The primary necessity for survival is the availability of air. Once you have air to breathe, water, food, and shelter become the next requirements for your continued existence on the planet; that is, clean water and properly prepared food.
Even in normal times, there are many instances where an outbreak of infectious disease occurs due to water of poor quality. Ingesting food that was incompletely cooked caused the deaths of medieval kings in medieval times and may even have sparked the Ebola epidemic in 2014.
Epidemics caused by organisms that cause severe diarrhea and dehydration have been a part of the human experience since before recorded history. If severe enough, dehydration can cause hypovolemic shock, organ failure, and death. Indeed, during the Civil War, more deaths were attributed to dehydration from infectious diseases than from bullets or shrapnel.
Off the grid, water used for drinking or cooking can be contaminated by anything from floods to a dead opossum upstream from your camp. This can have dire implications for those living where there is no access to large amounts of IV hydration.
Therefore, it stands to reason that the preparation of food and the disinfection of drinking water should be under supervision. In survival, this responsibility should fall to the community medic; it is the medic that will (after the patient, of course) be most impacted by failure to maintain good sanitation.
Many diseases have disastrous intestinal consequences leading to dehydration. They include:
Cholera: Caused by the marine and freshwater bacterium Vibrio cholera, Cholera has been the cause of many deaths in both the distant and recent past. It may, once again, be an issue in the uncertain future.
Cholera toxins produce a rapid onset of diarrhea and vomiting within a few hours to 2 days of infection. Victims often complain of leg cramps. The body water loss with untreated cholera is associated with a sixty per cent death rate. Aggressive efforts to rehydrate the patient, however, drops the death rate to only one per cent. Antibiotic therapy with doxycycline or tetracycline seems to shorten the duration of illness.
Typhus: A complex of diseases caused by bacteria in the Rickettsia family, Typhus is transmitted by fleas and ticks to humans in unsanitary surroundings, and is mentioned here due to its frequent confusion with “Typh-oid” fever, a disease caused by contaminated, undercooked food.
Although it rarely causes severe diarrhea, Typhus can cause significant dehydration due to high fevers and other flu-like symptoms. Five to nine days after infection, a rash begins on the torso and spreads to the extremities, sparing the face, palm, and soles. Doxycycline is the drug of choice for this disease.
Typhoid: Infection with the bacteria Salmonella typhi is called “Typh-oid fever”, because it is often confused with Typhus. Contamination with Salmonella in food occurs more often than with any other bacteria in the United States.
In Typhoid fever, there is a gradual onset of high fevers over the course of several days. Abdominal pain, intestinal hemorrhage, weakness, headaches, constipation, and bloody diarrhea may occur. A number of people develop a spotty, rose-colored rash. Ciprofloxacin is the antibiotic of choice but most victims improve with rehydration therapy.
Dysentery: An intestinal inflammation in the large intestine that presents with fever, abdominal pain, and severe bloody or watery mucus diarrhea. Symptoms usually begin one to three days after exposure. Dysentery, a major cause of death among Civil War soldiers, is a classic example of a disease that can be prevented with strict hand hygiene after bowel movements.
The most common form of dysentery in North America and Europe is caused by the bacteria Shigella and is called “bacillary dysentery”. It is spread through contaminated food and water, and crowded unsanitary conditions. Ciprofloxacin and Sulfa drugs, in conjunction with oral rehydration, are effective therapies.
Another type is caused by an organism you may have read about in science class: the amoeba, a protozoan known as Entamoeba histolytica. Amoebic dysentery is more commonly seen in warmer climates. Metronidazole is the antibiotic of choice.
Traveler’s Diarrhea: An inflammation of the small intestine most commonly caused by the Bacterium Escherichia coli (E. coli). Most strains of this bacteria are normal inhabitants of the human intestinal tract, but one (E. coli O157:H7) produces a toxin (the “Shiga” toxin) that can cause severe “food poisoning”. The Shiga toxin has even been classified as a bioterror agent.
In this illness, sudden onset of watery diarrhea, often with blood, develops within one to three days of exposure accompanied by fever, gas, and abdominal cramping. Rapid rehydration and treatment with antibiotics such as Azithromycin and Ciprofloxacin is helpful. The CDC no longer recommends taking antibiotics in advance of a journey, but does suggest that Pepto-Bismol or Kaopectate (Bismuth Subsalicylate), two tablets four times a day, may decrease the likelihood of Traveler’s Diarrhea.
Campylobacter: The second most common cause of foodborne illness in the U.S. after Salmonella, this bacteria resides in the intestinal tract of chickens and causes sickness when meat is undercooked or improperly processed. It’s thought that a significant percentage of retail poultry products contain colonies of one variety, Campylobacter Jejuni. It is characterized as bloody diarrhea, fever, nausea, and cramping which begins two to five days after exposure. Although controversial, Erythromycin may decrease the duration of illness if taken early.
Trichinosis: Trichinosis is caused by the parasitic roundworm Trichinella in undercooked meat, mostly from domesticated pigs. Trichinosis causes diarrhea and other intestinal symptoms, usually starting one to two days after exposure. Fever, headache, itchiness, muscle pains, and swelling around the eyes occur up to 2 weeks later. Recovery is usually slow, even with treatment with the anti-helminthic (anti-worm) drugs Mebendazole and Albendazole (Albenza).
Giardiasis: The most common disease-causing parasite in the world is the protozoa Giardia lamblia. It has even been found in backcountry waters in many national parks in the U.S. Symptoms may present as early as one day after exposure, although it more commonly presents in one to two weeks. Patients complain of watery diarrhea, abdominal cramping, violent (often called “projectile”) vomiting, and gas. Metronidazole is the drug of choice in conjunction with oral rehydration.
There are many other pathogens that can cause life-threatening dehydration if untreated. Although we have mentioned common antibiotic treatments where applicable, most of the above will resolve on their own over time with strict attention to oral (or intravenous) rehydration. Many antibiotics (Cipro is an example) are associated with adverse effects that can be worse than the illness they’re designed to treat, so use judiciously.
It should be noted that some of these illnesses may be mimicked by viruses that are completely unaffected by antibiotics, such as Norovirus. Norovirus has been implicated in many of the outbreaks you read about on cruise ships.
Air, food, water, and shelter is necessary for survival. Bad air, food, water, and shelter leads to the next requirement, and that is medical supplies. Have a good medical kit and know how to use all its components. If you can accomplish this goal, you’ll be an effective medic if things go South.
Joe Alton MD
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