Cholera - management and prevention

Safeguarding drinking water: A brief insight on characteristics, treatments and risk assessment of contamination

Water pollution stands as a critical worldwide concern, bearing extensive repercussions that extend to human health and the natural ecosystem. The sources of water pollution can be diverse, arising from natural processes and human activities and the pollutants may range from chemical and biological agents to physical and radiological contaminants. The contamination of water disrupts the natural functioning of the system, leading to both immediate and prolonged health problems. Various technologies and procedures, ranging from conventional to advanced, have been developed to eliminate water impurities, with the choice depending on the type and level of contamination. Assessing risks is a crucial element in guaranteeing the safety of drinking water. Till now, research is continuing the removal of contaminates for the sake of supplying safe drinking water. The study examined physical, inorganic, organic, biological and radiological contaminants in drinking water. It looked at where these contaminants come from, their characteristics, the impact they have and successful methods used in real-world situations to clean the contaminated water. Risk assessment methodologies associated with the use of unsafe drinking water as future directives are also taken into consideration in the present study for the benefit of public concern. The manuscript introduces a comprehensive study on water pollution, focusing on assessing and mitigating risks associated with physical, inorganic, organic, biological and radiological contaminants in drinking water, with a novel emphasis on future directives and sustainable solutions for public safety.

Nanoparticles-based technologies for cholera detection and therapy

Cholera is a waterborne disease caused by Vibrio cholerae bacteria generally transmitted through contaminated food or water sources. Although it has been eradicated in most Western countries, cholera continues to be a highly transmitted and lethal disease in several African and Southeast Asian countries. Unfortunately, current diagnostic methods for cholera have challenges including high cost or delayed diagnoses that can lead to increased disease transmission during pandemics, while current treatments such as therapeutic drugs and vaccines have limited efficacy against drug-resistant serogroups of Vibrio cholerae. As such, new solutions that can treat cholera in an efficient manner that avoids Vibrio cholerae's adaptive immunity are needed. Nanoparticles (NPs) are a suitable platform for enhancing current theranostic tools because of their biocompatibility and ability to improve drug circulation and targeting. Nanoparticle surfaces can also be modified with various protein receptors targeting cholera toxins produced by Vibrio cholerae. This review will address recent developments in diagnostics, therapeutics, and prevention against cholera particularly focusing on the use of metal-based nanoparticles and organic nanoparticles. We will then discuss future directions regarding nanoparticle research for cholera.

Cholera: An Overview with Reference to the Syrian Outbreak

Cholera is an acute type of diarrheal disease caused by intestinal infection with the toxin-producing bacteria Vibrio cholerae. The disease is still endemic in almost 69 countries, accounting for around 2.86 million cases and 95,000 deaths annually. Cholera is associated with poor infrastructure, and lack of access to sanitation and clean drinking water. The current cholera outbreak in Syria is associated with more than 10 years of conflict, which has devastated infrastructures and health services. There were 132,782 suspected cases reported between August 25, 2022 and May 20, 2023 in all 14 governorates, including 104 associated deaths. The recent earthquake in the region has complicated the situation, with an increase in cholera cases, and hindrance to a response to the disease. Climate change has driven a number of large cholera outbreaks around the world this year. The World Health Organization prequalifies three oral cholera vaccines. Cholera treatment mainly depends on rehydration, with the use of antibiotics in more severe infections. This review gives an overview of cholera bacteriology, pathogenesis, epidemiology, clinical manifestations, diagnosis, management, and prevention in light of global climate change and the ongoing outbreak in Syria, which poses a significant public health threat that requires urgent attention.

Organoids as a novel tool in modelling infectious diseases

Infectious diseases worldwide affect human health and have important societal impacts. A better understanding of infectious diseases is urgently needed. In vitro and in vivo infection models have brought notable contributions to the current knowledge of these diseases. Organoids are multicellular culture systems resembling tissue architecture and function, recapitulating many characteristics of human disease and elucidating mechanisms of host-infectious agent interactions in the respiratory and gastrointestinal systems, the central nervous system and the skin. Here, we discuss the applicability of the organoid technology for modeling pathogenesis, host response and features, which can be explored for the development of preventive and therapeutic treatments.

