Ministry Remains Mum as Cholera Fight Continues

Two weeks after health experts confirmed an outbreak of cholera, there remains precious little information about the scope of its reach or the numbers infected.

Ministry of Health officials refused to say this week that the disease was on the wane, but a number of hospital directors reported a drop in confirmed cases of cholera and watery diarrhea of unconfirmed origins.

“The situation is nearly the same,” said Dr Sok Touch, director of the Ministry of Health’s department of communicable disease control. “Not all people in the same commune are affected or using the same level of hygiene…. We’re still out there alerting people,” he said.

According to Dr Touch, there has still only been one confirmed cholera death since November. He would not provide updated numbers for cases (the last figure released by the Ministry was 128 confirmed cases between mid-November and mid-February) noting that the figures aren’t reflective of the spread of the disease as the typical practice is to stop testing for cholera after a few cases are confirmed.

“It is always difficult to get real estimates of cholera numbers,” explained Dr Nima Asgari, a public health specialist at the World Health Organization. “Even in the gold standard situation, once there’s an outbreak, you’ve tested seven people, you stop testing and just treat the cases. This has an effect on the numbers,” he said.

Compounding the difficulty in tracking the number of cholera cases, hospital directors have provided very differing accounts. In a public announcement this week, Dr Beat Richner, founder of the Kantha Bopha hospitals in Phnom Penh and Siem Reap, said he recorded 65 confirmed cholera cases in February alone. Chhour Y Meng, director of Phnom Penh’s National Pediatric Hospital, claimed to have seen just four cases since the beginning of the year, and none in more than a week. And the directors of the provincial health departments in Takeo, Kompong Cham and Kompong Speu, all reported a dip in cases. Commune chiefs in Prey Veng and Kompong Speu also said the outbreaks of severe diarrhea appeared to have calmed.

“In November and December we had some cholera cases in Batheay district, but it did not kill anyone,” said the director of the Kompong Cham department of health, Kim Sourphirun. “Right now, we have diarrhea cases, but not too severe. We’re monitoring this closely and checking reports each week.”

For years, the presence of cholera in Cambodia has been slight. The last outbreak of the disease occurred in 1999 in Ratanakkiri province.

Stymied by a lack of infrastructure and poor roads, containing the disease proved difficult and 56 people died then. In the intervening years, a rapid response approach to addressing diarrheal diseases in Cambodia and a focus on the joint UN Millennium Development Goal targets of improving access to clean water and proper sanitation had helped push cholera to the background.

Over the last few decades, cholera has become progressively more treatable as a disease.

“Forty years ago, cholera was very serious. Some villages or roads were blocked when it occurred,” said Ministry of Health Secretary of State Heng Taykry. The disease festered, jumped endlessly from person to person and proved highly fatal. Before the widespread availability of oral rehydration solution-a salt and sugar formula that is mixed with water and prevents dehydration-cholera and acute diarrhea of any origin was far more deadly.

Severe diarrhea nevertheless remains a danger to this day.

No matter what pathogen causes it, acute diarrhea continues to be among Cambodia’s top killers. Diarrhea is the number three cause of death overall, the number two killer of children younger than 5, and responsible for about 11,000 lives each year in Cambodia.

To combat this, anytime an area reports an outbreak of acute watery diarrhea, health officials go in with force and rapidity. Public information ads are broadcasted on TV and radio, educational pamphlets and distributed, health workers descent on the infected area to teach safe sanitation methods and hygiene practices.

But what many health officials don’t do, and which became clear earlier this month, is utter the word “cholera” very easily.

This week, it was apparent that stance had not changed.
Dr Ly Sovann, deputy director of the department of communicable disease control, said acute watery diarrhea had been seen in Phnom Penh, Takeo, Prey Veng, Kandal and Kompong Speu but that cholera cases appeared relatively intermittent.

“The cholera cases remain random[ly spread],” he said, avoiding a question on how many cholera cases had been confirmed.

“We don’t want to use the word cholera, we just say watery diarrhea,” Dr Sovann said.

Factbox

Cholera is an intestinal infection caused by the bacteria Vibrio cholerae. Its primary characteristic is severe diarrhea, which, in extreme cases, can cause life-threatening dehydration within a matter of hours.

How dangerous is it?

About 75 percent of those who contract the disease experience no symptoms. Five to 10 percent will have severe and potentially fatal diarrhea. With treatment, the fatality rate is under 1 percent, without treatment it is as high as five percent.

How is cholera treated?

As with all cases of acute watery diarrhea, the first line of treatment should be extra fluids and consumption of oral rehydration solution, which is available at shops, pharmacies and health facilities. Extremely dehydrated patients, those too weak to drink, for instance, must be brought to health facilities where they will be given fluids intravenously. Antibiotics should be prescribed only in the most severe of cases.

How is cholera caused?

Cholera is spread by “fecal-oral” transmission. This can be through any number of pathways but most frequently occurs through consumption of contaminated food and water. Typically, cholera spreads in conditions where the water supply is limited–such as following a natural disaster or during the dry season.

How are outbreaks contained?

Primarily with sanitation and hygiene. Those who contract any type of acute watery diarrhea should be treated in a timely manner, while neighbors should take special care to boil water, wash food, clean their hands and ensure a safe latrine system is in place.

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