Easy to introduce, hard to get rid of...

From NPR weekend edition yesterday:
After Bringing Cholera To Haiti, U.N. Plans To Get Rid Of It.


Haiti hadn't seen cholera for at least a century. Then suddenly, the first cases appeared in the central highlands near a camp for United Nations peacekeeping forces.

Since then the disease has struck 1 out of every 16 Haitians — nearly 640,000 people. It has killed 8,000.
...
Most scientists now think Nepalese soldiers unwittingly brought cholera to Haiti when they joined a U.N. peacekeeping force there in 2010. The outbreak started just downstream from their camp. Sewage from the camp spilled into a nearby river.
...

For its part, the U.N. hasn't admitted anything. But in December, Secretary-General Ban Ki-moon announced a plan to rid Haiti and the neighboring Dominican Republic of cholera.

Concannon says that's ambitious — but feasible.

"Cholera can certainly be eliminated from Haiti," he tells Shots. "It's been eliminated from the United States, from England, from many countries in South America," he says. "This is basically 19th century technology that needs to be installed in Haiti."

The Haitian government is expected to release a detailed blueprint for the first two years of the effort sometime this month. The entire project is expected to cost $2.2 billion and take at least 10 years.

But so far, the U.N. has identified only 10 percent of the money, most of it redeployed from earlier pledges. Concannon worries the rest may never be found.

Tchaikovsky's death

One of the strangest Cholera stories concerns the Russian composer Tchaikovsky who died from cholera in 1893, nine days after the premiere of his Sixth, and probably most famous, Symphony, the Pathétique.

There are no end of theories about how and why this occurred, ranging from an accident to suicide to forced suicide. We do know that on 2 November 1893 Tchaikovsky drank a glass of unboiled water - an unusual event given that by this date the mode of transmission of cholera was well known and a cholera epidemic was underway in Saint Petersburg.

If you'd like to read more about this curious story then you have the choice of the exhaustive detail of Wikipedia: Death of Pyotr Ilyich Tchaikovsky, a newspaper article from 2007: How did Tchaikovsky die?, a research paper from 2010: The cause of P.I. Tchaikovsky's (1840-1893) death: cholera, suicide, or both?, or, my favorite, the Straight Dope: How did Tchaikovsky really die?


And then there's the question of whether the Pathétique was written as a farewell to the world.

After the last rehearsal of the symphony under its composer's baton, Grand Duke Konstantin Konstantinovich, a talented poet and fervent admirer of the composer, ran into the green room weeping and exclaiming, "What have you done, it's a requiem, a requiem!"

The Ghost Map

The story of London's great stink, it's cholera epidemics, and the work of John Snow is well described in many books about epidemiology and public health.

Steven Johnson 2006 book called 'The Ghost Map: The Story of London's Most Terrifying Epidemic--and How It Changed Science, Cities, and the Modern World' is very readable and fairly vividly evokes the era. As part of the publicity for the book they made an amusingly educational (or educationally amusing) animated video that is well worth 3 minutes of your time.

Who discovered Cholera?

Or more precisely, who first discovered the organisms that cause Cholera? The smart money would be on Robert Koch who discovered many other disease causing organisms such as Anthrax in 1877 and Tuberculosis in 1882. However Koch only rediscovered Cholera (in 1883) because the causative agent had actually been discovered thirty years earlier by Filippo Pacini.

Pacini published a paper in 1854 entitled, "Microscopical observations and pathological deductions on cholera" in which he described the organism and its relation to the disease. Just to make his discovery perfectly clear to everyone his microscopic slides of the organism were clearly labeled with his name, the date and nature of his investigations.

But people still managed to overlook his work and Koch was usually given credit for the discovery - a mistake that was only fully rectified 1965 when the international committee on nomenclature adopted the formal name Vibrio cholerae Pacini 1854.

For more information check out 'Who first discovered Cholera' at UCLA's John Snow site.

