Between Life and Death Fr. Scott Binet MD, MI CTF-SOS D RS Sao Paulo, Brazil - October 20, 2011

Inform you about cholera and what the Camillians are doing to respond to the signs of the times through disaster relief Sensitize you to the suffering of those affected by man- made and natural disasters such as cholera Inspire you to get involved and dialogue amongst yourselves and with me about how we might collaborate in disaster relief

Cholera Between Life and Death

Presentation Outline 1.Summary of Cholera 2.Introduction to the Camillian Task Force (CTF) 3.A Convergence Camillians, Disasters and Risk 4.Disasters and Cholera - the World, Brazil 5.Cholera Cause, Symptoms, Treatment, Prognosis 6.The Cholera Epidemic in Haiti 7.Questions/Comments

Cholera - Summary Cholera is an infection of the small intestine that is caused by the bacterium Vibrio cholerae. Transmission occurs primarily when drinking water or food is contaminated by the diarrhea from an infected person or by the feces of an infected but asymptomatic person. The main symptoms are profuse watery diarrhea and vomiting. The severity of the diarrhea and vomiting can lead to rapid dehydration and electrolyte imbalance. Primary treatment is with oral rehydration solution (ORS) and if this is not tolerated, intravenous fluids. Antibiotics are beneficial in those with severe disease. Worldwide it is estimated to affect 35 million people and causes 100,000130,000 deaths a year as of 2010. Cholera was one of the earliest infections to be studied by epidemiological methods.

Camillians and Disasters

Core Ministers of the Infirm (Camillians) CTF Central SOS D RS *Missionaries of Mercy* Camillian Task Force A Network Caritas Archdiocese of Miami, USA Archdiocese of Port au Prince, Haiti Misericordiae CRS Missionaries of Charity ? Church and State Italian Episcopal Conference ?

CTF - SOS D RS A Vision To be Jesus merciful presence to the neediest of the needy who are suffering from man-made and natural disasters. To respond globally through a community-based, Eucharist-centered, Marian-inspired disaster relief organization.

CTF - SOS D RS A Mission To witness the merciful love of Christ for the poor and the sick in word, deed, and sacrament To serve the medical, pastoral, educational and humanitarian needs of people affected by man-made and natural disasters regardless of race, religion, or ethnicity.

Camillian Task Force 1- [SOS DRS Office]SOS DRS Office 2 [Haiti - Earthquake, Cholera, Hurricane, Slum] 3 - Italy [CTF Central/Earthquake] 4 - Horn of Africa [Famine] 5 - Pakistan [Floods] 6 - Thailand6 - Thailand [Floods]

A Convergence - Camillians, Disasters, Risk Camillians A Family Ready to Respond

A Convergence - Camillians, Disasters, Risk People at Risk - Globally People are Underprepared for Disasters Urbanization Increasing Numbers of Slums Underdeveloped Social Factors Spiritual, Societal and Family Deterioration Decreased Resilience, Mans Inhumanity to Man Global Warming - Deteriorating Environment People Live in Risk by Necessity and By Choice Lack of Early Warning Signs and Unpredictable Weather Increasing Number of Refugees and Internally Displaced

The Signs of the Times People at Risk Urbanization - The United Nations projected that half of the world's population would live in urban areas or cities at the end of 2008 2008 50%

The Signs of the Times People at Risk Increasing Numbers of Slums - The number of people living out their days in the squalor of a slum is almost one billion, the United Nations says - one-sixth of the world's population. By 2050, the UN says, there may be 3.5 billion slum dwellers, out of a total urban population of about six billion. Kibera Slum in Nairobi, Kenya

The Signs of the Times People at Risk Underdeveloped Social Factors - The earthquake in Chile was 1,000 times more powerful than that in Haiti where 230,000 people died, many more than in Chile. Social factors are much more important than geological when determining the vulnerability of people to a disaster like an earthquake. Haiti - January 12 Presidential PalaceChile February 27, 2010 Pelluhue

The Signs of the Times People at Risk Social factors include : 1. The economy of a country 2. The healthcare infrastructure 3. Presence of integrated emergency management system 4. Previous experience of handling disasters 5. Emergency plan 6. Educational level of the population 7. Availability of basic necessities: clean water, housing, etc. 8. The government effectiveness, trustworthiness

The Signs of the Times People at Risk People in Risk by Necessity and by ChoicePeople in Risk by Necessity and by Choice [:00-35; 6:15-7:10] Pakistan Floods 2010

The Signs of the Times People at Risk - Increasing Number of Refugees and Internally Displaced Tent City in the Slum of Solino, Port au Prince, Haiti

A Convergence - Camillians and Disasters Increasing Incidence and Severity of Disasters Disaster A serious disruption of the functioning of a community or a society causing widespread human, material, economic, or environmental losses that exceed the ability of the affected community or society to cope using its own resources.

Disasters Increasing in Incidence and Severity

Cholera Between Life and Death Seven Cholera Pandemics 1.In the past 200 hundred years, seven cholera pandemics have killed millions across the globe. 2.The seventh pandemic is still going on since 1961, but advancements in medical science have greatly reduced the number of people who die from it. 3. Modern-day sewage and water treatment systems have largely eliminated cholera from developed countries. But it continues to be a concern in the developing world, especially in areas ravaged by war and natural disasters such as earthquakes and hurricanes that leave people without access to clean drinking water.