Health effects of climate change in Africa: A call for an improved implementation of prevention measures

The world's climate, particularly in Africa, has changed substantially during the past few decades, contributed by several human activities. Africa is one of the continents that is most vulnerable to climate change globally. Since the beginning of 2022, extreme weather events in Africa have affected about 19 million people and killed at least 4,000 individuals. Cyclones, floods, heatwaves, wildfires, droughts, and famine were among the severe weather occurrences. Natural disasters and extreme weather events brought on by climate change may compromise access to clean water, sanitation systems, and healthcare facilities, making people more vulnerable to a number of illnesses. Floods and drought can lead to both communicable and non-communicable diseases. The African population is more likely to experience more mental health disorders than before because of natural disasters, which result in the loss of property and sometimes loss of lives more frequently. We, therefore, call for an improved implementation of strategies to prevent the health effects of climate change so that the health of the people in Africa can be maintained.

Vibrio Infections and the Twenty-First Century

The Vibrionaceae is a highly diverse family of aquatic bacteria. Some members of this ubiquitous group can cause a variety of diseases in humans ranging from cholera caused by Vibrio cholerae, severe septicemia caused by Vibrio vulnificus, to acute gastroenteritis by Vibrio parahaemolyticus. Planet Earth is experiencing unprecedented changes of planetary scale associated with climate change. These environmental perturbations paired with overpopulation and pollution are increasing the distribution of pathogenic Vibrios and exacerbating the risk of causing infections. In this chapter, we discuss various aspects of Vibrio infections within the context of the twenty-first century with a major emphasis on the aforementioned pathogenic species. Overall, we believe that the twenty-first century is posed to be both one full of challenges due to the rise of these pathogens, and also a catalyst for innovative and groundbreaking discoveries.

Diagnosis, Management, and Future Control of Cholera

Cholera, caused by Vibrio cholerae, persists in developing countries due to inadequate access to safe water, sanitation, and hygiene. There are approximately 4 million cases and 143,000 deaths each year due to cholera. The disease is transmitted fecally-orally via contaminated food or water. Severe dehydrating cholera can progress to hypovolemic shock due to the rapid loss of fluids and electrolytes, which requires a rapid infusion of intravenous (i.v.) fluids. The case fatality rate exceeds 50% without proper clinical management but can be less than 1% with prompt rehydration and antibiotics. Oral cholera vaccines (OCVs) serve as a major component of an integrated control package during outbreaks or within zones of endemicity. Water, sanitation, and hygiene (WaSH); health education; and prophylactic antibiotic treatment are additional components of the prevention and control of cholera. The World Health Organization (WHO) and the Global Task Force for Cholera Control (GTFCC) have set an ambitious goal of eliminating cholera by 2030 in high-risk areas.

Antimicrobial resistance in Vibrio cholerae O1/O139 clinical isolates: a systematic review and meta-analysis

OBJECTIVES

Vibrio cholerae O1/O139 is responsible for cholera epidemics; that remains a huge public health menace across the globe. Furthermore, an increasing resistance rate among V. cholerae strains has been reported around the world. Therefore, the objective of this meta-analysis was to evaluate the weighted pooled resistance (WPR) rates in clinical V. cholerae O1/O139 isolates based on different years, areas, antimicrobial susceptibility testing, and resistance rates.

RESEARCH DESIGN AND METHODS

: We searched the studies in PubMed, Scopus, Embase, and Web of Science (until January 2020). Statistical analyses were conducted using STATA software (ver. 14.0).

RESULTS

: A total of 139 studies investigating 24062 V. cholerae O1/O139 isolates were analyzed. The majority of the studies originated in Asia (n=102). The WPR rates were as follows: azithromycin 1%, erythromycin 36%, ciprofloxacin 3%, cotrimoxazole 79%, doxycycline 7%, tetracycline 20%. There was increased resistance to cotrimoxazole, ciprofloxacin, and tetracycline during the 1980 to 2020 years.