Do Natural Disasters Breed Health Epidemics?

An interesting article in Popular Science that touches on several issues we will cover in this class.

Do Natural Disasters Breed Health Epidemics?
A deadly outbreak of cholera followed the 7.0 earthquake that struck Haiti three years ago this week. Jonathan Katz, the only American reporter stationed in Haiti at the time, explains what caused the outbreak--and why it was anything but inevitable.

The great mass of people

'The great mass of people…. don’t know that the miasma of an impure alley is productive of cholera and disease. If they did know these things, people would take care that they inhabited better houses.’English Liberal Economist, Richard Cobden 1853

I included the quote above in the second lecture on Cholera.  Hopefully you all appreciate how condescending the sentiment is and I don't think many of us would say such a thing today about poor people in our own country.

However when we talk about other countries I think there is a greater tendency to make this mistake - if only people knew to boil their water and get their sick people to hospitals then the problem would be solved.

The Guardian, a British newspaper, have a short video clip on their website about the Zimbabwe cholera epidemic in 2008/2009. It is well worth watching. Notice how all these people know exactly how cholera is contracted but can do nothing about it, and know what a cholera patient needs, but don't have the funds to provide it.

Where did the Haiti cholera outbreak come from?

A Haitian protester in Port-au-Prince last year spray-paints a wall, equating the UN mission in Haiti (abbreviated here as MINISTA) with cholera.

 From the NPR health blog last week reporting on a paper published on June 18 2012 in The Proceedings of the national academy of Sciences (Genomic diversity of 2010 Haitian cholera outbreak strains)

Most researchers currently believe that United Nations peacekeeping soldiers introduced cholera to Haiti in October of 2010.
After all, Haiti hadn't recorded cholera for as long as a century, Nepal had experienced a cholera epidemic in the months preceding the soldiers' arrival, and the Haitian and Nepalese cholera strains were found to be nearly identical.
But it's not that simple, says a research group based at the University of Maryland.
  These researchers have found two very different cholera strains in some of the first Haitians to be struck by the disease.

Disease Sleuths

I've posted about Google's flu tracker and how Twitter is being used to track diseases before but I thought NPR's little animation was nice. The article: Disease Sleuths Surf for Outbreaks Online expands on it and is also interesting. This type of tracking is not suitable for all diseases:

In the early days of the cholera outbreak, Twitter and HealthMap data closely matched official reports. After 100 days online activity dropped off even though the epidemic raged on. Disease is easiest to detecte when it is out of the ordinary. Regularly recurring maladies like malaria are hard to follow online.

But it's a hot topic at the moment and even has a new name 'Webidemiology'. I hadn't realized that Google had expanded its surveillance to include Dengue Fever.

Love in the Time of Cholera

If you've never read it, or you've only seen the movie, I strongly recommend Gabriel García Márquez's novel Love in the Time of Cholera. Despite it's main theme, that lovesickness is literally an illness, a disease comparable to cholera, it is a beautifully written book that has a lot to say about love in its myriad forms.

Here's the start of Thomas Pynchon's review of the book for the New York Times:

Love, as Mickey and Sylvia, in their 1956 hit single, remind us, love is strange. As we grow older it gets stranger, until at some point mortality has come well within the frame of our attention, and there we are, suddenly caught between terminal dates while still talking a game of eternity. It's about then that we may begin to regard love songs, romance novels, soap operas and any live teen-age pronouncements at all on the subject of love with an increasingly impatient, not to mention intolerant, ear.

At the same time, where would any of us be without all that romantic infrastructure, without, in fact, just that degree of adolescent, premortal hope? Pretty far out on life's limb, at least. Suppose, then, it were possible, not only to swear love "forever," but actually to follow through on it -- to live a long, full and authentic life based on such a vow, to put one's alloted stake of precious time where one's heart is? This is the extraordinary premise of Gabriel García Márquez's new novel Love in the Time of Cholera, one on which he delivers, and triumphantly.

