Contents

Cholera

 Key facts

 Symptoms

 History

 Vibrio cholerae strains

 Risk factors and disease burden

 Prevention and control

 Treatment

 Outbreak response

 Oral cholera vaccines

 Travel and trade

 WHO response

Cancer
 Causes, incidence, and risk factors

 Symptoms

 Signs and tests

 Support Groups

 Expectations (prognosis)

 Complications

 Calling your health care provider

 Prevention

 References
 Cholera
Key facts
 Cholera is an acute diarrhoeal disease that can kill within hours if left untreated.
 There are an estimated 3–5 million cholera cases and 100 000–120 000 deaths due to
cholera every year.

 Up to 80% of cases can be successfully treated with oral rehydration salts.

 Effective control measures rely on prevention, preparedness and response.

 Provision of safe water and sanitation is critical in reducing the impact of cholera and
other waterborne diseases.

 Oral cholera vaccines are considered an additional means to control cholera, but should
not replace conventional control measures.

Cholera is an acute diarrhoeal infection caused by ingestion of food or water contaminated with
the bacterium Vibrio cholerae. Every year, there are an estimated 3–5 million cholera cases and
100 000–120 000 deaths due to cholera. The short incubation period of two hours to five days,
enhances the potentially explosive pattern of outbreaks.

Symptoms

Cholera is an extremely virulent disease. It affects both children and adults and can kill within
hours.

About 75% of people infected with V. cholerae do not develop any symptoms, although the
bacteria are present in their faeces for 7–14 days after infection and are shed back into the
environment, potentially infecting other people.

Among people who develop symptoms, 80% have mild or moderate symptoms, while around
20% develop acute watery diarrhoea with severe dehydration. This can lead to death if untreated.

People with low immunity – such as malnourished children or people living with HIV – are at a
greater risk of death if infected.

History

During the 19th century, cholera spread across the world from its original reservoir in the Ganges
delta in India. Six subsequent pandemics killed millions of people across all continents. The
current (seventh) pandemic started in South Asia in 1961, and reached Africa in 1971 and the
Americas in 1991. Cholera is now endemic in many countries.
Vibrio cholerae strains

Two serogroups of V. cholerae – O1 and O139 – cause outbreaks. V. cholerae O1 causes the
majority of outbreaks, while O139 – first identified in Bangladesh in 1992 – is confined to
South-East Asia.

Non-O1 and non-O139 V. cholerae can cause mild diarrhoea but do not generate epidemics.

Recently, new variant strains have been detected in several parts of Asia and Africa.
Observations suggest that these strains cause more severe cholera with higher case fatality rates.
Careful epidemiological monitoring of circulating strains is recommended.

The main reservoirs of V. cholerae are people and aquatic sources such as brackish water and
estuaries, often associated with algal blooms. Recent studies indicate that global warming creates
a favourable environment for the bacteria.

Risk factors and disease burden

Cholera transmission is closely linked to inadequate environmental management. Typical at-risk

areas include peri-urban slums, where basic infrastructure is not available, as well as camps for
internally displaced people or refugees, where minimum requirements of clean water and
sanitation are not met.

The consequences of a disaster – such as disruption of water and sanitation systems, or the
displacement of populations to inadequate and overcrowded camps – can increase the risk of
cholera transmission should the bacteria be present or introduced. Epidemics have never arisen
from dead bodies.

Cholera remains a global threat to public health and a key indicator of lack of social
development. Recently, the re-emergence of cholera has been noted in parallel with the ever-
increasing size of vulnerable populations living in unsanitary conditions.

The number of cholera cases reported to WHO continues to rise. For 2011 alone, a total of 589
854 cases were notified from 58 countries, including 7816 deaths. Many more cases were
unaccounted for due to limitations in surveillance systems and fear of trade and travel sanctions.
The true burden of the disease is estimated to be 3–5 million cases and 100 000–120 000 deaths
annually.
Prevention and control

A multidisciplinary approach based on prevention, preparedness and response, along with an

efficient surveillance system, is key for mitigating cholera outbreaks, controlling cholera in
endemic areas and reducing deaths.

Treatment

Cholera is an easily treatable disease. Up to 80% of people can be treated successfully through
prompt administration of oral rehydration salts (WHO/UNICEF ORS standard sachet). Very
severely dehydrated patients require administration of intravenous fluids. Such patients also
require appropriate antibiotics to diminish the duration of diarrhoea, reduce the volume of
rehydration fluids needed, and shorten the duration of V. cholerae excretion. Mass administration
of antibiotics is not recommended, as it has no effect on the spread of cholera and contributes to
increasing antimicrobial resistance.

