cholera

Mareike Müller is a freelance writer in the medical department and assistant doctor for neurosurgery in Düsseldorf. She studied human medicine in Magdeburg and gained a lot of practical medical experience during her stays abroad on four different continents.

More about the experts All content is checked by medical journalists.

Cholera is a serious infectious disease that is associated with massive diarrhea. It is caused by the bacterium Vibrio cholerae. Cholera is particularly prevalent in areas with poor hygiene. Mostly malnourished and weakened people are affected. If left untreated, the infection is often fatal. Here you can read everything you need to know about cholera.

ICD codes for this disease: ICD codes are internationally recognized codes for medical diagnoses. They can be found, for example, in doctor's letters or on certificates of incapacity for work. A00

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Cholera is an infectious disease caused by the bacterium Vibrio cholerae and is associated with severe diarrhea. It happens that patients also vomit bile. This is how the disease got its name: "Cholera" means "flow of yellow bile" in German.

The pathogens live worldwide in coastal waters and brackish water at a temperature of over ten degrees Celsius. However, the disease itself is only common in Asia, Africa, and South America. It mainly affects regions with poor drinking water supplies and inadequate hygienic conditions - for example refugee areas. In total, around six million cholera cases occur worldwide every year. The disease does not normally appear in Germany. It is very rare for travelers to introduce the disease from, for example, Southeast Asia.

Cholera has been known since the beginning of history. At first it occurred exclusively endemically in the Ganges Delta. An endemic area is a region in which a pathogen is permanently present and cannot be removed. From the 19th century, cholera spread worldwide in several pandemics. A pandemic is the frequent occurrence of a disease in the same period, but in different places.

There are different types of cholera bacteria. The most important are the classic Vibrio cholerae and the Vibrio cholerae of the El Tor type. The El Tor type is responsible for the last pandemic since 1960. It is considered more environmentally stable, but less dangerous than the classic type.

According to the definition of the World Health Organization (WHO), cholera is one of the quarantine diseases alongside plague, smallpox and yellow fever.A public health officer can therefore quarantine patients until there is no longer any risk of them infecting other people. Not only the disease itself, but also the suspicion of cholera must be reported.

Cholera: symptoms

The cholera symptoms usually start suddenly. In the beginning, they are very similar to other diarrheal diseases. Cholera begins with:

• watery diarrhea
• Vomiting of watery stomach contents, blood and bile
• stomach pain

The diarrhea is typically cloudy, increasingly watery, and contains flakes of milky white mucus. Hence it is called the rice water chair. Due to the massive loss of fluid caused by diarrhea - up to 20 liters per day - the body can become life-threatening and dry out. The loss of water and salt also causes the following cholera symptoms:

• "Vox cholerica" ​​(high, hoarse voice)
• Muscle spasms
• Sunken face, sunken eyes, sunken belly
• weak pulse in extremities
• low blood pressure
• fast beating heart (tachycardia)
• cold arms and legs without hydration

In the course of the disease, urinary retention may initially occur. This can lead to kidney failure, impaired consciousness and circulatory failure, which can be fatal.

Cholera: causes and risk factors

Cholera is caused by the bacterium Vibrio cholerae. It enters the human gastrointestinal tract via the mouth. There it must first pass through the stomach. Because it is acid sensitive, large amounts of the bacteria are killed by the stomach acid. So many pathogens are needed for an outbreak of disease. Only in this way is there a chance that some of them will survive the gastric passage and then multiply in the small intestine and attach to the mucous membrane. In people who produce less stomach acid, even a smaller amount of bacteria can lead to an outbreak of disease, as fewer pathogens are killed in the stomach.

If the bacteria are on the mucous membrane of the small intestine, they produce a poison, the so-called cholera toxin. It penetrates the mucous membrane and causes an enormous amount of water and salts (electrolytes) to be released into the interior of the intestine and then excreted as diarrhea.

Risk factors

The cholera pathogen is one of the water germs and is accordingly transmitted to humans via contaminated drinking water or contaminated seafood. A fecal-oral infection from person to person is also possible. This mainly happens with poor hand hygiene. The bacteria can be transmitted by cholera sufferers. There are also people who excrete the pathogen without becoming ill themselves.