Max Joseph von Pettenkofer

I love the Internet. Not just for its vast array of information but for the fact it provides me with this information in the comfort of my own home at any hour of the day.

I has been meaning to look up some more information on Max Joseph von Pettenkofer - that most famous of cholera drinkers. In particular I was curious if any of his students had died from their cholera drinking activities. It took only a few clicks to find this biographical sketch of von Pettenkofer published in the Journal of Nutrition in 1977.

In 1892, when almost 74 years of age, Pettenkofer performed on himself what he called his experimentum cruets. He swallowed 1cc of a cholera culture prepared from the "rice-water" stools of a dying man. No symptoms resulted except a "light diarrhea with an enormous proliferation of the bacilli in the stools".

Pettenkofer's students repeated the experiment on themselves. In two cases, the reaction was severe, but no one died. Pettenkofer considered the results a vindication of his views, but most epidemiologists were not swayed by these results.

So none of the students died but I was amazed to discover that Pettenkofer had carried out this experiment at the age of 74. I need to change the picture I use of him.

The Sewer King

I haven't watched it yet but I just discovered that Episode 4 of a BBC series entitled Seven Wonders of the Industrial Age is all about Joseph Bazalgette and the construction of London's sewer system.

Set in London during the 1850s, this episode focusses on the construction of the London sewerage system, built to replace the antiquated medieval system that was overworked and inadequate for the needs of the-then largest metropolis in the world, causing epidemics of disease and a permanent foul stench to fill the air. The episode follows the efforts and work of Joseph Bazalgette, the brilliant engineer who designed the influential and modern sewer system that would purify the city, transform the streets above and would result in the end of the epidemics of cholera and typhoid that had ravaged the population - although, ironically not for the reasons that he initially thought.

I found it on YouTube but only with subtitles I'm afraid. Looks good if you like your history reenacted.

First case of Cholera in Haiti

Man collecting water in Port-au-Prince, Haiti.

Earlier this week a Boston aid group reported that it had tracked down the first person to be infected by Cholera in Haiti's epidemic. Cholera had been eliminated from Haiti for many decades prior to the recent earthquake

A mentally ill man who bathed in and drank from a contaminated river most likely was the first person to be infected in the Caribbean country's deadly cholera outbreak. Althoug the man's family had access to clean drinking water he bathed in and drank frequently from a river into which the Meye River fed. The Meye has been identified as the likely source of the epidemic. Studies suggest the cholera was likely brought to Haiti by a United Nations peacekeeping battalion from Nepal, where the disease is endemic.

"It's a striking example of how mental health, infectious disease and community health affects overall well-being." Dr David Waltern, a co-author of the study.

Given the conditions in Haiti it is perhaps inevitable that cholera might break out but this interaction with mental health is especially interesting, and tragic.

Great stink

In the sweltering summer of 1858 the stink of sewage from the polluted Thames was so offensive that it drove Members of Parliament from the chamber of the House of Commons. Sewage generated by a population of over two million Londoners was pouring into the river and was being carried to and fro by the tides. The Times called the crisis "The Great Stink". Parliament had to act - drastic measures were required to clean the Thames and to improve London's primitive system of sanitation.

I was going to post a link to some more information about the book I mentioned, The Great Stink of London, in case anyone was curious about this, the smelliest period in history, when I discovered that someone has written a novel about it with a very similar title set in the same era.

It takes a world of confidence to name your debut novel The Great Stink, and to set it in a sewer. Not even a modern sewer--charmless though that may be--but the crumbling, cholera-laden, rat-infested, fungus-rich sewers of London in the mid-Victorian period, from which pockets of deadly gas frequently burbled to the surface. Clare Clark's unsavory but completely absorbing first novel is a Dantean tour of this reeking underworld and its denizens: both the scavengers--human and animal--and the reformers, who brave the tunnels in the service of public hygiene and social progress after the 1858 Act of Parliament that called for the rebuilding of the sewer system. The Great Stink juxtaposes two darknesses, both embodied in the filthy tunnels: the lawless desperation of the very poor, and the despair of madness.