In order to ensure timely access to treatment, cholera treatment centres (CTCs) should be set up
among the affected populations. With proper treatment, the case fatality rate should remain
below 1%.

Outbreak response

Once an outbreak is detected, the usual intervention strategy is to reduce deaths by ensuring
prompt access to treatment, and to control the spread of the disease by providing safe water,
proper sanitation and health education for improved hygiene and safe food handling practices by
the community. The provision of safe water and sanitation is a formidable challenge but remains
the critical factor in reducing the impact of cholera.

Oral cholera vaccines

There are two types of safe and effective oral cholera vaccines currently available on the market.
Both are whole-cell killed vaccines, one with a recombinant B-sub unit, the other without. Both
have sustained protection of over 50% lasting for two years in endemic settings.

Both vaccines are WHO-prequalified and licensed in over 60 countries. Dukoral has been shown
to provide short-term protection of 85–90% against V. cholerae O1 among all age groups at 4–6
months following immunization.

The other vaccine (Shanchol) provides longer-term protection against V. cholerae O1 and O139
in children under five years of age.
Both vaccines are administered in two doses given between seven days and six weeks apart. The
vaccine with the B-subunit (Dukoral) is given in 150 ml of safe water.

WHO recommends that immunization with currently available cholera vaccines be used in
conjunction with the usually recommended control measures in areas where cholera is endemic
as well as in areas at risk of out breaks. Vaccines provide a short term effect while longer term
activities like improving water and sanitation are put in place.

When used, vaccination should target vulnerable populations living in high risk areas and should
not disrupt the provision of other interventions to control or prevent cholera epidemics. The
WHO 3-step decision making tool aims at guiding health authorities in deciding whether to use
cholera vaccines in complex emergency settings.

The use of the parenteral cholera vaccine has never been recommended by WHO due to its low
protective efficacy and the high occurrence of severe adverse reactions.

Travel and trade

Today, no country requires proof of cholera vaccination as a condition for entry. Past experience
shows that quarantine measures and embargoes on the movement of people and goods are
unnecessary. Isolated cases of cholera related to imported food have been associated with food in
the possession of individual travellers. Consequently, import restrictions on food produced under
good manufacturing practices, based on the sole fact that cholera is epidemic or endemic in a
country, are not justified.

Countries neighboring cholera-affected areas are encouraged to strengthen disease surveillance

and national preparedness to rapidly detect and respond to outbreaks should cholera spread
across borders. Further, information should be provided to travellers and the community on the
potential risks and symptoms of cholera, together with precautions to avoid cholera, and when
and where to report cases.

WHO response

Through the WHO Global Task Force on Cholera Control, WHO works to:

 provide technical advice and support for cholera control and prevention at country level
 train health professionals at national, regional and international levels in prevention,
preparedness and response of diarrhoeal disease outbreaks

 disseminate information and guidelines on cholera and other epidemic-prone enteric

diseases to health professionals and the general public.
 Cancer
Cancer is the uncontrolled growth of abnormal cells in the body. Cancerous cells are also called
malignant cells.

Causes, incidence, and risk factors

Cancer grows out of normal cells in the body. Normal cells multiply when the body needs them,
and die when the body doesn't need them. Cancer appears to occur when the growth of cells in
the body is out of control and cells divide too quickly. It can also occur when cells forget how to
die.

There are many different kinds of cancer. Cancer can develop in almost any organ or tissue, such
as the lung, colon, breast, skin, bones, or nerve tissue.

There are many causes of cancer, including:

 Benzene and other chemicals

 Drinking excess alcohol

 Environmental toxins, such as certain poisonous mushrooms and a type of poison that can
grow on peanut plants (aflatoxins)

 Excessive sunlight exposure

 Genetic problems

 Obesity

 Radiation

 Viruses

However, the cause of many cancers remains unknown.

The most common cause of cancer-related death is lung cancer.

The three most common cancers in men in the United States are:

 Prostate cancer
 Lung cancer

 Colon cancer
In women in the United States, the three most common cancers are:

 Breast cancer
 Colon cancer

 Lung cancer

Some cancers are more common in certain parts of the world. For example, in Japan, there are
many cases of stomach cancer, but in the United States, this type of cancer is unusual.
Differences in diet or environmental factors may play a role.

Some other types of cancers include:

 Brain cancer
 Cervical cancer

 Hodgkin's lymphoma

 Kidney cancer

 Leukemia

 Liver cancer

 Non-Hodgkin's lymphoma

 Ovarian cancer

 Skin cancer

 Testicular cancer

 Thyroid cancer

 Uterine cancer

Symptoms

Symptoms of cancer depend on the type and location of the cancer. For example, lung cancer can
cause coughing, shortness of breath, or chest pain. Colon cancer often causes diarrhea,
constipation, and blood in the stool.