The first epidemic in Brazil? Cholera Between Life and Death Black Death in Brazil - 1855-1856 (Part of the 3 rd Cholera Pandemic) Cholera Strikes Brazil Again - 1991-1998 The last epidemic in Brazil? Brazil and Cholera ( Part of the 7 th Cholera Pandemic)

Cholera 1 st Pandemic 1817-1823 1817 First known pandemic of cholera originated in the Ganges River delta in India. The disease broke out near Calcutta. Hundreds of thousands died.

Cholera 1 st Pandemic 1817-1823 1820 Based on the 10,000 recorded deaths among British troops, researchers estimate that hundreds of thousands across India, Southeast Asia, Central Asia, the Middle East, Eastern Africa, and the Mediterranean coast succumbed to the disease. 1820 - 100,000 people died on the Indonesian island of Java alone. 1823 -Cholera had disappeared from most of the world, except around the Bay of Bengal.

Cholera 2 nd Pandemic 1829-1849 1829 - The 2 nd pandemic starts in India and reaches Russia by 1830 before continuing into Hungary (100,000 dead), Finland, Poland, Paris (100,000 dead). 1831 -1849 Epidemic goes from Ireland to Quebec to the US to Mexico. Hundreds of thousands die.

Cholera 2 nd Pandemic 1829-1849 -EXTRA 1832 - Irish immigrants, fleeing poverty and the potato famine, carried the disease from Europe to North America. On their arrival 1,220 died in Montreal and another thousand across Quebec. 1833 - The disease entered the U.S. through Detroit and New York and reached Latin America. It claimed 200,000 victims in Mexico. It is believed more than 150,000 Americans died during the two pandemics between 1832 and 1849. 1848 - Another outbreak across England and Wales began killing 52,000 over two years.

Cholera 3 nd Pandemic 1852-59 1852 - The third pandemic, generally considered the most deadly, originated once again in India. It devastated large swaths of Asia, Europe, North and South America and Africa mainly affecting Russia with over 1 million deaths (1,000,000). 1854 - British physician John Snow succeeded in identifying contaminated water as the transmitter of the disease 1860 - Deaths in India between 1817 and 1860 are estimated to have exceeded 15 million people.

Extra 1854 - The worst year, 23,000 died in Britain alone. 1854 - British physician John Snow succeeded in identifying contaminated water as the transmitter of the disease. Snow mapped the cases of cholera in the Soho area in London and traced the source to a water pump. After removing the pump handle, the number of cholera cases in the area immediately declined.

3 rd Cholera Pandemic Black Death in Brazil - 1855-1856 Cholera Epidemic - Black Death in Brazil - 1855-1856 1. This map represents the movement of the first terrible cholera epidemic in Brazil as it spread in 1855 and 1856. 2. Red indicates confirmed areas of disease.

Extra 1. Red lines indicate sporadic cases, 2. Red points are areas where cholera was probably infecting people, but this was not confirmed by the presidential reports

Extra 1. Rivers facilitated the spread of cholera 2. It did not cross mountain ranges 3. It always struck larger urban population centers on the coast before spreading inward; 4. the Brazilian North and Northeast were affected much more than the southern and south-central parts of Brazil. 5. A set of larger (.pdf) maps are available here.here

Cholera 4th Pandemic 1863-1879 1863 - The fourth pandemic began in the Bengal region of India from which Indian Muslim pilgrims visiting Mecca spread the disease to the Middle East, Russia, Europe, Africa and North America

Extra 1863 - At least 30,000 of the 90,000 Mecca pilgrims fell victim to the disease. 1866 - Cholera claimed 90,000 lives in Russia. 1870 - From Mecca, Saudi Arabia cholera migrated to Europe, Africa and North America

Cholera 5th Pandemic 1881- 1896 1881 - The fifth pandemic originated in the Bengal region of India and swept through Asia [Russia, Japan], Africa, South America and parts of France and Germany. US and Britain Spared [Quarantine] 1892 - Waldemar Haffkine, a Ukrainian bacteriologist who worked mostly in India, developed a human vaccine for cholera.

Extra 1883-84 Cholera claimed 200,000 lives in Russia 1887-89 Cholera claimed 90,000 lives in Japan 1890 - Quarantine measures based on the findings of John Snow kept cholera out of Britain and the United States. 1892 Last epidemic in a European city (Hamburg, Germany) claims some 8,000 lives.

Cholera 6th Pandemic 1899-1923 1899- The sixth pandemic killed more than 800,000 in India before moving into the Middle East, northern Africa, Russia, parts of Europe and Asia. 1910 11 - The last outbreak in the United States 1917 An estimated 23 million people in India died of cholera between 1865 and 1917. Russian deaths during a similar time period exceeded 2 million. 1923 - Cholera had receded from most of the world, although many cases were still present in India.

Cholera The 7 th Pandemic - 1961 to present 1961 - The seventh pandemic originates in Indonesia, not India. Vibrio Cholerae Biotype El Tor is the dominant strain/causative agent [ El Tor first identified in El Tor, Egypt in 1905 and then again in 1937, but it does not produce an epidemic until 1961]. El Tor is distinguished from the classic strain at a genetic level, although both are in the serogroup O1 and both contain Inaba, Ogawa and Hikojima serotypes. El Tor is also distinguished from classic biotypes by the production of hemolysins and the fact that it can remain in the human system longer allowing for a longer carrier state. 1971 - It ravaged populations across Asia and the Middle East, eventually reaching Africa by 1971. The 7 th Pandemic - Cholera in the World 1970- 2010The 7 th Pandemic - Cholera in the World 1970- 2010

Cholera The 7 th Pandemic - 1961 to present 1973 - The pandemic had spread to Italy. There were also small outbreaks of the same strain El Tor in Japan and the South Pacific late in the same decade. 1991 - 100 years after cholera was vanquished from South America, there was an outbreak in Peru that spread across the continent, killing 10,000 people. It was a similar strain to the seventh pandemic that petered out more than a decade earlier. Cholera Bar Graph 1989-2010Cholera Bar Graph 1989-2010.