CONCLUSIONS

: Temporal changes in antibiotic resistance rate found in this study demonstrated the critical continuous surveillance of antibiotic resistance. Also, ciprofloxacin, azithromycin, gentamicin, cephalexin, imipenem, ofloxacin, and norfloxacin were found to be the best antibiotics against V. cholera, with the highest and the lowest effectiveness resistance rate.

Synthesis of Pentasaccharide Repeating Unit Corresponding to the Cell Wall O-Polysaccharide of Salmonella enterica O55 Strain Containing a Rare Sugar 3-Acetamido-3-deoxy-d-fucose

A pentasaccharide repeating unit corresponding to the cell wall O-antigen of Salmonella enterica O55 containing a rare sugar, 3-acetamido-3-deoxy-d-fucose has been synthesized as its p-methoxyphenyl glycoside using a sequential stereoselective glycosylation strategy. A suitably functionalized 3-azido-3-deoxy-d-fucose thioglycoside derivative was prepared in very good yield and used in the stereoselective glycosylation reaction. Functionalized monosaccharide intermediates were prepared judiciously and stereoselectively assembled to get the desired pentasaccharide derivative in excellent yield.

Stable and Local Reservoirs of Mycobacterium ulcerans Inferred from the Nonrandom Distribution of Bacterial Genotypes, Benin

Mycobacterium ulcerans is the causative agent of Buruli ulcer, a neglected tropical disease found in rural areas of West and Central Africa. Despite the ongoing efforts to tackle Buruli ulcer epidemics, the environmental reservoir of its pathogen remains elusive, underscoring the need for new approaches to improving disease prevention and management. In our study, we implemented a local-scale spatial clustering model and deciphered the genetic diversity of the bacteria in a small area of Benin where Buruli ulcer is endemic. Using 179 strain samples from West Africa, we conducted a phylogeographic analysis combining whole-genome sequencing with spatial scan statistics. The 8 distinct genotypes we identified were by no means randomly spread over the studied area. Instead, they were divided into 3 different geographic clusters, associated with landscape characteristics. Our results highlight the ability of M. ulcerans to evolve independently and differentially depending on location in a specific ecologic reservoir.

Anti-diarrheal therapeutic potential of diminazene aceturate stimulation of the ACE II/Ang-(1-7)/Mas receptor axis in mice: A trial study

The angiotensin (Ang) II converting enzyme (ACE II) pathway has recently been shown to be associated with several beneficial effects on the body, especially on the cardiac system and gastrointestinal tract. ACE II is responsible for converting Ang II into the active peptide Ang-(1-7), which in turn binds to a metabotropic receptor, the Mas receptor (MasR). Recent studies have demonstrated that Diminazene Aceturate (DIZE), a trypanosomicide used in animals, activates the ACE II pathway. In this study, we aimed to evaluate the antidiarrheal effects promoted by the administration of DIZE to activate the ACE II/Ang-(1-7)/MasR axis in induced diarrhea mice models. The results show that activation of the ACE II pathway exerts antidiarrheal effects that reduce total diarrheal stools and enteropooling. In addition, it increases Na⁺/K⁺-ATPase activity and reduces gastrointestinal transit and thus inhibits contractions of intestinal smooth muscle; decreases transepithelial electrical resistance, epithelial permeability, PGE2-induced diarrhea, and proinflammatory cytokines; and increases anti-inflammatory cytokines. Enzyme-linked immunosorbent assay (ELISA) demonstrated that DIZE, when activating the ACE II/Ang-(1-7)/MasR axis, can still interact with GM1 receptors, which reduces cholera toxin-induced diarrhea. Therefore, activation of the ACE II/Ang-(1-7)/MasR axis can be an important pharmacological target for the treatment of diarrheal diseases.

