ProMED-mail post

Published Date: 2011-08-27 21:09:11
Subject: PRO/EDR> Cholera, diarrhea & dysentery update 2011 (26): Asia
Archive Number: 20110827.2623

CHOLERA, DIARRHEA AND DYSENTERY UPDATE 2011 (26):ASIA
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International Society for Infectious Diseases
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In this update:
[1] Cholera - Afghanistan (Ghor, Ghazni)
[2] Cholera - India (Gujarat)
[3], [4] Cholera - India (Maharashtra)
[5] Diarrhea - Pakistan (Khyber Pakhtunkhwa)
[6] Cholera - Pakistan (Khyber Pakhtunkhwa)
[7] Cholera - Bay of Bengal origin of current pandemic waves

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[1] Cholera - Afghanistan (Ghor, Ghazni)
Date: Wed 24 Aug 2011
Source: Wakht News Agency
http://www.wakht.com/en/021514.php

Recent outbreak of cholera-type diarrhea cases mostly created from
lack of potable water and hot summer had concerned the people in the
central Ghazni province, officials said on Wed 24 Aug 2011.

A cholera type diarrhea cases increase by the arrival of warm climate
of summer each year, but the mortality cases are increased among the
children compared to 2010, mostly due to lack of drinking water
originated from the 2011 drought, director for provincial public
health, Dr. Ghulam Nabi Yagana told Wakht News Agency adding that more
than 1000 people affected by diarrhea had been put under treatment
only in Chaghcharan, the capital city of Ghor province.

Head of provincial council, Fazul Haq Ihsan told Wakht News Agency
that the central hospital of the province had only housed 80 beds
while more than 200 patients are referring from the remote districts
of the province. A Ghor citizen told Wakht News Agency that there was
only a single clinic in each district of the province insufficient for
up to 30 000 residents.

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[2] Cholera - India (Gujarat)
Date: Sun 21 Aug 2011
Source: Indian Express [edited]
http://www.indianexpress.com/news/cholera-alert-sounded-near-vadodara/834909/

Days after 20 laborers working at a construction site near Vadodara
were reported to be affected by diarrhea, the district administration
has declared the area as cholera affected and rushed medical teams to
put in place preventive measures in the periphery of 8 kilometers [5
miles].

Between 17 and 19 Aug 2011, more than 20 labourers working at a
construction site of L&T near Ankhol village located on the National
Highway 8 complained about diarrhoea and were brought to a government
hospital for treatment. Most of them are migrants from Dahod, Godhra,
Madhya Pradesh and Bihar.

"Of the 20, 3 were diagnosed positive for cholera. We immediately
started preventive measures. 8 teams comprising 4 doctors and 20
paramedic staff are working in the area. We are examining every
resident in the periphery of 8 kilometers and medical services are
being provided round-the-clock. We have also taken water samples from
tankers provided by the company," said epidemic control officer
Vijaykumar Bidla.

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[3] Cholera - India (Maharashtra)
Date: Wed 10 Aug 2011
Source: DNA India [edited]
http://www.dnaindia.com/mumbai/report_cholera-cases-on-the-rise-at-kasturba-municipality-mum_1574423

While the municipal corporation has kept mum about the cholera cases
in the city, patients testing positive for the infectious disease and
being admitted to Kasturba Hospital are increasing. Ward number 15 of
Kasturba Hospital, the city's only infectious disease hospital, has
been reserved for cholera, severe diarrhea and hepatitis patients.

According to a nurse in charge of the ward, 60 percent of the patients
in the ward have tested positive for hanging drop test, the primary
test for cholera. A 60-year-old man was tested positive for cholera on
Saturday. "I had severe stomach cramps, vomiting and loose motions. I
was 1st taken to Noor Hospital. But after the hanging drop test was
positive, I was shifted to Kasturba hospital," he said. Most of the
cholera positive patients in Kasturba Hospital are from Byculla,
Bhendi Bazaar areas and Bandra.