Cholera in Brazil (1991-1998) Socioeconomic Characterization of Affected Areas 1. Cholera reappeared in Latin America in January 1991 and spread rapidly. 2. Vibrio cholerae O1 El Tor caused the disease. 3. Peru was the first country affected, with an explosive outbreak. 4. The high incidence of cholera in the Peruvian rain forest area in 1991 was probably the cause of emergence of cholera in Brazil through this unexpected route. 5. During this period in Brazil - 161,432 cases and 1,296 deaths from cholera were reported. 6. The most severely-affected regions of the country were the North and Northeast regions, accounting, respectively, for 7.0% and 92.2% of the cases and 6.6% and 90.5% of the deaths. Both the regions presented similar case fatality rates (0.79% and 0.76% respectively). 7. In both the regions, the most affected areas were small villages with a predominantly rural population, characterized by deprivation, low HDI ranking, poverty, high rates of infant mortality and illiteracy, and lack of sanitation. 8. During 1991-1996, Latin America reported 1.4 million cases and nearly 10,000 deaths.

Cholera in Brazil (1991-1998) Socioeconomic Characterization of Affected Areas 1. During this period, 161,432 cases and 1,296 deaths from cholera were reported. The most severely-affected regions of the country were the North and Northeast regions, accounting, respectively, for 7.0% and 92.2% of the cases and 6.6% and 90.5% of the deaths. Both the regions presented similar case fatality rates (0.79% and 0.76% respectively). 2. After almost 100 years of absence from Latin America, cholera re-appeared in January 1991 and spread rapidly. Vibrio cholerae O1 El Tor caused the disease. Peru was the first country affected, with an explosive outbreak. There were 420,000 cases and 3,300 deaths during the first 15 months of the epidemic. During 1991-1996, Latin America reported 1.4 million cases and nearly 10,000 deaths (1). The high incidence of cholera in the Peruvian rain forest area in 1991 was probably the cause of emergence of cholera in Brazil through this unexpected route.

1. In both the regions, the most affected areas were small villages with a predominantly rural population, characterized by deprivation, low HDI ranking, poverty, high rates of infant mortality and illiteracy, and lack of sanitation.

1. After 1995, the incidence of cholera fell sharply and quickly in the North and Northeast regions. This trend reflects the reduction of susceptible subjects among the vulnerable population and the improvement of cholera control programs. It also probably reflects the favorable evolution of some health and social indicators.

During the first half of the nineteenth century, there is little evidence of major epidemic activity beyond smallpox, measles, and scarlet fever in Brazil. Much of South America appears to have been spared from the cholera and influenza pandemics that killed millions in Asia, Europe and North America. Yellow Fever,Cholera, Small Pox, Bubonic Plague, Influenza

Extra 1994 - an outbreak among Rwandan refugee camps in the Democratic Republic of Congo killed tens of thousands in 1994. 2008 - the World Health Organization reported that nearly 500 people had died in an outbreak in Zimbabwe in the last few months of 2008. The outbreak affected most parts of the country and has so far involved almost 12,000 cases.. 2010 - October - an outbreak kills thousands of people in Haiti almost 10 months after a major earthquake devastated the country, killing more than 200,000 people

Cholera Between Life and Death The Evolving 7 th Pandemic 1980s - in the early 1980s, death rates are believed to have been greater than 3 million a year. [Lancet - Cholera 2004]Lancet - Cholera 2004 1989 -2010 - Reported Cases - Cholera Bar Graph 1989-2010Reported Cases - Cholera Bar Graph 1989-2010 2010 - It is estimated that cholera affects 3-5 million people worldwide, and causes 100,000-130,000 deaths a year as of 2010. [2010 WHO position paper]. This occurs mainly in the developing world.2010 WHO position paper 2010 - Number of reported cases - 317, 534 cholera cases were reported to WHO in 2010. 2010 Number of reported deaths -7,543 deaths due to cholera were reported globally in 2010 This represents a 52% increase compared to 2009 2010 Reported case fatality rate - The overall case fatality rate for cholera was 2.38%

Extra -Cholera 1 Cause Organism, Susceptibility and Transmission 2 Signs and symptoms 3 Mechanism - Genetic structure 4 Diagnosis - Enrichment media, Plating media 5 Prevention Hygiene, Surveillance and Vaccine 6 Treatment - Fluids, Electrolytes, Antibiotics 7 Prognosis 8 Epidemiology 9 History

Cholera Cause Organism Etymology Vibrio \Vib"ri*o\, noun; plural English Vibrios, from Latin expression Vibriones. [New Latin expression, from the Latin expression vibrare to vibrate, to move by undulations.]. Cholera - The word cholera is from Greek: kholera from khol "bile". Latin Cholera means bilious disease.Greek Light Microscopy Electron Microscopy

Cholera Cause Organism Groups, Strains: Biotypes and Serotypes Vibrio cholerae is a gram-negative, rod-shaped bacterium with a single, polar flagellum which renders them motile. and surface O antigens which form the basis of classifying the bacteria into more than 130 groups. Two of the groups, O1 and O139 (O for O antigen), have been known to cause epidemics of diarrhea. O1 causes the majority of outbreaks, while O139 first identified in Bangladesh in 1992 is confined to South-East Asia O1 strains fall into two biotypes (or biovars), called classical and El Tor, that are distinguished by their different hemolytic activity, relative resistance to the antibiotic polymyxin B, and their different susceptibilities to bacteriophage. The classical biotype is further divided into two serotypes (or serovars), based on the antisera that recognize them, and named after the place where they were first isolated: Inaba and Ogawa. Thus, any pathogenic strain of Vibrio cholerae has a name that reflects both the biotype and the serotype; for example, strain 569B has a classical biotype and the Inaba serotype.

