One Nurse At A Time modules are intended to help nurses understand disease processes that are uncommon in our work practices at home. They are intended to be practical guides and not exhaustive dissertations. Education is a dynamic, ongoing process. We value your input and comments on the content of this module. Please feel free to write to OneNurseAtATime@gmail.com.
It was a warm, humid evening in the far western corner of Ethiopia butted up against Sudan. I sat at my computer with dusk approaching when the doctor excitedly interrupted, “We’ve got cholera!” Tired from long days of work, I knew we had to mobilize immediately due to the seriousness of this disease. Cholera outbreaks aren’t new but our medical team was. Fortunately, we were prepared with the supplies and guidelines to respond quickly and appropriately.
Cholera is dramatic. Death can occur extremely rapidly even in healthy young adults. Headlines scare us: 200,000 cases with 3000 deaths in post-earthquake Haiti; Cameroon outbreak spreading to Chad and Nigeria; Bangladesh; Angola; Mozambique. Some places have massive outbreaks and others only a few scattered cases. It’s a confusing picture of a disease we don’t experience in the developed world.
So what is cholera and as a nurse, how do I deal with it?
Cholera is a diarrheal illness caused by the bacteria Vibrio cholerae. Contaminated water and food are the vehicles of transmission. Stomach acid kills most of these bacteria, but if conditions are right, the bacteria get into the small intestine where they produce an enterotoxin that creates extreme watery pale yellow diarrhea with chunks of white. “Rice water diarrhea” is the hallmark sign of cholera. Picture chicken with rice soup. The white “rice” chunks are intestinal lining sloughing off!
Treatment is fluid fluid fluid. And then more fluid.
This module will guide you through how to prevent the disease, how to recognize, diagnose and treat it. Hopefully the information will leave you more confident than I was when I heard, “We’ve got cholera!”
MORE ABOUT V. CHOLERAE
The Vibrio cholerae bacterium loves salty and alkaline environments. It is killed by acid (stomach acid, chlorine) and high temperatures (boiling). It lives in human GI tracts, fish, shellfish and aquatic plants. Transmission in the developed world tends to be from eating contaminated fish, shellfish and aquatic plants. Transmission in the developing world tends to be from water contaminated with human fecal matter carrying the bacteria.
The healthy human body can withstand a significant amount of cholera bacteria without showing any ill effects. But a “dose” of 100,000 bacteria (much less than 1 ml of infected fluid) usually will begin the cascade of symptoms that can rapidly kill. It takes usually 2 – 3 days to become symptomatic after ingesting an adequate amount of V. cholerae. The bacteria itself doesn’t infect or invade the body and doesn’t cause a systemic infection. The drastic symptoms are from the toxins produced. Young children are quite susceptible and for some unknown reason, people with type O blood.
Cholera outbreaks are normally seasonal – at the end of the dry season and beginning of the rainy season. As the dry season draws to a close, existing water levels have dropped and water has concentrated, usually becoming more salinized and alkaline. People congregate around scarcer sources of water, increasing the risk of contamination and transmission. Rain begins, falls on hard-packed earth, collects feces and runs off into rivers and wells and pools, carrying the cholera bacteria to its ideal petri dish – salty, alkali water.
Now, here comes a delicate discussion. Many developing countries do not have sanitary waste facilities. Moreover, often defecation takes place in the open in “shitting fields,” or by the side of the road, or in designated areas on the outskirts of a village. Often, those defecation areas are near water sources. Slow moving rivers are for washing, bathing, watering cattle, washing vehicles as well as drinking water.Even good septic systems or latrines can overflow during heavy rains with seepage going into wells and rivers. It’s not hard to imagine transmission of the cholera bacteria to a large portion of the population in these situations.
Remember, the human body can host a small amount of cholera bacteria without showing symptoms. People can be asymptomatic carriers. They will shed the bacteria in their stool, but remain healthy. It’s imperative to know and understand that even after being “cured,” a patient will continue to shed bacteria for weeks.
