Recognising Early Signs Of Cholera

  • Gregorio AnselmettiBachelor of Science - BSc, Neuroscience. University of Warwick
  • Regina LopesSenior Nursing Assistant, Health and Social Care, The Open University

Overview

Cholera is an acute infection caused by the bacterium Vibrio cholerae and is commonly characterised by loss of fluids and salts (electrolytes) from the body, leading to watery stools and other symptoms. The result of this high-volume fluid loss with electrolyte imbalance can lead to further complications including death.

As it is still a major public health concern in some parts of the world, it is important to recognise the early signs of this life-threatening acute illness to prevent fatality.

This article will explore how to identify early signs of cholera as well as steps to take upon recognition of the signs and symptoms of cholera.

Understanding cholera

Cholera is an infection that happens when a person accidentally swallows food or drinks that contain Vibrio cholerae (V. cholerae) bacteria. The bacteria can infect the small intestine and can cause diarrhoea with rapid and severe dehydration that can sometimes lead to death. Although it is not commonly found in the UK, there's still a small risk of getting it while travelling elsewhere.1

Causes of cholera

Cholera is caused by the V. cholerae bacterium which is known to live in salty rivers and coastal waters. If the water isn’t properly sanitised, the bacteria can get into the domestic water system. Therefore, people using this infected water to drink, cook, and wash can become infected with the bacteria. As the bacteria grow and multiply inside the small intestines they can cause the intestine to leak fluids, thereby, leading to severe diarrhoea.1

How cholera spreads

Cholera usually doesn’t spread directly, but it can as people infected with the bacteria can further spread this disease through their faeces. So when a person eats food or drinks water that has been contaminated by the infected faeces, the bacteria also get inside them. Good hand hygiene by washing your hands regularly is very important to prevent this infection.1

Early signs and symptoms of cholera

A cholera infection can range from mild to no symptoms, but it is believed that about 10% of infected people will eventually develop severe symptoms about 12 hours to 5 days after unfortunately swallowing the bacteria.1

Some of the symptoms include:

Diarrhoea

This is the most common first sign of cholera, occurring within a day or so of becoming infected with the bacteria. 

When the bacteria infects the intestine, it secretes a toxin that attaches to the cells on the lining of the small intestine and sometimes, the toxin can also enter into the intestinal cells. 

This then affects the enzyme that controls the pump necessary for moving water and electrolytes between the intestine and the circulatory system. This pump is affected as the toxin causes it to be locked in the “on” position, causing the outflow of about one litre of body fluids per hour to leak into the intestinal tract, leading to severe fluid stools (watery diarrhoea). The watery stools contain spots of mucus that look like the water we see after rinsing rice, which is why it is sometimes called the "rice-water stools.".2

Vomiting

It is believed that the cholera bacteria can also cause gastrointestinal discomfort due to the fluids and electrolytes loss, leading to vomiting. Vomiting can last for hours and with the combination of watery diarrhoea, can cause dehydration.

Dehydration

As the bacteria infect the intestine causing the body to lose a lot of fluids (water and salts) through diarrhoea and vomiting, the person infected can easily become dehydrated if the lost fluids are not replaced soon.

Some of the signs of dehydration include 

  • Feelings of Thirst
  • Dry mouth and tongue
  • Tiredness
  • Headaches2

Rapid heart rate

In severe cases where dehydration has occurred within hours of the first symptoms of water and electrolyte loss and treatment has not been started immediately, the patient can present with hypovolemic shock which includes symptoms of decreased urine output and fast heart rate (tachycardia).2

Additional symptoms

Muscle cramps

The loss of electrolytes from the body can result in a person having electrolyte imbalances, such as hypokalemia (low potassium), hypocalcemia (low calcium), or other salts and minerals like magnesium and calcium. These electrolyte imbalances can lead to muscle cramps and weakness in the body which can become severe.3

Low blood pressure

As severe fluid loss can result in the loss of salts and electrolytes, this can lead to loss of control and regulation of blood pressure. This means the infected person can experience symptoms such as low blood pressure, pulse becoming faint, eyes becoming hollow and sunken, and skin becoming wrinkled, leading to seizures as a result of extreme dehydration.3

Identifying early signs in different populations

Children

The first signs of cholera in children can range from mild to severe diarrhoea, other symptoms that might occur in children include abdominal discomfort and vomiting. If the cholera is severe, this can lead to fever, lethargy, and seizures due to extreme dehydration. If this occurs for 2 to 7 days and without hydration, a death rate of about 50% has been reported with the rates higher in children.4

Challenges in recognising cholera in children

Cholera outbreaks are known to be more common among vulnerable communities affected by war conflicts and famines. This means the lack of safe water systems, and inadequate sanitation and hygiene make it difficult to effectively recognise the signs or eliminate the transmission of cholera, thereby increasing the rate of fatality in children from these communities.5

Elderly

The most common and life-threatening signs of V. cholerae are severe fluid loss characterised by diarrhoea, reaching as high as 1 litre per hour in adults. Elderlies who travel to endemic areas, where cholera is prevalent without taking precautions, are more prone to getting infected with cholera. Some of the symptoms specific to the elderly include low blood pressure (hypotension), rapid heart rate (tachycardia), hypovolemic shock, and metabolic acidosis

If cholera infection is left untreated it can lead to death within hours in more than 50% of infected elderly.6

Steps to take upon recognising early signs

Seek medical attention

Prompt treatment is important to prevent further complications or even death to at least less than 1%. If you develop early signs of watery stools, vomiting, or dehydration, you must seek urgent medical attention as soon as possible. 