#cholera

Thanks to Julio for the tip on this article today in Nature reporting on a study that showed social media data, including Twitter posts, accurately tracked Haiti's cholera outbreak and provided this data up to two weeks before official reports.

Such data could allow health workers to "gain early insight into an evolving epidemic" — and help plan a response sooner.

Just an appendix...

Cholera cases by region. The size of a region shows the proportion of all cholera cases found in that region

We barely had time to get started with Cholera today but there was an interesting article on the Scientific American blog last week about how the appendix may not be as useless as we previously thought.

The essence of the argument is that in the presence of serious diarrheal diseases like Cholera the appendix forms a refuge for beneficial gut bacteria that are being purged from your intestines (hopefully along with the Cholera bacteria).

(T)he appendix serves as a nature reserve for beneficial bacteria in our guts. When we get a severe gut infection such as cholera (which happened often during much of our history and happens often in many regions even today), the beneficial bacteria in our gut are depleted. The appendix allows them to be restored.  In essence, Parker sees the appendix as a sanctuary for our tiny mutualist friends, a place where there is always room at the inn. If he is right, the appendix nurtures beneficial bacteria even as our conscious brains and cultures tell us to kill, kill, kill them with wipes and pills.

Cholera returns

From the Washington Post today:
Cholera returns to rural Haiti amid fears that relief funds to contain it are running dry

The epidemic began in rural Haiti last fall, likely brought by U.N. peacekeepers from Nepal. It swept through the countryside of an impoverished nation already overwhelmed by a January 2010 earthquake that left hundreds of thousands homeless and by political instability following disputed elections.
...
The disease faded in winter and spring, when rain is less frequent, and many aid workers moved on. U.N. troops in Haiti turned their attention to the country’s many other pressing problems.
Now there is a fear among aid workers who remain that there won’t be enough resources if the latest surge gets much worse.

Cholera - next stop Chad and the Ivory Coast

Heavy rains in a number of African countries bring the threat of Cholera;

Rainy season to worsen Chad cholera outbreak - Oxfam
A cholera outbreak that has killed more than 100 people in Chad could worsen this June as the rainy season starts in the Central African country, Oxfam warned on Wednesday.


The Chadian government says only 0.6 percent of the country’s households use improved latrines, while 88 percent of people defecate in the open. There is no garbage collection system in villages, while in towns waste water disposal and storm drainage systems are nearly nonexistent.
 
UNICEF responds to cholera outbreak in Ivory Coast
 Following the confirmation of 10 cases of cholera in the Koumassi district of Abidjan, Ivory Coast, UNICEF has provided medical supplies to local health authorities to treat up to 1,000 patients infected with the disease and kits with soap, chlorine, and water treatment products for 400,000 people.

Haiti Cholera update

Hillary Clinton washes her hands during a visit to Partners in Health Cholera Treatment Center.

If you read or watch the news you may have seen reports that Secretary of State Hilary Clinton was in Haiti yesterday touring a cholera clinic.

Although the number of new cases is finally declining the outbreak is still far from over.

Steven Smith, a health official at the US embassy, told Clinton that "we're seeing a decrease in the number of cholera cases. Even more important, we're seeing a decrease in the number of fatalities."
But he said there were still hundreds of new cases a day countrywide.
The number of new patients at the Cholera Treatment Center, managed by US government grantee Partners in Health, has been reduced by half to about 40 per day since the start of the epidemic, a State Department official said.
Five patients have died at the clinic, the official said.
The death toll from Haiti's cholera epidemic is 4,030, the Haitian health ministry said Thursday, while the number of cholera cases totaled 209,034 as of January 24.

Poverty, Violence, and Cholera. Oh my!

