1. Cholera and Global Health Dr Jaime Miranda, M.D. International Health and Medical Education Centre University College London London, March 2004

2. IHMEC International Health and Medical Education Centre, UCL IHMEC was established in 2000 to meet the growing demand from staff and students for the inclusion of international health in the medical curriculum We have been working to increase the possibilities for studying global health and have been publicising issues relating to the subject

3. Educating doctors for world health …UCL's International Health and Medical Education Centre is an important step forward in the effort to produce doctors who can make a difference in the world Lancet 2001;358:1471

4. Courses offered Intercalated BSc in International Health Fifth year Special Study Module and International Health Elective Special Study Modules for first year students

5. Objective To understand Cholera as a global health issue To Outline environmental, economical, social and political issues associated with Cholera

6. Love in the Time of Cholera...they no longer felt like newlyweds, and even less like belated lovers. It was as if they had leapt over the arduous calvary of conjugal life and gone straight to the heart of love. They were together in silence like an old married couple wary of life, beyond the pitfalls of passion, beyond the brutal mockery of hope and the phantoms of disillusion: beyond love. For they had lived together long enough to know that love was always love, anytime and anyplace, but it was more solid the closer it came to death. (Gabriel García Marquez)

7. Overview Definitions Cholera: clinical, epidemiology History and pandemics Peru: diary of Cholera’s epidemic Environmental factors Cholera today Conclusion

8. Overview Definitions Cholera: clinical, epidemiology History and pandemics Peru: diary of Cholera’s epidemic Environmental factors Cholera today Conclusion

9. Definitions Nomenclature Endemic, Epidemic, Pandemic International Health

10. Nomenclature Vibrio: a type of bacteria Vibrium cholerae: organism Serogroups: O antigen >200 groups O1, O139, non-O1 non-O139 O1 biotypes: Classical, El Tor Serotypes: Ogawa, Inaba, Hikojima Cholera: disease

11. …demic Endemic: a disease continually present in a region Epidemic: an outbreak of a disease, introduced from outside a community, attacks many people over a short period Pandemic: an extensive epidemic, affects populations of several countries or regions

12. International Health Conceptualising health as the end point of such complex processes involves looking at economic, cultural, historical, political, commercial and environmental factors on a global scale

13. Overview Definitions Cholera: clinical, epidemiology History and pandemics Peru: diary of Cholera’s epidemic Environmental factors Cholera today Conclusion

14. Cholera epidemiology Transmission: food in DC, water in LDC Seasonality Bangladesh: 2 peaks, b/a monsoon rain Peru: warm season Reservoir: shellfish and plankton Case:Infections = 1:3 to 1:100

16. Infection Intestinal immunity 10 8 – healthy subjects 10 5 – with antacids Lower in real: No volunteer conditions Low gastric ph Blood group O – evolution in Ganges?

18. Clinical Features Incubation: 18h – 5 days Watery diarrhoea, infectious Vomiting 10% severe Up to 0.5-1 L/h  dehydration

19. Treatment Replacement for dehydration Signs: 5% bodyweight Severe dehydration = 10% 50kg  5 L saline FAST!! Antibiotics:  Illness  diarrhoea  Use of fluids  hospital stay Vaccination?

21. Cholera outbreak … patient older than 5 years develops severe dehydration or dies from acute watery diarrhoea, or if there is a sudden increase in the daily number of patients with acute watery diarrhoea, especially patients who pass “rice water” stools typical of cholera (WHO definition)

22. Overview Definitions Cholera: clinical, epidemiology History and pandemics Peru: diary of Cholera’s epidemic Environmental factors Cholera today Conclusion

25. Cholera pandemics 1. 1817 – 1823 2. 1826 – 1838  UK 1831 3. 1839 – 1853 4. 1863 – 1874 5. 1881 – 1896 6. 1899 – 1923 7. 1961 - …  America 1991

26. What happened? Cholera extremely linked to social, economical and political change Initially: Indian subcontinent 19 th century: imperialism, trade, military conflict, migration Worldwide disease in 1826