At the emergency ward, you might be given antibiotics such as tetracycline during the first day of treatment. This is to help treat diarrhoea and reduce the further leakage of fluids from the small intestine.7

Hydration

The main treatment consists of replacing lost fluid and electrolytes with an alkaline solution of sodium chloride. The solution is made by using oral rehydration salts (ORS) which contain a measured mixture of glucose, sodium chloride, potassium chloride, and trisodium citrate. This prepackaged mixture can be purchased at your local pharmacy and can be administered by nonmedical personnel, allowing cholera to be treated even under adverse conditions.

It is also important to resume eating as soon as you can to avoid malnutrition and prevent any existing malnutrition from getting worse.7

Prevention strategies

Cholera remains a major public health issue in some parts of the world, particularly in developing countries. Cholera outbreaks generally occur when water sanitation and hygiene services are not safe for human consumption. Therefore access to clean water and hygiene education are important in preventing cholera infection.8

The use of oral vaccines is encouraged for people visiting countries where cholera is still on the rise. You should speak to your GP about the cholera vaccine if you believe that you might be at risk of being infected.

Access to clean water

Cholera prevention remains a matter of improving public health measures like proper sewage disposal and ensuring clean water for all as cholera-contaminated water is ingested by different means creating a never-ending cycle of cholera.8

Methods for ensuring clean water

This involves providing an improved or completely new water distribution system to reduce direct and indirect exposure to contaminated water.

This will include the installation of piped water supply, hand pumps, boreholes, or better distribution systems with water trucking or tankers; and, protection of water sources.

Another method is to improve the microbiological quality of drinking water at the source through regular assessment and monitoring of water quality for microbiological, chemical, and physical quality. In some countries, a system of removing or inactivating bacteria present in the water source by water treatment systems, filtration, sedimentation, chemical treatment, heat treatment, ultraviolet (UV) radiation, or flocculation has been used to achieve this.9

Sanitation

Proper disposal of waste

This involves improving or expanding the facilities for the safe management, disposal, and treatment of waste to reduce direct and indirect contact with human faeces. This involves constructing simple pit latrines or water-sealed flush toilets, piped sewer systems, and septic tanks for deprived communities or educating them on the use of a potty for the disposal of faeces.9

Hygiene practices

The promotion of hygiene practices surrounding personal, food, and hand hygiene, includes providing hygiene materials like soap, hygiene kits, handwashing stands, sinks, and other facilities. 

Some studies have also suggested creating hygiene promotion in deprived communities through house-to-house visits, community meetings, mass and social media, or other educational materials.9

Summary

Some of the common signs of cholera are diarrhoea and dehydration that if left untreated can lead to complications, such as death. Outbreaks of cholera are known to mostly occur in developing countries where sanitation and clean water systems may not exist. 

Therefore, interventions focusing on proper hygiene in conjunction with proper waste disposal and provision of safe drinking water have been proven to be effective approaches to prevent and reduce the spread of cholera infection in developed countries like the UK.

References

  1. Weil AR. Housing And Health: Editor-In-Chief Alan R. Weil highlights research articles in the February 2024 issue of Health Affairs. Health Affairs [Internet]. 2024 [cited 2024 Feb 9]; 43(2):149–149. Available from: http://www.healthaffairs.org/doi/10.1377/hlthaff.2024.00097.
  2. Ojeda Rodriguez JA, Kahwaji CI. Vibrio cholerae Infection. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 [cited 2024 Feb 10]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK526099/.
  3. Fanous M, King KC. Cholera. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 [cited 2024 Feb 10]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK470232/.
  4. Williams PCM, Berkley JA. Guidelines for the management of paediatric cholera infection: a systematic review of the evidence. Paediatr Int Child Health [Internet]. 2018 [cited 2024 Feb 10]; 38(Suppl 1):S16–31. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5972638/.
  5. Somboonwit C, Menezes LJ, Holt DA, Sinnott JT, Shapshak P. Current views and challenges on clinical cholera. Bioinformation [Internet]. 2017 [cited 2024 Feb 10]; 13(12):405–9. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5767916/.
  6. Ngwa MC, Liang S, Mbam LM, Mouhaman A, Teboh A, Brekmo K, et al. Cholera public health surveillance in the Republic of Cameroon-opportunities and challenges. Pan Afr Med J [Internet]. 2016 [cited 2024 Feb 10]; 24:222. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5075464/.
  7. Chowdhury F, Ross AG, Islam MT, McMillan NAJ, Qadri F. Diagnosis, Management, and Future Control of Cholera. Clin Microbiol Rev [Internet]. [cited 2024 Feb 10]; 35(3):e00211-21. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9491185/.
  8. Shannon K, Hast M, Azman AS, Legros D, McKay H, Lessler J. Cholera prevention and control in refugee settings: Successes and continued challenges. PLoS Negl Trop Dis [Internet]. 2019 [cited 2024 Feb 10]; 13(6):e0007347. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6586254/.
  9. Legros D. Global Cholera Epidemiology: Opportunities to Reduce the Burden of Cholera by 2030. J Infect Dis [Internet]. 2018 [cited 2024 Feb 10]; 218(Suppl 3):S137–40. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6207143/.
This content is purely informational and isn’t medical guidance. It shouldn’t replace professional medical counsel. Always consult your physician regarding treatment risks and benefits. See our editorial standards for more details.

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Omoteniola Olufon

MPharm, IP, University of Hertfordshire, England

Teni Olufon is a seasoned clinical pharmacist and independent prescriber with several years of clinical and management roles across diverse healthcare settings. With years of experience in patient and public health advocacy, she has since carved a niche for herself in the realm of contributing to writing evidence-based informations and policies to support patient care.

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