The Centers for Disease Control and World Health Organization have never supported a Cholera vaccine shot (parenteral) due to its low protective efficacy and the high occurrence of severe adverse reactions. However, a new oral vaccine (OCV) is available for travelers age two and older which is safe and effective, given in two doses two weeks apart. In the past few years this oral vaccine has been used in mass vaccination campaigns in select locales. It is an additional tool and is not meant to replace standard control measures such as community education, clean water, proper sanitation and good epidemiological surveillance/early warning systems.
The oral vaccine is typically given in population “rings” to prevent spread beyond the boundaries of the outbreak. Mass vaccinations campaigns are costly, require high levels of coordination, logistics, time and are man-power intensive. Additionally, the benefit of vaccines has a significant lag time until effective protection is achieved.
Water sources are not routinely tested for bacteria. Testing is too expensive, and not readily available. If the water is turbid, you can assume contamination but cannot prove there is cholera in the water. Turbid water can be filtered, then boiled, then chlorinated. But this multistep process is laborious and rarely practiced in the developing world.
Imagine, the minimum daily water requirement is 15 – 20 liters/person/day. That’s 5 gallons of water for every member of the household. Rarely is there running water in individual homes. Women have to carry, filter, boil, chlorinate and store water for daily use. Mother, father and 4 children = 30 gallons of water per day!
It’s easy to say, “Boil water for at least 10 minutes.” Remember, in most rural areas of developing countries, cooking is done over wood or charcoal fires. Women have to cut and carry firewood or pay for charcoal. Unless they have the means and the understanding of the rationale for “boil for 10 minutes” you can be sure it won’t happen.
Water treatment with chlorine is an effective preventative measure for clean water sources, for example at an area hand pump/well.
There are chlorine tabs to drop into water containers (a process called “bucket chlorination”). However, many rural populations access water from shallow hand-dug wells in a dry riverbed or from the slow moving curve in a river. Water gathered at these sources has a high concentration of organic matter which “binds up” the chlorine, leaving none to kill the V. cholerae. Turbid water will need to be filtered prior to chlorinating.
Hygiene practices can also be a challenge. The simple concept (for us) of “wash your hands after going to the toilet and before preparing food” is not so simple in low resource settings. Soap may not be readily available or costs money to purchase. You may be able to help break the cycle by providing hand-wash stations, soap, clean containers to store clean water, etc. If you have the means available, the ideal locations for hand-wash stations are near dedicated toileting areas and communal cooking locations.
Usually a refillable container (such as a covered garbage can or metal drum) can be fitted with a tap toward the bottom. Tie a bar of soap on a string to hang on the tap.
Another important mode of transmission is at funerals. There are many deaths initially in a cholera outbreak. Often there is a feast or wake (think of unsanitary preparation, communal eating/drinking, lack of hand washing, reused/unwashed utensils, etc.). The corpse is also a vector as V choleraebacteria are shed from all orifices. Cultural and societal practices of washing the corpse must be prevented (the persons who are washing and their clothing become contaminated as well as the water used for washing). Bodies should be strictly prepared immediately upon death using 2% chlorine-soaked cotton or other absorbent material placed in every orifice (mouth, nose and anus). The body is then wrapped
in leak-proof heavy plastic sheeting and buried immediately the same day. You will need community leaders to help people understand the need for interrupting cultural practices during an outbreak.
Funerals can also bring people to contaminated areas from a distance. After the gathering, they may carry the bacteria to their previously uncontaminated home, spreading the disease. In order to effect change in these practices, you will have to talk with religious and community leaders.
Flies can theoretically be vectors, so care should be taken to minimize their numbers on food with covers, area spraying, etc.
DIAGNOSING: HOW DO I KNOW IT’S CHOLERA AND NOT “JUST” DIARRHEA?
- You will not find one isolated case. You may see the first patient present to you with suspicious symptoms, but soon afterwards, there will be more and more.
- Cholera diarrhea is painless – no abdominal cramps, no fever. Cholera diarrhea literally runs out of the person like a faucet. In cholera treatment centers, special cots are used/constructed of heavy plastic with a 4 to 6 inch hole cut in the center. A bucket with chlorine is placed underneath to collect the liters and liters of diarrhea produced – even up to 20 liters per day!
