EPIDEMIC CHOLERA IN THE AMAZON - THE CHALLENGE OF PREVENTING DEATH

Epidemic cholera struck Peru in January 199 1, and spread rapidly. The national cholera case-fatality rate (CFR) was less than 1% in the fir st six months of the epidemic, but in some rural areas, the CFR exceed ed 10%. We investigated cholera mortality in the rural Amazon region, an area with a CFR of 6.3%. We conducted a case-control study, compari ng 29 decedents with 61 survivors of recent cholera-like diarrheal ill ness in 12 villages with a combined CFR of 13.5%. Of 29 decedents, 28 (96%) died in the village or en route to a health facility. Death occu rred within 36 hours of illness onset for 83% of the decedents. In 11 (92%) villages, the first or second recognized case was fatal. Death w as associated with receiving treatment only at home (odds ratio indete rminate; 95% confidence interval 3.5, indeterminate). Treatment with o ral rehydration salts (ORS) was not protective against death for patie nts who received treatment only at home. Treatment with homemade sugar -salt solution (SSS) was also not protective; fewer than one-third of respondents knew the correct SSS recipe. Most decedents experienced mu ltiple barriers to health care. Cholera victims died rapidly and early in village outbreaks, and few patients had access to health care. Pro vision of threatened villages with ORS supplies and education in their use before cholera strikes is essential to reducing cholera mortality in this region.