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Cholera: under-estimated and under-reported in India

According to this ICMR analysis paper on cholera, the incidence of the disease occurs over a wider geographic area in India than was previously recognized. The annual number of cholera cases reported to WHO by the government was several times lower than the numbers they obtained through strains received at the phage typing unit.Caused by bacteria, cholera is spread through contaminated water, and it kills by dehydrating victims through diarrhoea and vomiting.The WHO says about 100,000 people die worldwide from cholera each year. It is a rough estimate. Some countries do not report cases and victims often die in isolated rural communities, the cause of their deaths unrecorded.

The Indian subcontinent is vulnerable to this disease due its vast coastlines with areas of poor sanitation, unsafe drinking water and overcrowding. Climatic conditions also play a major role in the persistence and spread of cholera.In August of this year, as reported in The Indian Express- Chandigarh, cholera cases shot up to 26 in different areas.

As a WHO Collaborating Centre for Diarrhoeal Diseases Research and Training, the National Institute of Cholera and Enteric Diseases (NICED), Kolkata, West Bengal, India, receives about 1000 to 1500 strains of Vibrio cholerae every year from about 30 to 40 institutions from India and a few from outside the country for biotyping, serotyping and phage typing. (2007 figures)  This may have been due to lack of surveillance as well as proper laboratory support and, therefore, the burden of cholera in India is underestimated . Data from population-based diarrhoea surveillance in an endemic area of Kolkata, India, revealed a cholera incidence of 2.2 cases per 1000 person-years in 2012. The study’s findings indicated that cholera is an under-recognized problem in India.

One of the oral vaccines, Shanchol has been approved by the  WHO and the Gates Foundation has weighed in forcefully to promote its use. Among other steps, the foundation has pumped about $20 million into Shanchol and helped jumpstart manufacturing of the vaccine in India.Helen Matzger, senior program officer at the Gates Foundation feels that the decision to promote the vaccine made sense. However, the vaccine does have its drawbacks as it must be administered in two doses, two weeks apart, which can be a difficult task in an emergency. The vaccine only cuts a person’s risk of contracting the disease by an average of 50 percent to 65 percent over two years. After that, a recipient’s immunity drops even further.

In 2013, there was a cholera outbreak in a village in south India . According to this paper in the Journal of Infection and Public Health, timely action saved many lives.A household and sanitary survey, water samples and stool examination were conducted.Causes and risk factors of the outbreak were identified and immediate suitable action taken. The timely diagnosis and interventions resulted in zero deaths in spite of high attack rates of cholera. This paper articulates that this model can be used in any rural areas to prevent deaths and recurrence in cholera outbreaks.

Cholera Pandemic Timeline:

1817 – The first pandemic begins in India, where cholera has existed for centuries.

1820 – More than 100,000 people die on the island of Java in Indonesia.

1821 – In Basra, Iraq approximately 18,000 people die in a three week period.

1829 – The second pandemic begins in India.

1830 – Cholera reaches Moscow and St. Petersburg, Russia.

1832 – In June, more than 1,000 people die in Quebec, Canada .

1852 – The third pandemic begins in India-  the deadliest of the seven pandemics.

1854 – More than 23,000 people in Great Britain die, in the worst year of the pandemic.

1863 – The fourth pandemic begins in India.

1877-1879 – Approximately 90,000 people die in Japan.

1881 – The fifth pandemic begins in India.

1884 – The disease kills more than 5,000 in Naples, Italy.

1885 – More than 60,000 people die in two Spanish provinces.

1893-1894 – Approximately 200,000 people die in Russia.

1899 – The sixth pandemic begins in India.

1907-1908 – More than 20,000 pilgrims die oduring the Haj to Mecca, Saudi Arabia.

1923 – The sixth pandemic ends , cholera disappears except India.

1961 – The seventh pandemic begins on the Indonesian island of Celebes.

1970s – Cholera reaches Africa for the first time in 70 years.

1991 – The disease appears in Latin America (Peru) and approx 3,000 people die.

1994 – Cholera breaks out in Rwandan refugee camps near Goma, Zaire. Tens of thousands of people die within a month.

2008-2009 – An estimated 4,200 people die in Zimbabwe.

October 2010 – Cholera breaks out in Haiti, and more than 6,600 die within a year.

July 2012 – Cholera breaks out in Cuba for the first time in more than 100 years.

August 28, 2012 – Cuba’s government declares the cholera outbreak that inflected 417 and killed three, eradicated.

May 22, 2013 – Haiti reports 657,117 cases of cholera and 8,096 deaths since the 2010

2013 – An outbreak in Mexico leads to 159 confirmed cases of cholera.


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