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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [3]; Associate Editors-In-Chief: Priyamvada Singh, MBBS [4]

## Overview

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The cholera-causing bacterium was originally isolated in 1855 by Italian anatomist Filippo Pacini, but its exact nature and his results were not widely known. One of the major contributions to fighting cholera was made by the physician and pioneer medical scientist John Snow (1813–1858), who, in 1854, identified a link between cholera and contaminated drinking water.[1] Dr. Snow proposed a microbial origin for epidemic cholera in 1849.

## Historical Perspective

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* The Russian-born bacteriologist Waldemar Haffkine developed the first cholera vaccine around 1900. The bacterium had originally been isolated 45 years earlier (1855) by Italian anatomist Filippo Pacini, but its exact nature and his results were not widely known.
* One major contribution to the fight against cholera was made by the physician and pioneer medical scientist John Snow (1813–1858), who, in 1854, found a link between cholera and contaminated drinking water.[1] Dr. Snow proposed a microbial origin for epidemic cholera in 1849.
* In his major "state of the art" review of 1855, he proposed a substantially complete and correct model for the etiology of the disease.
* In two pioneering epidemiological field studies, he was able to demonstrate that human sewage contamination was the most probable disease vector in two major epidemics in London in 1854.[2] His model was not immediately accepted by the scientific community, but it was accepted as the most plausible possibility as medical microbiology developed over the next several decades.
* Cities in developed nations made massive investments in maintaining clean water supplies and well-separated sewage treatment infrastructures between the mid-1850s and the 1900s. This eliminated the threat of cholera epidemics from the major developed cities around the world. In 1883, Robert Koch identified V. cholerae with a microscope as the bacillus that caused cholera.[3]
* Cholera has been a representative case in the study of evolution of virulence. The province of Bengal in British India was partitioned into West Bengal and East Pakistan in 1947. Prior to the partition, both regions had cholera pathogens with similar characteristics. After 1947, India made more progress in the realm of public health than did East Pakistan (now Bangladesh). As a consequence, the strains of the pathogen that succeeded in India had a greater incentive in the longevity of the host. They have become less virulent than the strains prevailing in Bangladesh, which draw upon the resources of the host population and rapidly kill many victims.
* More recently, in 2002, Alam, et al., studied stool samples from patients at the International Centre for Diarrhoeal Disease in Dhaka, Bangladesh. From the various experiments they conducted, the researchers found a correlation between the passage of V. cholerae through the human digestive system and an increased infectivity state. Furthermore, the researchers found that the bacterium creates a hyperinfected state where genes that control biosynthesis of amino acids, iron uptake systems, and formation of periplasmic nitrate reductase complexes were induced just before defecation. These induced characteristics allow the cholera vibrios to survive in the "rice-water" stools, an environment of limited oxygen and iron, of patients with a cholera infection.[4]
* The term cholera morbus was used in the 19th and early 20th century to describe both non-epidemic cholera and gastrointestinal diseases that mimicked cholera. The term is not in current use, but is found in many older references.[5]