Dr Daksha Shah, head of epidemiology cell, Kasturba Hospital, refuted:
"We don't have any patients who have tested positive for hanging drop
test." Kasturba Hospital doctors said they are not cases of classic
cholera but the rising number of positive cases of hanging drop is
definitely a matter of concern.

"None of these cases are classic cholera, which is deadly. Many times,
the mild cholera goes undetected as they are not tested. But a
majority of cases in the out-patient department is of stomach
ailments. Byculla and Mohammed Ali Road, Bandra, Kurla are the
worst-affected areas," said the doctor.

While there is a rising number of cholera and severe diarrhea cases,
the hospital's infrastructure is not able to handle the load.

"72 patients have severe diarrhea symptoms. The ward has only 2
toilets," said a 25-year-old Byculla resident admitted to hospital on
Sat 7 Aug 2011.

[Byline: Somita Pal]

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[Denying that it is not classical cholera is silly since the strains
in the current pandemic are El Tor, not Classical ones, or so-called
Matlab variants with some phenotypic characteristics of both. -
Mod.LL]

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[4] Cholera - India (Maharashtra)
Date: Sat 6 Aug 2011
Source: Times of India [edited]
http://timesofindia.indiatimes.com/city/mumbai/MONSOON-OUTBREAK-Gastro-first-cholera-case/articleshow/9501813.cms

The spurt in gastroenteritis cases this monsoon has worsened with the
city registering its 1st case of cholera, the deadliest form of
diarrhea. A 4-year-old boy from Bainganwadi slum in Govandi has tested
positive for cholera. State-run J J Hospital 1st admitted His
8-month-old brother on Monday [1 Aug 2011], as he was suffering from
severe loose motions and dehydration. A day later, his 6-year-old
sister was admitted over similar symptoms. On Wed 3 Aug 2011 the
patient and his other brothers, aged 4 and 3, were also admitted.
Stool samples of all the 4 siblings were sent for testing; only the
4-year-old tested positive for cholera.

"The child tested positive not only in the hanging drop test, but also
in the ELISA test, which confirmed cholera," said Dr T P Lahane, dean,
J J Hospital.

As in the case of this family, there has been a sudden outbreak of
gastroenteritis cases in the Mumbai. While cholera is a severe form of
gastroenteritis, south Mumbai doctors said that gastroenteritis is
especially rampant in the Byculla, Dongri and Mumbai Central belt.

[Byline: Pratibha Masand]

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[5] Diarrhea - Pakistan (Khyber Pakhtunkhwa)
Date: Sun 21 Aug 2011
Source: Express Tribune [edited]
http://tribune.com.pk/story/236119/disease-outbreak-in-swat-hundreds-suffer-from-diarrhoea-epidemic/

The Swat Valley has been hit hard by a diarrhea epidemic, with
thousands of children and women falling victim to the fatal illness.
Contaminated water from ponds and streams is suspected to have caused
the outbreak.

Hundreds of patients have been admitted in different parts of the
valley; however, the situation in Bahrain, Swat is particularly
serious. The valley has only one basic health unit (BHU) which is not
only short of medicines and staff, but is also lacking space to
accommodate the patients.

"The situation in Bahrain is indeed very serious, with more than 300
people suffering from diarrhea. To add to their miseries, there is a
shortage of vaccines, physicians and even beds at the BHU," said
Zubair Torwali, a local civil society and human right activist. "The
people don't know where to go. We appeal to the concerned authorities
to take immediate action," he added.

Gut Bella, a remote area of Malam Jabba, is also in the grip of the
disease, where a woman and a child died because they could not get
access to medical facilities. Almost 250 people are have been affected
by diarrhea in the region.

