Epidemiology is a science, connecting medicine and social studies. It gives people a chance to be aware of some risk factors that lead to the development of numerous contagious diseases. One of such infectious disorders is cholera. Though nowadays it is not common for some territories, other countries still suffer of this epidemic. The history of the disease demonstrates that cholera is easily transmitted and causes many deaths. The purpose of this paper is to give a brief historic overview of cholera pandemics in the USA and all over the world. Moreover, it aims to investigate preventive measures for the disease and prove that in spite of a vast research, the only way to prevent the spread of cholera is close cooperation between people and medical professionals in fighting all causes of cholera outbreak.
The history of cholera outbreaks in the USA is a separate aspect in the research on the cases of cholera throughout the world. In fact, more than 150,000 Americans departed as a result of the American epidemics of cholera. In 1832, the country experienced the first case of a disease. Discussing the reasons why cholera attacked North America, it is possible to consider the main risk factors,
Cholera transmission is closely linked to inadequate environmental management. Typical at-risk areas include peri-urban slums, where basic infrastructure is not available, as well as camps for internally displaced persons or refugees, where minimum requirements of clean water and sanitation are not met. (World Health, 2015, para. 10)
However, the historic reasons for its transmission are established trade connections between India and the USA. Rosenberg (2009) determined the causes of the quick spread of cholera in New York and other big American cities without any hesitations, stating that “New York was dirty, and the dirt seemed to breed disease – not only cholera, but yellow fever, malaria, and every other sort of pestilence” (p. 17). With time, the pandemic covered Boston, Chicago and reached even Canada. The majority of people claimed that the reasons were disorganized actions of the local governments that were not productive in the prevention of the spread of a disease. In some time, it was stopped, but not forever.
The second great cholera epidemic took place in 1849. In addition to the effect of anti-sanitary conditions, the American researchers firmly believed in person-to-person transmission of a disease. They considered certain national minorities to be a risk factor, emphasizing “That the Irish suffered severely from cholera was but additional testimony to their ignorance, their habitual filth and drunkenness [<…]>” (Rosenberg, 2009, p. 137). Moreover, an increased poverty level demonstrated that low-income citizens were affected by cholera most of all. It is worth noting that there were more world cholera outbreaks that affected the USA. With each of them, cholera research design got more key points and caused a conflict between ideological and scientific ideas. The increasing number of people believed that cholera was a result of the fact that the governments stopped following the laws stipulated by Lord. “Dirt and degradation are antagonistic to divine law; men would naturally suffer, if they persisted in defying the divine ordering of things” (Rosenberg, 2009, p. 220). At the same time, God cooperated in all actions related to the improvement of people’s health. For example, the vaccination in Europe saved many lives and God let it take place. However, the divine nature of cholera faded with time.
Nowadays, cholera is considered to be a rare disease for the United States. “During 1965–1991, an average of 5 cases per year was reported” (Newton et al., 2011, p. 2166). In 2010, cholera revealed itself again in the prosperous USA with 23 registered cases. The sanitary situation in the country and the quality of water is considerably better compared to the dirty and unhygienic living conditions of 1832. Therefore, scientists started seeking the connection between the cases registered in the USA and the epidemic in Haiti. The answer was found quite quickly, since “Twenty-two case-patients reported travel to Hispaniola and 1 reported consumption of seafood from Haiti” (Newton et al., 2011, p. 2166). The patients travelled to Haiti with different purposes like tourism and medical volunteering. Newton et al. (2011) state that “person-to-person transmission of cholera has only rarely been reported; cases in medical workers are almost always attributable to consumption of contaminated food or water” (p. 2168). Hereby, scientists are sure that person-to-person contacts with the inhabitants of Haiti influenced the infection less than water and food consumption (Newton et al., 2011). However, the cholera pandemic of 1849 in the USA was partly explained by the contacts with the Irish immigrants. Therefore, the U.S. cholera history confirms that in spite of numerous investigations performed by scientists, there is no single reason for the spread of the disease.