- Vomiting may or may not occur with cholera.
- Dehydration occurs very rapidly with cholera. In fact, right before your eyes.
- “Normal” diarrhea is brown and smelly. Cholera diarrhea is clear to light yellow (remember chicken with rice soup) and odorless.
If you suspect cholera, obviously treat your patients, but do not try to manage this all by yourself. Cholera is an emergency. CALL FOR HELP! It is highly contagious. Do not wait for confirmation to begin isolation of patients and treatment (discussed below). In an outbreak, ANY patient with diarrhea and vomiting has cholera until proven otherwise.
Report your findings immediately to your organization, the Ministry of Health, other medical organizations in the area. World Health Organization and ministries of health are very concerned about cholera and will be on the alert. WHO prepositions treatment kits in endemic areas. Interventions must start immediately – most deaths in a cholera outbreak are in the first few days before the cavalry arrives. The Ministry of Health or WHO will decide on a case definition which will not change during the outbreak. The usual case definition is: A patient with 3 or more liquid stools in the past 24 hours with or without vomiting.
There are rapid tests that can be used in the field to confirm cholera. Usually only a few samples are obtained – once half a dozen are confirmed, there is no need to continue with rapid tests. WHO or Centers for Disease Control may obtain samples for sero-typing, but that is not your concern at this point. What you can do is obtain information from the patients and start a line list (spread sheet):
Date of birth (or if people don’t use birthdates, age is acceptable)
Date of onset of symptoms
“Address” or location where the person lives in order to identify water sources and close contacts
LOGISTIC SUPPORT. As nurses at home, we normally don’t become involved “behind the scenes,” but in a cholera outbreak, it’s all hands on deck. You need to know the logistical side as well as medical when dealing with an outbreak. No fair saying, “I’m just a nurse!”
Much of cholera management is logistics:
- Disposal of contaminated waste and water.
- Construction of special beds.
- Management of cleaning protocols and personnel.
- Mixing different concentrations of chlorine solutions for hand washing and cleaning.
- Providing food for caretakers and staff.
- #1 is chlorine. Regular bleach will serve the purpose if hypochlorite is not available.
- Plastic buckets for collection of diarrhea (one under every bed) and for cleaning.
- Smaller plastic buckets with lids for collection of vomit (one at every bedside)
- Cholera beds: a rectangular frame with plastic/washable cover and a center hole
- Plastic containers for hand wash stations
Logistic Human Resources
- Cleaners are indispensable. They will be working day and night mopping floors with chlorinated water, cleaning spills of vomit and diarrhea, emptying and replenishing chlorinated buckets and containers for diarrhea and vomiting.
- “Traffic control” personnel enforce isolation and prevent contamination. Every person entering or leaving the contamination area must step with both feet into a chlorine foot bath to prevent transmission of bacteria.
- Registrars keep good records of all cases.
- ORS (Oral Rehydration Solution) station attendants – these do not need to be medical people but must follow strict guidelines for oral fluid resuscitation in potentially large numbers of patients.
ASSESSING AND TREATING DEHYDRATION
An important role for you as a nurse is to evaluate the patient for degree of dehydration. Treatment for dehydration is 1. Fluids. 2. Fluids. 3. Fluids
Treatment is fluids, not antibiotics. With adequate, aggressive fluid resuscitation, antibiotics like Doxycycline may be of some benefit in terms of reducing the severity of the disease and shed of bacteria in stool, but are difficult to manage in a large outbreak (remember 200,000 cases in Haiti!). Azithromycin is the first-line antibiotic for children and pregnant women. Overuse in parts of the world has caused resistance to antibiotics. Antibiotics should be considered for hospitalized patients to reduce stool volume and duration of diarrhea, but should not be used prophylactically during cholera outbreaks. When available, 10 – 20 mg zinc (oral, usually melt-in-the-mouth tablets) should be added for treatment of Cholera in children to reduce duration and severity of diarrhea. Of note, zinc can be used for any source of diarrhea in children.
