A new trend in cholera epidemiology

Combating cholera by building predictive capabilities for pathogenic Vibrio cholerae in Yemen

Cholera remains a global public health threat in regions where social vulnerabilities intersect with climate and weather processes that impact infectious Vibrio cholerae. While access to safe drinking water and sanitation facilities limit cholera outbreaks, sheer cost of building such infrastructure limits the ability to safeguard the population. Here, using Yemen as an example where cholera outbreak was reported in 2016, we show how predictive abilities for forecasting risk, employing sociodemographical, microbiological, and climate information of cholera, can aid in combating disease outbreak. An epidemiological analysis using Bradford Hill Criteria was employed in near-real-time to understand a predictive model's outputs and cholera cases in Yemen. We note that the model predicted cholera risk at least four weeks in advance for all governorates of Yemen with overall 72% accuracy (varies with the year). We argue the development of anticipatory decision-making frameworks for climate modulated diseases to design intervention activities and limit exposure of pathogens preemptively.

Cholera outbreaks in the classical biotype era

In the Indian subcontinent description of a disease resembling cholera has been mentioned in Sushruta Samita, estimated to have been written between ~400 and 500 BC. It is however not clear whether the disease known today as cholera caused by Vibrio cholerae Vibrio cholerae O1 is the evolutionary progression of the ancient disease. The modern history of cholera began in 1817 when an explosive epidemic broke out in the Ganges River Delta region of Bengal. This was the first of the seven recorded cholera pandemics cholera pandemics that affected nearly the entire world and caused hundreds of thousands of deaths. The bacterium responsible for this human disease was first recognised during the fifth pandemic and was named V. cholerae which was grouped as O1, and was further differentiated into Classical and El Tor biotypes. It is now known that the fifth and the sixth pandemics were caused by the V. cholerae O1 of the Classical biotype Classical biotype and the seventh by the El Tor biotype El Tor biotype . The El Tor biotype of V. cholerae, which originated in Indonesia Indonesia and shortly thereafter began to spread in the early 1960s. Within the span of 50 years the El Tor biotype had invaded nearly the entire world, completely displacing the Classical biotype from all the countries except Bangladesh. What prompted the earlier pandemics to begin is not clearly understood, nor do we know how and why they ended. The success of the seventh pandemic clone over the pre-existing sixth pandemic strain remains largely an unsolved mystery. Why classical biotype eventually disappeared from the world remains to be explained. For nearly three decades (1963-1991) during the Seventh cholera pandemic seventh pandemic, cholera in Bangladesh has recorded a unique history of co-existence of Classical and El Tor biotypes of V. cholerae O1 as epidemic and endemic strain. This long co-existence has provided us with great opportunity to improve our understanding of the disease itself and answer some important questions.

Rapid screening of fecal samples for Vibrio cholerae by a coagglutination technique

A coagglutination procedure for detecting Vibrio cholerae was applied directly to 125 watery fecal samples received in the laboratory for bacteriological culture: many of these were from suspected cases of cholera. Of 47 bacteriologically proved cases of cholera, 44 (93.6%) gave positive results by the coagglutination method. There was a good correlation between the coagglutination method, dark-field microscopy, and culture.

Isolation of Vibrio cholerae from nightsoil during epidemics of classical and E1 Tor Cholera in East Pakistan

A clear difference has been observed between the classical Inaba V. cholerae and the El Tor Ogawa V. cholerae in relation to the ability to isolate the organism from the environment.An early attempt to utilize nightsoil sampling as a tool to measure the extent of infection in the community during an epidemic of classical Inaba cholera in Dacca, East Pakistan, in the spring and fall of 1968 proved unsuccessful. During an epidemic caused by both the classical Inaba and the El Tor Ogawa vibrios in Chittagong between July 1968 and March 1969 the reasons for this failure became apparent. In Dacca, only 2 isolations of classical Inaba were made from 9906 individual latrine and pooled communal nightsoil samples, whereas in Chittagong, from 62 588 similar samples in which 2 classical Inaba isolations were also made, there were 52 El Tor Ogawa isolations. In areas where cases due to both biotypes were occurring simultaneously, El Tor Ogawa vibrios were isolated 10 times more frequently than the classical Inaba.It remains unclear whether the differences observed between El Tor Ogawa and classical Inaba are related to the biotype or to the serotype of the organism, or to both. An extrapolation of nightsoil sampling, therefore, to the incidence and prevalence of infection in a community must consider both the biotype and the serotype.

Cholera vaccine field trials in east Pakistan. 2. Effectiveness in the field

A cholera-vaccine field trial in a rural area of East Pakistan where cholera is highly endemic has indicated that a high-potency whole-cell vaccine can provide significant protection against disease due to Vibrio cholerae for at least 18 months. This vaccine gave more than 70% protection during the first cholera season after vaccination. In the second cholera season after the administration of a single dose of vaccine, protection fell in those under 5 years of age, while continuing at significantly effective levels in older persons.Purified Ogawa antigen (lipopolysaccharide) afforded significant protection to adults against disease due to the heterologous Inaba serotype, but only protected children against milder diarrhoeas.The effect of cholera vaccine on the incidence of infections among family contacts of cholera patients was variable. Vaccine had no effect on the proportion of asymptomatic infections.Diarrhoeal disease associated with V. cholerae occurred predominantly among children, while protection was most marked among adults. Adverse reactions were practically restricted to the adults, suggesting that children will not only tolerate a larger dose, but actually require a larger dose for maximum protection against infection.

Classical and El Tor cholera: a clinical comparison

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Interaction of Vibrio cholerae and Vibrio El Tor

Soon after its entry into the Indo-Pakistan subcontinent in 1964, cholera El Tor progressively replaced classical cholera. One of the probable reasons for this was found from laboratory studies of the interaction of the two choleragenic vibrios, V. cholerae and V. El Tor. It was observed, in both in vitro and in vivo experiments, that in mixed culture El Tor vibrios from cholera cases are capable of outgrowing and rapidly eliminating V. cholerae. The apathogenic El Tor strains from the Middle East countries differed significantly from the pathogenic type of El Tor strains isolated from cholera cases in that the former did not inhibit the growth of V. cholerae strains. The possible mechanism of interaction of the pathogenic El Tor vibrios and V. cholerae was studied in detail. Various possibilities, including higher rates of multiplication of El Tor vibrios, competition for nutrients, secretion of inhibitory substances and liberation of lethal bacteriophage or vibriocins by El Tor vibrios, were examined. Although it was not possible to establish the actual mechanism of this interaction, the possible biological effect on the epidemiology of cholera was evident.