First do no harm: making oral rehydration solution (ORS) safer in a cholera epidemic

Oral rehydration solution (ORS) is lifesaving therapy for cholera and pediatric diarrhea. During a cholera epidemic in Guinea-Bissau, we evaluated the microbiologic quality of ORS prepared at a hospital and tested a simple intervention using special vessels for disinfecting tap water with bleach and for preparing, storing, and dispensing ORS. Few coliform bacteria and Escherichia coli were recovered from tap water; however, pre-intervention ORS contained numerous bacteria including E. coli and toxigenic Vibrio cholerae O1. In contrast, ORS samples from intervention vessels had few or no coliform bacteria, no E. coli, and no V. cholerae. Mean pre-intervention counts of coliform bacteria (3.4 X 10 colony-forming units [cfu]/100 ml) and E. coli (6.2 X10 cfu) decreased significantly during the intervention period to 3.6 X 10 cfu and 0 cfu, respectively (P < 0.001). This simple system using bleach disinfectant and special storage vessels prevents bacterial contamination of ORS and reduces the risk of nosocomial transmission of cholera and other enteric pathogens. Since its discovery in the mid-1960s, oral rehydration solution (ORS), hailed as "the greatest medical discovery of the 20th century,"[1] has become the cornerstone of modern therapy for cholera and pediatric diarrheal disease and has saved countless lives around the world [2]. Despite evidence that enteropathogenic bacteria survive and multiply in ORS [3-5] and that ORS prepared in the developing world is frequently contaminated with these pathogens [6-10] the benefits of administering ORS to dehydrated patients with diarrhea have always been perceived as outweighing the risks.