Cholera is caused by the Gram-negative, rod-shaped bacterium Vibrio cholerae, which on first isolation may appear curved, and is shown in Figure 3.1. The bacteria have a single, polar (at one end) flagellum, which renders them motile. Based on the properties of their O antigens (Book 2, Section 2.2), more than 130 groups have been identified, but only two of them, O1 and O139 (O for O antigen), have been known to cause epidemics of diarrheal disease. Until very recently, however, only O1 Vibrio strains were known to cause disease. These O1 strains fall into two biotypes (or biovars), distinguished by their metabolic activities in this case, their different hemolytic activity, relative resistance to the antibiotic polymyxin B, and their different susceptibilities to bacteriophage. The two biotypes are called classical and El Tor. The classical biotype is further divided into two serotypes (or serovars), based on the antisera that recognize them, and named after the place where they were first isolated: Inaba and Ogawa. (You will learn more about the use of serum to identify microbes in Book 4.) Thus, any pathogenic strain of Vibrio cholerae has a name that reflects both the biotype and the serotype; for example, strain 569B has a classical biotype and the Inaba serotype. Two serogroups of V. cholerae O1 and O139 cause outbreaks. V. cholerae O1 causes the majority of outbreaks, while O139 first identified in Bangladesh in 1992 is confined to South-East Asia. Non-O1 and non-O139 V. cholerae can cause mild diarrhea but do not generate epidemics.

Cholera Susceptibility Societal and Individual Risk Factors Societal - Peri-urban slums Societal - Camps for IDPs or refugees Societal - Post-disaster disruption of water/sanitation Individual - Ingestion of 100,000,000 bacteria in healthy adult. Individual - Lower gastric acidity Individual - Children two to four years of age Individual - O blood type Individual - Lower immunity (AIDS, malnourished children) Individual - Cholera workers/unprotected

Extra Cholera transmission is closely linked to inadequate environmental management. Typical at-risk areas include peri-urban slums, where basic infrastructure is not available, as well as camps for internally displaced people or refugees, where minimum requirements of clean water and sanitation are not met. The consequences of a disaster such as disruption of water and sanitation systems, or the displacement of populations to inadequate and overcrowded camps can increase the risk of cholera transmission should the bacteria be present or introduced. Epidemics have never arisen from dead bodies.

Extra About one hundred million (100,000,000) bacteria must typically be ingested to cause cholera in a normal healthy adult. This dose, however, is less in those with lower gastric acidity (for instance those using proton pump inhibitors). Children are also more susceptible with two to four year olds having the highest rates of infection. Individuals' susceptibility to cholera is also affected by their blood type, with those with type O blood being the most susceptible. Persons with lower immunity such as persons with AIDS or children who are malnourished are more likely to experience a severe case if they become infected. [H owever, it should be noted that any particular person, even a healthy adult in middle age, can experience a severe case. About 75% of people infected with V. cholerae do not develop any symptoms, although the bacteria are present in their feces for 714 days after infection and are shed back into the environment, potentially infecting other people. [ Among people who develop symptoms, 80% have mild or moderate symptoms, while around 20% develop acute watery diarrhea with severe dehydration. This can lead to death if untreated. People with low immunity such as malnourished children or people living with HIV are at a greater risk of death if infected.

Cholera Cause - Transmission Transmission is primarily due to the fecal contamination of food and water due to poor sanitation. This bacterium can, however, live naturally in any environment, particularly water reservoirs.

Cholera Prevention Halting Spread, Surveillance, Vaccination, Preparedness to Respond Cholera may be prevented by halting spread (remember diagram): Disposal and treatment (fecal waste/contaminated materials) Sterilization with bleach/hot water of contaminated materials Sterilization of hands (antimicrobial soap, water); Antibacterial treatment of sewage before it enters water supply Post warnings about possible cholera contamination around contaminated water sources with directions on how to decontaminate the water (boiling, chlorination etc.) Water purification: Water used for drinking, washing, or cooking should be sterilized by either boiling, chlorination, ozone water treatment, ultraviolet light sterilization or antimicrobial filtration. Cholera Prevention - Animated Video

Extra Sterilization: Proper disposal and treatment of infected fecal waste water produced by cholera victims and all contaminated materials (e.g. clothing, bedding, etc.) is essential. All materials that come in contact with cholera patients should be sterilized by washing in hot water, using chlorine bleach if possible. Sterilization: Hands that touch cholera patients or their clothing, bedding, etc., should be thoroughly cleaned and disinfected with chlorinated water or other effective antimicrobial agents. Sewage: antibacterial treatment of general sewage by chlorine, ozone, ultraviolet light or other effective treatment before it enters the waterways or underground water supplies helps prevent undiagnosed patients from inadvertently spreading the disease.