The disease occurs more frequently in areas with a high population density and poor hygienic conditions, such as in refugee areas. It is considered to be the "disease of the poor" because particularly malnourished, weakened people suffering from another underlying disease get cholera. In addition, young children and old people in particular get sick.

Cholera: examinations and diagnosis

If cholera is suspected, your doctor will first ask you in detail about your medical history (anamnesis). He will ask you the following questions, for example:

• Have you been abroad recently?
• Did you drink tap water or eat raw foods such as lettuce there?
• When did the symptoms first appear?
• How many times a day do you have diarrhea?
• Can you describe the diarrhea?
• Are you vomiting or having a stomach ache?

This is followed by the physical examination. The doctor will feel your pulse and hear and feel your stomach.

The diagnosis of cholera is confirmed with a stool sample. This is examined for the pathogen in the laboratory, either under the microscope or after the bacteria have been grown in a culture. In addition, vomit and small intestinal secretions (duodenal juice) are suitable as sample material.

Cholera must be differentiated from other diarrheal diseases that are triggered, for example, by salmonella or shigella. Especially with mild courses, this is not always possible due to the similar symptoms. The full picture of cholera must also be differentiated from infection with the bacterium Clostridium difficile, other food poisoning or a tumor of the pancreas (VIPoma).

Cholera: treatment

If cholera is suspected, therapy must be started immediately in a hospital! In this way, the course and outcome of the disease can be positively influenced. Most important is the symptomatic treatment of cholera. This means that the heavy loss of fluid and salt must be replaced. This works best with glucose-containing liquids that are given to the patient to drink. It is also possible to give the patient fluids and salts (electrolytes) as an infusion into the vein.

Antibiotics only come second in the treatment of cholera. These are active ingredients that kill bacteria or prevent them from multiplying. In the case of cholera, classes of antibiotics such as quinolones or macrolides are used.

You can do something about the massive loss of fluid and salt at home: give the sick person plenty of cola and sweet tea to drink and offer them pretzel sticks. However, treatment in the hospital must be carried out as quickly as possible!

Cholera: prevention

The best way to prevent diarrhea is through good food and drinking water hygiene. However, this is often not guaranteed, especially in very poor countries, crisis areas and refugee camps. As a traveler to cholera areas, you should:

• only drink boiled water or mineral water from sealed bottles.
• do not use tap water to brush your teeth or wash dishes.
• do without ice cubes in your drink.
• do not consume raw foods such as salads.
• Disinfect your hands regularly, especially before eating.

The normal tourist has little risk of contracting cholera. The hygienic conditions in hotels are often sufficient.

Cholera vaccination

There is a possibility of vaccination against cholera. This is not generally recommended as it only protects against illness in 60 percent of cases and is only effective for up to six months. There are two different vaccines available: an oral vaccine and a dead vaccine. The oral cholera vaccination contains weakened pathogens, the dead vaccine contains dead pathogens. Both vaccines cannot trigger the full picture of cholera disease. Nevertheless, they stimulate the human immune system to produce specific antibodies. A vaccination should only be given if a travel destination requires it or if people work as disaster relief workers in a cholera area.

Quarantine and mandatory reporting

Immediate therapy is required if cholera develops. In order to avoid further infections (epidemics), it is important to maintain strict hygiene. Sick people are therefore quarantined. In addition, suspected cholera must be reported so that disease control measures can be initiated.

Cholera: disease course and prognosis

Cholera begins after an incubation period of several hours to five days. This corresponds to the time between infection with the pathogen and the onset of symptoms - usually after two to three days. A distinction is made between mild and severe courses. A mild form of the disease usually ends after five days. The symptoms usually no longer worsen after just two days. When cholera is full, the disease usually ends after six days. The first 24 hours are the hardest with the elimination of up to one liter of watery stool per hour. Cases have also been reported where patients succumbed to cholera within a few hours.

With timely treatment, both mild and severe courses can often be treated. Despite treatment, about two percent of patients with severe cholera die. If left untreated, cholera is fatal in up to 60 percent of cases. The lives of children in particular are at risk from cholera, as they dry out faster than adults and are less able to compensate for salt loss.

After the illness has been overcome, only limited immunity against the pathogen remains. This means that those affected can catch cholera again.

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