Diagnosis and treatment of cholera in the United States. Are we prepared?
R. E. Besser, D. R. Feikin, J. E. Eberhart-Phillips, L. Mascola and P. M. Griffin
Foodborne and Diarrheal Diseases Branch, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Ga 30333.
OBJECTIVE--To assess cholera recognition and treatment by US health care
workers in the largest cholera outbreak in the United States this century.
DESIGN--We reviewed the medical records of passengers from a flight on
which a cholera outbreak occurred. To determine the availability of oral
rehydration solutions, we surveyed treatment facilities and referral
pharmacies. SETTING--On February 14, 1992, more than 100 passengers on a
flight from South America to Los Angeles, Calif, were infected with
toxigenic Vibrio cholerae O1. SUBJECTS--Fifty-four of 67 passengers who
sought care in California and Nevada. RESULTS--We reviewed the records of
54 passengers, including 39 with diarrhea and 15 without symptoms. All 17
persons who sought treatment before the outbreak was widely reported by the
media had diarrhea. For 12 of these persons, recent travel to South America
was noted, but only those four whose records listed cholera as a possible
diagnosis were immediately hospitalized. Seven sought care again within 3
days; three were dehydrated, two of these three were hospitalized, and one
of these two died. None of the 26 patients suspected to have cholera
received appropriate fluids; severely dehydrated patients did not receive
Ringer's lactate solution and those not severely dehydrated did not receive
an oral rehydration solution. None of the facilities and pharmacies
involved stocked World Health Organization oral rehydration salts solution,
the preferred solution for treating cholera and other diarrheal diseases.
CONCLUSIONS--Treatment of cholera in the United States was suboptimal. Oral
fluids appropriate for the treatment of cholera and other diarrheal
diseases were generally unavailable. Widespread cholera in the developing
world means that US physicians should be prepared to treat "imported"
cases. Physicians evaluating patients with diarrhea should obtain a travel
history, should consider cholera in patients returning from countries with
endemic or epidemic cholera, and should instruct patients in appropriate
use of World Health Organization oral rehydration salts solution or other
oral rehydration solutions containing 75 to 90 mmol/L of sodium. Pharmacies
and medical facilities should stock these solutions.