A comprehensive review of therapeutic approaches available for the treatment of cholera

Objectives

The oral rehydration solution is the most efficient method to treat cholera; however, it does not interfere in the action mechanism of the main virulence factor produced by Vibrio cholerae, the cholera toxin (CT), and this disease still stands out as a problem for human health worldwide. This review aimed to describe therapeutic alternatives available in the literature, especially those related to the search for molecules acting upon the physiopathology of cholera.

Key findings

New molecules have offered a protection effect against diarrhoea induced by CT or even by infection from V. cholerae. The receptor regulator cystic fibrosis channel transmembrane (CFTR), monosialoganglioside (GM1), enkephalinase, AMP-activated protein kinase (AMPK), inhibitors of expression of virulence factors and activators of ADP-ribosylarginine hydrolase are the main therapeutic targets studied. Many of these molecules or extracts still present unclear action mechanisms.

Conclusions

Knowing therapeutic alternatives and their molecular mechanisms for the treatment of cholera could guide us to develop a new drug that could be used in combination with the rehydration solution.

Immunogenicity and protective efficacy of a live, oral cholera vaccine formulation stored outside-the-cold-chain for 140 days

Background

Cholera, an acute watery diarrhoeal disease caused by Vibrio cholerae serogroup O1 and O139 across the continents. Replacing the existing WHO licensed killed multiple-dose oral cholera vaccines that demand ‘cold chain supply’ at 2–8 °C with a live, single-dose and cold chain-free vaccine would relieve the significant bottlenecks and cost determinants in cholera vaccination campaigns. In this direction, a prototype cold chain-free live attenuated cholera vaccine formulation (LACV) was developed against the toxigenic wild-type (WT) V. cholerae O139 serogroup. LACV was found stable and retained its viability (5 × 10⁶ CFU/mL), purity and potency at room temperature (25 °C ± 2 °C, and 60% ± 5% relative humidity) for 140 days in contrast to all the existing WHO licensed cold-chain supply (2–8 °C) dependent killed oral cholera vaccines.

Results

The LACV was evaluated for its colonization potential, reactogenicity, immunogenicity and protective efficacy in animal models after its storage at room temperature for 140 days. In suckling mice colonization assay, the LACV recorded the highest recovery of (7.2 × 10⁷ CFU/mL) compared to those of unformulated VCUSM14P (5.6 × 10⁷ CFU/mL) and the WT O139 strain (3.5 × 10⁷ CFU/mL). The LACV showed no reactogenicity even at an inoculation dose of 10⁴–10⁶ CFU/mL in a rabbit ileal loop model. The rabbits vaccinated with the LACV or unformulated VCUSM14P survived a challenge with WT O139 and showed no signs of diarrhoea or death in the reversible intestinal tie adult rabbit diarrhoea (RITARD) model. Vaccinated rabbits recorded a 275-fold increase in anti-CT IgG and a 15-fold increase in anti-CT IgA antibodies compared to those of rabbits vaccinated with unformulated VCUSM14P. Vibriocidal antibodies were increased by 31-fold with the LACV and 14-fold with unformulated VCUSM14P.

Conclusion

The vaccine formulation mimics a natural infection, is non-reactogenic and highly immunogenic in vivo and protects animals from lethal wild-type V. cholerae O139 challenge. The single dose LACV formulation was found to be stable at room temperature (25 ± 2 °C) for 140 days and it would result in significant cost savings during mass cholera vaccination campaigns.

Burden of typhoid fever and cholera: similarities and differences. Prevention strategies for European travelers to endemic/epidemic areas