The epidemiological science states that cholera has terrorized the humanity for many centuries. The research shows that some disease similar to cholera was recorded in India in 1000 AD. Generally speaking, “cholera is an acute diarrhoeal disease that can kill within hours if left untreated” (World Health Organization, 2015, para. 1). In fact, this disease is caused by the consumption of water or food contaminated with the bacterium Vibrio cholera. Though some form of cholera was recorded in ancient Indian medical protocols, its official history started in 1817, when it left its motherland the Gang Delta (World Health Organization, 2015). The reason why cholera spread to other continents is an unanswered question. Echenberg (2011) confirms this fact and offers only one possible reason by stating “How modern cholera emerged remains a mystery. Extreme climate change may have been a factor” (p. 17). It is impossible to present exact statistical data on cholera deaths and Echenberg (2011) confirms that “statistics for cholera cases and deaths in the nineteenth century are impressionistic and serve only to provide a qualitative picture” (p. 3). Thus, it is crucial to analyze world cholera pandemics since it provides more data for the research.
The first pandemic of cholera hit China, Japan, parts of Southeast Asia, the Middle East, and Madagascar. In 1823, it slowed its pace in order to attack Europe through the British trade routes a little later. The second pandemic was even worse than the first attack, “[<…]> news of the First Pandemic must have frightened westerners, but the actual arrival of the Second Pandemic involved emotions and fears not experienced since the bubonic plague of the fourteenth century” (Echenberg, 2011, p. 19). As it was mentioned above, the next area terrorized by cholera was North America in 1832. In fact, there were more repeated large-scale cholera attacks, covering the central part of Europe again, Central America, Asia and Africa in 1841 – 1859 and 1863 – 1875. With regard to the Asian region, it suffered most of all in the 1900s. It is worth stating that a lot of African developing countries suffer from the pandemics of cholera nowadays (Echenberg, 2011). Therefore, cholera has a long history of development and spread, and it is good that medicine progressed in parallel with the disease and opened new possibilities for cholera prevention and treatment.
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Though cholera statistical data is highly approximate and inaccurate, all civilized countries and medical scientists have always tried to calculate the deaths and losses. Thus, “researchers have estimated that there are 1.4 to 4.3 million cases, and 28 000 to 142 000 deaths worldwide due to cholera every year” (World Health Organization, 2015, para. 1). In 2008, 5.143 deaths were registered, while in 2013, there were 29.064 reported cases in 47 countries with 2.102 deaths. However, not all cholera cases have always been reported in the history of pandemics either because the patients neglected to report and missed the time to ask for help or the obligation to report was cancelled. The biggest complication to the establishment of diagnosis of cholera is the fact that a patient contaminated by Vibrio cholera most likely reveals no symptoms within 1 – 10 days after being infected. Apparently, this period is the most dangerous since the person can infect other people. In fact, “Among people developing symptoms, 80% of episodes are of mild or moderate severity. The remaining 10%-20% of cases develop severe watery diarrhoea with signs of dehydration” (World Health Organization, n. d., para. 1). The severity of cholera revelations is crucial in making health prognosis and prescribing necessary treatment. From the data provided by the World Health Organization, the greatest number of cholera deaths in 2013 took place in Angola (86). On the contrary, the rates in other countries are much lower (World Health Organization, 2015). Although the humanity achieved progress in reducing cholera death cases, scientists still have a lot to investigate. Thus, it is vital to find the way to diagnose cholera before the incubation period passes and to prevent its transmission in countries where people are doomed to live in anti-sanitary conditions.
According to the history of cholera outbreaks, the disease affected many populations from different areas, regardless of their age, nationality, social status and other factors. However, medical scientists worked hard to determine certain causes of cholera outbreaks that are common for all cases. Apparently, they include people not having access to clean drinking water, limited access to health care and no educational health care trainings as to cholera management (World Health Organization, 2015). These are general determining factors in the development of the disease. However, the history of the spread of cholera proves that separate areas may have more individual reasons for the outbreaks.
