History of cholera

Hand bill from the New York City Board of Health, 1832. The outdated public health advice demonstrates the lack of understanding of the disease and its actual causative factors.

It is estimated that cholera affects 3–5 million people worldwide, and causes 100,000–130,000 deaths a year as of 2010. This occurs mainly in the developing world. In the early 1980s, death rates are believed to have been greater than 3 million a year. It is difficult to calculate exact numbers of cases, as many go unreported due to concerns that an outbreak may have a negative impact on the tourism of a country. Cholera remains both epidemic and endemic in many areas of the world.

Although much is known about the mechanisms behind the spread of cholera, this has not led to a full understanding of what makes cholera outbreaks happen some places and not others. Lack of treatment of human feces and lack of treatment of drinking water greatly facilitate its spread. Bodies of water have been found to serve as a reservoir, and seafood shipped long distances can spread the disease. Cholera did not occur in the Americas for most of the 20th century after the early 1900s in New York City. It reappeared in the Caribbean toward the end of that century and seems likely to persist.

Deaths in India between 1817 and 1860, in the first three pandemics of the nineteenth century, are estimated to have exceeded 15 million people. Another 23 million died between 1865 and 1917, during the next three pandemics. Cholera deaths in the Russian Empire during a similar time period exceeded 2 million.

Pandemics

First

• 1816–1826: The first cholera pandemic, though previously restricted, began in Bengal, and then spread across India by 1820. Hundreds of thousands of Indians and ten thousand British troops died during this pandemic. The cholera outbreak extended as far as China, Indonesia (where more than 100,000 people succumbed on the island of Java alone) and the Caspian Sea in Europe, before receding.

Second

• 1829–1851: A second cholera pandemic reached Russia (see Cholera Riots), Hungary (about 100,000 deaths) and Germany in 1831; it killed 150,000 people in Egypt that year. In 1832 it reached London and the United Kingdom (where more than 55,000 people died) and Paris2. In London, the disease claimed 6,536 victims and came to be known as "King Cholera"; in Paris, 20,000 died (of a population of 650,000), and total deaths in France amounted to 100,000. The epidemic reached Quebec, Ontario and New York in the same year, and the Pacific coast of North America by 1834. In the center of the country, it spread through the cities linked by the rivers and steamboat traffic.

In 1846, cholera struck Mecca, killing over 15,000 people. A two-year outbreak began in England and Wales in 1848, and claimed 52,000 lives.

In 1849, a second major outbreak occurred in Paris. In London, it was the worst outbreak in the city's history, claiming 14,137 lives, over twice as many as the 1832 outbreak. Cholera hit Ireland in 1849 and killed many of the Irish Famine survivors, already weakened by starvation and fever. In 1849, cholera claimed 5,308 lives in the major port city of Liverpool, England, an embarkation point for immigrants to North America, and 1,834 in Hull, England.

An outbreak in North America took the life of former U.S. President James K. Polk. Cholera, believed spread from Irish immigrant ship(s) from England, spread throughout the Mississippi river system, killing over 4,500 in St. Louis and over 3,000 in New Orleans. Thousands died in New York, a major destination for Irish immigrants. Cholera claimed 200,000 victims in Mexico.

That year, cholera was transmitted along the California, Mormon and Oregon Trails as 6,000 to 12,000 are believed to have died on their way to the California Gold Rush, Utah and Oregon in the cholera years of 1849–1855. It is believed more than 150,000 Americans died during the two pandemics between 1832 and 1849.

During this pandemic, the scientific community varied in its beliefs about the causes of cholera. In France doctors believed cholera was associated with the poverty of certain communities or poor environment. Russians believed the disease was contagious, although doctors did not understand how it spread. The United States believed that cholera was brought by recent immigrants, specifically the Irish, and epidemiologists understand they were carrying disease from British ports. Lastly, some British thought the disease might rise from divine intervention.

Third

• 1852–1860: The third cholera pandemic mainly affected Russia, with over one million deaths. In 1852, cholera spread east to Indonesia, and later was carried to China and Japan in 1854. The Philippines were infected in 1858 and Korea in 1859. In 1859, an outbreak in Bengal contributed to transmission of the disease by travelers and troops to Iran, Iraq, Arabia and Russia. Japan suffered at least seven major outbreaks of cholera between 1858 and 1902. The Ansei outbreak of 1858-60, for example, is believed to have killed between 100,000 and 200,000 people in Tokyo alone.

