I’m just back from Burundi, a small, beautiful country in Africa, sandwiched between Rwanda, Democratic Republic of Congo and Tanzania. It’s capital, Bujumbura, sits on the shore of the deep, gorgeous Lake Tanganyika, where on a clear day you can see the mountains of DRC on the other side.
I went to Burundi with the Norwegian Red Cross to support trainings on a really cool strategy to fight cholera.
Cholera, as you probably know, is a diarrheal disease that still kills people in the 21st century (between 21,000 and 140,000 per year, according to WHO). It causes vomiting and what we call Acute Watery Diarrhea or AWD.
Acute, because it starts very suddenly and lasts only a few days. Watery, because the diarrhea very quickly becomes mostly water. It’s even called “rice water diarrhea”, as it looks like the whitish water left behind after you’ve washed rice. (I hope you are not having lunch while reading this!). The reason for all this water is because the bacteria that causes cholera, Vibrio cholera, has a toxin that pumps water out of the cells in the intestines.
Cholera can quickly (in a matter of hours) lead to dehydration that can result in death, even in healthy adults. Basically, it’s the dehydration that kills the person, so the treatment for cholera focuses on keeping the person well hydrated while the body fights off the infection.
In severe cases, if the person has lost consciousness or can't drink enough, this has to be done by giving the person fluids intravenously at a hospital or clinic. But in the majority of cases, giving fluids orally is enough.
When I talk about fluids I’m not talking about water, though. Water is fine for rehydration purposes in regular life, but in cases of AWD, oral rehydration solutions (ORS) with the right concentration of salts and sugar allow a much faster rehydration and a better balance of electrolytes, and thus have a much better track record of saving lives.
In any given cholera epidemic, most people won’t develop symptoms, although they will still shed the bacteria in their faeces and thus transmit the infection. Among those who do develop symptoms, only around 20% will be severe cases requiring intravenous fluids and hospitalization.
But what usually happens is that most people with symptoms end up at hospitals or cholera treatment centers anyway. In a bad epidemic, this can overwhelm the healthcare system. Plus it usually means that people are coming to the hospital late in the disease, and more dehydrated.
So, how can we provide access to rehydration closer to home to all those cases that don’t require hospitalization? Well, if you come from a middle or high income country, you might be thinking, “Duh… just go to the pharmacy and buy one of those electrolyte drinks”.
Unfortunately, that doesn’t work in poor communities in developing countries, or in camps for displaced people, which is where cholera epidemics usually happen. Here there’s usually no pharmacies, no electrolyte drinks, and most importantly, no clean and safe drinking water.
Enter the ORPs, short for Oral Rehydration Points. A place in the community where community health workers can provide water purification tablets and sachets to prepare ORS.
The Red Cross has now taken the ORP concept one step further by developing ORP kits. These compact kits can be quickly set up in the communities during an epidemic. They contain two key ingredients for treating cholera: a water filter that produces clean and safe drinking water, and sachets of ORS (plus other goodies like soap, water treatment tablets, glasses, jugs, etc).
One of the key resources of the Red Cross is its volunteers, who exist in communities in almost all countries in the world. During an epidemic, community health workers and other health staff can get very busy and be in short supply. Trained volunteers from the Red Cross can provide support by staffing these ORPs.
Volunteers can provide the communities with quick access to rehydration by giving sick people ORS straight away (with cholera, time is key) at the ORP. They also teach families how to prepare the ORS sachets at home (just mix them in a liter of safe drinking water) and how to make water potable by boiling it or treating it. They distribute chlorine tablets for water purification and soap for hand-washing.
Volunteers are trained to detect severe dehydration and quickly refer these cases to the hospital or cholera treatment center. They also provide communities with information on how to prevent cholera, such as washing hands with soap, protecting food from flies, using latrines and avoiding open-air defecation.
My trip to Burundi was about supporting the Burundi Red Cross in training its volunteers to install and use the ORP kits. Burundi has experienced intermittent cholera outbreaks, especially among the areas close to the Tanganyika lake. They now plan to preposition the ORP kits in case they are needed, to be able to respond quickly and give people in affected communities early access to rehydration.
I love simple, practical solutions like this one. I’m looking forward to seeing results from studies analyzing the impact of ORPs during cholera epidemics.
Did you like this post? I’m planning on writing more posts like these on interesting solutions to health topics around the world. Are there any particular subjects you would like to know more about? Please let me know in the comments!