1. Cholera bacterium Vibrio cholerae Toxin alters sodium pump in intestinal cells resulting in fluid loss

2. Cholera 1800s

3. Cholera: the Disease Entry: oral Colonization: small intestine Symptoms: nausea, diarrhea, muscle cramps, shock

4. Infant with Cholera

5. First Cholera Pandemic Why does an epidemic end?

6. Second Cholera Pandemic

7. Cholera New York 1830s

8. John Snow and the Pump Handle John Snow and cholera in 1854 London

9. John Snow John Snow is credited by many with developing the modern field of epidemiology

11. London in the 1850’s Germ theory of disease not widely accepted People lived in very crowded conditions with shared water and toilets facilities outside

12. Water Supply London 1850’s

13. John Snow’s Observations People with cholera developed immediate digestive problems: cramps, vomiting, diarrhea Face, feet, hands shriveled and turned blue; died in less than a day Probably spread by vomiting and diarrhea

15. Cholera Epidemiology Comparison of pump location with cholera deaths, first 3 days of epidemic in 1854

16. Cholera Epidemiology Of 83 people, only 10 lived closer to a different pump than Broad Street Of these 10, 5 preferred taste of Broad Street water and 3 were children who went to nearby school

17. Cholera Epidemiology Snow convinced neighborhood council to let him remove handle from water pump on Broad Street - # new cases declined dramatically Many on council not convinced by his evidence

18. Snow Index Case

19. Index case is first person to become ill 40 Broad Street – husband and infant child became ill Wife soaked nappies in bucket and emptied it into the water tank next to pump

20. The Great Experiment Two water companies supplied central London Customers mixed in same neighborhood Snow went door to door asking which water company served home and compared locations with cholera data

21. The Great Experiment Lambeth Company: water intake upstream of London sewage outfall into Thames Southwark & Vauxhall Company: water intake downstream of sewage outfall

22. The Great Experiment # Houses# Deaths Deaths/ 100,000 S and V40,0461263315 Lambeth26,1079837

23. Cholera in the 1990s Epidemic in Peru beginning 1991 From 1991-1994 –Cases 1,041,422 –Deaths 9,642 (0.9%) Originated at coast, spread inland

25. World Cholera 2000-01

26. Why Has Cholera Re-emerged? Deteriorating sanitary facilities as larger population moves into shanty towns Trujullo, Peru – fear of cancer from chlorination so water untreated Use of wastewater on crops Africa – civil wars and drought caused migrations into camps

27. How Has Cholera Re-emerged? Simultaneous appearance along whole coast of Peru Traveled in ship ballast? Traveled in plankton from Asia? Always present in local zooplankton (copepods) but dormant until triggered by ???

28. Copepod Carrying Vibrio cholerae

30. Cholera and El Niño Periodic warming of water near coast of Central and South America Large plankton blooms, especially in coastal waters with nutrients from sewage runoff

31. Cholera and El Niño Cholera in Bangladesh also seen to fluctuate with El Niño, but with 11 month lag Rita Colwell and multinational group studying link between climate and cholera Satellite and surface data used to show cholera incidence is related to sea surface temperature

32. Cholera from Space

33. Cholera and Sea Surface Temperature

34. Cholera in the 1990s Cholera O139 emerges in Asia Different O (coat) antigen, 99% genetic identity O antigen is how human immune system recognizes and protects against V. cholerae More people susceptible

35. Cholera Antibiotic Resistance Cholera is becoming resistant to several antibiotics