COVID-19; is it time to hit the PANIC button?

Say hello to the madness; we are in a pandemic. In my last column I mentioned that the spread outside of China was still rare. Eeeuh, that didn’t age well… Today, three different continents are confronted with outbreaks of the virus, probably others will follow soon. Thousands are infected and a percentage of them have died. Since the virus hit the West it almost seems the world is in panic mode. There is such an overflow of good/vague/bad information surrounding this outbreak that is hard to keep track of it all and put things in perspective.

Luckily, I am here to change that: your very own, Thailand based, Infectious Disease Epidemiologist.

CO-NA-NA, what’s my name?

The issue with a new disease is that it is hard to immediately give it the right name. Some parents might now this feeling, waiting days after a birth to name their kid. The current disease almost changed names more often than Sean Combs, Puff Daddy, P. Diddy, Diddy, Puffy, Fluffy, Duffy, H. Duffy, Hilary Duffy, Hilary Duff did.

Today we call what used to be the “Wuhan-virus”, the “Corona Virus”, the “nCoV” by its WHO approved official name: COVID-19. It stands for “COronaVIrus Disease”-2019 (let’s don’t do a 2020 or 2021 version), the virus itself is called SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2).

FACT 1 : COVID-19 (still) not as bad as previous outbreaks

Let’s update the table from the last blog:

COVID-19 MERS SARS H1N1
Year 2019 2012 2002 2009
Origin country China Saudi Arabia China Mexico
Source Bats Dromedary camels Bats Swines
Number of people infected to date 82.294 2.494 8.096 208.269
Case fatality Susp. 2% 37% 9.6%% 4.20%
Countries with reported infections 57 27 27 175
Countries outside origin with reported deaths 7 16 8 124

https://www.who.int/docs/default-source/coronaviruse/situation-reports/; MERS-CoV: Middle East Respiratory syndrome; SARS-CoV: Severe Acute Respiratory Syndrome; H1N1: Swine flu

Although COVID-19 seems to be “better” than SARS, MERS and H1N1, it loses the battle in a who-is-a-good-disease competition to seasonal flu. In comparison with the seasonal flu COVID-19 has a higher case-fatality ratio. Seasonal flu has approximately 0.5% mortality rate, COVID-19 currently has a 2% rate (please read FACT 3).  COVID-19 also has a higher reproduction number; seasonal flu infects about 1 to 1.5 other person (tiny persons also count for 1, it is just statistics), COVID-19 appears to infect 1.5-2.5 other person. This means that COVID-19 could spread more widely. Lastly, for seasonal flu we have a vaccine!

FACT 2 : Younger than 50? No reason to panic

(Rest assured: this does not imply the following: Older than 50? Call your local undertaker at 555-…..)

Let me remind you that Coronaviruses have been among us humans for a long time already. Yes, this is a new variant and yes, it is more severe than the previously known ones, but if you look at the figures published by the Centers for Disease Control, China, you can see that if you’re younger than 50 years old, you will be fine.

And even if you do catch the virus, you would probably not even go to see a doctor. Symptoms are fever, dry cough and shortness of breath but range from mild (80% of the cases), severe (14% of the cases) and critically ill (5% of the cases).

Men are at higher risk of dying from COVID-19 than women (rate 3,25 to 1). And people with underlying illnesses like COPD (smoking history), diabetes or a bad working immune system due to medication or old age are also at higher risk [1]. These vulnerable groups are also the people that we usually give the vaccine for seasonal flu. You can see how they are at higher risk of dying from the COVID-19.

Also, <10 years old there have been (to date) no deaths and very few infections reported.