Mason (2009), conducting a research of the situation with cholera in Zimbabwe, states that “during the past 5–10 years, the health system in Zimbabwe has been compromised by critical shortages of finance and declining infrastructure” (p. 148). Therefore, the author states that the last epidemics in Zimbabwe were caused by the lack of clinic professionals who could diagnose the illness at its primary stages. Moreover, the general economic crises, food shortage and lack of transport to arrive at the nearest medical centers contributed to the increasing number of patients. Furthermore, financial difficulties are the contributory factor in cholera outbreaks in other African countries (Mason, 2009). Rebaudet, Sudre, Faucher, and Piarroux (2013) report interesting findings relating to the environmental, natural and even geographic causes of cholera in Africa. Hereby, in their article, they mention that “the major finding of our review is that most of the cholera cases recently recorded in Africa concerned inland areas, while maritime and estuarine locations represented only a minority of the total recorded cases” (Rebaudet et al., 2013, p. 53). The authors find a direct correlation between cholera outbreaks and the geographic, climatic and human factors. Therefore, they state that inland disposition combined with closeness to lakes, rainfalls that make the distance to the equator longer, natural disasters, and even rafting on the rivers are leading reasons for the spread of cholera in inland Africa (Rebaudet et al., 2013). Rebaudet et al. (2013) are sure that it is possible to prevent the spread of cholera in inland Africa by taking into consideration the mentioned reasons, namely “thorough dynamic reports of outbreaks; ecological studies of water bodies; systematic collecting, genotyping, and comparison of environmental and clinical strains; as well as social and economical studies should be implemented” (p. 53). It is possible to affirm that in addition to some artificially created determinants like low quality of water and economic crisis, many other objective causes of cholera, namely environmental, geographic and climatic, may be discussed.
Numerous investigations of cholera offer more options for preventing the disease. In fact, as contaminated water is officially recognized as the main source of cholera, the first preventive measure “mostly consist of providing clean water and proper sanitation to populations who do not yet have access to basic services” (World Health Organization, n. d.). However, cholera outbreaks are described in the history of many developed countries that do not experience any difficulties related to the quality of drinking water. In this case, the next preventive measure that is health education on food hygiene will be very useful. “Communities should be reminded of basic hygienic behaviors, including the necessity of systematic hand-washing with soap after defecation and before handling food or eating, as well as safe preparation and conservation of food”(World Health, n. d., para. 1). Thus, radio and television channels or newspapers can be very helpful in propagate elementary hygienic rules.
Nowadays, a physician is not obliged to officially inform the administration of the cholera case. However, to insure the safety of the patients’ family and administer the correct treatment, it is vital to issue a warning and take control of the situation. The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies (n. d.) believe that “The most effective means for reducing a disease burden is through preventive strategies” (p. 301). The federation offers three main guidelines on the cessation of cholera outbreaks that include prevention of the development of infectious agents, improvement of the populations’ immunity and minimization of opportunities for the exposure of the patients to the infections. Moreover, the federation provides a short but wise plan of action for cholera prevention, stating that it is crucial to “improve sanitation, water supply, hygiene” (The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies, n. d., p. 296). Keeping in mind the fact that it is very important to correctly diagnose the patient, the federation states that “in areas where laboratory facilities are lacking, diagnostic sticks, clinical and symptom-based diagnosis for communicable diseases [cholera] remain the standard for case management” (The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies, n. d., p.308). Therefore, prevention of cholera transmission is seen as a main objective in the process of disease fighting, and this fact is confirmed by a bulk of preventive measures elaborated by different health care organizations.