Extra - Cholera Diagnosis In epidemic situations, a clinical diagnosis may be made by taking a history and doing a brief examination. Treatment is usually started without or before confirmation by laboratory analysis. Stool 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 rapid dip-stick test is available to determine the presence of V. cholerae. In those that test positive, further testing should be done to determine antibiotic resistance. If an epidemic of cholera is suspected, the most common causative agent is Vibrio cholerae O1. If V. cholerae serogroup O1 is not isolated, the laboratory should test for V. cholerae O139. A number of special media have been employed for the cultivation for cholera vibrios: Enrichment media and Plating media. 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 Vibrio and its inhibition by appropriate antisera. Diagnosis can be confirmed, as well, as serotyping done by agglutination with specific sera.

Surveillance - Prompt reporting allows for containing epidemics Surveillance - Cholera is seasonal in many endemic countries (rainy) Vaccine - Is additional control in cholera-endemic countries Vaccine - High-risk such as 2-4 year olds, pregnant, HIV-infected, healthcare workers. Vaccine - Pre-emptive vaccination should be considered Vaccine - Two types of safe and effective oral vaccines that are whole-cell killed, one with a recombinant B-sub unit (Dukoral), the other without (Shanchol). Both have sustained protection of over 50% lasting for two years in endemic settings. Vaccine Dukoral is WHO prequalified and licensed in over 60 countries. Dukoral has been shown to provide short-term protection of 8590% against V. cholerae O1 among all age groups at 46 months following immunization. Vaccine Shanchol provides longer-term protection against V. cholerae O1 and O139 in children under five years of age. Vaccine - Both vaccines are administered in 2 doses given between 7 days and 6 weeks apart. Dukoral is given in 150 ml of safe water. Vaccine Immunization should be used in conjunction with the usually recommended control measures. Cholera Prevention Halting Spread, Surveillance, Vaccination, Preparedness to Respond

Vaccines There are two types of safe and effective oral cholera vaccines currently available on the market. Both are whole-cell killed vaccines, one with a recombinant B-sub unit, the other without. Both have sustained protection of over 50% lasting for two years in endemic settings. One vaccine (Dukoral) is WHO prequalified and licensed in over 60 countries. Dukoral has been shown to provide short-term protection of 8590% against V. cholerae O1 among all age groups at 46 months following immunization. The other vaccine (Shanchol) is pending WHO prequalification and provides longer- term protection against V. cholerae O1 and O139 in children under five years of age. Both vaccines are administered in two doses given between seven days and six weeks apart. The vaccine with the B-subunit (Dukoral) is given in 150 ml of safe water. WHO recommends that immunization with currently available cholera vaccines be used in conjunction with the usually recommended control measures in areas where cholera is endemic as well as in areas at risk of outbreaks. Vaccines provide a short term effect while longer term activities like improving water and sanitation are put in place. When used, vaccination should target vulnerable populations living in high risk areas and should not disrupt the provision of other interventions to control or prevent cholera epidemics. The WHO 3-step decision making tool aims at guiding health authorities in deciding whether to use cholera vaccines in complex emergency settings.

Extra People infected with cholera often have diarrhea, and if this highly liquid stool disease transmission may occur. The source of the contamination is typically other cholera sufferers when their untreated diarrheal discharge is allowed to get into waterways or into groundwater or drinking water supplies. Vibrio cholerae can lie dormant in an environment and become the source of infection when people are exposed, e.g. through it entering the water supply. The main reservoirs of V. cholerae are people and aquatic sources such as brackish water and estuaries, often associated with algal blooms. Recent studies indicate that global warming creates a favorable environment for the bacteria.

Cholera Cause - Transmission Primarily due to the fecal contamination of food and water due to poor sanitation when diarrhea from those with cholera enters waterways or groundwater or drinking water. Vibrio cholerae can lie dormant in an environment and become the source of infection when people are exposed, e.g. through it entering the water supply. Main reservoirs of V. cholerae are people and aquatic sources such as brackish water and estuaries, often associated with algal blooms.

Cholera Vaccine A number of safe and effective oral vaccines for cholera are available. Dukoral, an orally administered, inactivated whole cell vaccine, has an efficacy of 85%, with minimal side effects. It is available in over 60 countries. Dukoral March 2010 WHO Position Paper on Vaccines Cholera is a rapidly dehydrating diarrheal disease caused by ingestion of toxin-producing strains of serogroup O1, or less commonly, serogroup O139, of the bacterium Vibrio cholerae. The disease is spread mainly by fecal contamination of water and food and is closely linked to poor sanitation and lack of clean drinking water. All age groups may be affected. The actual global disease burden is estimated to be 35 million cases and 100 000130 000 deaths per year. The emergence of more virulent strains of V. cholerae O1 in large parts of Africa and Asia and the spread of antibiotic-resistant mutants are causing concern. Currently, only the oral cholera vaccines DukoralM and ShancholM/mORCVAXM are available*. Dukoral is based on killed bacteria of serogroup O1 plus the cholera toxin B-subunit. (Toxin B induces short-term protection against enterotoxigenic Escherichia coli (ETEC), an important cause of travelers diarrhea). Shanchol and mORCVAX are almost identical vaccines based on V. cholera O1 and O139, but without toxin B. Dukoral is widely available internationally, Shanchol is intended for both the Indian and international markets, whereas mORCVAX is currently intended for use in Viet Nam. These vaccines are all safe and induce adequate short-term protection (see below). The manufacturers recommend a primary series of two doses and, for those at continued risk of infection, a booster dose at intervals of about 2 years. Work is under way to investigate the role of mass vaccination. The World Health Organization (WHO) recommends immunization of high risk groups, such as children and people with HIV, in countries where this disease is endemic. [3] If people are immunized broadly, herd immunity results, with a decrease in the amount of contamination in the environment. [4]HIVendemic [3]herd immunity [4]