Characteristics Confirmed cases, Deaths, Case fatality
N (%) N (%) rate, %
Overall 44,672 1,023 2.3
Age, years
 0–9 416 (0.9)
 10–19 549 (1.2) 1 (0.1) 0.2
 20–29 3,619 (8.1) 7 (0.7) 0.2
 30–39 7,600 (17.0) 18 (1.8) 0.2
 40–49 8,571 (19.2) 38 (3.7) 0.4
 50–59 10,008 (22.4) 130 (12.7) 1.3
 60–69 8,583 (19.2) 309 (30.2) 3.6
 70–79 3,918 (8.8) 312 (30.5) 8.0
 ≥80 1,408 (3.2) 208 (20.3) 14.8

[2]

Just to clarify: these current mortality rates only apply on people of whom it is determined that they have COVID-19 (see again FACT 3). If you don’t have COVID-19: well, don’t text and drive!

FACT 3 You can have the virus and be fine

The symptoms of COVID-19, like I stated above, can be very mild with just some cough and runny nose. Recently, Yan Bai et al. published an interesting article of how even asymptomatic carriers can transmit the virus [3]. This means that you can be infected with COVID-19 and not have any symptoms.
That sheds an interesting light on the 2% mortality rate in FACT 1. If we would test the whole world, we would probably get a higher number of infected persons. Infected persons without even knowing it. This affects the mortality rate: which is deaths from the virus divided by persons infected by the virus. If currently more persons are unknowingly infected the mortality rate could be much lower (as the nominator increases). The absolute number of deaths of course doesn’t change, which is sad, but it might put the severity of the COVID-19 in a different perspective.

Conclusion: during an outbreak it is super difficult to make sense of any of the numbers and to have a complete picture of the outbreak.

FACT 4 Closing an office for 48 hours is pointless

Some companies close their office for two days when an employee is found to have COVID-19. The reason? Intensive cleaning of the office. This does not solve anything!

Yes, the virus can survive long on surfaces, so a good cleaning is very smart. But if after the big cleaning you will re-open the office again you might as well not have bothered. Persons have the disease in them for at least two weeks … spreading it to others … who probably come back to the office on day 3 … you understand where I am heading?

Recently I was in a hotel and at check in they took my temperature and every morning before breakfast they checked me before I could enter the breakfast room. That is a much smarter way to contain the outbreak. That gives us FACT 5.

FACT 5 Do’s and don’ts

Do Don’t
Wash hands regular Go to the current outbreak hotspots
Use desinfecting handgel Go to a place where you are packed with other people with potential bad hygiene
Sneeze and cough in elbow Panic
Read scientific facts Trust Facebook
Think twice before traveling anywhere Panic!!

Do the do’s and stay home when you have any symptoms and you are helping to stop this outbreak.

Well done, stay smart, until a next update!

 

References:

  1. Sun P, Lu X, Xu C, Sun W, Pan B. Understanding of COVID-19 based on current evidence. J Med Virol 2020.
  2. The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) — China, 2020[J]. China CDC Weekly, 2020, 2(8): 113-122.
  3. Bai Y, Yao L, Wei T, et al. Presumed Asymptomatic Carrier Transmission of COVID-19. JAMA.Published online February 21, 2020. doi:10.1001/jama.2020.2565

 

 

How to tame your outbreak: 2, the fight against Malaria

In part 1 of How to tame your outbreak I have shared with you the three necessary steps to control an outbreak. These were: gather information, contain the spread and keep it safe. In theory it is as simple as opening a bag of crisps on a lonely and rainy Tuesday evening whilst sitting on the couch ready to watch Legally Blonde for the tenth time. Controlling an outbreak in practice is a whole different ballgame.

Now , I could share with you all the Outbreak control plans and actions about every Virus, Bacteria and what, but since I work closely with a Malaria Elimination Task Force (METF) at the Myanmar-Thailand border, let’s use Malaria as example.

So here we go: how to tame your Malaria Outbreak?

Step 1: gather information

Malaria is caused by a parasite and is transmitted via mosquito’s. They suck blood from a Malaria patient and inject that blood into a new patient, thus infecting them. We know what it is and also how it spreads. That was the easy part.