The first cholera investigations were not well-organized because at that time medicine did not offer many opportunities for a scientific research. “For most of the nineteenth century, medical remedies for cholera remained as varied – and often as downright harmful – as they were ineffective” (Echenberg, 2011, p.10). The civilized world endeavored to find the ways to prevent the illness after it spread from India to Europe. Thus, it is reasonable to mention the name of John Snow, a prominent epidemiologist who conducted numerous studies on cholera history. The scientist firmly believed that water was the source of contamination and showed correlations between pumps of water used by people, the area in which they lived and a number of patients (Echenberg, 2011). “Snow applied his theory by means of a map he drew of the St. James outbreak, showing the destiny of cases clustered around the pump on Broad Street” (Echenberg, 2011, p. 34). Though the local council treated Snow’s argument skeptically at that time, supporting it by the fact that water cannot be both sweet and contagious at the same time, his contribution to the epidemiological study is difficult to underestimate in modern times.
Current cholera research design can be considered in terms of Haiti pandemic. A team of researchers from France and Haiti performed a complex investigation of a cholera outbreak in 2010. They used the method of spatial and temporal clusters to learn which populations were most affected in order “to better estimate the relationship between the epidemic spread and the distance to the epidemic source” (Piarroux et al., 2011, p. 1162). First of all, they kept statistical records of all hospital admissions, ambulatory patients and deaths. Apparently, some field surveys took place in the most affected areas, where the researchers interviewed doctors. The pandemic gradually covered more areas, and the research team examined the samples of river water that people drank and made the most significant conclusion that cholera was imported to Haiti. Hereby, they concluded that “There was an exact correlation in time and places between the arrival of a Nepalese battalion from an area experiencing a cholera outbreak and the appearance of the first cases in Meille a few days after” (Piarroux et al., 2011, p. 1165). Thus, the discussed research proved the importance of a field investigation in the areas affected by cholera within the period of epidemics.
The first attempts of John Snow to analyze water samples were a good start for the second part of cholera research design. In addition to determination of the reasons and risk factors of cholera, it is important to be aware of the ways to neutralize the bacteria causing the illness. As it was mentioned, Vibrio cholera is the main organism that causes the illness. To be more precise and following the results of the modern research, cholera may be caused by “Vibrio cholerae O1, serotype Ogawa, biotype El Tor” (Parraoux, 2011, p. 1161). Nowadays, medical professionals state that cholera is an easily curable disease in case it is promptly diagnosed; thus, “up to 80% of people can be treated successfully through prompt administration of oral rehydration salts” (World Health Organization, 2015, para.1). Proper hydration is the main part of cholera treatment. Talking about antibiotics (Doxycycline for adults and azithromycin for children), they are recommended for severely ill patients whose dehydration has reached the peak. Numerous health organizations issue recommendations as to the antibiotic treatment of cholera (Centers for Disease Control and Prevention, 2015). However, “None of the guidelines recommend antibiotics as prophylaxis for cholera prevention, and all emphasize that antibiotics should be used in conjunction with aggressive hydration” (Centers for Disease Control and Prevention, 2015, para. 12). It is important to remember that sometimes, the routine treatment of patients with antibiotics can give a reverse effect as this type of medicine increases the resistance of a microbe to the agent. Therefore, there will not be any effect on the spread of cholera (World Health Organization, n. d.). Taking the above information into account, it is worth stating that the most effective cholera research design includes field investigations, surveys and doctors interviews, as well as keeping records of the positive patient’s outcome after the prescribed treatment.
To conclude, it is possible to claim that there is no country in the world that was not affected at least once by the cholera pandemic. The reason for this is the fact that the discussed disease is easily transmitted through drinking water and from person to person. Geographic, environmental, economic and other factors cause cholera outbreaks. Some preventive measures such as keeping people’s households clean and in a good sanitary state may be effective. It should be the primary concern of African countries and India where it is difficult to observe hygienic rules. It is crucial that people are educated by medical professionals as to cholera risk factors and the importance of prompt treatment. Thus, the governments should do their best to improve the economic and social conditions in their countries to prevent the spread of the disease.
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