The burden of diarrheal diseases is very high, accounting for 1.7 to 5 billion cases per year worldwide. Typhoid fever (TF) and cholera are potentially life-threatening infectious diseases, and are mainly transmitted through the consumption of food, drink or water that have been contaminated by the feces or urine of subjects excreting the pathogen. TF is mainly caused by Salmonella typhi, whereas cholera is caused by intestinal infection by the toxin-producing bacterium Vibrio cholerae. These diseases typically affect low- and middle-income countries where housing is overcrowded and water and sanitation are poor, or where conflicts or natural disasters have led to the collapse of the water, sanitation and healthcare systems. Mortality is higher in children under 5 years of age. Regarding their geographical distribution, TF has a high incidence in sub-Saharan Africa, India and south-east Asia, while cholera has a high incidence in a few African countries, particularly in the Horn of Africa and the Arabian Peninsula. In the fight against these diseases, preventive measures are fundamental. With modern air travel, transmissible diseases can spread across continents and oceans in a few days, constituting a threat to global public health. Nowadays, people travel for many reasons, such as tourism and business. Several surveys have shown that a high proportion of travelers lack adequate information on safety issues, such as timely vaccination and prophylactic medications. The main objective of this overview is to provide information to help European travelers to stay healthy while abroad, and thus also to reduce the potential importation of these diseases and their consequent implications for public health and society. The preventive measures to be implemented in the case of travel to countries where these diseases are still endemic are well known: the adoption of safe practices and vaccinations. It is important to stress that an effective preventive strategy should be based both on vaccinations and on hygiene travel guidelines. Furthermore, the emergence of multidrug-resistant strains is becoming a serious problem in the clinical treatment of these diseases. For this reason, vaccination is the main solution.

Effect of well drilling on Buruli ulcer incidence in Benin: a case-control, quantitative survey

BACKGROUND

Buruli ulcer is the third most common mycobacterial disease worldwide. The public health burden of this neglected tropical disease is large, particularly in poor areas of west and central Africa. The development of appropriate preventive strategies is hampered by an incomplete understanding of the epidemiology and transmission of the disease. We investigated the effect of the drilling of wells on Buruli ulcer incidence.

METHODS

In this case-control, quantitative survey, we obtained field data for Buruli ulcer incidence over a 10-year period from a specialised centre that collected data for the Ouémé and Plateau departments in Benin, and data for well drilling from the Ministry of Energy, Water and Mines in Benin. The coordinates of the wells drilled were obtained during site visits. A case-control study was then done to investigate the role of well water use in protecting against Buruli ulcer.

FINDINGS

We found a strong inverse correlation between the incidence of Buruli ulcer and the number of new wells drilled in the Bonou municipality (r²=0·8818). A case-control study (106 cases and 212 controls) showed that regular use of the water from the wells for washing, bathing, drinking, or cooking was protective against Buruli ulcer (adjusted odds ratio 0·1, 95% CI 0·04-0·44; p=0·0012).

INTERPRETATION

This study opens up new possibilities for developing an effective yet affordable policy to fight the disease on a substantial geographical scale. Our study shows that providing access to protected water is an efficient and feasable way to reduce the incidence of Buruli ulcer.

FUNDING

Fondation Francaise Raoul Follereau, French National Institute of Health and Medical Research, and Région Pays de Loire.

Analysis of Factors Contributing to the Spread of Cholera in Developing Countries

Objective

Cholera has been endemic in Nigeria since the 1970s and has resulted in several early deaths, which probably could have been avoided. This study examined the various factors that contribute to the infection and spread of cholera in Benue State, Nigeria, from 2008 to 2017. We also proposed a cloud based health management system (CBHMS) for the timely identification and management of cholera in an epidemic.

Materials and Methods

A cluster random sampling in the form of a close ended questionnaire was used to collect data from a sample of 420 participants comprising farmers, traders, housewives, and students who were randomly selected from different locations in Makurdi. Statistical analyses, such as demographics, reliability, and descriptive analysis, of the collected data were performed, and a socio-technical design approached was used in the system development.

Results

Terrorism, floods, improper sewage disposal, and lack of environmental hygiene were the main causes of the spread of cholera in Benue State.

Conclusion

The research highlights the factors aiding the spread of cholera in Nigeria by directing donor agencies and government to channel their focus and prepare ahead in view of an emergency. The proposed CBHMS will aid the early detection and management of cholera in an epidemic.