Step 2: contain the spread

To contain Malaria there are really three options we could take:

Option 1: eliminate the mosquito. In real life, super difficult, it is easier to erase the West African Black rhinoceros than these little biters.

Option 2: prevent it from biting you. DEET or bednets are helpful, but it’s not realistic for people living in remote areas to use DEET all the time.

Option 3: make sure everybody that gets infected is treated before a mosquito can bite them and spread it further. This means early detection and treatment with the anti malaria drugs that kill the parasite. With the upcoming resistance (here we go again) this option can also become very challenging.

So which option to choose? You could start with option 3: early treatment. Now this can be a tricky part. Especially in a rural area like right here on the border, there are many villages and people tend not to stay in just one place. They work in one place, live in a next and their family is somewhere else again. This means that in order to successfully contain the outbreak, you will have to map out all the villages that you need to target. In the case of METF this is over 1500 villages. Then you need:

  • Healthposts where people can go to get tested and treated.
  • Healthworkers, educated people to diagnose and treat patients
  • Medication, power supply, charts, needles, tests, alcohol (not to party into the night but to disinfect), etc.
  • Education of all people, including villagers. People need to understand what you’re doing and why they need to come as soon as they have fever.
  • A way of communication between the health posts and the hospitals in order to be able to send the severe patients in time for care

METF currently has over 1200 health posts with more than 1600 health workers. Can you imagine the work goes in to an operation like that?! And how much money, perseverance, guts (especially in the remote and unsafe areas) and love for the people? In the meantime, you can try option 1 and 2 (kill the mosquito and prevent the bites).

Step 3: keep it safe

The WHO grants a certificate that a country is “Malaria Free” (like Paraguay recently) when:

“a country has proven, beyond reasonable doubt, that the chain of local transmission of all human malaria parasites has been interrupted nationwide for at least the past 3 consecutive years; and that a fully functional surveillance and response system that can prevent re-establishment of indigenous transmission is in place.”

This means that, although my wonderful colleagues at METF have done a tremendous job already, saving thousands of lives in at least two countries, we’re not getting the certificate yet.

Containing an Outbreak is newsworthy and is a certain money collector. Keeping it safe is the part of the “outbreak” that funders are least interested in. It’s not news anymore. No extra figures to show. It’s just being there and staying there and not going anywhere until you’re sure. And that could take years and years. However, don’t get your guard down. Venezuela was declared malaria free in 1960 but had a big outbreak in 2016 with 240,613 patients and 280 deaths. As soon as you stop being prepared, it will come back.

So thank you METF and keep fighting the good fight.

 

Picture: Suphak Nosten: In the middle of the border, the one crossing for care, the one to provide care, across the border

 

How to tame your outbreak

After all the previous blogs we can honestly say that outbreaks occur. Already many times in history and definitely many times more in the future. These outbreaks range from being relatively mild (the seasonal flu) to very deadly (Ebola), from being brand new and scary (Nipah virus in India) to being as old as the Pyramids and almost extinct (Polio).

With every outbreak Super Avenging Guardians of the Corporis fighters – normally called Epidemiologists – ask themselves the same questions: how do we manage and contain the outbreak? How can we improve the public health in order to eliminate the pathogen (Viruses, Bacteria and all other stuff that makes people sick)?

Well, in short, it is like the ‘Program for a Treatment of Alcohol Addicts’ by HouseofRecovery.org …  it takes three steps.

Step 1: Gather information

In order to control an Epidemic, we have to find out “what” before we can proceed with “how” and “when”. It is essential to gain more information about the pathogen and the way it infects people. An outbreak of flu requires a different approach than a diarrhea illness.

And should it be an unknown pathogen, you start with searching for the first infected patient. Then try to figure out how the other patients got infected, write a book about it, become the world leading expert and get a Nobel Prize at the age of 79. Oh, and during all this don’t forget to go to step 2.