1854: An outbreak of cholera in Chicago took the lives of 5.5% of the population (about 3,500 people). In 1853–4, London's epidemic claimed 10,738 lives. The Soho outbreak in London ended after the physician John Snow identified a neighborhood Broad Street pump as contaminated and convinced officials to remove its handle. His study proved contaminated water was the main agent spreading cholera, although he did not identify the contaminant. It would take many years for this message to be believed and acted upon. Throughout Spain, cholera caused more than 236,000 deaths in 1854–55. In 1854 and 1855, it entered Venezuela; Brazil also suffered in 1855. During the third pandemic, Tunisia, which had not been affected by the two previous pandemics, thought Europeans had brought the disease. They blamed their sanitation practices. Some United States scientists began to believe that cholera was somehow associated with African Americans, as the disease was prevalent in the South in areas of black populations. Current researchers note their populations were underserved in terms of sanitation infrastructure, and health care, and they lived near the waterways by which travelers and ships carried the disease.

Fourth

• 1863–1875: The fourth cholera pandemic spread mostly in Europe and Africa. At least 30,000 of the 90,000 Mecca pilgrims died from the disease. Cholera ravaged northern Africa in 1865. Traveling southeastward, cholera reached Zanzibar, where 70,000 people are reported to have died in 1869–70. Cholera claimed 90,000 lives in Russia in 1866. The epidemic of cholera that spread with the Austro-Prussian War (1866) is estimated to have taken 165,000 lives in the Austrian Empire. Hungary and Belgium each lost 30,000 people, and in the Netherlands, 20,000 perished. In 1867, Italy lost 113,000 lives. That same year, cholera traveled to Algeria and killed 80,000.

1892 cholera outbreak in Hamburg, hospital ward

1892 cholera outbreak in Hamburg, disinfection team

Outbreaks in North America in 1866–1873 killed some 50,000 Americans.

In London, a localized epidemic in the East End claimed 5,596 lives, just as the city was completing construction of its major sewage and water treatment systems; the East End section 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, relatively quickly identified the East London Water Company as the source of the contaminated water. Quick action prevented further deaths. Also, a minor outbreak occurred at Ystalyfera in South Wales, caused by the local water works using contaminated canal water. Workers associated with the company and their families were most affected, and 119 died. In the same year, more than 21,000 people died in Amsterdam, The Netherlands. In the 1870s, cholera spread in the U.S. as an epidemic from New Orleans along the Mississippi River and to ports on its tributaries; thousands of people died.

Fifth

• 1881–1896: The fifth cholera pandemic, according to Dr A. J. Wall, the 1883–1887 part of the epidemic cost 250,000 lives in Europe and at least 50,000 in the Americas. Cholera claimed 267,890 lives in Russia (1892); 120,000 in Spain; 90,000 in Japan and over 60,000 in Persia. In Egypt, cholera claimed more than 58,000 lives. The 1892 outbreak in Hamburg killed 8,600 people. Although the city government was generally held responsible for the virulence of the epidemic, it went largely unchanged. This was the last serious European cholera outbreak, as cities improved their sanitation and water systems.

Sixth

• 1899–1923: The sixth cholera pandemic had little effect in western Europe because of advances in public health, but major Russian cities and the Ottoman Empire were particularly hard hit by cholera deaths. More than 500,000 people died in the Russian Empire of cholera during the first quarter of the 20th century, which was also a time of social disruption because of revolution and warfare.

The 1902–1904 cholera epidemic claimed 200,000 lives in the Philippines. Twenty-seven epidemics were recorded among pilgrims to Mecca from the 19th century to 1930, and more than 20,000 pilgrims died of cholera during the 1907–08 hajj. The sixth pandemic killed more than 800,000 in India.

The last outbreak in the United States was in 1910–1911, when the steamship Moltke brought infected people from Naples to New York City. Vigilant health authorities isolated the infected in quarantine on Swinburne Island. Eleven people died, including a health care worker at the hospital on the island.

In this time period, because immigrants and travelers often carried cholera from infected locales, the disease became associated with outsiders in each society. The Italians blamed the Jews and gypsies, the British who were in India accused the “dirty natives”, and the Americans saw the problem coming from the Philippines.

Seventh

• 1961–1975: The seventh cholera pandemic began in Indonesia, called El Tor after the strain, and reached East Pakistan (now Bangladesh) in 1963, India in 1964, and the Soviet Union 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.

Notable recent outbreaks

By 12 February 2009, the number of cases of infection by cholera in sub-Saharan Africa had reached 128,548 and the number of fatalities, 4,053.

• January 1991–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), which was named O139 Bengal. It was first identified in Tamil Nadu, India and for a while displaced El Tor in southern Asia. It decreased 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. Scientists warn of evidence of wide-spectrum resistance by cholera bacteria to drugs such as trimethoprim, sulfamethoxazole and streptomycin.