[Byline: Fazal Khaliq]

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[Many of these cases may well be cholera-related. - Mod.LL]

[6] Cholera - Pakistan (Khyber Pakhtunkhwa)
Date: Mon 22 Aug 2011
Source: Express Tribune [edited]
http://tribune.com.pk/story/231487/disease-outbreak-cholera-pandemic-in-khyber-agency/

A cholera outbreak has been reported in Khyber Agency, infecting
hundreds of people in Paseedkhel, Charbagh, and Landikotal areas. An
official of Landikotal Tehsil's political administration, Abdul Nabi
Bangash, on Sun 21 Aug 2011, confirmed that the disease has turned
pandemic in Paseedkhel and Charbagh.

He said that measures are being taken to control the spread of the
disease and medical teams, ambulances and required funds are being
provided to the local health departments to ensure free treatment to
patients.

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*****
[7] Cholera - Bay of Bengal origin of current pandemic waves
Date: Thu 25 Aug 2011
Source: BBC [edited]
http://www.bbc.co.uk/news/health-14664450

A major cholera pandemic has spread in at least 3 waves from a single
global source: the Bay of Bengal. A study in Nature reveals cholera's
spread over the last 60 years into Asia, Africa, Europe and the
Americas, continent-hopping on long-haul flights. The research by a
team from Cambridge's Sanger Institute showed the infection is
evolving, with the newest waves showing antibiotic resistance.

Cholera is a bacterial infection of the intestine that causes
diarrhoea. It affects 3-5 million people annually in 56 countries,
killing between 100 000 and 150 000. If untreated, it can kill within
hours through dehydration. It is easily treated by drinking clean
water, but without this, severe cases have a 30-50 percent mortality
rate. In this study, the researchers sequenced the genome of 154
samples collected from patients around the world. Genome sequencing
technologies have been getting better, faster and cheaper. Until
recently, sequencing would be carried out on just 4 or 5 bacteria
samples.

The ecology and climate of the Bay of Benghal could be why cholera has
spread from there. Similarities between cholera genomes showed how the
various strains are related, while subtle differences showed how it is
evolving. By investigating these bacteria at the genetic level, the
authors were able to piece together the story of the latest, and
ongoing, global cholera pandemic.

"We were surprised to see that the pattern we see is very clear. All
of the samples were related. There is a single global source of
cholera in the Bay of Bengal," said co-author Dr Nick Thomson of the
Sanger Institute. It is not yet clear why the Bay of Bengal is at the
centre of the pandemic, though cholera bacteria exist naturally within
some marine ecosystems. The local ecology, climate, and the presence
of large river deltas are likely to be key factors in its presence
there.

The results show several cases of cholera suddenly jumping between
continents, suggesting that it was spread by passengers on long-haul
flights. "I think that's the only possible explanation. Our data show
that this has happened, for example from Angola to South America. Many
people can have cholera with no symptoms, so they transmit it without
realising," added Dr Thomson.

The most recent outbreak is in Haiti where it took hold shortly after
the 2010 earthquake after being absent for more than a century. So far
it has killed nearly 6000 people and hospitalized 200 000.

Another worrying pattern emerged from the genome analysis. 3 waves of
cholera have come out of the Bay of Bengal since the 1950s, and from
the 2nd wave onwards, all of the strains were antibiotic resistant.
That means that the resistance was acquired within 15 years of the 1st
clinical use of antibiotics tetracycline and furazolidone for cholera
treatment.

Dr Thompson said: "I'm not surprised it happened so fast. We think
that antibiotic resistance moves between strains, and in one fell
swoop a strain can become multi-resistant. Antibiotics are clearly one
of the major driving forces in cholera evolution. However, in general
antibiotics just reduce the length of infection in people."

Dr Valerie Curtis of the London School of Hygiene and Tropical
Medicine said: "It's an appalling scandal that in the 21st century
people are still suffering from this ancient disease. Cholera is
symptomatic of countries where something has gone badly wrong, where
the infrastructure of sanitation and clean water has broken down. This
is really about poverty. What this study shows is that it's easy for
pockets of poverty in Africa to affect pockets of poverty in the
Americas, for example. It's almost impossible to stop the spread of
such diseases but what we must do is invest in the public health of
poor countries."

[Byline: Hamish Pritchard]

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