Step 2: Contain the spread

If you know how it spreads, you have to try to contain it. Step 2 is actually two different routes:

Route 66: You take care of the current patients

Road to perdition: You try to not let any more people get infected

Sometimes driving these roads can be fairly easy. For the biggest outbreak of Cholera in London back in the mid-19th century (killed hundred thousand people), all they needed to do to stop it was shutting down the main water pump. But to be fair it took them years to figure out the answer to step 1: what it was and how it spread. We’ll come back to that in a different blog.

But most of the time, driving these roads are very challenging. Especially because you have to drive them at the same time.

Step 3: keep it safe

At this point you have successfully stopped the big outbreak, very well done. But the challenge that you’re facing now is to keep it that way. Because if one patient gets infected from a different part where there are no health posts, this one patient can be the patient zero for the next outbreak and you’ll have to start all over again.

This means that you can never let your guard down. Not until a long time.

There you have it. Now we can tackle any outbreak!

Next time I’ll give you a nice example of outbreak control…

 

 

picture: Louise Annaud/Medecins Sans Frontieres via AP

Ebola – why not to kiss dead people

Once upon a time, well actually 1976, in the beautiful country of Zaire, now Congo, there was a river named Ebola. In a small town a couple of miles from the river a crisis emerged when people started dying fast and horribly. The nuns in the town took care of the sick people but they too became ill. What was going on? If you guessed this wrong, wow, impressive.

Nun’s blood

The river town people somehow managed to send some vials of a nun’s blood. It was travelling on a normal commercial flight, in a thermos bottle, just in the hand luggage. For the youngsters: those were the days that no airline was worrying about bringing liquids on the plane. First stop, the Institute of Tropical Medicine in Antwerp, Belgium (Zaire was a former Belgian colony).

When the Belgians took out the vials and put under their microscope they saw “a gigantic worm like structure – gigantic by viral standards (…) a very unusual shape for a virus.” The virus looked like a virus called the “Marburg virus”. This virus had been infecting laboratory people in the German city Marburg after they had worked in Uganda with ill monkeys. The Marburg virus was also known to be very deadly. After sharing this information, the World Health Organization told them to immediately send samples to a British military laboratory and to the Centers for Disease Control in Atlanta. In the end it was the CDC that proved that although it looked similar to Marburg, it was a totally new disease.

Outbreaks
Ebola causes an outbreak every so often. The outbreaks often start from one person that gets infected by an animal. The symptoms are witnessed after a couple of days. First some that compare to how you feel the day after a night of heavy drinking and karaoke singing: sore throat, muscular pain and headaches. Then symptoms you might have expected earlier, probably at the karaoke bar, instead of days later: vomiting and diarrhea. Then the most frightening thing happens: you start bleeding from every pore, from the biggest one (yep, that one) to ones so small you didn’t even know you had them. After one or two weeks the person is dead. Well, in reality on average 50% of the persons die. But I don’t think that this percentage really comforting.

In fact: Ebola is killing its victims so quick, the outbreaks, as terrible as they are, usually outrun themselves. Simply because there are no more people left to infect.

Anybody who crosses here may die

In 1976, one of the Belgian doctors Peter Piot was send to the village to do some true epidemiology research. In his own words: “I was so excited about seeing Africa for the first time, about investigating this new virus and about stopping the epidemic.” Excitement was probably not really what the sick people were looking for, but I have to admit that from a professional perspective I understand the emotion.
Peter Piot also mentioned that when he got to the town two weeks after the outbreak there was a barrier with a sign saying: “Please stop, anybody who crosses here may die.” A true dare for even the most adventurous thrill seekers.

The medical team discovered many things, like pregnant women were injected with vitamins (that is a good thing) using just five needles to inject everyone (not a good idea…). One interesting fact they also noticed was that people were getting ill after attending funerals.