Cholera Mechanism of Infection Vibrio cholera bacteria are ingested and survive the acidity of the stomach. The bacteria exit into the small intestine, produce protein flagellin to make flagella, Flagella that rotate allow the bacteria to propel themselves through the mucus of the small intestine. Upon reaching the intestinal wall, V. cholerae stop producing flagellin and start producing the toxic proteins that give the infected person a watery diarrhea. The cholera toxin (CTX or CT) is an oligomeric complex made up of protein subunits. Upon binding, the complex is taken into the cell via receptor- mediated endocytosis. This in turn leads to secretion of H 2 O, Na +, K +, Cl , and HCO 3 into the lumen of the small intestine and rapid dehydration. 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 diarrhea. The diarrhea 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.

Extra Vibrio cholera bacteria are ingested and survive the acidity of the stomach They exit into the small intestine, produce protein flagellin to make flagella, Flagella that rotate allow the bacteria to propel themselves through the mucus of the small intestine. On reaching the intestinal wall, V. cholerae stop producing flagellin and start producing the toxic proteins that give the infected person a watery diarrhea. The cholera toxin (CTX or CT) is an oligomeric complex made up of protein subunits. Upon binding, the complex is taken into the cell via receptor- mediated endocytosis. This in turn leads to secretion of H 2 O, Na +, K +, Cl , and HCO 3 into the lumen of the small intestine and rapid dehydration. 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 diarrhea. 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.

Cholera Diagnosis and Treatment Rice Water Stools

Cholera Diagnosis and Treatment In epidemic situations, history and doing a brief examination are the basis for a clinical diagnosis. Treatment is usually started without or before confirmation by laboratory analysis. For laboratory analysis, stool and swab samples of diarrhea collected in the acute stage of the disease, before antibiotics have been administered, are the most useful specimens. A rapid dip-stick test is available to determine the presence of V. cholerae. In those that test positive, further testing can be done to determine antibiotic resistance. A number of special media have been employed for the cultivation for cholera vibrios: Enrichment media and Plating media. 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 Vibrio and its inhibition by appropriate antisera. Diagnosis can be confirmed, as well, as serotyping done by agglutination with specific sera. If an epidemic of cholera is suspected, the most common causative agent is Vibrio cholerae O1. If V. cholerae serogroup O1 is not isolated, the laboratory should test for V. cholerae O139.

Extra Cholera Genetic Structure Amplified fragment length polymorphism fingerprinting of the pandemic isolates of Vibrio cholerae has revealed variation in the genetic structure. Two clusters have been identified: Cluster I and Cluster II. For the most part, Cluster I consists of strains from the 1960s and 1970s, while Cluster II largely contains strains from the 1980s and 1990s, based on the change in the clone structure. This grouping of strains is best seen in the strains from the African continent. [13] [13]

Cholera Diagnosis and Treatment First steps for Managing an Outbreak of Acute Diarrhea The First Days THE FIRST TWO QUESTIONS ARE: 1. Is this the beginning of an outbreak? 2. Is the patient suffering from cholera or shigella? A. Is this the beginning of an outbreak? - You might be facing an outbreak very soon if you have seen an unusual number of acute diarrheal cases this week and the patients have the following points in common: 1. They have similar clinical symptoms (watery or bloody diarrhea) 2. They are living in the same area or location 3. They have eaten the same food (at a burial ceremony for example) 4. They are sharing the same water source 5. There is an outbreak in the neighboring community 6. You have seen an adult suffering from acute watery diarrhea with severe dehydration and vomiting 7. If you have some statistical information from previous years or weeks verify if the actual increase of cases is unusual over the same period of time.

Cholera Diagnosis and Treatment First steps for Managing an Outbreak of Acute Diarrhea The First Days 2. Is the patient suffering from cholera or shigella? - If so, it is an emergency Cholera = acute watery diarrhea Shigella dysentery = acute bloody diarrhea 1. Both transmitted by contaminated water, unsafe food, dirty hands and vomit or stools of sick people. 2. Cholera and shigella produce outbreaks which represent an immediate threat to the community. 3. Symptoms/Signs differentiate them (stool [amount/character]; fever; abdominal cramps; vomiting; rectal pain] 4. Establish clinical diagnosis for patient, family members with acute diarrhea, take stool samples/send for analysis or refrigeration; Dont wait for lab to start treatment; estimate supplies needed; protect community; collect patient data

Cholera Diagnosis and Treatment First steps for Managing an Outbreak of Acute Diarrhea The First Days What are the next 3 questions to ask if you suspect an outbreak? Who do I inform and ask for help from? How do I protect the community? How do I treat the patients? What 3 things not to forget? 1. PROTECT YOURSELF FROM CONTAMINATION Wash your hands with soap before and after taking care of the patient Cut your nails 2. ISOLATE CHOLERA PATIENTS Stools, vomit and soiled clothes of patients are highly contagious Latrines and patients buckets need to be washed and disinfected with chlorine Cholera patients have to be in a special ward, isolated from other patients 3. CONTINUOUS PROVISION OF NUTRITIOUS FOOD is important for all patients, especially for those with shigella dysentery Provide frequent small meals with known foods during the first 2 days Provide food as soon as the patient is able to take it Breastfeeding of infants and young children should continue

