1. Overview Definitions Cholera: clinical, epidemiology
History and pandemics
Peru: diary of Cholera’s epidemic
Environmental factors
Cholera today
Conclusion
history & Peru will touch social, economical and political factors

2. C Seas, J Miranda, AI Gil, et. al.
New insights on the emergence of Cholera in Latin America during 1991: the Peruvian experience
C Seas, J Miranda, AI Gil, et. al.
Am J Trop Med & Hyg 2000; 62(4):513-7

4. Cholera epidemic in Peru, 1991
Officially started January 23, 1991 in Candelaria, a valley near Chancay
Within a week, cases alongside the 900 km of Peruvian coast
300,000 cases (peak 45,000/wk)
Low mortality (~1%)

5. Hypothesis presented Ships coming from infected areas
Contaminated water eliminated to the sea
V. cholerae non toxigenic acquired virulence through phages
V. cholerae toxigenic was present in low concentrations or in viable state but not cultivatable

6. Our hypothesis
V. cholerae, originally from the water environment, was present in multiples coastal places, maybe related with El Niño phenomenon, and increased in concentrations enough to produce human infection
This provoked sporadic and dispersed clinical cases before the start of the epidemic
The epidemic continued because of massive water and food contamination

7. Material and Methods Revision of case records and emergency files
Where? 7 coastal cities and ports (Lima, Chancay, Huacho, Chimbote, Trujillo, Chiclayo y Piura)
Period of study: Sep-Jan 1989/90 & 1990/91
Case definition: patients >5 years, watery diarrhoea and severe dehydration

8. Results 3640 records reviewed
7 people (90/91) fulfill cholera’s clinical definition
First case identified 4 months before the beginning of epidemic
Comparison % diarrhoeal periods 90/91 and 89/90: no difference between Sep-Jan, high Feb-Mar

9. Cases Compatibles Date Place Distance (Km) 23 Oct 90 Trujillo (*) 570
11 Dec 90 Chimbote
24 Dec 90 Trujillo
26 Dec 91 Chancay
29 Dec 90 Trujillo
13 Jan 91 Lima
16 Jan 91 Chancay
23 Jan 91 Epidemic’s official beginning
(*) Cases identified were from two different hospitals

11. Discussion (i) Majority of infections are asymptomatic
V. cholerae is associated with phytoplankton and zooplankton in sea environment
V. cholerae O1 (non-toxigenic) and no-O1 have been cultivated in this region in the last 15 years

13. Discussion (ii)
Suggest V. Cholerae was present in Peru at least several months before the recognition of the epidemic
Cases alongside the Peruvian north coast explains the large dispersion of Vibrio in the environment

14. Discussion (iii)
Dissemination of vibrios possibly related to selected plankton populations, increased because of El Niño phenomenon1991
Limitation: microbiological confirmation

15. Plankton concentrations during El Niño 82-83 in Bangladesh

17. Overview Definitions Cholera: clinical, epidemiology
History and pandemics
Peru: diary of Cholera’s epidemic
Environmental factors
Cholera today
Conclusion
history & Peru will touch social, economical and political factors

20. en

25. Summary Rehydration and antibiotics
Clear links with poverty, instability and deprived conditions
Economical and political actors also play a role
Still a problem for some groups

26. Overview Definitions Cholera: clinical, epidemiology
History and pandemics
Peru: diary of Cholera’s epidemic
Environmental factors
Cholera today
Conclusion
history & Peru will touch social, economical and political factors

27. Conclusion
“V cholerae cannot be eradicated; it is a part of the normal flora an ecology of the surface water of our planet. Thus, we have to learn to coexist with the vibrios” (Sack DA, et al)
Need to tackle social problems to avoid future outbreaks

28. Further reading Sack DA, et al. Cholera. Lancet 2004;363:223-33
Lee K, Dodgson R. Globalization and Cholera: Implications for Global Governance. Global Governance 2000;6:213-36
Panisset U. International Health Statecraft: Foreign Policy and Public Health in Peru’s Cholera Epidemic. Lanham: University Press of America, 2000
WHO, PAHO