TcpP L152A Constitutively Activating Virulence Gene Expression in Vibrio cholerae

Vibrio cholerae, the causative agent of severe watery diarrheal disease cholera, requires production of a number of virulence factors during infection which results from the activity of a cascading system of regulatory factors by sensing to different environmental signals. TcpP, a membrane-localized transcription activator in V. cholerae, activates virulence factors production by responding to human host signals. To better characterize the transmembrane helix in regard to its roles on TcpP positive effectors sensitivity, site-directed mutagenesis was performed to identify specific mutations in this region which could enhance TcpP transcription activity in the absence of stimuli, like bile salts. We found that TcpP L152A constitutively forms homodimer and activates toxT expression in the absence of bile salts. However, being active, TcpP L152A needs to form disulfide bonds between the cysteine residues in the periplasmic domain of TcpP. We also found that TcpP L152A showed a competitive advantage in the infant mouse colonization model by coadministrating the bile salt-sequestering resin cholestyramine. All these results demonstrate that the transmembrane helix of TcpP plays an important role in regulating TcpP transcription activity in response to its positive effectors.

Antidiarrheal activity of α-terpineol in mice

Diarrhea is one of the leading causes of infant death in the world accounting for high child mortality rate. It is also present in different pathophysiologies related to several etiological agents. The aim of this study is to investigate the antidiarrheal effect of α -Terpineol (α-TPN) in different diarrhea models in rodents. The antidiarrheal effect of α-TPN in the treatment of acute diarrhea and enteropooling induced by castor oil or PGE₂ in Swiss mice pretreated orally with saline (NaCl 0.9%), Loperamide (5 mg/kg) and α-TPN (6.25, 12.5, 25 and 50 mg/kg) was analyzed. Additionally, parameters of severity, total weight of faeces and post-treatment for 4 h were evaluated. Modulation of the opioid and cholinergic pathways was performed and intestinal transit model using activated charcoal as marker was also used. The effect of α-TPN on secretory diarrhea was investigated using the model of fluid secretion in intestinal loops isolated from cholera toxin-treated mice. α-TPN showed antidiarrheal effect (*p < 0.05), reducing the total stool amount (*55%, *48%, *44%, *24%) and diarrheal (*47%, *66%; *56%, 10%) respectively for the doses tested. All doses investigated in the enteropooling test presented significant changes (*46%, *78%, *66%, *41% respectively) in relation to the control. α-TPN through the muscarinic pathway reduced the gastrointestinal transit (*31%), besides inhibiting PGE₂-induced diarrhea (*39%). α-TPN also reduced fluid formation and loss of Cl^- ions, by interacting directly with GM1 receptors and cholera toxin, thus increasing the uptake of intestinal fluids. The results suggest an anti-diarrheal activity of α-TPN due to its anticholinergic action, ability to block PGE₂ and GM1 receptors and interaction with cholera toxin in secretory diarrhea, making it a promising candidate drug for the treatment of diarrheal diseases.

Interaction of microbial pathogens with host exocytic pathways

Many microbial pathogens co-opt or perturb host membrane trafficking pathways. This review covers recent examples in which microbes interact with host exocytosis, the fusion of intracellular vesicles with the plasma membrane. The bacterial pathogens Listeria monocytogenes and Staphylococcus aureus subvert recycling endosomal pathways of exocytosis in order to induce their entry into human cells. By contrast, entry of the protozoan pathogen Trypanosoma cruzi or the virus adenovirus into host cells involves exploitation of lysosomal exocytosis. Toxins produced by Bacillus anthracis or Vibrio cholerae interfere with exocytosis pathways mediated by the GTPase Rab11 and the exocyst complex. By doing so, anthrax or cholera toxins impair recycling of cadherins to cell-cell junctions and disrupt the barrier properties of endothelial cells or intestinal epithelial cells, respectively. Uropathogenic Escherichia coli (UPEC) is expelled from bladder epithelial cells through two different exocytic routes that involve sensing of bacteria in vacuoles by host Toll-like receptor 4 (TLR4) or monitoring of the pH of lysosomes harbouring UPEC. The TLR4 pathway is mediated by multiple Rab GTPases and the exocyst, whereas the other pathway involves exocytosis of lysosomes. Expulsion of UPEC through these pathways is thought to benefit the host.