Check the supplies you have and record available quantities IV fluids (Ringer Lactate is the best) Drips Nasogastric tubes Oral Rehydration Salt (ORS) Antibiotics (see Table 2) Soap Chlorine or bleaching powder Rectal swabs and transport medium (Cary Blair or TCBS) for stool samples Safe water is needed to rehydrate patients and to wash Cholera Diagnosis and Treatment First steps for Managing an Outbreak of Acute Diarrhea The First Days

PROTECT THE COMMUNITY: Stool and vomit are highly contagious Isolate the severe cases Provide information on how to avoid cholera through simple messages and on the outbreak Disinfect water sources with chlorine Promote water disinfection at home using chlorine Avoid gatherings PRECAUTIONS FOR FUNERALS Disinfect corpses with chlorine solution (2%) Fill mouth and anus with cotton wool soaked with chlorine solution Wash hands with soap after touching the corpse Disinfect the clothing and bedding of the deceased by stirring them in boiling water or by drying them thoroughly in the sun GIVE SIMPLE MESSAGES TO AVOID CHOLERA/SHIGELLA Wash your hands with soap: after using toilets and latrines; before preparing food; before eating Boil or disinfect the water with chlorine solution Only eat freshly cooked food Do not defecate near the water sources Use latrines and keep them clean In case of acute diarrhea Start oral rehydration with ORS before going to the health centre Go to the health centre as soon as possible Cholera Diagnosis and Treatment First steps for Managing an Outbreak of Acute Diarrhea The First Days

Summary of the treatment 1. Rehydrate with ORS or IV solution depending on the severity 2. Maintain hydration and monitor the hydration status 3. Give antibiotics for severe cholera cases and for shigella cases Cholera Diagnosis and Treatment First steps for Managing an Outbreak of Acute Diarrhea The First Days

BOX 1. HOW TO PREPARE HOME-MADE ORS SOLUTION If ORS sachets are available: dilute 1 sachet in 1 liter of safe water Otherwise: Add to 1 liter of safe water: Salt 1/2 small spoon (3.5 grams) Sugar 4 big spoons (40 grams) And try to compensate for loss of potassium - for example, eat bananas or drink green coconut water Cholera Diagnosis and Treatment First steps for Managing an Outbreak of Acute Diarrhea The First Days

When is it useful to give antibiotics? For cholera cases with severe dehydration only. Ideally for all of Shigella dysenteriae cases, but as a priority for the most vulnerable patients: children under five, elderly, malnourished, patients with convulsions. Cholera Diagnosis and Treatment First steps for Managing an Outbreak of Acute Diarrhea The First Days

Which antibiotics? Cholera Adults doxycycline - 1 dose 300 mg or tetracycline 12.5 mg/kg 4 times a day for 3 days; Young children: erythromycin liquid 12.5 mg/kg 4 times a day for 3 days Shigella Adults: ciprofloxacin 500 mg twice a day for 3 days Children: ciprofloxacin 250 mg/15kg twice a day for 3 days For children below 6 months of age: add zinc 10 mg daily for 2 weeks For children 6 months to 5 years of age: add zinc 20 mg daily for 2 weeks Cholera Diagnosis and Treatment First steps for Managing an Outbreak of Acute Diarrhea The First Days

About 75% of people infected with V. cholerae do not develop any symptoms, although the bacteria are present in their feces for 714 days. Among people who develop symptoms, 80% have mild or moderate symptoms that can be treated with ORS; while around 20% develop acute watery diarrhea with severe dehydration. With untreated cholera, the mortality rate rises to 5060%. In an outbreak, the fatality rate should be around 1% For certain genetic strains of cholera, such as the one present during the 2010 epidemic in Haiti and the 2004 outbreak in India, death can occur within two hours of the first sign of symptoms. Cholera Prognosis Between Life and Death

Cholera - Research 1855 - The bacterium originally isolated by Italian anatomist Filippo PaciniFilippo Pacini 1900 - The Russian-born bacteriologist Waldemar Haffkine developed the first cholera vaccine around 1900.Waldemar Haffkine 1854 - Physician and pioneer medical scientist John Snow (18131858), found a link between cholera and contaminated drinking water. [41] He was able to demonstrate human sewage contamination was the most probable disease vector in two major epidemics in London in 1854.John Snow [41]sewage 1885 - Robert Koch identified V. cholerae with a microscope as the bacillus causing the disease..Robert 1947 - The province of Bengal in British India was partitioned into West Bengal and East Pakistan in 1947. Prior to partition, both regions had cholera pathogens with similar characteristics. After 1947, India made more progress on public health than East Pakistan (now Bangladesh). As a consequence, [clarification needed] the strains of the pathogen that succeeded in India had a greater incentive in the longevity of the host. They have become less virulent than the strains prevailing in Bangladesh. These draw upon the resources of the host population and rapidly kill many victims.British IndiaWest East PakistanBangladeshclarification needed 2002 - Alam, et al., studied stool samples from patients at the International Centre for Diarrheal Disease (ICDDR) in Dhaka, Bangladesh. Researchers found a correlation between the passage of V. cholerae through the human digestive system and an increased infectivity state. Bacteria create a hyperinfected state where genes that control biosynthesis of amino acids, iron uptake systems, and formation of periplasmic nitrate reductase complexes were induced just before defecation. These induced characteristics allow the cholera vibrios to survive in the "rice water" stools, an environment of limited oxygen and iron, of patients with a cholera infection. [43]International Centre for Diarrheal DiseaseDhaka, Bangladeshgenesamino acidsiron [43]