In late 2008, as Zimbabwe struggled in the grips of a cholera epidemic, it was not only the disease's victims who suffered, but everyone.

The country, overrun with poverty, saw an inflation rate of 231 Million percent in 2008. Grocery shelves were often completely empty. (did someone say, lowered-immune-systems-due-to-malnutrition?) And soldiers upset about their pay had run through the streets of the nations capital, Harare, looting buildings and robbing currency changers. The citizens were outraged at the banking industry's inability to give them access to their money.

Also in Harare, protests from doctors and nurses who were appalled at their working conditions had to be broken up by police. They claimed that they lacked basic sanitation supplies, (obviously important for a cholera outbreak) and even medical necessities such as needles. The health system was seeing huge problems even before the cholera outbreak which killed 625 people and infected over 12,000 others.

To make matters worse, the government had run out of money to treat water, and the contaminated supply could not be cleaned.

At the top of all this, the current presidential administration of Robert Mugabe had one year earlier forced a political challenger out of the election through methods of violence.

So, what does all of this tell us?

We can see that problems tend to become much worse when they overlap into common sectors, i.e, public health and politics. But what happens when the sector in the center of it all hits rock bottom? That is what we saw in Zimbabwe. The economy was in ruin, leading to overwhelming problems reaching into every aspect of the country's infrastructure. As we learned in class, cholera very seldom has serious effects in developed countries. Zimbabwe at this time in 2008 gave the disease the perfect opportunity to take hold, showing us that a country's infrastructure plays the role of its immune system.

http://www.nytimes.com/2008/12/04/world/africa/04zimbabwe.html?_r=1

Cholera and death

I stressed several times last week that Cholera is a VERY treatable disease and once you have reached a clinic and been diagnosed your prognosis is very good. Yet I have seen several statistics giving data from countries where the cholera death rate in hospitals is ~5% amongst those that are admitted to the hospital. This made me curious about what was actually causing these deaths.

I found an interesting paper from the year 2000 that examined this very question in Bangladesh where Cholera is endemic: Mortality, morbidity, and microbiology of endemic cholera among hospitalized patients in Dhaka, Bangladesh.

The prevalence of Cholera in the area meant that the sample sizes were very large - 174,000 cases over 10 years! In the last year of the study for example 19,100 cholera patients were treated, 887 (4.6%) were admitted, and 33 of the admitted patients died (mortality rate 3.7% of cholera inpatients or 0.14% of all cholera patients). Why did these 33 patients die?

The main finding of our study is that concomitant infection accounted for the majority of deaths in hospitalized patients with cholera cared for in this endemic area. Concomitant infection was the cause of four of every five deaths in cholera patients in this study, and accounted for almost all deaths in children twelve months of age or younger. Although concomitant infection has previously been recognized as contributing to the morbidity and mortality associated with cholera, its role as a leading cause of death has not previously been reported. This finding is in large part due to the success of rehydration therapy programs and the virtual elimination of hypovolemia as a cause of death among hospitalized patients with cholera in this setting. The number of individuals with cholera who die before reaching medical attention in this modern urban area endemic for cholera, however, is not presently known. Two concomitant infections predominated in cholera patients in this study: respiratory infections and enteric coinfections. Mortality was primarily associated with the former.

Concomitant infections are other infections (apart from cholera) which the patients had upon admission.
Hypovolemia is loss of blood volume (due to dehydration in this case) which can be very dangerous.

Figure 2 at the end of the paper is interesting because it shows that ALL of the six cases in 1996 who died of Cholera died within a few hours of entering the hospital - ie they had probably arrived too late to be helped, four of them were noted to be pulseless and unconscious upon arrival.

So the bottom line is very clear. If you arrive at a clinic before you are unconscious and provided you do not have another infection (particularly a respiratory infection) that might be able to take advantage of your weakened state, cholera will not kill you. Cholera deaths are truly a failure of healthcare.