Outpatient vs Inpatient treatment: Not everyone with cholera diarrhea needs inpatient treatment. The goal is to manage as many people as possible in the outpatient setting. Most people, children and adults, can be treated with Oral Rehydrating Solution (ORS) as outpatients. ORS comes in small bags of powder to mix in clean water to give sugar and electrolytes to replace what is lost in diarrhea. If you don’t have prepackaged ORS, you can make an acceptable substitute with one liter of CLEAN water plus 6 – 8 teaspoons of sugar and half a teaspoon of salt. About 25% of cholera patients will need aggressive inpatient IV resuscitation, with an average length of stay of 3 days.
Treat as OUTPATIENT if:
No to mild or moderate vomiting. Give small frequent amounts of ORS under observation. If the patient can keep up his/her fluid balance orally, continue to treat as an outpatient.
Treat as INPATIENT if:
Severe dehydration or uncontrollable vomiting, admit immediately for IV fluids. Do not delay – this patient can go into hypovolemic shock in minutes.
There are 3 levels of dehydration with appropriate treatment plans:
Patient is alert, eyes are normal, makes tears, mouth and tongue are moist, drinks normally, skin pinch goes back quickly. Use Treatment Plan A – Oral hydration for patients without dehydration.
Mild to Moderate Dehydration:
Patient is restless and irritable, eyes are sunken, does not make tears, mouth and tongue are dry, thirsty and drinks eagerly, skin pinch goes back slowly. Use Treatment Plan B – oral rehydration for patients with mild to moderate dehydration.
Patient is lethargic, unconscious, floppy. The eyes are sunken and eyeballs are dry, does not make tears. Mouth and tongue are very dry. Drinks poorly or is unable to drink at all. Skin pinch goes back very slowly. Use Treatment Plan C – IV rehydration for patients with severe dehydration.
PLAN A – Maintenance of hydration in patients who show no signs of dehydration
Patient should receive ORS under observation until you are sure he/she is able to continue drinking appropriately at home. Give enough ORS packets to the caretaker for 2 days and instruct on preparation (in clean container, with clean water, and discard the excess after 24 hrs).
- Less than 24 months of age, drink 50 – 100 ml ORS after each loose stool
- 2 – 9 years, drink 100 – 200 ml ORS after each loose stool
- 10 yrs and older, drink as much as desired after each loose stool.
Instruct to return if condition worsens, vomiting becomes severe, fever or blood in stools.
PLAN B – Rehydration for mild to moderate dehydration. Patient should receive the following amount of ORS in the first FOUR hours:
- Less than 4 months and under 5 kg : 200 – 400 ml or 1 – 2 cups
- 4 – 11 months ( 5 – 7.9 kg) : 400 – 600 ml or 2 – 3 cups
- 12 – 23 months (8 – 10.9 kg) : 600 – 800 ml or 3 – 4 cups
- 2 – 4 years (11 – 15.9 kg) : 800 – 1200 ml or 4 – 6 cups
- 5 – 14 years (16 – 29.9 kg) : 1200 – 2200 ml or 6 – 11 cups
- 15 years and older (30 kg or more) : 2200 – 4000 ml or 11 – 20 cups
If the patient vomits, wait 10 minutes and try again slowly.
Obviously, this individual will need a caretaker to assist with fluid administration and a tally sheet for amount consumed per hour. The tally sheet should also count number of stools and vomiting episodes (not necessary to count urine output).
Reassess for dehydration every 2 hours. If after 4 hours, if the patient no longer shows signs of dehydration, move to Plan A. If the patient continues to show signs of dehydration after 4 hours, repeat Plan B for 4 more hours.
Instruct to return if condition worsens, vomiting becomes severe, fever or blood in stools.
At any time, if patient shows signs of severe dehydration or clinically worsens, move to plan C immediately.
PLAN C – IV rehydration for patients with severe dehydration.
The goal is to restore hydration in 3 – 6 hours. Ringers Lactate (or “Hartman’s Solution”) is the fluid of choice because of additional electrolytes. If available, use 500 ml bottles for children. You may find different presentations of IV containers and tubing than what you’re used to at home. Tubing typically is unvented. However, IV solutions may be in glass or hard plastic bottles. Vent a glass bottle with a 19g (or any size you may have available) needle stuck into the rubber stopper where the tubing plugs in. Vent a hard plastic bottle with a needle stuck into the top. If you don’t vent these bottles, the IV will stop partway through.