A Case Study of Convergence - Haiti Camillians, Signs of the Times, Disasters Cholera is a New ThreatCholera is a New Threat [October 2010] Earthquake - Moments After The Cathedral [1:30 ] [ January 2010] Hurricane ThomasHurricane Thomas [November 2010]

Haiti Epidemic - Summary 1. The epidemic is ongoing and has a history: 2 On October 21, 2010 the US Centers for Disease Control and Prevention (CDC) confirmed that the cases of diarrheal illness first seen at hospitals in the Artibonite region had been receiving had been identified as cholera. 3. The rural Artibonite Department of Haiti, [3] about 100 kilometers (62 mi) north of the capital, Port-au-Prince, Artibonite (Gonaves) 1 Centre (Hinche) Grand'Anse (Jrmie) 3 Nippes (Miragone) Nord (Cap-Hatien) Nord-Est (Fort-Libert) Nord-Ouest (Port-de-Paix) Ouest (Port-au-Prince) -8 Sud-Est (Jacmel) Sud (Les Cayes)

Haiti Epidemic - Summary 1. By November 2010 the epidemic spread to the Dominican Republic and there was a single case in Florida, United States; 2. By the first 10 weeks of the epidemic to all of Haiti's 10 departments or provinces (December 2011). 3. By January 2011 a few cases were reported in Venezuela. 4. By March 2011 the epidemic had killed 4672 people and hospitalized thousands more. Some 252,640 cases had been reported by March 2011. 5. By late September 2011, some 6,435 deaths have been reported and this number is expected to increase

Haiti Cholera Epidemic Background in the World During the 1900s, six major cholera pandemics had spread around the world. At the time of this Cholera outbreak in Haiti, the world was experiencing the seventh, caused by a new strain of the Vibrio cholerae bacterium, El Tor.Vibrio choleraeEl Tor Epidemics involving this El Tor strain started in 1961 in Indonesia, and spread rapidly elsewhere in eastern Asia and then to India and Bangladesh, the USSR, Iran and Iraq. This was the first Cholera outbreak in Haiti in over 50 years.

Haiti Cholera Epidemic Background the Source The suspected source for the epidemic was the Artibonite River, from which some of the affected people had drunk water.Artibonite River A UN team investigated samples of a suspected sewage spill from a Nepali peacekeeping base that may have infected the river system.Nepali Vincenzo Pugliese of MINUSTAH confirmed that the tests were positive for cholera. [14] The US CDC said its tests of "DNA fingerprinting" showed various samples of cholera from Haitian patients were identified as Vibrio cholerae serogroup O1, serotype Ogawa, a strain found in South Asia.MINUSTAH [14] The Swedish ambassador to Haiti said the epidemic had strains originating in Nepal. However, Nepal's representative to the United Nations "categorically refuted" the hypothesis that Nepali peacekeepers were the source of the outbreak. Following the claims the UN said it would investigate the source of the cholera strain. [23] [23] UN peacekeepers from Nepal brought the strain of cholera to Haiti responsible for an epidemic that has killed 5,500 people, according to a study published by the US Centers for Disease Control and Prevention (CDC). The study is the first to establish a direct link between the arrival of the Nepalese UN battalion near the small town of Mirebalais and the cholera epidemic that erupted in mid-October 2010. [citation needed]citation needed

Haiti Epidemic -Domestic Response On 15 November, a riot broke out in Cap-Hatien following rumors that the outbreak was caused by U.N. soldiers from Nepal.Cap-Hatien At least 5 people were killed in the riots, including 1 UN personnel. [28] [28] Riots then continued for a second day. [29] Following the riots the UN said the outbreak was being staged for "political reasons because of forthcoming elections", as the Haitian government sent its own forces to "protest" the UN peacekeepers. [30] [29] [30] During a third day of riots UN personnel were blamed for shooting at least 5 protestors but denied responsibility. [31] On the fourth day of demonstrations against the UN presence, police fired tear gas into an IDP camp in the capital. [32] [31]IDP [32]

Haiti Epidemic - Source On 15 March 2011, a report was issued by the University of California that predicted total infections would number up to 779,000 and total deaths up to 11,000 by November 2011, compared with earlier UN estimates that around 400,000 people would end up infected. The revised numbers were based on more factors than the UN's estimates, which assumed a total infection rate of between two and four percent of the population. [6] In a statement released at the same time, the WHO said total deaths thus far had reached 4,672, with 252,640 cases reported. [6]University of California [6]

Interactive Map of Cholera Epidemic in Haiti

First Mission Artibonite October, 2010

Second Mission Grand Anse December- February, 2010

Cholera Bed

Most Recent News jedi, 20 oktb 2011 Ayiti: Depatman Sante Piblik ak Popilasyon Pral Lanse yon Kanpay Vaksinasyon kont Kolera Ayiti: Depatman Sante Piblik ak Popilasyon Pral Lanse yon Kanpay Vaksinasyon kont Kolera madi, 11 oktb 2011 20 Moun Mouri anba Maladi Kolera nan Depatman Grand' Ans 20 Moun Mouri anba Maladi Kolera nan Depatman Grand' Ans

Camillian Task Force 1- [SOS DRS Office]SOS DRS Office 2 [Haiti - Earthquake, Cholera, Hurricane, Slum] 3 - Italy [CTF Central/Earthquake] 4 - Horn of Africa [Famine] 5 - Pakistan [Floods] 6 - Thailand6 - Thailand [Floods]

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Documents

Between Life and Death Fr. Scott Binet MD, MI CTF-SOS D RS Sao Paulo, Brazil - October 20, 2011