.⁸ These multifaceted approaches have helped to reduce the risk of contracting cholera and have improved the general well-being of children.