Don’t kiss dead people

Ebola is spread through contact with infected bodily fluids. And because there is a lot of this leaking bodily fluid, it is very easy for the Ebola virus to infect other people. When someone dies from Ebola, the body is still full of the virus. Any direct contact, such as washing or preparation of the deceased without protection can be a serious risk. Moreover, in a lot of African cultures it is tradition to kiss the deceased at the funeral.

The 2014 Outbreak : West Africa

In 2014 the outbreak got bigger and hit the worldwide news. It all started with a child that got infected, probably by eating bush meat, and died. The funeral took place on the border of Guinee, Sierra Leone and Liberia and people form everywhere joined. Maybe the child was kissed, maybe not, but sure thing the disease spread when the guests went back.

By the time the authorities were notified a shocking thing happened. People didn’t understand the disease. After almost 40 years of Ebola Outbreaks information about it was still lacking in villages in Guinee, Liberia and Sierra Leone. The common understanding about the disease was: if you go to the hospital, you die. The scary outfits of the medical staff probably didn’t help either. This resulted in sick and infected people hiding from the medical personnel in order not to get killed in the hospital. Thus, spreading the infection further and further.

In order to control an epidemic like this, good medical personnel just isn’t enough. You need community engagement and you need education. Preferably from local people that everybody knows and trusts.

And please, don’t kiss dead people if you don’t know how or why they died.

 

 

 

http://www.bbc.com/news/magazine-28262541

Picture credit: Nahid Bhadelia/CDC

Endemic, Epidemic, Pandemic: Semantic

Doctors have this habit of using a different vocabulary, making easy things sound very complicated. An example: ‘melena can be an indication of peptic ulceration’ actually means ‘blood out of your ass can be caused by stomach ulcers’. Why use difficult words: a. the doctor wants to sound very important and smart or b. they just don’t know the subject well enough to explain it in normal words. Or, as it said on one of the tiles on the wall at grandma’s house: ‘It takes an assbleeder to talk about assbleeders’.
Even in this blog we go over so many infections and sometimes I can get lost in the semantics. So, this time no specific infection, it’s just about how you can sound smart whilst taking about them.

Endemic

Endemic refers to a disease or condition that takes place in a specific region. For instance, Malaria is endemic in sub Saharan Africa but is not endemic in Europe. At least, not any more. Some diseases become endemic in new places all the time, the flu for example or the common cold. Other endemic conditions don’t move unfortunately: like the scraping throats and spitting on the floor at 5AM at our neighbor’s place in Thailand. Endemic as such is in short not something to be really scared about, especially when you take precautions (anti-malaria pills, flu-shot, earplugs)

Epidemic/Outbreak

Turning it up a notch. Epidemic means that in a period of time, more cases than expected in a community/area/season are suffering from the same condition or are infected with a specific disease. Scary stuff right. For instance, the epidemic of Ebola in 2014. Or obesity in America. By the way, a different word for epidemic is ‘Outbreak’. Remember that movie with Dustin Hoffman? That sweet little monkey – a real one, not mr. Hoffman – that turned out to be a real badass decease carrier? Outbreak = epidemic. Choose whatever sounds more spectacular.

Pandemic

Now the real trouble is when an Epidemic becomes a Pandemic, in which case the infection has spread worldwide. We’ve seen this, for instance, in the H1N1 time. More notorious examples are the Black Death pandemic (1346-1353: up to 200 Million deaths), the (Spanish) Flu pandemic (1918 – up to 50 Million deaths) and the HIV/AIDS Pandemic (peak 2005-2012 – 36 Million deaths)

Another movie example, watch ‘Contagion’ and you’ll understand what I’m talking about (really nice movie actually with Matt Damon and Jude Law… need I say more?). Storyline summary: ‘As the contagion spreads to millions of people worldwide, societal order begins to break down as people panic.’ Panic! If you do, you know you’re experiencing a Pandemic… Other movie must sees in this genre are Twelve monkeys (not about twelve monkeys) and World War Z.

