cholera n : an acute intestinal infection caused by ingestion of contaminated water or food [syn: Asiatic cholera, Indian cholera, epidemic cholera]
EtymologyLatin from Greek χολή (bile).
Cholera, sometimes known as Asiatic cholera or epidemic cholera, is an infectious gastroenteritis caused by the bacterium Vibrio cholerae. Transmission to humans occurs through the process of ingesting contaminated water or food. The major reservoir for cholera was long assumed to be humans themselves, but considerable evidence exists that aquatic environments can serve as reservoirs of the bacteria.
Vibrio cholerae is a Gram-negative bacterium that produces cholera toxin, an enterotoxin, whose action on the mucosal epithelium lining of the small intestine is responsible for the characteristic massive diarrhoea of the disease. In its most severe forms, cholera is one of the most rapidly fatal illnesses known, and a healthy person may become hypotensive within an hour of the onset of symptoms; infected patients may die within three hours if treatment is not provided. In a common scenario, the disease progresses from the first liquid stool to shock in 4 to 12 hours, with death following in 18 hours to several days without oral rehydration therapy.
SymptomsThe diarrhoea associated with cholera is acute and so severe that, unless oral rehydration therapy is started promptly, the diarrhoea may within hours result in severe dehydration (a medical emergency), or even death.
According to novelist Susan Sontag, cholera was more feared than some other deadly diseases because it dehumanized the victim. Diarrhoea and dehydration were so severe the victim could literally shrink into a wizened caricature of his or her former self before death.
Other symptoms include rapid dehydration, rapid pulse, dry skin, tiredness, abdominal cramps, nausea, and vomiting.
Traditionally, Cholera was widespread throughout third world countries, however more recently outbreaks have occurred in more rural parts of England and the United States' mid-west region.
TreatmentWater and electrolyte replacement are essential treatments for cholera, as dehydration and electrolyte depletion occur rapidly. Prompt use of oral rehydration therapy is highly effective, safe, uncomplicated, and inexpensive.
The use of intravenous rehydration may be absolutely necessary in severe cases, under some conditions.
In addition, tetracycline is typically used as the primary antibiotic, although some strains of V. cholerae exist that have shown resistance. Other antibiotics that have been proven effective against V. cholerae include cotrimoxazole, erythromycin, doxycycline, chloramphenicol, and furazolidone. Fluoroquinolones such as norfloxacin also may be used, but resistance has been reported.
Rapid diagnostic assay methods are available for the identification of multidrug resistant V. cholerae. New generation antimicrobials have been discovered which are effective against V. cholerae in in vitro studies.
PreventionAlthough cholera can be life-threatening, prevention of the disease is straightforward if proper sanitation practices are followed. In the first world, due to advanced water treatment and sanitation systems, cholera is no longer a major health threat. The last major outbreak of cholera in the United States occurred in 1911. Travelers should be aware of how the disease is transmitted and what can be done to prevent it. Good sanitation practices, if instituted in time, are usually sufficient to stop an epidemic. There are several points along the transmission path at which the spread may be halted:
- Sterilization: Proper disposal and treatment of the germ infected fecal waste (and all clothing and bedding that come in contact with it) produced by cholera victims is of primary importance. All materials (such as clothing and bedding) that come in contact with cholera patients should be sterilized in hot water using chlorine bleach if possible. Hands that touch cholera patients or their clothing and bedding should be thoroughly cleaned and sterilized.
- Sewage: Treatment of general sewage before it enters the waterways or underground water supplies prevents undiagnosed patients from spreading the disease.
- Sources: Warnings about cholera contamination posted around contaminated water sources with directions on how to decontaminate the water.
- Water purification: All water used for drinking, washing, or cooking should be sterilized by boiling or chlorination in any area where cholera may be present. Boiling, filtering, and chlorination of water kill the bacteria produced by cholera patients and prevent infections from spreading. Water filtration, chlorination, and boiling are by far the most effective means of halting transmission. Cloth filters, though very basic, have significantly reduced the occurrence of cholera when used in poor villages in Bangladesh that rely on untreated surface water. Public health education and appropriate sanitation practices can help prevent transmission.
A vaccine is available outside the US, but this prophylactic is short-lived in efficacy and not currently recommended by the CDC.
SusceptibilityRecent epidemiologic research suggests that an individual's susceptibility to cholera (and other diarrhoeal infections) is affected by their blood type: Those with type O blood are the most susceptible, while those with type AB are the most resistant. Between these two extremes are the A and B blood types, with type A being more resistant than type B.
About one million V. cholerae bacteria must typically be ingested to cause cholera in normally healthy adults, although increased susceptibility may be observed in those with a weakened immune system, individuals with decreased gastric acidity (as from the use of antacids), or those who are malnourished.
It has also been hypothesized that the cystic fibrosis genetic mutation has been maintained in humans due to a selective advantage: heterozygous carriers of the mutation (who are thus not affected by cystic fibrosis) are more resistant to V. cholerae infections. In this model, the genetic deficiency in the cystic fibrosis transmembrane conductance regulator channel proteins interferes with bacteria binding to the gastrointestinal epithelium, thus reducing the effects of an infection.