- Children less than 1 year – give 30 ml/kg in the first hour, then 15 ml/kg/hr.
- Children 1 – 14 yrs – give 30 ml/kg in the first 30 minutes, then 30 ml/kg/hr.
- 15 and older – give 1 liter over 15 minutes. Typical adult cholera patients will require 8 liters of IV fluid and 10 liters of ORS for a course of treatment.
If improvement in condition after the first liter, give a second liter over 45 minutes and every 2 – 5 hours adjusted to meet patient response.
If no improvement in condition after the first liter, give a second liter over 15 minutes. Continue 1 liter every 2 – 5 hours adjusted to meet patient response.
Remember, cholera patients rapidly dehydrate – literally right before your eyes. Obtain IV access without delay. If you are unable to access a peripheral vein in an adult or child, put in a Intraosseous (IO). If you don’t have an IO needle, you can use a 19 g injection needle and insert directly into the upper anterior tibia. Secure the 19 g and attach the tubing directly to the hub. Once the patient is somewhat rehydrated, more peripheral veins will appear and the site can be changed.
If signs of respiratory distress occur, labored breathing, eyelid or facial swelling – the patient may be fluid overloaded. Monitor this patient carefully to balance fluid needs and retention. Sit or prop the patient upright and try to hang legs over the side of the bed. Use oxygen if you have it available. Administer furosemide 1 mg/kg IV in children and 40 mg IV stat dose in adults. May repeat the same dose after 15 minutes if no improvement.
Once the patient’s fluid balance is restored with IV fluid and vomiting has stopped, begin ORS orally. Once the patient is able to drink enough to maintain hydration and has had no liquid stools for 24 hours, you can discharge home (usually about 3 days). Remember, these patients still shed the bacteria in their stool and remain infectious for weeks after symptoms have resolved. Encourage hand washing with soap and water. Occasionally, the patient will relapse and require treatment again.
PRACTICAL TIPS AND COMMENTS:
Do not bother to take blood pressure – adjust your therapy according to patient response. A strong pulse is your best guide. (Blood pressure cuffs can become contaminated and move from patient to patient. Also, your assistants may not know how to take a blood pressure, but can be shown how to feel for a radial pulse.)
Check patient every 15 minutes for the first hour. If improving, check at least every 2 hours.
Begin to give ORS in addition to IV fluids as soon as the patient can drink.
If treated aggressively, death rates are low. If not, mortality can easily reach 50 – 60%.
Pregnant women have increased rate of miscarriage and stillbirth especially with severe dehydration in the third trimester. Treatment remains the same.
Children and the elderly are at increased risk of volume overload – be extra cautious.
ORS will not cause fluid overload. IV fluids may.
Children can quickly become hypoglycemic, so give ORS or IV glucose (1 mg/kg of Dextrose 50%) early in the treatment process.
If the decision to give antibiotics is made, give after adequate IV rehydration. Decision making will be by the country Ministry of Health in association with WHO.
Assessment of dehydration in severely malnourished children is difficult. (See our module on Malnutrition)
Resume feeding with normal food when vomiting stops.
Children should continue to breastfeed.
Governments are reluctant to declare they have cholera. The common phrasing is “Acute Watery Diarrhea” or simply “AWD.” The declaration of Cholera has grave economic impact. There is usually a drastic drop in tourism. Products for export are no longer desired by the rest of the world because they might be contaminated. Ships are blocked from entering subsequent ports if they have travelled to a Cholera outbreak country. And that government, in essence, has to openly admit to the world they have inadequate water and sanitation infrastructure and can’t provide appropriate healthcare for their citizens. You may find, due to the above reasons, the Ministry of Health or other government agencies may try to censor your work or reporting.
Cholera is a true emergency that requires clear thinking, logistical support and appropriate supplies. Now is not the time to panic! You will need to rely on your most basic nursing skills to treat these patients. By reacting calmly and quickly, you can literally save thousands of lives.