Epidemiology

All these terms are very important for people that study diseases, epidemiologists. You might need some practice to master that word. I followed a masters in epidemiology and my husband still can’t pronounce it different than “epidedemology”, or something like that. Anyway, an epidemiologist studies how a disease behaves, spreads, etc. It is not that I am wearing a T-Shirt that says “I Love Pandemics”, … but that is only because I didn’t find it yet…

There you have it, some new words to drop in any conversation when you’re ordering beers at a bar and try to impress someone. Choose your words wisely though, nobody wants to know about the Endemics in your pants, the Epidemic fail you had at work or the Pandemic boxes you want to open… 

The Black Death

The Plague, aka the black death, aka bad news, is a disease most people only know from their history lessons and the Middle Ages. But it is also hitting the news right now. In Madagascar, last month 30 persons died of the plague, more than 200 are infected. With Dr Eric Bertherat, a WHO epidemiologist in our mind saying “You can become contaminated in the morning and be dead by the evening.” It makes you wonder: is history going to repeat itself?

Today, the plague can be avoided with the right hygienic measures and, if prevention fails, easily treated when diagnosed in time. In Madagascar both are lacking right now. The cause is probably the overcrowded and unhygienic prisons infested with rats and remote rural areas with rats that come out during rain season. And don’t think the prison walls can hold this infection inside. And definitely don’t think those straw-roofed houses can truly keep the rats outside.

So while the health care officials do all they can in Madagascar and try to solve it, let’s understand first what the deal is with this disease and why it is so infamous (by the way, don’t think the plague only shows up in remote African countries. Here is a map of affected regions in 2012).

The disease is transmitted through the bite of a flea from a rat. It can also be transmitted from human to human via contaminated fluids, tissue or droplets to fly through the air like kamikaze pilots. Although, the disease is scary, not to mention the fluids, fleas and rats, the plague is actually a “normal” bacterial infection, just like Chlamydia. It is caused by the bacterium Yersinia pestis, causing the bubonic plague and the plague of the lungs (90% mortality rate of that one). But wait, I hear you think, bacterium, the world has antibiotics to treat those!

Well, not in the late Middle Ages.

In those days, people dreaded the plague even more than people fear Simon Cowell’s verdict these days. Between 1347-1351, the plague was responsible for the death of nearly one third of the entire population of Europe. If this would happen today in Europe, you could drive from the Netherlands – where I was born – to Spain – where we would spend the occasional holiday – without ever seeing a living person. Well, I like to have some peace and quiet, but this was too much. It was the mother of epidemics.

Not only the rats and their fleas were to blame though.

The whole thing supposedly started with the Mongols (from the land Mongolia). They had used the disease to their advantage in 1346 when they wanted to invade the city of Kaffa (Ukraine). During the fight they would shoot the dead bodies of plague victims over the walls of the city using catapults, thus infecting the inhabitants. They must have been some real Angry Birds. The surviving inhabitants of Kaffa fled back to their daddies and mommies who still lived Italy. Through Italy the disease could spread further in Europe.

Venice had a fantastic plan to stop infections after the death of almost half the Venetians during the first half of the outbreak. They implemented the rule that all ships had to remain in the harbor without docking for 40 days. Probably from the 40 days of fasting from the bible. After those 40 days of quarantine, they could step on land.

Quick party conversation “fun”-fact: quarantine derives from the Italian word for 40 which is “quaranta”.

In the meanwhile, the medical school jumped to the opportunity to train the so-called plague doctors. These doctors didn’t wear the classical white coat, but they wore an ankle length black overcoat, black hat (quite stylish I must say) and a beaked mask. This beak was very smart to prevent infection (sure…) but also to eliminate the horrible smell coming from their patients. In the end of the beak they would put herbs and flowers to prevent them from gagging at their patient’s side, because that just isn’t professional.