Some cancers may not have any symptoms at all. In certain cancers, such as pancreatic cancer,
symptoms often do not start until the disease has reached an advanced stage.

The following symptoms can occur with most cancers:

  Chills
 Fatigue

 Fever

 Loss of appetite

 Malaise

 Night sweats

 Weight loss

Signs and tests

Like symptoms, the signs of cancer vary based on the type and location of the tumor. Common
tests include the following:

 Biopsy of the tumor

 Blood tests (which look for chemicals such as tumor markers)

 Bone marrow biopsy (for lymphoma or leukemia)

 Chest x-ray

 Complete blood count (CBC)

 CT scan

 Liver function tests

 MRI scan

Most cancers are diagnosed by biopsy. Depending on the location of the tumor, the biopsy may
be a simple procedure or a serious operation. Most patients with cancer have CT scans to
determine the exact location and size of the tumor or tumors.

A cancer diagnosis is difficult to cope with. It is important, however, that you discuss the type,
size, and location of the cancer with your doctor when you are diagnosed. You also will want to
ask about treatment options, along with their benefits and risks.

It's a good idea to have someone with you at the doctor's office to help you get through the
diagnosis. If you have trouble asking questions after hearing about your diagnosis, the person
you bring with you can ask them for you.
Treatment

Treatment varies based on the type of cancer and its stage. The stage of a cancer refers to how
much it has grown and whether the tumor has spread from its original location.

 If the cancer is confined to one location and has not spread, the most common treatment
approach is surgery to cure the cancer. This is often the case with skin cancers, as well as
cancers of the lung, breast, and colon.
 If the tumor has spread to local lymph nodes only, sometimes these can be removed.

 If surgery cannot remove all of the cancer, the options for treatment include radiation,
chemotherapy, or both. Some cancers require a combination of surgery, radiation, and
chemotherapy.

 Lymphoma, or cancer of the lymph glands, is rarely treated with surgery. Chemotherapy
and radiation therapy are most often used to treat lymphoma.

Although treatment for cancer can be difficult, there are many ways to keep up your strength.

If you have radiation treatment, know that:

 Radiation treatment is painless.

 Treatment is usually scheduled every weekday.

 You should allow 30 minutes for each treatment session, although the treatment itself
usually takes only a few minutes.

 You should get plenty of rest and eat a well-balanced diet during the course of your
radiation therapy.

 Skin in the treated area may become sensitive and easily irritated.

 Side effects of radiation treatment are usually temporary. They vary depending on the
area of the body that is being treated.

If you are going through chemotherapy, you should eat right. Chemotherapy causes your
immune system to weaken, so you should avoid people with colds or the flu. You should also get
plenty of rest, and don't feel as though you have to accomplish tasks all at once.

It will help you to talk with family, friends, or a support group about your feelings. Work with
your health care providers throughout your treatment. Helping yourself can make you feel more
in control.
Support Groups
The diagnosis and treatment of cancer often causes a lot of anxiety and can affect a person's
entire life. There are many resources for cancer patients.

Expectations (prognosis)

The outlook depends on the type of cancer and the stage of the cancer when diagnosed.

Some cancers can be cured. Other cancers that are not curable can still be treated effectively.
Some patients can live for many years with cancer. Other tumors are quickly life threatening.

Complications
Complications depend on the type and stage of cancer. The cancer may spread.

Calling your health care provider

Contact your health care provider if you develop symptoms of cancer.

Prevention

You can reduce the risk of getting a cancerous (malignant) tumor by:

 Eating a healthy diet

 Exercising regularly

 Limiting alcohol

 Maintaining a healthy weight

 Minimizing your exposure to radiation and toxic chemicals

 Not smoking or chewing tobacco

 Reducing sun exposure, especially if you burn easily

Cancer screenings, such as mammography and breast examination for breast cancer and
colonoscopy for colon cancer, may help catch these cancers at their early stages when they are
most treatable. Some people at high risk for developing certain cancers can take medication to
reduce their risk.

References
1. Moscow JA, Cowan KH. Biology of cancer. In Goldman L, SchaferAI, eds. Cecil
Medicine. 24th ed. Philadelphia, Pa: Saunders Elsevier;2011:chap 185.
2. Thun MJ, Jemal A. Epidemiology of cancer. In Goldman L,Schafer AI, eds. Cecil
Medicine. 24th ed. Philadelphia, Pa: Saunders Elsevier;2011:chap 183.

3. WHO Media Centre