Volume 2 No.
STATISTICAL NOTES is primarily a management tool. It is produced and circulated monthly to health managers and healthcare providers.
It is produced on the principle that health data should be translated into information that is useful for improving health provision and quality of care; for better planning and management at all levels and to inform policy development.
Timeous and accurate information should enable improvements in the services that we provide. Colleagues, reporting health events timeously is extremely important. The success of our health information system depends on good reporting.
Please write in if there is anything that can be done to support your reporting practice.
Submissions from directorates which collect data are welcome. The most updated information should be submitted by the 1st day of each month. It should be on both hard copy and disk or email.
The contents of the "STATISTICAL NOTES" may be quoted freely provided that appropriate acknowledgement is made (i.e. Department of Health, Statistical Notes, Vol 2, No. 14, March 2000). Complete articles may not be published without the prior permission of the Director, Health Systems Research, Research Co-ordination & Epidemiology.
The root of cholera is basically bad water. It is associated with low socio-economical conditions, whereby good clean water is either hard to come by or taken for granted.
Cholera received its name from the Greek word chole, meaning bilious. It is an endemic disease in Asia, mainly on the delta of the river Ganges with its alkaline waters that favor the cholera bacterium, vibrio cholerae. Through this route and migratory movements, it extended to Africa. This was in the early 19th century and throughout this century, science could not trace the mode of transmission of the disease.
By the end of the 19th century, cholera appeared to retreat as a global health threat. It re-emerged in Africa and Latin America in 1991 and remains endemic throughout these regions. The dramatic rise in the cholera cases was at that time blamed on political and economic turmoil, as well as overcrowding e.g. in urban slums or refugee camps. These conditions were accompanied by poor living conditions and deteriorating water sanitation. In 1991 Peru engineers of the public water supply system stopped chlorine disinfection of water, fearing that the byproducts posed a carcinogenic risk. In Latin America, the disease was traced to the growing use of wastewater to irrigate crops near urban areas.
To explain why cholera seemed to have disappeared between the end of the 19th century and 1991, environmental conditions have been identified. The cholera organism has been found to remain dormant in coastal waters for long periods, only to re-appear when conditions are favorable. This explains the seasonal cholera epidemic in Bangladesh, which often coincides with plankton blooms in the Bay of Bengal. Periodic changes in weather patterns e.g. El Nino, may also have contributed. The warm sea surface temperatures brought by El Nino encourage plankton blooms, which then awakens the cholera organism. This dependence on environmental factors may have some important implications for the future of cholera.
It is an acute bacterial disease caused by Vibrio cholerae. It affects the intestinal tract and results in a watery diarrhoea and leg cramps. Although there are often no stomach cramps or fever, the diarrhoea can cause severe dehydration which follows prolonged vomiting and the watery diarrhoea. Cholera can be distinguished from other forms of acute diarrhoea by its lack of blood, mucous or pus in the typical "rice-water" stools. If not controlled, cholera can kill in less than eight hours. Death is usually the result of shock. The symptoms may appear six hours to five days after exposure. Asymptomatic carriers of the disease are common.
Cholera is spread by eating contaminated food e.g. undercooked seafood from warm coastal waters, or drinking water contaminated by faecal waste of an infected person. Certain strains of cholera can survive in fresh water for a long period of time.
Diagnosis is made by taking a stool sample and testing it in the laboratory to isolate the bacteria. The basic treatment of cholera is the replacement of fluids by mouth or giving Hartmann's solution intravenously. If managed at home, the fluid should contain electrolytes (salt and sugar). Vomiting can deter sufficient rehydration. In this case, hospitalisation is necessary. Antibiotics can be administered to kill the bacteria and shorten diarrhoeal duration but the toxins already produced by these bacteria will continue causing massive fluid loss. Drug administration is therefore only an adjunct to hydration therapy.
Tetracycline is the drug of choice for adults, at 250mg four times daily dosage. It is not recommended for children 8 years or younger and pregnant women, since it stains the developing teeth of children and foetus. Antibiotics such as Furoxone, Cipro or Bactrim will also shorten the duration of illness.
Breastfed children are protected from gastric achlorhydria that increases the risk of infection. Reinfection is unlikely since infection results in agglutinating, vibriocidal, and antitoxic antibodies leading to resistance.
ï· Eat only food that is thoroughly cooked and still hot or fruit that you have peeled yourself.
ï· Avoid all salads.
ï· Avoid tap water, unless it has been boiled or treated with chlorine or iodine.
ï· Avoid food and beverages from street vendors.
ï· A simple rule of thumb - Boil it, cook it, peel it, or forget it!
To infested countries like Madagascar, a single 300mg dose of the prophylactic Doxycycline regimen is still in use, with alternatives for those who cannot take it. Cholera vaccine provides less than 50% protection for three to six months, which then translates to no useful protection. It is therefore no longer recommended by the World Health Organisation (WHO) for travelers to or from infested areas. Its present use is only to satisfy entry requirements for those few countries that still insist on cholera vaccination.
An adequate disease surveillance programme involves keeping daily records of diarrhoea cases seen in health facilities and by health workers in the community. This facilitates early detection of an outbreak.
ï· there is a sudden increase in the daily number of cases of patients passing 'rice-water' stools typical of cholera.
Such changes prompt for sudden notification of the nearest referral health facility or the local health officer. The name, address, age and the date of illness of the patient should be specified. Members of the community should also be encouraged to help in detecting and reporting cases as well as preventing further spread of the disease. When the information comes from an area where cholera has not been confirmed, bacteriological and epidemiological origin need to be promptly investigated so as to determine the origin of the outbreak.
The far-reaching effect of cholera outbreak often calls for an immediate action from the national co-ordinating committee, reinforced by senior members from relevant ministries.
ï· implementation, monitoring and evaluation of control activities.
In South Africa, a National Outbreak response team has been set up to fulfill these responsibilities. This structure is supported in its work by provincial outnbreak response teams. Together they played an important role in the control of the cholera outbreak that errupted after the recent floods in Southern Africa.
Looking back at the past twenty years, cholera has last posed a major public health problem in 1980-1985. Kwa-Zulu-Natal (KZN) has had at least 1 case almost every year during that period, contributing over 73.0% of all the reported cases.
Following Kwa-Zulu Natal are Mpumalanga (11.7%) and the Northern Province (10.4%), contributing more than 10.0% each. In the year 2000, three cases have already been reported following the recent floods. The worst cholera epidemic occurred in 1982 when nearly 14 000 cases were diagnosed.
The first South African to be diagnosed was a woman from Komatipoort. This happened two months after the floods struck the Northern Province and Mpumalanga. The 21-year old farm worker contracted the disease when her brother-in-law returned from visiting family in neighbouring Mozambique.
Since the beginning of the year, two cases of cholera from North West have been reported through the notification system. The patients were males of 35 and 55 years of age. More reports are still expected from areas which were stricken by floods.
About 3 668 terminations have so far been reported since the beginning of the year. This brings to total 110 547 terminations, which have been reported by the designated facilities since the implementation of the Choice of Termination of Pregnancy (CTOP) Act in 1997. With exclusion of cases of unknown age, the results show that about 55% of terminations are performed on women above 18 years. About 71% of the total terminations are performed during the first trimester. It should be noted that the figures on the TOP table (below are likely to change, especially for the end of 1999 and for 2000, since not all data has so far been received for the specified period.