Overview

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Overview

• Definitions
• Cholera clinical, epidemiology
• History and pandemics
• Peru diary of Choleras epidemic
• Environmental factors
• Cholera today
• Conclusion

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New insights on the emergence of Cholera in Latin
America during 1991 the Peruvian experience

• C Seas, J Miranda, AI Gil, et. al.
• Am J Trop Med Hyg 2000 62(4)513-7

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Cholera epidemic in Peru, 1991

• Officially started January 23, 1991 in
  Candelaria, a valley near Chancay
• Within a week, cases alongside the 900 km of
  Peruvian coast
• 300,000 cases (peak 45,000/wk)
• Low mortality (1)

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Hypothesis presented

• Ships coming from infected areas
• Contaminated water eliminated to the sea
• V. cholerae non toxigenic acquired virulence
  through phages
• V. cholerae toxigenic was present in low
  concentrations or in viable state but not
  cultivatable

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Our hypothesis

• V. cholerae, originally from the water
  environment, was present in multiples coastal
  places, maybe related with El Niño phenomenon,
  and increased in concentrations enough to produce
  human infection
• This provoked sporadic and dispersed clinical
  cases before the start of the epidemic
• The epidemic continued because of massive water
  and food contamination

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Material and Methods

• Revision of case records and emergency files
• Where? 7 coastal cities and ports (Lima, Chancay,
  Huacho, Chimbote, Trujillo, Chiclayo y Piura)
• Period of study Sep-Jan 1989/90 1990/91
• Case definition patients gt5 years, watery
  diarrhoea and severe dehydration

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Results

• 3640 records reviewed
• 7 people (90/91) fulfill choleras clinical
  definition
• First case identified 4 months before the
  beginning of epidemic
• Comparison diarrhoeal periods 90/91 and 89/90
  no difference between Sep-Jan, high Feb-Mar

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Cases Compatibles

• Date Place Distance (Km)
• 23 Oct 90 Trujillo () 570
• 11 Dec 90 Chimbote 440
• 24 Dec 90 Trujillo
• 26 Dec 91 Chancay 60
• 29 Dec 90 Trujillo
• 13 Jan 91 Lima 0
• 16 Jan 91 Chancay 1050
• 23 Jan 91 Epidemics official beginning
• () Cases identified were from two different
  hospitals

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Discussion (i)

• Majority of infections are asymptomatic
• V. cholerae is associated with phytoplankton and
  zooplankton in sea environment
• V. cholerae O1 (non-toxigenic) and no-O1 have
  been cultivated in this region in the last 15
  years

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Discussion (ii)

• Suggest V. Cholerae was present in Peru at least
  several months before the recognition of the
  epidemic
• Cases alongside the Peruvian north coast explains
  the large dispersion of Vibrio in the environment

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Discussion (iii)

• Dissemination of vibrios possibly related to
  selected plankton populations, increased because
  of El Niño phenomenon1991
• Limitation microbiological confirmation

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• Plankton concentrations during El Niño 82-83 in
  Bangladesh

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Overview

• Definitions
• Cholera clinical, epidemiology
• History and pandemics
• Peru diary of Choleras epidemic
• Environmental factors
• Cholera today
• Conclusion

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en
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Summary

• Rehydration and antibiotics
• Clear links with poverty, instability and
  deprived conditions
• Economical and political actors also play a role
• Still a problem for some groups

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Overview

• Definitions
• Cholera clinical, epidemiology
• History and pandemics
• Peru diary of Choleras epidemic
• Environmental factors
• Cholera today
• Conclusion

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Conclusion

• V cholerae cannot be eradicated it is a part of
  the normal flora an ecology of the surface water
  of our planet. Thus, we have to learn to coexist
  with the vibrios (Sack DA, et al)
• Need to tackle social problems to avoid future
  outbreaks

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Further reading

• Sack DA, et al. Cholera. Lancet 2004363223-33
• Lee K, Dodgson R. Globalization and Cholera
  Implications for Global Governance. Global
  Governance 20006213-36
• Panisset U. International Health Statecraft
  Foreign Policy and Public Health in Perus
  Cholera Epidemic. Lanham University Press of
  America, 2000
• WHO, PAHO