### Cholera pandemics

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* 1816-1826 - First Cholera pandemic: Previously restricted, the pandemic began in Bengal, then spread across India by 1820. It extended as far as China and the Caspian Sea before receding.
* 1829-1851 - Second Cholera pandemic reached Europe, London, and Paris in 1832. In London, it claimed 6,536 victims (see: http://www.mernick.co.uk/thhol/1832chol.html); in Paris, 20,000 succumbed (out of a population of 650,000) with about 100,000 deaths in all of France [5]. It reached Russia (Cholera Riots), Quebec, Canada, Ontario, Canada] and New York in the same year and the Pacific coast of North America by 1834.
* 1849 - Second major outbreak in Paris. In London, it was the worst outbreak in the city's history, claiming 14,137 lives, ten times as many as the 1832 outbreak. In 1849 cholera claimed 5,308 lives in the port city of Liverpool, England, and 1,834 in Hull, England.[6] An outbreak in North America took the life of former U.S. President James K. Polk. Cholera spread throughout the Mississippi river system killing over 4,500 in St. Louis [6] and over 3,000 in New Orleans [7] as well as thousands in New York.[7] In 1849 cholera was spread along the California and Oregon trail as hundreds died on their way to the California Gold Rush, Utah and Oregon.[8]
* 1852-1860 - Third Cholera pandemic mainly affected Russia, with over a million deaths. In 1853-4, London's epidemic claimed 10,738 lives.
* 1854 - Outbreak of cholera in Chicago took the lives of 5.5 per cent of the population (about 3,500 people).[8]. Soho outbreak in London stopped by removing the handle of the Broad Street pump by a committee instigated to action by John Snow .[9]
* 1863-1875 - Fourth Cholera pandemic spread mostly in Europe and Africa.
* 1866 - Outbreak in North America. In London, a localized epidemic in the East End claimed 5,596 lives just as London was completing its major sewage and water treatment systems--the East End was not quite complete. William Farr, using the work of John Snow et al. as to contaminated drinking water being the likely source of the disease, was able to relatively quickly identify the East London Water Company as the source of the contaminated water. Quick action prevented further deaths.[10] Also a minor outbreak at Ystalyfera in South Wales. Caused by the local water works using contaminated canal water, it was mainly it's workers and their families who suffered. Only 119 died.
* 1881-1896 - Fifth Cholera pandemic ; The 1892 outbreak in Hamburg, Germany was the only major European outbreak; about 8,600 people died in Hamburg, causing a major political upheaval in Germany, as control over the City was removed from a City Council which had not updated Hamburg's water supplies. This was the last serious European cholera outbreak.
* 1899-1923 - Sixth Cholera pandemic had little effect in Europe because of advances in public health, but Russia was badly affected again.
* 1961-1970s - Seventh Cholera pandemic began in Indonesia, called El Tor after the strain, and reached Bangladesh in 1963, India in 1964, and the USSR in 1966. From North Africa it spread into Italy by 1973. In the late 1970s there were small outbreaks in Japan and in the South Pacific. There were also many reports of a cholera outbreak near Baku in 1972, but information about it was suppressed in the USSR.[11]
* January 1991 to September 1994 - Outbreak in South America, apparently initiated when a ship discharged ballast water. Beginning in Peru there were 1.04 million identified cases and almost 10,000 deaths. The causative agent was an O1, El Tor strain, with small differences from the seventh pandemic strain. In 1992 a new strain appeared in Asia, a non-O1, nonagglutinable vibrio (NAG) named O139 Bengal. It was first identified in Tamil Nadu, India and for a while displaced El Tor in southern Asia before decreasing in prevalence from 1995 to around 10% of all cases. It is considered to be an intermediate between El Tor and the classic strain and occurs in a new serogroup. There is evidence of the emergence of wide-spectrum resistance to drugs such as trimethoprim, sulfamethoxazole and streptomycin.
* 2007 - The U.N. reported of a Cholera outbreak in Iraq.[12]

## References

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1. ↑ 1.0 1.1 Rosenberg, Charles E. (1987). The cholera years: the United States in 1832, 1849 and 1866. Chicago: University of Chicago Press. ISBN 0-226-72677-0.
2. ↑ Dr John Snow, The mode of communication of cholera, London 1855
3. ↑ Aberth,John. Plagues in World History. Lanham, MD: Rowman & Littlefield, 2011, 101.
4. ↑ Merrell DS, Butler SM, Qadri F; et al. (2002). "Host-induced epidemic spread of the cholera bacterium". Nature. 417 (6889): 642–5. doi:10.1038/nature00778. PMC 2776822. PMID 12050664. Unknown parameter `|month=` ignored (help)CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
5. ↑ Archaic Medical Terms.
6. ↑ IBMS Institute of Biological Science [1]
7. ↑ The Cholera Years: The United States in 1832, 1849, and 1866 by Charles E. Rosenberg
8. ↑ Trails of Hope: California, Oregon and Mormon Trails [2]
9. ↑ On the Mode of Communication of Cholera (1855) by John Snow, M.D. (1813-1858) [http://eee.uci.edu/clients/bjbecker/PlaguesandPeople/week8a.html
10. ↑ "The Ghost Map" by Steven Johnson, pg. 209
11. ↑ World Health Organization. Global epidemics and impact of cholera. (2016) http://www.who.int/topics/cholera/impact/en/ Accessed on October 5th, 2015
12. ↑ "U.N. reports cholera outbreak in northern Iraq" (HTML). CNN. Retrieved 2007-08-30.

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