• In 2000, some 140,000 cholera cases were officially reported to WHO. Africa accounted for 87% of these cases.
• November 2010: The cholera outbreak that began in Haiti the previous month spread into the Dominican Republic. Nepalese UN soldiers are believed to have acted as carriers and passed it through poorly maintained septic systems. Asian cholera strains have already been spread around the world, e.g. by ballast water of ships. Scientists have found that Vibrio cholera bacteria can survive between outbreaks in brackish warm water. It is possible that refugees with low resistance have contracted the disease from such waters. A woman who had visited Haiti returned with the disease to Florida. Cholera has occurred in Southern USA in recent years without causing major epidemics.

• July–December 2007: A lack of clean drinking water in Iraq has led to an outbreak of cholera. As of 2 December 2007, the UN had reported 22 deaths and 4,569 laboratory-confirmed cases.

• August 2007: The cholera epidemic started in Orissa, India. The outbreak has affected Rayagada, Koraput and Kalahandi districts, where more than 2,000 people have been admitted to hospitals.

• March–April 2008: 2,490 people from 20 provinces throughout Vietnam have been hospitalized with acute diarrhea. Of those hospitalized, 377 patients tested positive for cholera.

• August–October 2008: As of 29 October 2008, a total of 644 laboratory-confirmed cholera cases, including eight deaths, had been verified in Iraq.

• November 2008: Doctors Without Borders reported an outbreak in a refugee camp in the Democratic Republic of the Congo's eastern provincial capital of Goma. Some 45 cases were reportedly treated between November 7 and 9.

• January 2009: The Mpumalanga province of South Africa confirmed over 381 new cases of Cholera, bringing the total number of cases treated since November 2008 to 2276. Nineteen people died in the province since the outbreak.

• August 2008–April 2009: In the 2008 Zimbabwean cholera outbreak, which continued into 2009, an estimated 96,591 people in the country had been infected with cholera and, by 16 April 2009, 4,201 deaths had been reported. According to the World Health Organization, during the week of 22–28 March 2009, the "Crude Case Fatality Ratio (CFR)" had dropped from 4.2% to 3.7%. The daily updates for the period 29 March 2009 to 7 April 2009, list 1748 cases and 64 fatalities, giving a weekly CFR of 3.66% (see table above). Those for the period 8 April to 16 April list 1375 new cases and 62 deaths (and a resulting CFR of 4.5%). The CFR had remained above 4.7% for most of January and early February 2009.

• October 2010: In late October a cholera outbreak was reported in Haiti, and as of November 16 the Haitian Health Ministry reported the number of dead to be 1,034, with hospitalizations for cholera symptoms totaling over 16,700. It is believed that cholera was spread to Haiti from an encampment of United Nations peacekeepers from Nepal who were draining untreated sewage into a nearby river and the Haitian outbreak is of a Nepali strain. As of January 2012, the epidemic has sickened nearly 500,000 people and killed nearly 7,000.

• August 2010: Nigeria was reaching epidemic proportions after widespread confirmation of the cholera outbreaks in 12 of its 36 states. 6400 cases have been reported with 352 reported deaths. The health ministry blamed the outbreak on heavy seasonal rainfall and poor sanitation.

• In January 2011, about 411 Venezuelan citizens were invited to a wedding ceremony to be held in the Dominican Republic, where they ate ceviche (raw fish cooked in lemon juice). By the time they returned to Caracas and other Venezuelan cities, some of these people were suffering from symptoms of cholera. By January 28, almost 111 cases had been confirmed by the Venezuelan Health Authorities, who quickly instituted an 800 number for patients who wondered whether they were infected. Internationally, this small outbreak prompted Venezuela's western neighbor, Colombia, to secure its border against immigrants and probable transmission of the disease. Also, Dominican authorities started a nationwide study to determine the cause of the outbreak, and warned their residents of the imminent danger associated with the consumption of raw fish and shellfish. As of January 29, 2011, none of the cases in Venezuela proved fatal, but two degraded critical and the patients were hospitalized. Since the victims had quickly sought help, the outbreak was detected and contained.

• 2011: Cholera spread from Haiti to the Dominican Republic. There were outbreaks in Nigeria and Democratic Republic of Congo, which had suffered years of disruption from warfare. Somalia has suffered a double hit of cholera outbreak and famine.

False reports

Main article: Chicago 1885 cholera epidemic myth

A persistent urban myth states 90,000 people died in Chicago of cholera and typhoid fever in 1885, but this story has no factual basis. In 1885, a torrential rainstorm flushed the Chicago River and its attendant pollutants into Lake Michigan far enough that the city's water supply was contaminated. But, as cholera was not present in the city, there were no cholera-related deaths. The incident led to the city making changes to improve its treatment of sewage.

See also

• List of epidemics