Persons infected with cholera have massive diarrhoea. This highly-liquid diarrhoea is loaded with bacteria that can spread to infect water used by other people. Cholera is transmitted from person to person through ingestion of water contaminated with the cholera bacterium, usually from feces or other effluent. The source of the contamination is typically other cholera patients when their untreated diarrhoea discharge is allowed to get into waterways or into groundwater or drinking water supply. Any infected water and any foods washed in the water, as well as shellfish living in the affected waterway, can cause an infection. Cholera is rarely spread directly from person to person. V. cholerae harbors naturally in the plankton of fresh, brackish, and salt water, attached primarily to copepods in the zooplankton. Both toxic and non-toxic strains exist. Non-toxic strains can acquire toxicity through a lysogenic bacteriophage. Coastal cholera outbreaks typically follow zooplankton blooms, thus making cholera a zoonotic disease.
Laboratory diagnosisStool and swab samples collected in the acute stage of the disease, before antibiotics have been administered, are the most useful specimens for laboratory diagnosis. A number of special media have been employed for the cultivation for cholera vibrios. They are classified as follows:
Holding or transport media
- Venkataraman-ramakrishnan (VR) medium: This medium has 20g Sea Salt Powder and 5g Peptone dissolved in 1L of distilled water.
- Cary-Blair medium: This the most widely-used carrying media. This is a buffered solution of sodium chloride, sodium thioglycollate, disodium phosphate and calcium chloride at pH 8.4.
- Autoclaved sea water'
- Alkaline peptone water at pH 8.6
- Monsur's taurocholate tellurite peptone water at pH 9.2
- Alkaline bile salt agar (BSA): The colonies are very similar to those on nutrient agar.
- Monsur's gelatin Tauro cholate trypticase tellurite agar (GTTA) medium: Cholera vibrios produce small translucent colonies with a greyish black centre.
- TCBS medium'': This the mostly widely used medium. This medium contains thiosulphate, citrate, bile salts and sucrose. Also in oysters and lobster in some cases. Cholera vibrios produce flat 2-3 mm in diameter, yellow nucleated colonies.
Direct microscopy of stool is not recommended as it is unreliable. Microscopy is preferred only after enrichment, as this process reveals the characteristic motility of Vibrios and its inhibition by appropriate antiserum. Diagnosis can be confirmed as well as serotyping done by agglutination with specific sera.
Biochemistry of the V. cholerae bacteriumMost of the V. cholerae bacteria in the contaminated water that a host drinks do not survive the very acidic conditions of the human stomach. The few bacteria that do survive conserve their energy and stored nutrients during the passage through the stomach by shutting down much protein production. When the surviving bacteria exit the stomach and reach the small intestine, they need to propel themselves through the thick mucus that lines the small intestine to get to the intestinal wall where they can thrive. V. cholerae bacteria start up production of the hollow cylindrical protein flagellin to make flagella, the curly whip-like tails that they rotate to propel themselves through the mucous that lines the small intestine.
Once the cholera bacteria reach the intestinal wall, they do not need the flagella propellers to move themselves any longer. The bacteria stop producing the protein flagellin, thus again conserving energy and nutrients by changing the mix of proteins that they manufacture in response to the changed chemical surroundings. On reaching the intestinal wall, V. cholerae start producing the toxic proteins that give the infected person a watery diarrhoea. This carries the multiplying new generations of V. cholerae bacteria out into the drinking water of the next host—if proper sanitation measures are not in place.
Microbiologists have studied the genetic mechanisms by which the V. cholerae bacteria turn off the production of some proteins and turn on the production of other proteins as they respond to the series of chemical environments they encounter, passing through the stomach, through the mucous layer of the small intestine, and on to the intestinal wall. Of particular interest have been the genetic mechanisms by which cholera bacteria turn on the protein production of the toxins that interact with host cell mechanisms to pump chloride ions into the small intestine, creating an ionic pressure which prevents sodium ions from entering the cell. The chloride and sodium ions create a salt water environment in the small intestines which through osmosis can pull up to six liters of water per day through the intestinal cells creating the massive amounts of diarrhoea.The host can become rapidly dehydrated if an appropriate mixture of dilute salt water and sugar is not taken to replace the blood's water and salts lost in the diarrhoea.
By inserting separately, successive sections of V. cholerae DNA into the DNA of other bacteria such as E. coli that would not naturally produce the protein toxins, researchers have investigated the mechanisms by which V. cholerae responds to the changing chemical environments of the stomach, mucous layers, and intestinal wall. Researchers have discovered that there is a complex cascade of regulatory proteins that control expression of V. cholerae virulence determinants. In responding to the chemical environment at the intestinal wall, the V. cholerae bacteria produce the TcpP/TcpH proteins, which, together with the ToxR/ToxS proteins, activate the expression of the ToxT regulatory protein. ToxT then directly activates expression of virulence genes that produce the toxins that cause diarrhoea in the infected person and that permit the bacteria to colonize the intestine. Current research aims at discovering "the signal that makes the cholera bacteria stop swimming and start to colonize (that is, adhere to the cells of) the small intestine."