So, the mask a lot of people wear during carnivals is actually a plague mask. Makes you look slightly different at the crowd, doesn’t it? Or what about the “Eyes Wide Shut” orgy scene? Maybe in 500 years a remake will be made with the future Tom Cruise and Nicole Kidman with the gear we wear today: white coats, chalked gloves and properly sealed mouth caps.

Strange world we will live in.

How an infection becomes an epidemic

After every disaster – man-made or natural – the news gets flooded with warnings about an eminent epidemic of infectious diseases, like for instance cholera. And in all fairness, it is indeed a serious risk. But how does that work?

Many infectious diseases are transmitted from person to person. Either directly by normal contact, sexual intercourse (in both a normal and abnormal way) or blood contact, or indirectly via a mosquito for instance. And this is completely different from all the other causes of illness.

For example:

  • I can’t get diabetes because I had unprotected sex with someone with diabetes whom I just met in a bar after too many Jägerbombs (don’t judge me)
  • The passengers in the bus can’t get kidney stones because someone sits too close to them, it’s just annoying if someone gets in your personal space

To get an infectious disease most of the time you have to actively do or actively not do something. In theory it should be easy to not get infected.

Actively do: if I have unprotected sex I am prone to get infected with all kinds of nasty stuff, so I should have made him wear a condom (I know, easier said than done, but still very effective).

Actively not do: if I stick the needle from someone else in my arm, I am bound to be infected with that person’s blood infections like HIV or hepatitis B (I … have … to … resist …)

Actively do and actively not do: if I don’t wash my hands (so please do) after I touch someone with diarrhea (please don’t, no really don’t), I am likely to infect myself and the persons I get in contact with afterwards.

Sounds simple to protect yourself, doesn’t it? Here’s the catch: in practice it is not always that easy and sometimes nearly impossible. Because what if you can’t get condoms? What if you need an immediate blood transfusion? Or if you don’t have fresh and safe water you can drink and wash your hands with? Let’s use this last example to make it clearer.

Lack of sanitation and fresh water is like throwing a big party for all infectious diseases to come and pick people to infect. You are reading this, so you probably have internet access and thus, most likely, access to clean water from a tap or other resources close by.

But don’t get too comfortable, if a hurricane occurs that destroys your supply, that flushes away your toilet and breaks open your sewer system letting all human waste flood the streets, you too will be in big trouble.

Cholera is one of the many diseases and always present in nature. With good hygiene, clean water, and a good health system it is not a big problem. But without it, cholera is the party animal. It starts with infecting just one or two people. They will soon get the typical heavy diarrhea that’s like pooping rice water all day long (not that I have any experience with it). They will dehydrate and they will die without care.

Unfortunately, this is not the end, cholera is just getting started.

Where is the diarrhea going when the sewer system to flush with it no longer exists? What happens with the buckets that are used to catch the diarrhea? How do you wash your hands after you’ve picked up that bucket? And what about the small children that have no idea what basic hygiene entails? That’s exactly what cholera likes. Easy access to a lot of people that basically have nowhere to hide. It will go from 1 person to 3, to 9, to 27 and so on and so on. Until an entire group that’s living closely together is infected, for instance in the emergency camp that has just been founded after a hurricane.

So, an epidemic is just moments away for all of us if we don’t have basic hygiene and knowledge of the infectious agents. And after a natural disaster it is hard to stay healthy and all the right support needs to be provided as fast as possible.

In all other cases, think about what you can actively do and actively should not do. Go wash your hands, use clean needles and please, don’t kiss a dead person when you don’t know what he or she died of (if not convinced, more about why not to do this will follow soon).

Do this and you’ll probably be fine, … for now.

 

Picture: Refugee camp for Rwandans in Kimbumba, eastern Zaire (current Democratic Republic of the Congo), following the Rwandan genocide.This image is a work of the Centers for Disease Control and Prevention, part of the United States Department of Health and Human Services, taken or made as part of an employee’s official duties. As a work of the U.S. federal government, the image is in the public domain.