Origin and spreadCholera was originally endemic to the Indian subcontinent, with the Ganges River likely serving as a contamination reservoir. The disease spread by trade routes (land and sea) to Russia, then to Western Europe, and from Europe to North America. Cholera is now no longer considered a pressing health threat in Europe and North America due to filtering and chlorination of water supplies, but affects heavily the developing countries populations.
- 1816-1826 - First cholera pandemic: Previously restricted, the pandemic began in Bengal, and then spread across India by 1820. The cholera outbreak extended as far as China and the Caspian Sea before receding.
- 1829-1851 - Second cholera pandemic reached Europe, London and Paris in 1832. In London, the disease claimed 6,536 victims; in Paris, 20,000 succumbed (out of a population of 650,000) with about 100,000 deaths in all of France. The epidemic reached Russia (see Cholera Riots), Quebec, Ontario and New York in the same year and the Pacific coast of North America by 1834.
- 1849 - Second major outbreak in Paris. In London, it was the worst outbreak in the city's history, claiming 14,137 lives, over twice as many as the 1832 outbreak. In 1849 cholera claimed 5,308 lives in the port city of Liverpool, England, and 1,834 in Hull, England.
- 1863-1875 - Fourth cholera pandemic spread mostly in Europe and Africa.
- 1866 - Outbreak in North America. In London, a localized epidemic in the East End claimed 5,596 lives just as London was completing its major sewage and water treatment systems--the East End was not quite complete. William Farr, using the work of John Snow et al. as to contaminated drinking water being the likely source of the disease, was able to relatively quickly identify the East London Water Company as the source of the contaminated water. Quick action prevented further deaths.
Other famous people who succumbed to the disease include:
- Major General Edward Hand, Adjutant General of the Continental Army and congressman
- James K. Polk, eleventh president of the United States
- Mary Abigail Fillmore, daughter of U.S. president Millard Fillmore
- Elizabeth Jackson, mother of U.S. president Andrew Jackson
- Elliott Frost, son of American poet Robert Frost
- Nicolas Léonard Sadi Carnot
- Georg Wilhelm Friedrich Hegel
- Samuel Charles Stowe, son of Harriet Beecher Stowe
- Carl von Clausewitz
- George Bradshaw
- Adam Mickiewicz
- August von Gneisenau
- William Jenkins Worth
- John Blake Dillon
- Daniel Morgan Boone, founder of Kansas City, Missouri, son of Daniel Boone
- James Clarence Mangan
- Mohammad Ali Mirza Dowlatshahi of Persia
- Ando Hiroshige, Japanese ukiyo-e woodblock print artist.
- Juan de Veramendi, Mexican Governor of Texas, father-in-law of Jim Bowie
- Grand Duke Constantine Pavlovich of Russia
- William Shelley, son of Mary Shelley
- William Godwin, father of Mary Shelley
- Judge Daniel Stanton Bacon, father-in-law of George Armstrong Custer
- Inessa Armand, mistress of Lenin and the mother of Andre, his son.
- Honinbo Shusaku, famous go player.
- Henry Louis Vivian Derozio, Eurasian Portuguese Poet and Teacher. Resided in India.
- Alexandre Dumas, père, French author of The Three Musketeers and The Count of Monte Cristo, also contracted cholera in the 1832 Paris epidemic and almost died, before he wrote these two novels.
- Charles X of France
ResearchOne of the major contributions to fighting cholera was made by physician and self-trained scientist John Snow (1813-1858), who found the link between cholera and contaminated drinking water in 1854. In 1885, there was a torrential rainstorm that flushed the Chicago river and its attendant pollutants into Lake Michigan far enough that the city's water supply was contaminated. However, because cholera was not present in the city, there were no cholera-related deaths, though the incident caused the city to become more serious about its sewage treatment.
Cholera morbusThe term cholera morbus was used in the 19th and early 20th centuries to describe both non-epidemic cholera and other gastrointestinal diseases (sometimes epidemic) that resembled cholera. The term is not in current use, but is found in many older references. The other diseases are now known collectively as gastroenteritis.
Other historical informationIn the past, people traveling in ships would hang a yellow flag if one or more of the crew members suffered from cholera. Boats with a yellow flag hung would not be allowed to disembark at any harbor for an extended period, typically 30 to 40 days. '''
- Johnson, S.(2006) The Ghost Map: a street, an epidemic and the two men who battled to save Victorian London Penguin
- The Painted Veil (2006 film), starring Naomi Watts and Edward Norton, in which the disease cholera is a prominent subject.
- Cholera - World Health Organization
- What is Cholera? - Centers for Disease Control and Prevention
- Cholera information for travelers - Centers for Disease Control and Prevention
- Steven Shapin, "Sick City: Maps and mortality in the time of cholera", The New Yorker May 2006. A review of Steven Johnson, “The Ghost Map: The Story of London’s Most Terrifying Epidemic — and How It Changed Science, Cities, and the Modern World”
- Cholera Epidemic in NYC in 1832 NYTimes April 15 2008
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